As more primary care providers become aware of pre-exposure prophylaxis (PrEP), do they know how to best reach the people who need it? One poster -- demonstrating a model that increased PrEP use in Chicago clinics -- was presented at the International AIDS Society Conference on HIV Science in Mexico City in July. The poster, called, "Leveraging Interprofessional Student Collaboration to Educate Health Care Providers and Increase Access to Pre-Exposure Prophylaxis: Results of a Novel Educational Approach," was presented by Samuel R. Bunting, medical student at the Chicago Medical School at Rosalind Franklin University of Medicine and Science.
Terri Wilder: So, talk to me a little bit about your poster. This is obviously about clinical education and helping medical providers provide great care to people who want PrEP. Tell me a little bit about why you thought this was important to venture into. I would imagine you're a very busy medical student who doesn't have a lot of time.
Samuel R. Bunting: I think as an inquisitive person, we're always looking for explanations to the things that we see happening in the world. And, as someone who kind of felt the sting of discrimination in health care, being sent to an infectious disease specialist for primary preventative care when I was ready to begin PrEP and I had made that decision, it got me wondering: Surely, I can't be the only one.
So I wanted to look a bit deeper and to kind of understand what the landscape was, in terms of access to PrEP, specifically through the primary care avenue. This is primary preventative medicine, and the analogy would be, if you needed a mammogram, you would never send a woman to a cancer specialist. You know, primary care physicians order mammograms day in, day out.
TW: So if I want PrEP, why would you send me to an infectious disease doctor? It doesn't make any sense.
SRB: Right. If I want PrEP, why are you sending me to a specialist? And even in this particular case, you don't call infectious disease to prevent things; that's not what they're trained to do. It's a waste of resources, and it's just a misappropriation of time, if you have to take a day out of your clinic or a day out of your practice in a hospital to see people for preventative medicine. That's just not the way that the profession is set up.
TW: And then when you got to this specialist, you had a copay.
SRB: Yeah. It really didn't hit me until I was at the desk, checking in; and the secretary says, "OK, well, so we'll take your copay now. It's $50."
And I said, "But why? I've never paid a copay at my [primary care physician], ever." Even though, you know, if it was a small one -- I think the most we'd ever paid when we changed was $15. And so I was like, "Why is it so expensive?"
And she goes, "Well, you're seeing a specialist." And that was what I think kind of hit me. And being raised the way I was -- my father's a physician, so kind of growing up in the climate -- I knew a bit about the way things worked.
But really, when it happens to you, it kind of feels different. You're like, "Why do I need specialist care?" And so that kind of piqued my interest in this. And this kind of all serendipitously happened right as I was graduating from undergrad and was getting ready to start medical school.
That's where this project kind of developed, was from that experience. And anecdotes of friends that I'd had conversations with, that had had similar experiences.
The project that we developed was really meant for a twofold approach. One, we wanted to educate students about PrEP for HIV prevention.
TW: Medical students?
SRB: A mix of students. The team that we worked with was medical, pharmacy, PA [physician assistant], psychology, and health care administration students.
TW: So, like a health care team.
SRB: Yeah. Kind of a small health care team. We tried to hit everyone that would at some point be involved in a care continuum for providing PrEP. And so that team of students got together at the Chicago Medical School, and they worked through a service-learning model that I developed. So it's a four-stage service-learning model that involves getting an interprofessional team of students together, partnering with a campus or community agency, to design training that meets their needs.
We've got a lot of literature about national trends. We've got a lot of literature about national disparities. But we've got a real dearth of literature and observation at the local level. And we know that primary care, specifically -- that's where most entry into the health care system starts. That's where a bulk of Americans get their health care, is at their primary care physician -- specifically those that are local and those that are small, independent, primary care–based organizations.
We really wanted to make the training that we did something that was directly translatable, and something that was directly integrated into the clinical practice of the people that we were educating.
So, there are four domains of information that we wanted to include. And for each one, we wanted to include a local and a national level.
