Implement and Maintain a PrEP Program in Your Clinic

Sexual History Taking 101: How Do I Start the Conversation with My Patients? | HIV Pre-Exposure Prophylaxis (PrEP) – Who’s it for? | Initial Visit, Dosing, and Follow Up | The PrEP Guidelines Center | Implement and Maintain a PrEP Program in Your Clinic

Review the latest recommendations with

Jonathan Shuter, MD, a Professor of Medicine in the Division of Infectious Diseases at Montefiore Medical Center and the Albert Einstein College of Medicine

Uriel Felsen, MD, an Associate Professor of Medicine in the Division of Infectious Diseases at Montefiore Medical Center and the Albert Einstein College of Medicine

Raffaele M. Bernardo, DO, an Assistant Professor of Medicine in the Division of Infectious Diseases at Montefiore Medical Center and the Albert Einstein College of Medicine

SUMMARY:

Pre-exposure prophylaxis (PrEP) should be viewed as a sexual health program that our patients can utilize. It involves integration of targeting sexual history-taking, comprehensive behavioral evaluations, and a discussion of a patient’s approach to achieving sexual pleasure while also incorporating HIV prevention options tailored to their needs

KEY POINTS:

PrEP is a highly effective prevention tool that can reduce HIV transmission among our patients
PrEP is a service that can be folded into a clinical practice similar to other specialized services
Successful PrEP delivery requires passion, planning, and utilization of innovative delivery systems
PrEP is an HIV prevention option that can be used by anyone who is sexually active

PrEP is a program, not a pill

PrEP Regimens

Currently there are two daily oral PrEP regimens that patients can access and an intramuscular regimen every eight weeks
- F/TDF 200mg/300mg orally daily (Truvada)
- F/TAF 200mg/25mg orally daily (Descovy)
- Cabotegravir 600mg IM every eight weeks after initiation phase of administration at week zero and week four
Promotes overall sexual health
Monitors and screens actively for sexual transmitted infections (STIs)
Serves as a gateway to normalizing routine health care
Will soon involve other delivery systems beyond pills and injections

PrEP as a collaborative effort

Involvement with local community-based organizations to create programs
Continued involvement with community to evaluate and improve services
Provision of other social programs can help assist in healthcare access

Innovative models

PrEP has been FDA-approved as an HIV prevention option since 2012

Traditional Models

Traditional models for PrEP evaluation and distribution were primarily clinic-based
over time these models have evolved to include approaches that provide more ways in which patients can access this sexual health option

Telemedicine

Telemedicine: While telehealth models for PrEP were being explored earlier, the onset of the COVID-19 pandemic accelerated the use of telemedicine for PrEP services
- As an option for in person visits
- As a bridge between in person visits
- Coupled with at home HIV and STI testing
- Used to access “PrEP mentors” who provide expert guidance

Pharmacy-Based

Pharmacy-based: Given the demand to see more patients placed on primary care providers in outpatient clinics, there may not be enough time for them to conduct a thorough sexual history and PrEP evaluation. PrEP programs that are pharmacist-led have been shown to be effective, as pharmacists are uniquely poised to bring a level of expertise that many clinicians may not have:
- Experienced guidance on medications, side effects, and drug interactions
- Familiarity with navigating the red tape PrEP with varied insurance plans
- Familiarity with patient assistance programs for patients who are uninsured or underinsured

Multi-disciplinary and other models

Multidisciplinary models
- Community-led and maintained
- Peer-navigators facilitate linkage to care and continued engagement
Nurse-led programs

Ongoing monitoring

See our post on Initial Visit, Dosing, and Follow-up for initiation of PrEP

The current recommendations for ongoing care once oral PrEP has been initiated include:

In-person or telehealth follow up visit every three months
Prescription refills every three months
HIV test every three months (typically done as part of refill of prescription on the same timeline and can be administered as at-home testing)
Renal and hepatic labs every six months
UPT as indicated
STI testing as directed by sexual health review done at each follow up visit.
Assessment of sexual and general health needs
Review of any new medications and medical updates

The current recommendations for ongoing care once IM PrEP has been initiated include all the above at two-month intervals except renal and hepatic lab monitoring

Practical Tip

While there is no “how-to” manual about starting and maintaining a PrEP program, there are some things you should consider when establishing one at your workplace:

Personnel
- Recruit staff who are passionate and interested in doing sexual health & PrEP work
- Some of the routine follow ups and other visits do not have to be conducted by a medical provider
- You can have medical assistants and peer navigators involved as much as they would like
Timing
- consider either integrating PrEP visits as part of everyday sessions OR make special clinic days or sessions devoted to seeing patients interested in PrEP
- You can always start small and ramp up available hours of service if needed
Pharmacy
- Get pharmacy staff involved from the beginning throughout the process if you have a pharmacy on site
- Skilled pharmacists can help to navigate patients through patient assistance programs and copay cards as well as insurance coverage for generic versus brand name PrEP
- If you don’t have a pharmacy on-site, identify a local pharmacy who handles HIV and PrEP often to make the process easier for patients

Note: Mail-order delivery is a must-have option for many patients

Optimize Electronic Medical Records
- Create “smart sets” for PrEP visits, both initial and follow-up
- This can help providers walk patients through appropriate history, physical exam details, and appropriate lab orders
Telehealth is an essential aspect of many PrEP programs that allows for quick “check-ins” and other follow-up
- Ensures that patients have enough refills for PrEP
- Can identify what testing is necessary if they cannot make a visit in person
Marketing
- Make sure your clinic’s website, waiting area, and exam rooms include information about PrEP services you offer will help ease some of the stigma patients may feel about asking about PrEP themselves

Learn More – Primary Sources:

Funding Resources

Primary Sources

The Well Project: PrEP for Women

Commercial Support

This educational activity is supported by an independent educational grant from Gilead Sciences

Faculty Disclosures

Dr. Shuter has no relevant financial relationships to disclose

Dr. Felsen has no relevant financial relationships to disclose

Dr. Bernardo has no relevant financial relationships to disclose

Special Thanks

Special thanks to David Malebranche, MD, MPH and Ariel Watriss, MSN, NP for their insights and contribution.

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