Although the Centers for Disease Control and Prevention (CDC) estimates that just over a million people are at sufficient risk of HIV to meet pre-exposure prophylaxis (PrEP) prescribing guidelines, less than one in ten of these individuals are taking PrEP. What's more, the uptake of PrEP has been highly skewed, with some people who need PrEP the most being less likely to get it.
At last week's Conference on Retroviruses and Opportunistic Infections (CROI), the CDC said that although around 500,000 African Americans would be eligible for PrEP, just 7,000 prescriptions had been filled for African Americans at retail pharmacies or mail order services. Another analysis at the same conference showed low PrEP uptake among women, people under the age of 24, and people over the age of 55 who need it. Striking geographic inequalities exist too, with PrEP implementation lagging in many states, especially those in the U.S. South.
How can health care organizations address these issues? In an article recently published in the Journal of Acquired Immune Deficiency Syndromes (JAIDS), Kenneth Mayer, M.D., of the Fenway Institute and his co-authors analyzed the current state of PrEP implementation in the U.S. With attention to PrEP delivery in diverse settings and a concern for reducing health disparities, Mayer highlighted four evolving models to enhance PrEP access and uptake.
Related: CDC: Few People Who Could Benefit From PrEP Are Using It
Sexually Transmitted Infection Clinics Partner With PrEP Providers
Sexually transmitted infection (STI) clinics are used by large numbers of individuals at substantial risk of HIV, and their focus on sexual health makes PrEP easy to integrate in the provider-patient discussion. HIV testing, risk assessments, and discussions about HIV prevention are already happening. Partner notification services could identify individuals who might benefit from PrEP.
In addition, STI clinics tend to be "safety net" providers, supporting a substantial proportion of uninsured or under-insured people.
On the other hand, they do not provide continuous care and many lack the staff time, resources, or infrastructure to develop onsite PrEP services. Partnerships with other organizations can help them facilitate their patients' access to PrEP.
For example, the Chicago Department of Public Health has created partnerships with PrEP providers in community health centers and university medical centers. They identified providers that were geographically accessible to the city's STI clinics.
An "active referral" approach was developed: The clinician at the STI clinic determines a patient's eligibility for PrEP and seeks consent for referral to a PrEP provider. Within 72 hours, a navigator at the PrEP provider reaches out to provide information, discuss options, help with insurance, and link the patient to care. Although the system engages more individuals with PrEP care than does simply giving patients information about PrEP providers ("passive referral"), there have been significant drop-offs at each stage of the process. Current work focuses on making the process more seamless for the client, with more PrEP capacity within the STI clinics.
Educational Outreach Programs for Primary Care Providers
Primary care providers face some barriers to providing PrEP. In contrast to STI clinics, some may be less comfortable discussing sexual behavior and conducting risk assessments. Many are likely not to be experienced with prescribing HIV medications, and they might have apprehensions about medication toxicities and drug resistance, as well as concerns about insurance and other financial barriers.
But, in a number of other ways, they are well placed to prescribe PrEP: They have long-term relationships with many patients and have the infrastructure to provide the ongoing, coordinated care that is needed. They can discuss PrEP in the context of a person's overall health, addressing issues such as depression or substance use that may underlie sexual risk behavior.
The New York City Department of Health and Mental Hygiene used "academic detailing," a form of educational outreach in which PrEP experts conducted focused, one-on-one, interactive educational visits with primary care providers at their practice sites to educate them about PrEP and help them develop solutions to perceived barriers to PrEP provision. The program was associated with an increase in first-time prescribing of PrEP, especially when the presentation to providers lasted more than ten minutes.
Pharmacy-Based PrEP Services
Many community pharmacies are already delivering vaccinations, HIV testing, and other preventative services. A number have trained pharmacists to contribute to the management of patients living with HIV, including providing adherence counseling. Their fee-for-service charges, irrespective of insurance coverage, may help people overcome cost barriers to accessing PrEP. And, with over 60,000 pharmacies in the U.S., around half of which are part of a large retail chain, this sector has the potential to greatly contribute to a nationwide scale-up of PrEP.
A community pharmacy in Seattle has established a pharmacist-managed PrEP clinic that aims to provide access to PrEP during a single visit. A pharmacist takes a medical and sexual history, makes a risk assessment, performs laboratory testing, provides patient education, and prescribes and dispenses the medication when appropriate. A collaborative drug therapy agreement between a local HIV primary care physician and the pharmacist provides the framework allowing the pharmacist to prescribe. Similarly, Walgreens has a launched a PrEP service in around 200 stores, using nurse practitioners and physician assistants.
Nonetheless, the review does identify some barriers to this model, including pharmacies not having sufficient private space to conduct risk assessments or staff trained in sexual risk counseling. Moreover, pharmacies may need to develop strong local referral networks, especially to counseling services, in order to address needs that they cannot deal with themselves.
Support With Insurance and Coverage
Inadequate insurance coverage contributes to disparities in engagement with PrEP. Twenty-six million Americans are uninsured, with younger people, ethnic minorities, and LGBT people being especially likely to be uninsured.
Programs exist that enable many uninsured people to obtain coverage and for people with substantial co-payments or out-of-pocket expenses to be reimbursed. The states of New York, Massachusetts, Illinois, Colorado, and Washington have created special PrEP reimbursement programs to provide better coverage. The situation is more challenging for providers in states that declined Medicaid expansion and serve largely uninsured communities.
For both health care professionals and consumers, the system is baffling, so PrEP navigators are needed. While many providers lack the specialist knowledge or time to support patients with coverage, they can partner with social service and community-based organizations that have expertise.
A program in Chicago is working with three HIV testing providers that have strong links and engagement with young black men who have sex with men. Their intervention provides health insurance navigation and Medicaid enrollment at the time of HIV testing to engage these men with health care, with hoped for benefits for the PrEP care continuum.
However, the federal programs that enable access to PrEP are under threat. The JAIDS article authors note, "A major looming question is whether the momentum [of PrEP uptake] can be maintained or accelerated in a time of uncertainty about federal support of health care for disenfranchised populations."