Pre-Exposure Prophylaxis (PrEP) Community of Practice, Session #2 Presenters: Douglas Krakower, MD, Mike Yepes, B.Sc., Amir Dixon, BA 9 August 2016
Implementing PrEP in Clinical Settings Douglas Krakower, MD P4C Webinar August 9, 2016
No new HIV infections among 677 persons using PrEP in clinical setting Volk JE, et al. Clin Infect Dis. 2015
24.7% sexually active MSM=492,000 18.5% of Persons who inject drugs=115,000 0.4% of heterosexual adults=624,000 Data derived from national probability surveys July 2016: ~80,000 PrEP initiators since 2012 Rawlings IAS 2016
Be PrEPared to Identify potential candidates Routine risk assessments in primary care Patients seeking PrEP Referral from HIV/STI testing programs Support informed decision-making Identify and address financial barriers Prescribe PrEP medications (e.g. protocol) Provide monitoring, counseling, support 5
Fenway PrEP Protocol Initiation and Monitoring 1. HIV Testing: at onset and q 2-3 months; (VL vs. 4 th Gen) 2. STI Testing: including HBV screen with vaccination if needed 3. Safety Labs: at onset and q3 months; include uhcg testing 4. Informed Verbal Consent a) Common vs, serious side effects b) Risk of HIV, STI, pregnancy c) Potential interactions: drug-drug, drug-disease d) Risk of acute seroconversion reaction 5. Counseling a) Drug and alcohol use b) Adherence c) HIV prevention: counseling/testing, risk reduction, condom education, STI counseling 6. Reassessment: discontinue upon abatement of risk Gonzalez IAPAC, 2016 6
Models of PrEP Integration Municipal STI Clinics (Risk Prevalence) Primary Care/Self Referral to ID Specialist (Clinical Expertise) Primary Care (Care Infrastructure) Example San Francisco City Clinic PrEP Demo Project Kaiser Permanente (San Francisco) Whitman-Walker Health Center (DC) Example Miami-Dade County Health Department PrEP Demo Project Froedtert Hospital / Medical College of Wisconsin (Milwaukee) Fenway Health (Boston) Gonzalez IAPAC 2016
Multidisciplinary, Team Based Care Primary care provider (physician, PA, NP) Team Nurse Team Medical assistant Team Behavioral Health Specialist Team Case Manager Clinical Pharmacist PrEP Specialist/Health System Navigator Gonzalez IAPAC 2016
PrEP at Trillium Health Holt IAPAC 2016
Financial Barriers Survey of 32 Fenway PCPs (Feb 2015) 31/32 had prescribed PrEP (median 20 patients) Financial barriers encountered A patient with lack of insurance coverage 48% A patient unable to pay out-of-pocket costs - 45% Neither of the above 39% Patient Assistance Gilead Patient Assistance Patient Advocate Foundation: http://www.patientadvocate.org/ Krakower IAPAC 2016
Billing and Coding ICD-10 Codes Z72.51 High risk heterosexual behavior Z72.52 High risk homosexual behavior Z72.53 High risk bisexual behavior Z11.4 Encounter for screening for human immunodeficiency virus [HIV] Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV] Z79.899 Other long term (current) drug therapy 11
Generalists are experts in preventive medicine As a primary care provider, I hope that it s my job to do a range of things that are important for health maintenance and prevention It s a conversation that I would be willing and happy to do I would have to do it once or twice. I don t think I need a week long CME course about it. It s safe. Effective. Clear cut guidelines. It s sort of like Plan B. [Generalist] Krakower IAPAC 2015
Final thoughts Great need to increase access to PrEP in primary care settings PrEP provision is feasible in care settings Multiple delivery models exist Identify local needs and staff accordingly Outside resources as needed Local expert colleagues Clinical Consultation Center @ UCSF: (855) HIV-PrEP Primary care providers are prevention experts! 13
Thank you! Collaborators/Support Ken Mayer Alex Gonzalez Kevin Maloney The Fenway Institute, Fenway Health Harvard University CFAR Sylvie Ratelle STD/HIV Prevention Training Center MA Department of Public Health New England AIDS Education and Training Center Funding NIMH (K23 MH098795) Harvard University Center for AIDS Research (CFAR), an NIH funded program (P30 AI060354)
Health Navigation Fenway Health & Multicultural AIDS Coalition (Boston, MA) By: Mike Yepes & Amir Dixon
Objectives O Who is our target population? O Day to day health navigator operations. O Current steps to assist in PrEP navigation. O Current obstacles in care initiation and retention. O Clinical setting vs social determinants of health. O Future plans/potential action steps.
