In the third month of shutdowns to minimize the spread COVID-19 in the United States, some facility-based pre-exposure prophylaxis (PrEP) service providers are struggling with how to continue clinical services when their facilities have shut down. Many have had questions about how to do labs and how to help patients navigate new insurance guidelines (or lack of insurance)—all amid the background stress of the pandemic.
The U.S. Centers for Disease Control and Prevention (CDC) has issued new guidance for PrEP clinical services to help maximize resources and minimize disruption in services. Released last week, the guidelines reaffirm that PrEP care is an essential health service, and that clinicians should ensure PrEP availability for new and continuing patients. The CDC recommends:
Quarterly HIV and STI testing, through a home specimen collection kit when visiting a lab for such testing isn’t possible. This includes a finger-prick blood-sample test for HIV, as well as urine and saliva samples for sexually transmitted infections (STIs).
An oral (saliva) HIV self-test when lab-only visits or other testing options are not available. CDC says that these tests are not optimal for detecting recent HIV infections or infections that took place while using PrEP, so they should only be used if there is no other option.
Prescriptions for a 90-day supply of PrEP medication (rather than a 30-day supply with two refills) to minimize trips to the pharmacy and to encourage adherence.
Establishing referral relationships with other clinics, telemedicine services, and pharmacies so that clients may remain engaged in PrEP care if a clinic closes or suspends services.
If PrEP clinical services have not been disrupted, providers should continue to follow recommendations outlined in the 2017 PrEP Clinical Guidelines and Clinical Provider Supplement, the CDC says.
Many providers are already following CDC guidelines, and some, like the Desert AIDS Project (DAP) in Palm Springs, California, haven’t needed to cut or suspend operations. In addition to virtual visits and case management, DAP added live virtual weekly talks to make sure people know how to get started on PrEP and post-exposure prophylaxis (PEP), and ridesharing for those who need to come to the STI clinic.
“We knew this crisis would cut people off from HIV testing, so we started offering self-testing in April. However, it was meant for the myriad other reasons people need testing—not for PrEP per se,” said C.J. Tobe, DAP’s director of community health, in a statement.
“However, what can we do to ensure regular STI testing and lab work is completed for PrEP patients, with limiting their exposure to COVID-19?” Tobe continued. “Now, more than ever, health care organizations need to be innovative when looking at current systems and requirements that are in place to eliminate barriers to provide services to patients.”
Shannon Weber, M.S.W., founder and director of PleasePrEPMe, agreed that innovation to lower the barrier to PrEP and PEP is needed—even after the crisis.
“Brick and mortar providers can look at ways of integrating services to increase access and support retention by not requiring in-person visits, and lowering barriers to lab tests,” Weber said.
Weber notes that PrEP navigators and other health providers have had their communication patterns disrupted as they pivot to COVID-19–related activities. “We get calls saying that health departments in some parts of California are not open and people don’t know how to get their medication.”
Weber added that rapid access to PEP is also an issue during the pandemic. “We help a number of people get PEP, but it would be great to have faster delivery. Providers have experienced delays with shipping and difficulty getting labs, plus prescriptions and pills, all within the 72-hour window.”
How Has PrEP Use Changed?
Terry Smith, director of HIV prevention services at APLA Health in Los Angeles, said they’ve seen slightly fewer new PrEP users, likely due to shelter-in-place orders that have curtailed hookups, but that clients “still see and understand the importance of PrEP towards their sexual health.”
“I have friends who have stopped their PrEP because of the quarantine and plan to start back up once it is lifted,” Smith said. “And we are still getting clients who need PEP, so people are still having sex during this time, and they know where to access PEP if they need it.”
Though some people have re-assessed PrEP use during the pandemic, providers emphasize that nobody should discontinue use or avoid PrEP—or PEP—just because there are different ways of accessing it now.
The CDC, in its new guidance, promotes several programs that make PrEP affordable or free, including Ready, Set, PrEP and Gilead’s Medication Assistance Program.
As for hooking up in the time of COVID-19, the CDC doesn’t give specific guidelines. Their recommendations pertain to social or sexual activities—social distancing, masks, and staying at home when possible—tactics that would, theoretically, preclude sex with a stranger, whether on PrEP or not.
The Netherlands, however, devised relaxed guidance for single people who find forced celibacy unacceptable (and ultimately, not realistic). The National Institute for Public Health and the Environment suggests discussing risks with a partner before physical or sexual contact and ensuring that all parties are free of illness. “Make good arrangements with this person about how many other people you both see,” The Dutch guidance says. “The more people you see, the greater the chance of [spreading] the coronavirus.”