Issues of Cost and Implementation in Other Studies
However, some programs are already sorting these issues out. At the HIV clinic in Houston, individuals presenting for HIV testing and counseling are screened to determine their risk for HIV acquisition.
Out of 381 walk-in HIV tests performed from May 2013 to May 2014, 58 individuals (15.2%) were deemed at to be at highest risk for HIV infection, and agreed to an appointment in the HIV prevention clinic.
Fifty of these patients (94%) were in a serodiscordant relationship, 10
(19%) identified as MSM (men who have sex with men), and 49 (92%) had reported unprotected sex.
Notably, over half the patients in the prevention clinic (57%) were women.
In total, 36 patients (61%) attended their first appointment, 23 patients (40%)
completed at least one follow-up appointment, and 20 patients (34%) started
PrEP. There have been no HIV infections among these patients to date.
Payment issues were largely sorted out for the patients -- most (70%) of these patients relied on Harris Health System programs for subsidized cost of medical care. Four individuals (17%) had Medicaid and three (13%) had private insurance, while 10 received medication from the pharmaceutical assistance program.
According to a cost-modeling study of researchers in Toronto and London, the cost of treating every MSM in Toronto with PrEP would indeed be high, with costs per quality-adjusted life year (QALY) increasing from $230,000 to $300,000. However, by optimizing adherence and efficacy, and targeting PrEP primarily to reach 25% of the MSM at highest risk, with HIV testing every 3 months, a $32,000 cost per QALY was achieved.
From NPEP to PrEP
Among those most obviously at high risk, are people who recurrently present for NPEP due to high-risk behavior, but there has been little data about whether or not these individuals are being transitioned to PrEP.
So researchers in Boston conducted a survey of a convenience sample of participants enrolled in an ongoing NPEP study at Fenway Health, a large urban community health center from May 1, 2013 to March 30, 2014. The study included 45 individuals, mostly MSM of around 35.3 years of age.
On day 14 of being on NPEP, participants were queried about their baseline knowledge of PrEP, interest in using PrEP, where PrEP could be accessed and barriers to PrEP use. On day 90 of the study, participants were queried again.
Almost a quarter had never heard of PrEP, but most had heard of it at least 6 months or a year ago. However, of the 80% with a primary care physician (PCP), a third did not feel comfortable talking to their PCP about PrEP; 58.3% cited not being comfortable discussing sexual practices. Most thought that they would be more likely to obtain it from either an STD clinic, LGBT clinic or an HIV care provider.
About a fourth of those who completed the NPEP study were referred to PrEP.
The majority of NPEP users reported a high interest in using PrEP, especially after using NPEP -- which suggests that linkages should be strengthened between NPEP and PrEP programs.
Given the reticence among the patients to discuss PrEP or their sexual activity with their primary care provider, the authors concluded that doctors should be encouraged to proactively discuss PrEP with NPEP-experienced patients.
Theo Smart is an HIV activist and medical writer with more than 20 years of experience. You can follow him on Twitter @theosmart.
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