There are things about HIV risk and PrEP that are the same across the country, right? HIV is [contracted] just the same in Illinois as it is in New York, as it is in Arkansas, as it is in Florida, as it is in California. It doesn't matter. The virus works the same. PrEP works the same. General trends and risk are the same.
But what we really wanted to make sure we did was provide some local context to that. Because we wanted this information to be directly translatable into practice, such that if, the second we left a training and the people who were there, if they went back to clinic --
TW: -- they could apply it.
SRB: If the very next patient they saw said, "Hey, I'm having unprotected sex with men," they could immediately start a conversation about PrEP. Or they would feel comfortable to ask their patient, "Who are you having sex with? And do you use protection?" We don't do anyone any good if we're afraid to ask difficult questions.
So, what we did is provide training for the primary health care teams at the Lake County Health Department, which is near where the school is. The students led the training, and we had used case studies that we designed to specifically mirror patients in our community that were at risk for HIV.
TW: So the students, who are physicians, pharmacists, psychologists, etc., were then training physicians, pharmacists, etc.
SRB: Yup. So it was a classic train-the-trainer approach. But we did it through interactive workshops. Nobody wants to sit in more lecture than they absolutely have to. So we did about 75-minute workshops. Probably 20 minutes or so was based just purely on a didactic presentation of the material. But the remainder was based on a presentation of the case studies, as precedent for how this looks in clinical practice.
TW: So, when people signed up to come to this training, did they have to have any knowledge about PrEP prior to the training?
SRB: No. We were fortunate that this was a priority for the health care department that we worked with. We held our workshops using an hour of the clinic's all-staff meeting time. So they had designated time in each month for each clinic that was set aside for their administrative. And that was where we were able to use some of the time to present.
There was absolutely no prerequisite knowledge: Come as you are. So we had people from what I call the door-to-door approach. The first person they saw when they walked in the door -- the secretary, the medical assistant, the nurse, the pharmacists, dentists, mental health professionals, social workers, physicians, end to end -- we wanted everybody to get the training.
And by no means am I saying that a secretary needs to know the pharmacology of emtricitabine tenofovir -- by no means. But what they were able to pick up was (a) the information that was relevant to their scope of practice; but (b) what their role is in the continuum, and how their role fits in with the others as things move forward, in prescribing a patient PrEP, and also following up for a patient taking PrEP.
TW: So, talk to me about the four discrete domains within your training module design. I recognize that you said the majority of the time was spent on the cases. But if you can kind of just break it down for me, what you guys did cover during the didactic.
SRB: Yeah. We based this on previously reported trainings. So we looked at the [Centers for Disease Control and Prevention]. We looked at the AIDS education and training centers. We looked at what had been previously done. And we tried to pull out the common denominators.
Almost all of these materials include some background about how HIV is infectious, how it's transmitted, who gets it in the United States. Almost all include some degree of follow-up care for patients taking PrEP, the required lab testing for patients to begin PrEP and then continue.
Some, not all, were robust enough to include the role of stigma in providing preventative services; LGBT health care discrimination, specifically, with the [men who have sex with men] population, many of whom identify as gay; and also the broad health disparities that exist for those patient populations that are at risk for HIV. And then also very few included a robust set of information about financial assistance in the insurance landscape. We're naive if we talk about this in a vacuum without considering the cost of treatment.
So, then, for each of those four domains -- the background, the pharmacology prescription, social, cultural, and financial and administrative factors -- we also wanted to include a local component. So that included, in Lake County: Who's at risk for HIV? Who's getting HIV? How are they getting it? Is it sex? Is it drugs? Is it tattooing practices? What are the common transmission routes here in our community?
TW: How did you decide what case to use?
SRB: When we wanted to build the case studies, first of all, each case included all four domains. There was an element of all four of the training domains in every case. And we went to the STI clinic at the health department, who was the one clinic that we didn't train because they were pretty well versed already. And we said, "When you're diagnosing new HIV, what does that patient look like? Where do they come from? How was it transmitted? What are their barriers to care? What are their barriers to even coming in to get diagnosed in the first place?"
