It’s well known among HIV prevention advocates that too many people who could benefit from pre-exposure prophylaxis (PrEP) are not using it. And those who have been prescribed PrEP are not always adherent. Some of the roadblocks include pre-authorization insurance issues, scheduling doctor visits, travel to labs and pharmacies—and finding an understanding physician who is willing to prescribe PrEP. There are several mobile-friendly digital platforms and mobile apps that can remove some of these roadblocks. Three of them are direct-to-consumer virtual health care providers (telemedicine), and one is established as a patient-reminder platform, now improving adherence for PrEP users.
All of these platforms offer similar security features: encrypted messages, log-out time, and adherence to HIPAA standards. Representatives from each company say health files are as secure as those in a doctor’s office, with software sometimes more advanced than in an office—with the caveat that you shouldn’t leave your phone unattended without logging out, of course—and most are password and/or fingerprint protected. All companies say they don’t sell health or financial information.
PlushCare: Online Doctor’s Office
In PlushCare’s PrEP treatment program, you can request a virtual visit with a PlushCare-affiliated physician—choose the doctor based on the bio—to talk about your needs and the pros and cons of PrEP. You can also order lab testing through PlushCare. Once the results come in, a prescription is issued by the doctor. You can then pick up a 90-day supply at your preferred pharmacy, and PlushCare will remind you when it’s time for a refill.
PlushCare also provides end-to-end care, if needed, so a patient can come for PrEP and also get diagnosed and treated—through telemedicine—for any other acute illnesses. Unlike Nurx and Mistr, there is no in-home testing option, so you must physically go to a lab for HIV tests as well as ongoing testing while on PrEP. That means you might get a bill from the lab, depending on your insurance situation. PlushCare can enroll you in cost-assistance programs.
James Wantuck, M.D., physician and chief medical officer at PlushCare, explained that most people don’t pay anything for PrEP, and that uninsured or low-income patients in California can get visits and labs paid for by the state, thanks to the company’s partnerships with the California Department of Health, the San Francisco Department of Health, and UCLA.
“PlushCare has 10,000 users on PrEP, and more than 100,000 users total for all needs,” Wantuck said. “You have the flu, you need PrEP, or both, come to us.”
A physician consultation fee is $99. Copays are extra, and patients are on their own for lab payments.
MISTR: Exclusively for PrEP
Mistr, a company started by Tristan Schukraft, launched its platform in 2019, now has more than 10,000 people on PrEP, and hopes to add 15,000 this year.
Mistr is the only telemedicine platform exclusively for PrEP, and it’s marketed to gay-identifying men and other men who have sex with men, though Schukraft is working on a companion platform for women and another for Spanish speakers. Mistr is not an app, but rather a mobile-friendly web site, though most customers access it through their phones, Schukraft said. You can log in and schedule all lab tests required for PrEP to be done at a local lab, or with an in-home testing kit. A doctor reviews the results and then can consult with the patient through video chat. If you do want PrEP, the doctor sends a prescription to a partner pharmacy. Mistr will also send PrEP renewal and testing reminders. Schukraft said the company has seen an adherence rate approaching 95%.
Mistr shields users from dealing directly with insurance and jumping through hoops of prior authorizations, and the platform can also enroll customers in assistance programs, though, unlike the other digital PrEP platforms, Mistr does not take insurance. It does, however, offer the option of in-home tests, though many insurance companies do not reimburse for in-home testing—it is considered a luxury item. You can also do all your STI testing through the Mistr platform.
One small downside is the lack of choice in doctors: You’re assigned a physician from the Mistr pool. Another potential downside is that emtricitabine/tenofovir alafenamide (Descovy), not emtricitabine/tenofovir disoproxil fumarate (Truvada), is the default choice. Schukraft said that’s because Descovy is newer. But patients can opt for Truvada, and they can and should ask their doctor about the differences if they’re concerned.
Mistr costs $99 every quarter in most states, and that fee includes all labs and consultation time (Residents of nine states—California, Florida, Indiana, Oregon, Alabama, Mississippi, Georgia, South Carolina, and Texas—are in luck: The $99 fee is waived, thanks to Mistr’s partnerships with nonprofits in those states). Schukraft said, because doctor consultations and labs aren’t always covered by insurance—or if they are, there could be a copay—“Many find it cheaper to just pay us the $99 and get everything.”
Nurx: Women’s Health App Expands to PrEP
Though the company started with a focus on women and reproductive health, Nurx now has a PrEP treatment program, offering another relatively seamless way to get PrEP.
When you request PrEP through the Nurx app or website, you’ll have to answer some questions about your health and sexual activity, then PrEP navigators will help you determine whether PrEP is a healthy option. If you decide that you want PrEP, you can order in-home testing (in a discreet package) or get it done at a local lab, and the results will be sent to the Nurx team. Unlike the other platforms, Nurx requires testing for not only HIV and kidney function, but hepatitis B, pregnancy (if applicable), and other STIs. You’ll be notified when your results come back, and you may be prescribed a three-month supply of PrEP. Nurx can bill your insurance plan directly, or you could pay out of pocket.
Though the percentage of PrEP patients is relatively small, “We’re pleased with the impact we’ve been able to make in providing PrEP to several thousand patients across the country,” said Allison Hoffman, a spokesperson for Nurx. Nearly 40% of its PrEP patients live in southern states, the region with the highest HIV infection rates, according to Hoffman.
Since August 2018, when Nurx introduced home testing for PrEP, it has seen a tenfold increase in requests for PrEP, Hoffman said. Nurx also offers a home testing kit that includes testing for additional STIs.
For those without insurance, there’s a $129 one-time fee for home testing, including everything needed to get on PrEP. If you also want to test for STIs at home, the cost is $199. For those with insurance, there’s a $35 fee for the PrEP lab kit, but you’ll have to work with your insurance company to determine out-of-pocket costs. There is a $15 consultation fee for PrEP evaluation. As with other platforms, the vast majority of patients on Nurx pay nothing for the medication.
Healthvana, for PrEP Adherence
Healthvana, a patient-engagement platform used by many clinics and physicians to share test results with patients, is exploring a free version of Healthvana for any patient who is already on PrEP or interested in finding a location (e.g., pharmacy, health care provider, or virtual option) to get it, according to CEO Ramin Bastani. Right now, Healthvana does not have direct-to-consumer virtual health care providers like Mistr, Nurx, and PlushCare do. But it does have a web-based platform to help frontline clinic staff manage patients on PrEP. It sets automated reminders to patients as soon as patients start PrEP. They can get automatic messages about medication, education and testing reminders, and lab results. Through a partnership with UrSure, Healthvana can help patients understand if they’re taking PrEP as prescribed. Healthvana can be accessed via iPhone or Android apps, though most patients use the mobile web version.
“We have early data that patients love using Healthvana to make it easier to stay on PrEP—leading to almost 90% adherence after six months,” Bastani said.
For patients, nothing. Clinics pay a couple hundred dollars a month to use the Healthvana platform, depending on the size of the clinic and the level of integration into their existing technology and workflow.