In Washington State, we've spent a lot of time talking about pre-exposure prophylaxis (PrEP), the use of antiretroviral medication to prevent HIV infection, and what it means for our work. We've been inspired to acknowledge our fears, both known and hidden, and to seize the hope and promise that's evolving before our eyes. We've given ourselves space to be curious, to make mistakes and to be OK with not creating the perfect plan. More importantly, we've made the decision to act, even as we continue to define our commitment.
As health departments explore PrEP, we'd like to share some lessons we've learned.
- Acknowledge and embrace PrEP as an essential strategy in the HIV prevention toolbox. As we see it, current science is conclusive -- PrEP works -- and we own the responsibility to get this information out to the communities we serve. We also believe it's our responsibility to correct misinformation and to challenge ambivalence, including our own.
- Listen to and learn from our communities. We spent months talking with our state's HIV planning group about PrEP, and they ultimately recommended it as one of six priorities in our state's HIV Prevention Framework. The group's courage and conviction set the stage for much of what we've been able to accomplish. To gain deeper insight, we actively monitor and participate in online communities, such as My PrEP Experience and various Facebook groups. Here, we gather real-time, free-flowing information about PrEP, including the role it plays in health and wellness, i.e., health / health insurance literacy, healthcare utilization and enhanced self-efficacy.
- Motivate our communities to use PrEP. We depend on our community-based organizations to actively engage folks about PrEP, with a primary focus on healthcare access and utilization. We Are 1, a three-county marketing campaign, and #myHIVmoment, a community mobilization partnership in Seattle, are two projects funded to promote health and wellness, including PrEP, among gay and bisexual men and trans people in Washington. These efforts, in conjunction with community forums and trainings, provide bidirectional information sharing and useful tools that help support successful PrEP use.
- Educate and support our healthcare providers. We support several activities for healthcare providers, including informal gatherings to learn about PrEP, mentorship between champions and clinicians newly interested in PrEP, publishing online PrEP provider lists and small PrEP demonstration projects. Overall, investments in provider engagement have been small, but their impact continues to grow.
- Understand and influence payer systems. We heard clearly that cost would be a primary obstacle for PrEP. To respond, our HIV Client Services program (Ryan White Part B and AIDS Drug Assistance Program [ADAP]) and Infectious Disease Prevention program established the Washington State PrEP Drug Assistance Program (PrEP DAP) in April 2014. The first of its kind in the nation, PrEP DAP is built on the backbone of our state's ADAP eligibility and pharmacy benefits systems, though it is funded exclusively with state funds. Currently, the program provides coverage for Truvada for insured, under-insured and un-insured persons.
- Integrate PrEP into core public health functions. Individuals at high risk for HIV infection routinely interface with our public health programs. As such, we now require disease intervention specialists to refer gay/bisexual men diagnosed with syphilis and rectal gonorrhea and/or partners of persons newly diagnosed with HIV to local clinicians who prescribe PrEP. In Seattle, where HIV morbidity is highest in our state, we directly fund a PrEP clinic within the city's standing STD clinic.
PrEP is a cornerstone in our efforts to reduce new HIV infections in Washington State. Over the last few years, we have invested in a multi-faceted portfolio to promote PrEP. In the future, we will continue to make investments to close gaps, including:
- A multi-county PrEP marketing campaign for communities and providers.
- Navigation/case management for PrEP users.
- Enhancing PrEP DAP to reduce additional barriers to care, e.g., co-pays for medical and lab costs.
- Leveraging resources available through Gilead's PrEP patient assistance program.
- Creating a data collection system to monitor PrEP utilization by partnering with health insurance plans and Medicaid.
While each state and locality is unique, we are hopeful that all jurisdictions will embrace PrEP as a key strategy in our collective efforts to end HIV in the U.S.
For more information, please contact Dave Kern or Richard Aleshire.
Dave Kern is the manager of the Infectious Disease Prevention Section at the Washington State Department of Health.