And then we used those demographics and those common trends to build cases that mirror those patients. Again, we wanted this training to be directly integratable into whatever scope of practice the person left our training and went back to.
TW: Let's talk about how you got people to show up, how you evaluated it, and what you're thinking worked. You know, is there room for improvement? How could this be applied by other people who are really searching for, "How do we get our medical providers trained?"
SRB: So a lot of training initiatives, their assessments stop at, "Did you enjoy this training? Do you feel that you learned anything? Do you think that what you learned is going to be directly actionable?" And then they go on the shelf -- and we all move on with our day, and a new CME credit.
But we wanted to go one step further and say, "Fine. You said you enjoyed it. You said you were going to be able to learn what we did. Prove it."
And so we were able to query the EMR [electronic medical records]. And we looked at the providers that had come to training. And we looked at their pre- and their post-prescription rates. And, again, we were training at a system level. So we monitored at the provider level, yes; because we know the prescription needs to initiate with the provider. But we looked at the clinic level, as well, to see how each was operating in kind of its own little ecosystem and its own system level. Because we had done training for all levels of the system.
We queried for the three months before and the three months after. And we were able to evidence an increase in PrEP prescriptions directly following training. The question becomes now, for future assessment, whether or not that trend continues; whether or not that trend is long-term. If it plateaus, does that mean we're capturing everybody? Have we captured 50%? Or is it particular clinics, particular providers, changes in staff that have now introduced new deficiencies and knowledge, that we need to go back and retrain and target specifically where those deficiencies lie as they come up? And also, as the landscape changes -- as clinical guidelines change, as drug approvals change -- we need to be able to go backwards and look as those things change, and redesign training to make sure that everyone stays up to date, just in time for what the current landscape looks like.
TW: Let's talk about what you found out from your evaluation.
SRB: So we wanted to see, first of all, if people enjoyed the training; if they had a better understanding of the stigma factors and how those interfere with people's ability to access PrEP; how the insurance landscape fits in with people's ability to access PrEP. Most people were really surprised to learn that in Illinois, PrEP is free. Our state Medicaid programs cover it. And then we have a state-funded program that will pay additionally, even for people who aren't citizens of the United States. So, most people were really surprised to hear that.
And so that was something that we were able to provide. OK. Great. Now you know about it. This is the number to call the next time you run into someone who needs navigation services. And like I said, we're less concerned about what people thought at the end. We were more concerned with the ability to actually evidence a change. So, when we queried the EMR, we looked at African-American and white patients who are at risk for HIV. And we were able to query by risk factor. And then the results that we looked [at] were, if those risk factors were captured in the sense of a prescription of PrEP being written and then filled.
So, we went from 8% to 22% for African-American patients, and from 25% to 36% among white patients, both groups which had risk factors for HIV. We were able to show that this did introduce a change in prescription practices, and a change in ability to identify risk factors and then act on that information.
Whether or not that was occurring because people were asking questions they had not asked before, or if it was because they were now aware that their system was able to support prescriptions for PrEP and that they were not anything special -- it was the same as writing any other prescription -- or that the follow-up testing was nothing that required any advanced training beyond primary care practice, that remains to be seen. And that's really the goal of the follow-up assessment that we're involved with now, is saying, "What was it about these that really made the difference for you?"
TW: So, what are future directions? Because this is something that obviously is very needed, and what you did by this kind of follow-up and querying the EMR is something that a lot of educators don't have time to do.
SRB: What we did in Lake County was really work through this model and make sure that it worked. This was something that I had conceptualized and theorized, broke down, planned out; but then, having people actually work through it, we identified some areas that needed improvement. We standardized the assessment mechanisms a little bit better.
Now we've had groups around the country that have actually replicated the model. So they've been able to take not only the steps of the service-learning approach, but also the training module materials. And they've been able to design their own from the ground up to meet the needs of their own patient populations that they serve. So they've been able to customize. On top of what is known nationally, they've been able to investigate what HIV risk and PrEP access looks like in their neighborhoods, in their own community, and provide training for either their student-run clinics, or primary care providers in the community, their own health department.
