As the U.S. enters the worst of the COVID-19 health crisis, brick-and-mortar medical practices are learning how to quickly shift non-essential appointments online. These practices are relying on telehealth to minimize in-person interactions, and the theory is, even if labs are required, eliminating person-to-person interaction in the office can help prevent the spread of COVID-19. But in many cases, the learning curve for clinics and doctor’s offices is steep. Moving pre-exposure prophylaxis (PrEP) appointments to a virtual space is somewhat easier than doing the same with ongoing HIV management—and some practitioners have been doing it for a while.
Philip Chan, M.D., an infectious disease physician at the Rhode Island Department of Health, said his practices, a hospital-based clinic and community clinic, have been “very proactive” in moving to telehealth for non-essential visits.
“PrEP aligns well with telemed, because most [patients] don’t have symptoms and don’t need an exam,” Chan told TheBodyPro. “Our community clinic was able to ramp up fast, thanks to a savvy office manager. But there are lots of logistics, and we’ve had endless discussions about billing.
“For people with HIV, there can be additional considerations when moving to a virtual space for appointments,” Chan added. “There are two groups of people with HIV, those who are doing well and undetectable, who can safely use telemed. And there are those who struggle, and we worry about them most. But there are varying degrees of essential [appointments] even for patients who are struggling.”
Even some PrEP patients may need a little extra attention, according to Jason Farley, Ph.D., M.P.H., RN, a professor at the Johns Hopkins University School of Nursing and director of the REACH Initiative.
“What I’m concerned about is, are we all moving supportive services to the virtual space?” Farley told TheBodyPro. “It’s hard to tell, because this [pandemic] happened so quickly.”
Farley also expressed concern about those who are in poverty and don’t have the same access to technology. “For places that serve more patients in poverty, like federally qualified health centers, they’re going to have to work even harder to make sure their patients are virally suppressed,” he said.
In a joint webinar between the Association of Nurses in AIDS Care and American Academy of HIV Medicine on HIV care during the COVID-19 crisis, Farley presented an escalation matrix for adherence using electronic HIV-related checkups. In tier one, all patients get standardized information through email, electronic health record blasts, and robocalls. Tier two, patients with long-term viral suppression, get automatic refills by the pharmacy for a 90-day supply of meds. Tier three, patients with a viral load of fewer than 20 copies/mL but who are vulnerable to non-adherence, need at least weekly contact and added virtual support. Tier four, those with changing viral suppression, need more frequent contact, via texts and phone calls, and need pill boxes shipped when possible.
Will Giordano-Perez, M.D., clinical assistant professor of family medicine with the Warren Alpert Medical School of Brown University, said that so far, telehealth has been mostly an upside for his clinic. “Prior to COVID-19, we were doing monthly phone check-ins with my adolescent patients who are on PrEP or HIV positive, understanding that monthly contact has been shown to increase medication adherence and in-person follow-up.”
Now, follow-up visits for all patients, including for PrEP, are offered by telephone, and prescriptions are filled for 90 days rather than 30, though the clinic remains open for STD testing and treatment, Giordano-Perez said.
“Our no-show rate for telephonic visits is about 5%, with almost everyone answering and participating in their follow-up visits now that they are being done over the phone,” he said. “Our in-person no-show rate was previously about 20%. We have known for quite some time now that for our patients on PrEP, HIV-positive patients, and even our patients on [medication-assisted treatment for substance use], that telehealth visits would be much more patient-friendly and that we would increase adherence. The issue is that we weren’t being reimbursed for telehealth visits, so they weren’t being offered.”
Learning to Innovate, Quickly
On the cusp of the widespread COVID-19 outbreak in late February, TheBodyPro compared four telehealth apps that could be used for accessing PrEP. In recent weeks, these platforms have seen a significant increase in customers, and in some cases brick-and-mortar health care facilities are teaming up with the app providers rather than building their own telehealth infrastructure from scratch, quickly.
John Huckaby, CEO of AIDS Foundation Houston (AFH), told TheBodyPro that AFH had to innovate linkage to care during the COVID-19 crisis—but, fortunately, they had already been using a PrEP telehealth app, Mistr. “We have seen the traffic to the [Mistr] site increase dramatically, and our patient registrations and also those receiving PrEP prescriptions have doubled in two months. Accessing PrEP fully online was conceived for convenience and privacy, but we find that in the age of COVID-19, it offers an additional benefit of not having to leave home to access PrEP.” AFH also created a PrEP care hotline, 832-AFH-PREP, for information about accessing PrEP through Mistr, and is engaging Houstonians on social media, dating apps, and their web site about Mistr. AHF is also preparing to launch a new electronic health record system, E-Clinical Works, that will have an integrated, secure app for video appointments with their clinical team.
“We are also launching Zoom Health this week, to enable us to better communicate with all of our PrEP care patients during the COVID-19 crisis, and we believe that one outcome of the pandemic will be greater use and acceptance of telemedicine going forward,” Huckaby said.
Christopher Hall, M.D., a senior medical advisor to the telehealth app Nurx, agreed that more people will find telemed apps an acceptable alternative to brick-and-mortar medical outlets, even after the COVID-19 crisis wanes.
“We see this [crisis] as a tipping point for digital health and telehealth,” Hall told TheBodyPro. “I think this could be the new normal for nonessential medical visits.”
But it’s hard for many brick and mortars to set up their own telehealth apps overnight, Hall added. “They can do video connections, but that’s a limited one-off interaction. Digital health providers can give even more—for example, home lab tests and results you can see on the app.”
Chan agreed that telehealth apps could become more routine for nonessential appointments, and that brick-and-mortar health facilities need to look into innovative approaches to make sure they’re usable and accessible by all patients.
“For example, could we provide the technologies, like schools give computers to students who need them? Could we lend a smartphone to patients? We could, but the clinical world is still getting up to speed with the infrastructure [for telemed visits] and isn’t yet thinking about that.”