Getting PrEP to Those Who Need It During COVID-19 Has Presented New Challenges

During the initial wave of COVID-19 cases in March, many health care centers put HIV prevention and community outreach initiatives on the back burner. As a result, both prevention and treatment options became less available, which directly impacted usage. A U.S. survey of 394 pre-exposure prophylaxis (PrEP) users from April noted that the percentage of respondents who took PrEP daily fell from 95.3% to 61.6% after the COVID-19 pandemic began. (The other 4.7% were taking event-based PrEP. That number fell to 2.9%.) Despite the dip in people taking PrEP, the need for HIV prevention services is still present and is being affected by how thinly spread the health care field is.

HIV prevention and community outreach have evolved to include telehealth visits and virtual panel discussions around health, along with sexually transmitted infection (STI) and HIV testing and condom kits that can be delivered upon request. Even still, there are vulnerable populations being missed by present outreach measures. The impact of COVID-19 will be felt for many months to come, and it is essential to ensure continuous access to HIV prevention tools. Proper planning for the future must include assessing the digital measures health care organizations undertook in the crisis, as well as evaluating barriers people faced during the crisis to see how access can be improved.

Immediate Structural Changes

On March 11, when the World Health Organization officially declared COVID-19 a pandemic, many health care organizations in the Washington, D.C. and Maryland region changed operations dramatically within a short period. Much of the immediate attention went toward assessing how to stay open while maintaining patient and staff safety. “Our grantees are busier than ever just trying to provide services to the community,” Ashlee Wimberly, M.P.H., program manager for the Washington AIDS Partnership, told TheBody. Site directors and program managers quickly assessed what procedures were essential and what could be delayed, and many health departments either closed or shifted their focus to COVID-19 prevention.

Shifting to this care model has involved determining what tasks could be done at home, such as calling patients for scheduling, and what needed to be done in a clinic, like lab work. Clinics had to quickly inform patients with scheduled appointments that their visit would now be done using their phones or laptops, and affirm that staff who would be working from home had the space to conduct appointments confidentially. Despite the numerous components involved, training happened swiftly, and within a matter of a few weeks, most clinics had some variation of a rotating staff schedule. Thankfully, telehealth adaptations allowed for many established patient appointments to continue, including PrEP follow-up appointments.

Sites such as Chase Brexton Health Care, a community health clinic in Baltimore, conducted a hybrid system of seeing established patients via telemedicine and conducting initial PrEP appointments in person so that patients could begin medication on the same day. Several clinics, such as Mary’s Center, a clinic in the Adams Morgan area of D.C. founded on providing health care through a social-justice framework, made PrEP and HIV-related questions part of the routine screening calls made to patients. Faith Mitchell, who started as the clinic’s HIV prevention coordinator in March, reflected that her start came at a time when “there was great need to really streamline the PrEP process.” Much of this programming, while necessary for the time, was done in crisis mode, and not many clinics have had the time to take a step back and assess how well new procedures are working.

Adapting Outreach to the Digital Space

Significant changes have occurred in HIV testing and PrEP outreach. Outreach has adapted to involve mailing sexual health toolkits and Facebook live sessions, along with Zoom roundtable discussions connecting HIV prevention with the realities of quarantine and COVID. Wimberly commented, “We used to have these in-person dinners with women around sex that was really well attended. Obviously the dinners can’t happen in the same way, but we’ve started hosting [Instagram] live events where they bring on different sexual health experts.”

Following the guidelines provided by the Centers for Disease Control (CDC) in May, several clinics have implemented HIV/STI home testing programs and are extending PrEP prescriptions from 30-day to 90-day supplies. Whitman-Walker Health, an HIV prevention- and treatment-focused federally qualified health center with locations in Northwest and Southeast D.C., has begun sending its patients HIV/STI testing equipment that can be dropped off for analysis at the clinic. The Johns Hopkins I Want The Kit program, an initiative that delivers testing tools and directions right to one’s door, has continued to serve D.C. and Maryland residents throughout the past few months. The Washington, D.C. Department of Health has also approved a home testing initiative.