Target Population O MA currently sees approximately 600 700 new HIV infections annually. O Communities most impacted are MSM and transgender women of color. O CDC states 1 in 2 Black MSM and 1 in 4 Latino MSM will become HIV+ if prevention efforts are not implemented.
Daily Operations O Counseling O Risk Assessment/Reduction O Serum Testing (HIV, HCV, Syphilis) O Referrals O Results Delivery O Scheduling follow up care (if needed)
Current PrEP Navigation O Navigators assess current knowledge of PrEP and PEP during counseling. O How it works? O Where to obtain it? O Benefits/side effects? O Cost/Resources?
Current PrEP Navigation O Address additional information barriers: O Stigma of PrEP reacting with hormone therapy. O Concerns of PrEP leading to increased STI rates. O Access to bilingual staff to address language barriers. O If considering PrEP provide client with resources on data/information. O If wanting to start PrEP refer to provider.
Client PrEP Navigation O Testing & Navigation O Navigation into Network of Care O Behavior Health, PrEP, Mental Health Services etc O PrEP services O Buddy system O Regular follow ups and check ins O Create schedule for repeat testing
Navigation Obstacles Health Navigators O Limited long-term follow up. O Clients do not attend medical appointments. O Limited internal communication. O Limited staff/resources.
Navigation Obstacles - Clients O Distrust of Western Medicine OTuskegee Syphilis Study OIndigenous Populations Sterilizations O Hierarchy of Needs O Are there more pressing concerns than sexual health management? O Do alternate needs exacerbate health disparities?
Navigation Obstacles - Clients O Lack of information on resources. O Testing Centers O Types of sexual health products O Medication Options O STI transmission information
Navigation Obstacles - Clients O Communication Fatigue O Passed around by medical departments. O Frustration from speaking with staff who cannot answer their questions. O Time delays in getting connected to appropriate personnel.
Solutions/Action Steps O Health Navigators O Increase staff size to amplify patients seen. O Create databases to follow up with patients long-term (Excel, Microsoft Access, etc.). O Create call back systems to follow up with no shows.
Solutions/Action Steps O Health Navigators O Create staff/team trainings and seminars. O Ensure all staff have general knowledge of who to refer patients to for specific services (i.e. xyz for behavioral health).
Solutions/Actions Steps O Health Navigators O Create pods/units that work in close proximity (i.e. teams that handle PrEP prescriptions PCP, HN, social worker, etc). O Ensure team communicates care plan with each other before reaching out to patient.
Solutions/Action Steps O Accommodate community needs. O i.e. If most clients work several jobs with no benefits provide night and evening clinics. O Provide information that works with patients needs (i.e. PrEP may be more useful than condoms for sex workers gives them agency).
Solutions/Access Steps O Provide assistance with care outside of clinical setting. O Housing programs O EBT/WIC programs (alleviate food deserts) O Employment (reduce financial obstacles to healthcare) O Childcare programs O Increased communication with social workers/case management.
Solutions/Action Steps O Providers can learn more about social determinants of health. O Transportation Assistance O Increase Resource Availability
WE NEED YOU! Participate as Health Center co-presenter. Contact: Victor Ramirez, P4C HIV TAC Collaborative Training Coordinator vramirez@mayatech.com
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