Urgent care centers in the United States are expanding in most major cities. They offer an opportunity for people with non-emergency medical concerns to be seen the same day with no appointment, when their primary care doctor may not have any available appointments for weeks out, without having to wait for hours to be seen as they would in an emergency room.
Urgent care centers also can play a critical role in sexually transmitted disease (STD) testing and treatment, but are they also a place where pre-exposure prophylaxis (PrEP) care can be delivered? Samantha Williams, Ph.D., a public health scientist with the Centers for Disease Control and Prevention (CDC) in the Division of STDs, presented on this question at the National HIV Prevention Conference in Atlanta in March. Her poster was entitled, "Availability of PrEP in Urgent Care Centers: Findings from a Rapid Gap Assessment in Metro Atlanta."
Terri Wilder: There's been obviously lots of buzz for many years now about PrEP, after Truvada [emtricitabine/tenofovir disoproxil fumarate] for PrEP was approved by the Food and Drug Administration in July 2012. And it feels like folks are trying hard to figure out how to implement it in all possible health care settings. So your poster was something I was very, very interested in. And I'm wondering if you could talk about the idea behind this project. What was the goal of the project, and what were the analysis and conclusions from the data that you received?
Samantha Williams: The project that we presented actually was secondary analysis of an assessment that we did in partnership with the Georgia Department of Public Health. They wanted to know, and we wanted to know, more about the STD services that were available in a setting such as an urgent care setting. And part of [the research] is under review right now at the Journal of STDs.
Before I go a little further, let me tell you a little bit about how we got to this point. When we examined the STD services, we did that by using a mixed-method approach. We did a modified rapid assessment approach, and we did this research in January and February of 2017. And we actually used a tool that we have online, that people can use, as well. It's called the STD Preventive Services Gap Assessment Checklist. And that checklist, we adapted it for urgent care centers so that we can learn more about those STD services. Part of STD services is also HIV preventive services, as well.
So what we tried to do is to find urgent care centers across Metro Atlanta, the five contiguous counties around Metro Atlanta, and to make sure that we had a good selection of urgent care centers across the county.
We started out with about 75 different urgent care centers, and once we matched those urgent care centers according to zip codes that had higher morbidity areas, and also looked at urgent care centers that actually had STDs coming out of those urgent care centers, we ended up with about 19 urgent care centers that actually agreed to talk to us in that timeframe. Once we actually talked to them and we collected the data, we then began to analyze that.
TW: Can you talk us through some of those results and what were you looking for, in terms of those domains?
SW: Sure. We were looking specifically at PrEP. But we also felt it was important to look at HIV testing, as well, because testing for HIV that can confirm that the patient is HIV negative is important, before prescribing PrEP. So all of the urgent care centers offer HIV testing. And all of the urgent care centers offer rapid testing, as well as blood HIV testing.
But with regard to PrEP, what we found is that about eight didn't provide any type of information or counseling for PrEP. And, actually, that wasn't necessarily unusual. And there were two of the urgent care centers that did not know the term PrEP but knew Truvada. And we actually think that has a lot to do with advertising, more so than them not knowing about PrEP. Because they actually did know the medication.
And about 28% -- five of the urgent care centers -- provided referrals. And they provided those referrals when the patients asked about PrEP. However, six, or approximately 31%, of the urgent care centers provided information and counseling.
But when it came to the medications, this is where the actual surprise was: Six of the urgent care centers actually provided PrEP medication and/or a prescription. Urgent care centers are actually providing PrEP. And out of those six that provided prescriptions, we found that about half of those had PrEP on hand in the office that they could actually give to the patients. So the patients could start the regimens sooner, rather than later.
The other part we asked about was referrals. Because, remember, they're urgent cares. They're not the same as a private provider. You come in, you get your service. There's a continuity of care issue. So, what the clinics did is that they would give a referral, or they would ask the patient, "OK. Now that you have your PrEP, we are referring you back to your private provider, if you have one." And for some out of the six, if the client or the patient didn't have a private provider, they would try to link them to a private provider.
TW: It sounds like some of the urgent cares already have these linkage agreements. I think that when we look at PrEP, while it's an HIV prevention intervention, there is a belief among many people in the HIV community that it's a primary care issue. So, you know, when you mentioned that one of the maybe key concerns of providers at the urgent care was what do you do about the continuity use over time? I think that really speaks to that they're kind of this very unique health care delivery system, where they're not used to having repeat patients -- where it's an urgent need. They take care of it, and then they leave.
I'm wondering, in the qualitative piece of the research, did they talk about how did they come up with who to refer people to, so that they could continue to get their labs drawn and get checked in on, regarding their PrEP, and address any issues that they may or may not be having?
SW: Yeah. It was really interesting that, with the urgent care centers, the model is to be available for patients when they're needed -- very similar to an emergency room, but leaving room for emergency rooms to handle the more potentially severe-to-fatal health or medical issues. And the urgent cares being available to handle those really urgent matters, but those that are not deadly at that moment, you know, like a gunshot wound.