To help patients who do not have telehealth capabilities, Chase Brexton, which has locations throughout Maryland, has designated appointment slots and medical rooms with screens for telehealth usage. Mary’s Center has made additional adjustments. Mitchell explained, “[Peer] educators who are highly trained talk to the patient over the phone, ask questions that are important to know before starting the medication, and as long as everything goes well during the assessment, we're able to order labs, they get their lab work done, and they can start PrEP.” As the situation in D.C., Maryland, and Virginia starts to ease up, more HIV prevention programs are exploring avenues to reintegrate older, traditional outreach methods with newer processes started in reaction to COVID-19.

Lack of Access and Awareness

While there’s been a lot of innovation during the COVID-19 crisis, there are still populations that digital HIV prevention misses. The groups that are at elevated risk for HIV infection also face a number of other socioeconomic issues and often have a lack of consistent phone and internet access. While current measures are useful for individuals interested in sexual health conversation and those already engaging in PrEP, barriers still exist for those looking to initiate, and those not having these conversations at all. “There’s still people in the community that aren’t tied to any medical facility that we can’t reach through posting virtual flyers or events on Instagram,” stated Mitchell. “Our priority population who could really benefit from this information may not be following the accounts. When we’re in the community, we can say, ‘Hey, follow this page.’ We want to reach those that are not necessarily in the conversation already.”

With the rapid changes that occurred, it can be difficult for individuals to know what resources still exist and where to access things like HIV testing and post-exposure prophylaxis (PEP) that wouldn’t put one at risk for possible coronavirus exposure. Wimberly commented, “One of my grantees that primarily focuses on the Latinx community has a really cool outreach program created in light of COVID. They’re actually reaching out to patients, especially the more vulnerable like the elderly, folks who may have limited English proficiency. It’s a great way of letting folks know you’re available as a resource.” Concerns related to linkage to care and effective avenues for PrEP linkage for those doing home testing have also been raised, as being alone in the event the home test is positive is never ideal.

Disengagement With Services

There are also aspects of HIV prevention that don’t translate well into the virtual space. “Human contact is very important in the work we do,” Mitchell stressed. “Sometimes when you’re talking about sexual health through the phone, people aren’t as open.” Many HIV clinics have programs in which PrEP navigators see patients during their visits to discuss PrEP and connect them with prescription assistance, which isn’t a possibility for telehealth appointments. “The whole PrEP continuity has been affected,” expressed Tiffany Onyejiaka, a peer navigator at Chase Brexton. “When patients came in, providers could easily refer to [peer navigators] to pop in and talk to them, but with appointments now being virtual and less people coming in for testing, there’s less direct outreach happening.” Even for those aware of the services, it’s hard to convince individuals to prioritize PrEP and their sexual health needs in the midst of all the problems that have come about during the pandemic.

With social distancing being a major component of quarantine, fewer people are engaging in sex, and many report that PrEP isn’t really a priority for them. “I’ve heard a lot more people say, “Oh, I’m not taking it, I’m on a break,’ which is OK if that’s what they feel their need to be. It is a bit worrisome, since PrEP isn’t a medication that is active in your system immediately, so we’ve been reminding patients that they’re going to need time before being sexually active when looking to restart,” Onyejiaka explained. “One worry I have is that we may see an uptick in cases where people were off PrEP and reengage but start engaging in sex without condoms too quicky—and as a result seroconvert.”

Sexual health needs are still important, even in the midst of a pandemic. Mitchell commented, “People have been saying, ‘Oh, no one’s having sex right now,’ and that’s simply not true. And that’s OK. Health is sexual health. The big challenge is getting people to think about sex like you do normal health stuff.” Change is inevitable, and as new circumstances arise, it is essential that programs shift to continue meeting the needs of the community. Now that the initial shock of COVID is gone, it’s time to assess what structures are effective, contextualize the methods being used with present shifts in PrEP utilization, and be intentional in what methods are used going forward. A lot of the work in the future months will be around assessing what’s worked for the community and for clinics, and what more can be done to tackle the barriers that now exist to HIV prevention outreach.