TelePrEP: Sidestepping Stigma in Rural America

For the past several years, Cody Shafer has worked at the Johnson County Public Health Department's HIV rapid testing clinic in Iowa City. Many of his patients drive several hours to get to Iowa City for fear of being spotted seeking HIV prevention services at clinics their small towns.

As a gay man who grew up in a small town in Iowa, Shafer knows firsthand what it feels like to face the stigma of seeking HIV prevention tools. He also realizes that the patients who drive to his clinic are the lucky ones: people with the time, money and a vehicle to seek preventative services in a safe environment.

After pre-exposure prophylaxis, or PrEP, for HIV came on the market, he wondered how he could bring this new and increasingly popular prevention tool to the rural parts of Iowa. In 2015 Shafer met Mike Ohl, M.D., an infectious disease doctor, who proposed that they start a new telemedicine program exclusively for PrEP.

The idea was transformative: Any patient with a phone or computer would be able to get a prescription for PrEP after a Skype-like consultation with a provider, rather than an in-person visit to a clinic.

"We had an idea that we could demedicalize the delivery of PrEP through telehealth that would be specially designed to overcome barriers related to geography and stigma unique to a rural state," said Shafer, who transitioned to work for the Iowa Department of Public Health full time in January. Shafer and Ohl pulled together funding and began working with pharmacists Angie Hoth, Pharm.D., M.P.H., and Dena Behm Dillon, Pharm.D., AAHIVP.

The team forged a partnership between the University of Iowa Health Care, the Signal Center for Health Innovation and the Iowa Department of Public Health. In June 2017, they launched TelePrEP, a pioneering telemedicine programs designed exclusively for PrEP.

Here's how it works: After an initial phone call, patients can download an app and queue up their virtual meeting with Hoth using their cell phone or computer. During the 30 to 60 minute consultation, Hoth reviews their medical history and answers any questions about PrEP. Thanks to a collaborative practice agreement in the state of Iowa, Hoth, a pharmacist, has the power to write a prescription for PrEP herself.

Patients can complete their mandatory lab work at an outpatient site or through Iowa's network of public health providers. Then, prescriptions can either be picked up at a local pharmacy or mailed directly to an address of choice.

"We really wanted to focus on privacy," said Hoth. "People can be as private with the visits as they wish to be."

"I think it's very creative," said Michelle Iandiorio, M.D., medical director of the HIV TeleECHO Clinic at the University of New Mexico School of Medicine. "I think we have to be creative when thinking about diverse solutions to our various settings," said Iandiorio, who directs a telehealth peer-to-peer doctor training program and is not involved in Iowa's TelePrEP model.

"Thinking outside the box like they did is going to work for their population," Iandiorio said. TelePrEP is still in a pilot phase in Iowa and only covers about one-quarter the state, limited to geographic regions in which the program has affiliate lab partners. So far, Hoth has consulted with about 35 patients, of whom 30 have started on PrEP, she estimated.

"Like anything that's innovative and new, we are not going to jump into the deep end," said Shafer. The pilot phase has given the TelePrEP team an opportunity to work slowly with a smaller set of patients to identify areas that can be improved.

Under a TelePrEP model, it would be possible for one prescriber to write 300 to 400 prescriptions in a year, Hoth said. Eventually, the TelePrEP team hopes to expand to this capacity by hiring additional administrative staff.

The team is currently targeting at-risk populations in Iowa by contacting partners of people who test positive at HIV clinics and people who have had other sexually transmitted infections, as well as by reaching out to communities where injection drug use has led to a spike in infections.

For Shafer, one of the bigger hurdles is convincing people that they can probably afford PrEP -- either via Medicaid or patient assistance programs -- despite all the media coverage of the $1,300 per month price tag.

Shafer and Hoth also hope this program will be relevant in other states.

"Iowa is not unique in our issues related to geography [constraints] and stigma around HIV prevention and sexual health," said Shafer. "There are a lot of rural states with similar problems, which is why we are being so detail oriented, so that this could be a replicable and scalable model in other rural states."

"If you have one pharmacist that can do 300 [prescriptions] per year, you're looking at reducing overhead costs for PrEP available for a rural setting," Shafer continued.

Although the TelePrEP team's model is a creative approach to a difficult problem, Iandiorio also emphasized that the long-term solution to poor PrEP uptake is to change the way our society looks at people who seek HIV prevention. Without so much stigma, she said, people would feel comfortable being totally honest with their primary care doctors and visiting providers within their communities, which would lead to better overall health outcomes.

However, Iandiorio said, "We're not there yet."

In fact, one of the goals of the program is to link people to primary care services, said Hoth. But the reality is that stigma is a strong factor influencing patients' decisions to seek PrEP, so an intermediary service is desperately needed.

"For some of our patients, this will be a transition, but for others, it will go on indefinitely," she said.