With urgent care models, they want to meet the patient where they are. And that's one of the reasons why it would make sense that PrEP would be available. Because we in public health also try to meet people where they are. And so it makes sense to try to be able to do that in an urgent care center.
So, with regard to continuity of care, interestingly enough, although there are characteristics about urgent care centers that make it so that they can call themselves an urgent care center, not all urgent care centers are alike. So there are some urgent care centers that do have agreements; and then there are other urgent care centers that are already linked to larger systems or hospital systems, or other types of systems. They can -- they may have an easier time, so to speak -- of making a referral so that they can help facilitate that continuity of care.
And then it also may be, in the case with the urgent care centers that we spoke to, that there were times where a patient may come in, they may get their service, they may get their PrEP; and they maybe still have a private provider that they could go back to, to continue their care.
Regardless, going back to the concerns that were expressed -- because we did ask, "What concerns do you have, not just about providing PrEP, but meeting the needs of clients who are seeking STD services, in general?" When we asked that more general question, there are urgent care centers who had that very specific answer about PrEP. And they included PrEP being affordable.
There was one particular urgent care center that always comes to mind, where the provider that we spoke to was so concerned about PrEP being affordable for his patients, to where he was like, "You know, we give them coupons when we have them. But how long can that last? You know, if the goal for our patients is to have them be able to have PrEP for as long as they need it, how long can we give them coupons? And how long can they actually have that be affordable?"
For the continuity of PrEP over time, I think that was more of a recognition of changes in life, and whether or not it's feasible for the patient. And I think that that was just a concern that the urgent care center had about making sure that the patients would be able to continue their care, and also making sure that they were linked to health care.
But once they left the urgent care center, once they were handed over (if they were handed over) to a provider, that was a concern that they had. But once that patient left, they didn't have a way of following up.
Another concern that was articulated was the use of PrEP, but not knowing whether or not the patient continued to use another form of preventive measures, such as condoms, which is important. So, to use PrEP as HIV prevention, but also recognizing the importance of continuing to prevent for other STDs, as well. So that was also expressed as a concern by the providers that we talked to.
TW: I feel like this is a great opportunity to explore how to operationalize PrEP in urgent care. You know, when you think about the cost and the affordability of PrEP, I don't know if Georgia has a PrEP assistance program through their Department of Health [Georgia passed a bill after this interview was conducted to establish its first PrEP drug assistance program]. New York State has one. I know some other states do -- so that if a person is uninsured or under-insured, they can be referred to that program, where it helps pay for some of the labs and the medical appointment. And then the actual meds are paid for through the manufacturer.
One of the most important pieces to PrEP implementation is that you have to start with an HIV test, and making sure that that happens, and that people are thinking about that. Does Georgia have an HIV testing law, where medical providers are mandated to offer an HIV test to someone?
And finally, what just screams to me as an opportunity is, perhaps, a PrEP detailing campaign. You know, I think the conclusions around helping these urgent cares provide the best HIV prevention services possible as it relates to PrEP, making sure that they have access to clinical practice guidelines around PrEP and STD prevention guidelines -- it feels like this is such a major opportunity, not only for the Atlanta metro area, but maybe something to consider across the country, as local health departments are trying to think about ways to increase access. Maybe materials can be branded and put together, and public health -- the detailing employees can go out and actually meet with urgent cares to make sure that they have all that information and are provided some kind of technical assistance to help operationalize PrEP.
SW: You know, it's wonderful that you say all of that, particularly the latter part about the different packages. The collaboration that we have with the Georgia Department of Health -- part of that collaboration also included a summary of what we found. And also in a part of the summary were suggestions that we included.
The latter part of what you mentioned, which was the inclusion of STD prevention guidelines and HIV prevention guidelines; those were some of the very suggestions that we made. Not that they haven't done it, but sort of a reminder that this is just another way that the two entities can better interface. Because there were urgent care centers who had already partnered with the health department, who already had access to those resources. And then there were urgent care centers who -- and let me just say that all of them were very familiar with reporting STDs and HIV, but everything that you just mentioned is always helpful to kind of reconnect them back to that.
I sit in the Division of STDs, and doing this work around PrEP just highlighted how little we know about the types of services that are available in urgent care centers, and how important it is that we learn more about what type of sexual health services, as far as thinking more holistically, are available in various types of settings.
And also, again, meeting people where they are and making sure that those resources are available. So I would not be surprised if many of those resources are available in Georgia. It's just a matter of making sure that they are accessible and easy to find.
Terri L. Wilder, M.S.W., has been part of the HIV community since 1989. She served on the New York Governor's Task Force to End AIDS, was recognized by POZ magazine for her work in HIV, and is highlighted in the book Fag Hags, Divas and Moms: The Legacy of Straight Women in the AIDS Community by Victoria Noe. She loves this community and will keep fighting until the epidemic is over.