Helping Providers Increase Capacity to Care for Patients on PrEP
A lot of the work to increase pre-exposure prophylaxis (PrEP) utilization in the U.S. has focused on awareness and letting people who may be most in need of PrEP know that it exists and where to get it. But there's less discussion about what happens when demand for PrEP outpaces the health care system's ability to serve people who are on PrEP: It's the routine HIV and sexually transmitted infection (STI) screenings; it's the sexual health history-taking; it's the insurance and payer systems. A poster presented at AIDS 2018 in Amsterdam demonstrated how one technical assistance program for providers has been helping increase capacity in different clinical settings. That poster was PrEP Implementation in New York State: Using Technical Assistance to Support Clinical Scale-Up, by Christopher Ferraris, LMSW, with the Mount Sinai Institute for Advanced Medicine in New York City.
Terri Wilder: If you can just take us through the background, description, lessons learned, and conclusions of your poster.
Christopher Ferraris: Well, one of the things that people keep talking about with PrEP is that PrEP is not reaching its full potential.
What me and my collaborators looked at is basically, what are some of the challenges and barriers to providers in screening and prescribing PrEP to their patient populations?
And so, we looked at a lot of qualitative data through technical assistance sessions, through the [[New York State AIDS Institute Clinical Education Initiative http://www.CEItraining.org]].
We looked at a grouping of technical assistance sessions that we've had over the past two years. And we had seven really good technical assistance sessions. Of those seven, two were family planning centers, two were hospital centers, one was a student health center, and two were community health clinics.
And so, we brought them really great technical assistance. Sometimes it was in person; sometimes it was over the phone.
What we found are three big things: We found clinic flow. We found HIV testing technologies. And we found that one of the perceived strengths -- or one of the things that they could look to -- would be electronic medical records (EMR).
In terms of clinic flow, clinic flow was basically seen as: Where is all of this education [going to happen]? Where is all this adherence counseling going to happen? Who's going to be doing it? Everybody has a packed day. How are we possibly going to be able to do all of this in a given day? [PrEP] comes with STI testing. It comes with all of these things that providers themselves do not believe [they can do] and absolutely cannot do every single time.
We talked about task sharing. We talked about how people can do different things with nurses, with social workers. We shared a little bit of our model at Mount Sinai so that they could see a much more comprehensive approach. And, again, the difference is that we're a very resource-rich setting. We talk to a lot of general practitioners, a lot of general settings, who don't have as much as we might have.
And so, we talked about, "How you can at least minimize the clinician's role in all of this so that they can be getting all of these things on the side?"
HIV testing technology -- this was also a really big thing. One of the providers asked us, "If I'm testing someone who just had a big risk exposure 14 days ago, and I run a first generation on the 14th day, accounting for everything that's happened, can I put this person on PrEP? Do I need to bring them back in one week?"
That's a great question, and it seemed like this was enough of an ambiguous situation, where it's like, I don't know what to do in this situation. Is PrEP worth it if I'm still being bogged down in the details? Should I still go forward if I still don't know a lot of these things?
We talked through a lot of these detailed situations that could come up -- What can you do? How do you go about doing this? -- and we really just tried to build comfort. And then, what we also talked about is electronic medical record enhancements. What we really talked about is that what we benefit from is an electronic medical record where you can change some things.
Clinicians like it. They feel like, when it's in an electronic medical record, it's coming less from this personal provider, and it's just more of a routine practice. "I'm just going to talk with you about PrEP. Here, it's in my electronic medical records, so I'm going to ask you about it." It felt like that would be a really good way to routinize and normalize the conversation and not [have] it come from a strange place.
TW: I just want to make sure that we highlight this electronic record that you're describing. It has these different sections within it: the visit type: Is it one week, one month, three months, six months, 12 months, quarterly, continuation? There's a space for gender identity: male, transgender male-to-female, female, transgender female-to-male. It also asks about the partners' genders, their adherence with PrEP: less than 95%, 75 to 95%, over 95%, etc. PrEP side effects: Did they have no side effects? Did they have weight loss, headaches, nausea? And then there's a fill-in-the-blank.
And then, also, patient reports [of] any STI symptoms. So, no STI symptoms, genital discharge, anal discharge, rash, etc. Then there's a fill-in-the-blank.
Patient reports [of] symptoms of HIV seroconversion. You're looking for things like acute HIV infection here. So, fever, rash, etc.
And then there's a patient education section: Was this discussed with the patient?
CF: Symptoms of seroconversion. The need for adherence recommendations.
TW: Were condoms offered to the patient?
CF: Exactly. So, again, I think that what's good about this is that it's reaffirming that we're not prescribing PrEP so you can throw everything else you did out the window: We're prescribing PrEP and, hopefully, you can still maintain some behaviors that you did that kept you negative and just sort of strengthen them.
And it's good. We've gotten a mixed reaction from this.
TW: From the providers?
CF: From providers, right.
TW: At Mount Sinai?
CF: Right. Right. Yes. Some really love it. Some say that it's really helped them streamline through a PrEP visit, which can be complex in certain times, especially if people might not be so used to talking about sex, so used to talking about sexual risk and things like that. And then some people say: "There's a lot of clicks to this. I feel like it's also interfering with my face-to-face interaction with the patient."
We've listened to all of that. So, we're also looking into a little bit more of a broken-up version, so that a provider doesn't have to adopt the full thing and have to go through with all of it for it to be rendered on the medical record. They can adopt certain facets of it, certain parts, so that they're like: "Oh, I like the adherence measures. I like this. I'm going to use this and this -- but I'm not going to touch the rest."
TW: In terms of the technical assistance that you provided to the seven different organizations, did they get sent a screenshot of this?
CF: Yes, they did.
TW: Did anybody start looking at ways that they could implement this template into their own electronic medical record?
CF: One of our technical assistance sessions was specifically about electronic medical record. We were able to sit with the IT staff, more of the EMR side of things, people on the back end. And they were very interested.
We also shared those lessons learned. We also shared, like, "Hey, when you're looking at things like this, you don't want to make it too intensive. You don't want the provider to feel like if they bring up this PrEP template 'the rest of my 15 minutes are just going to be spent drowning in this template, making sure I have everything clicked, so I can proceed.'"
So, we really talked about making it a little bit of a lower effort, you know, maybe get a focus group with your providers. Find out what they really want more guidance on. If they have to click six times, what are those six things you want to be able to click? Again, not putting everything on it, but tailoring it to your setting.
The productive side of this, our punchline, is that providers feel supported and comfortable prescribing PrEP to people that are coming in saying, "I want PrEP." But what we know is that, if we want to see this scale up, if we want to see this really big wall-to-wall carpeting of PrEP, our providers in New York state do not feel supported to systematize it on such a scale. And so, we're asking for increased guidance from the state, increased guidance from the country, to really increase HIV testing guidance so people feel very comfortable about what to do. You know, PrEP can be treated like diabetes. Who does diabetes education? Who does hypertension education?
I would find it hard to believe that an M.D. or an NP is spending all that time going over things. You're probably doing it for other things, for other conditions. So, just look at it the same with PrEP.
And then, talking about those other conversations, like sexual health, sexual risk, making sure that you're able to do the things that lead up to PrEP prescription. And, of course, insurance navigation is a huge part of that.
Our aim is that, when we overcome enough of these things, we're going to start seeing PrEP prescriptions go more and more up. So, that's our hope.
This transcript has been lightly edited for clarity and brevity.