The diversity of perspectives that we've included has been really expansive -- which is really important, because we need to make sure that we're keeping the ball rolling in terms of talking about risk for all sectors of our population, and not just the ones that we classically hear about.
That's where we are now, in terms of extending the model. I think next steps will be really assessing what that looks like. We've assessed the students, and we know what their experience has been like, working through the process and being able to really integrate what they read about with the face of the front-line public health care professionals who are working in this field, and getting their perspectives, as well -- so, going back to that train-the-trainer interface.
But really, what we want to look at next is: Could this model be applied to another public health problem? Everything that I designed, we centered it around HIV, of course. But it was designed from the beginning to be translatable to any other chronic health care condition.
So, if you want to use this model, talk about diabetes risk in your community, talk about hepatitis, talk about another chronic health care condition that is entirely preventable and that we can do a lot to help people increase their odds of survival and having a quality life.
TW: Do you ever think there's any additional training that needs to be done around acute HIV infection? Or understanding the HIV testing technology? I feel like a lot of times medical providers have questions around the HIV testing results -- how to identify acute [HIV]. Because, obviously, the person has to be HIV negative before they start PrEP.
SRB: Right. That was something that we really harped on, as well. And we did it through a case study. We had a patient who was presenting with flu-like symptoms. And we said, "All right. You know?" And we were doing training in February. So we were like, "It's entirely logical that, yeah, this person quite literally has the flu."
So we said, "What would you like to ask them?" And so we let them go through and ask their questions, and said, "OK. Now, who thought to take a sexual history here?" And, you know, some people did.
And we said, "OK. Now, did you think that because of the title of what we're here to train you about? In reality, would you have asked this?"
So that was kind of how we presented that topic. And then, you know, we kind of followed the vignette forward. And the lab tests came back. They were positive for HIV-1. So we said, "Next steps. What are you going to do?"
It was like, well, obviously, you have to link them to ART care. For that, we do need infectious disease. We don't need infectious disease to prevent it from happening, though. So, going backwards, we said, "What would you have done differently here with this patient? As this patient stands now, are they a PrEP candidate?" Of course not. They're already HIV positive. "Three months ago, would they have been a PrEP candidate, if they had disclosed their sexual activities to you and they said that they were having, had, multiple partners, etc. Would this person have been a PrEP candidate? Yes."
I think the awareness question has been analyzed to death. I think a lot of providers, if they have ever seen a New England Journal, there's almost always an article in the Journal or JAMA about PrEP. They've at least heard the acronym.
Now we're at the point of really saying, "What is it that you specifically don't know? Is it the lab testing results, or the lab testing protocol, that you don't feel comfortable with? We can train you on that. Is it the fact that you think your patients aren't at risk for HIV? We can teach you how to suss out their risk factors."
I think that's where we're moving. Instead of these kind of vague assessments of awareness and general knowledge, I think we're now moving to the, OK: People know the basics. Let's really fine tune what we're teaching them.
TW: If people have questions, how would they ask those questions?
SRB: The materials that we developed, the training materials, they've all been published. They're online at the MedEdPORTAL at the AAMC. So, I'm sure that can get linked.
Also, I'm happy to field emails if people have questions. I'm the corresponding author on the paper. So people can absolutely send me questions if they are interested in taking the materials that we developed and adapting them, if they're interested in learning more about what we did, or if they're interested in adapting the model to a different health care problem. I would love to engage in that conversation. I think that the field really has a lot to gain from, I would hope, empowering the next generation of students to ask the powerful questions in their community and to be the change agents that start to change the conversation a bit.
And that was one thing that I will say about my generation, is most people were completely outraged when they found out that PrEP existed and that, you know, during the last seven or eight years or so, incidence for rich, white guys like me has gone down, while it's gone up for black and Latino patients. And most found that to just be -- and it is -- absolutely unacceptable.
So I think when people are given the information, the innate fire of social justice is already within them. We just need to give them the tools. And we need to give them the facts to go out and make change. And I never doubt the power of my contemporaries to do that.