Peer Insights

Introduction to PrEP for HIV prevention [0:00]

When we first had PrEP approved in 2012, it was the first time we had a biomedical intervention to help reduce the risk of HIV.

I always tell all my new providers, before PrEP, we would diagnose one or two new cases of HIV every month.

So PrEP is an abbreviation, P-r-E-P. It stands for pre-exposure prophylaxis. So this is a way to prevent, in this case HIV infection for people who are at risk of sexually acquired HIV. And when taken as prescribed, it is 99% effective at preventing sexually acquired HIV.

Yeah. Pre-exposure prophylaxis is prevention for HIV only. It doesn't prevent from other STIs.

But it's one tool we use for prevention of HIV. There are multiple other things we can also recommend to our patients, but this is just one great example that works very well.

I think the other thing, as a primary care provider, busy clinic, I got something I want to do. I want an algorithm, I want a guideline I can go to, and we have that for PrEP from multiple places that are free, or easy to access or get on your phone.

Knowing that person's HIV status is the most important thing.

Who is an appropriate candidate for PrEP? [1:34]

So, when it comes to that question of who's an appropriate candidate for PrEP

It's somebody who says they want PrEP and they're HIV negative.

And I think people also forget that PrEP is for male, female.

That's right. Transgender.

Transgender. Regardless of the sexual partners, you have same sex, opposite sex. Anybody can be a candidate for PrEP.

Anyone can get HIV.

I mean, I think anyone who's had an STI in the recent past or past six months certainly is someone to talk to about PrEP.

Somebody who has a positive, an HIV-positive partner.

People who may not know their sexual partner status…

Anyone who asks for it.

Anyone who asks for it—yes, I agree. And maybe depending on where they live, there are certain areas that have a higher prevalence of HIV. So, knowing where they are I think could be very helpful. If you practice in a city where HIV is prevalent, you should be aware of how to prescribe PrEP.

Yeah, it should definitely be on the menu. And the U-S-P-S-T-F, the United States Preventive Services Task Force, has put it on the menu. And they gave it their highest recommendation.

It's a Grade A recommendation, which means that according to this panel of experts in preventative health, that this is something that should be available to all people in this country.

Right. Because we're talking about all these other things we do that are grade A: cervical cancer screening and colon cancer screening.

Who is a candidate for PrEP and the current guidelines, the current CDC guidelines are, I'm going to summarize anybody who says they want it. Then, if they say they're interested in PrEP, we should explore that and offer them PrEP.

That's right. We shouldn't be what's hindering them from getting that access.

What is same day start? [3:50]

Some of the guidelines talk about same day start—Do y'all do same day start? What do you think? How would you describe what it is?

Same day start means you prescribe the medicine the same day they ask for it, don't wait. You can either do a rapid HIV test in your office, make sure they're negative or you can prescribe them the medicine to go to the lab. You'll get the results in a day so they can start the medicine the next day.

What we've done at our practice is when patients come in and they want same day PrEP, we do a rapid HIV test. So we have the result before we prescribe anything. We also draw blood at that time so that we've got some other tests. We're not going to have those test results right away, but when we've got that baseline negative HIV test, we can give them PrEP.

And so we do it that same day. We'll be able to do some other testing as well. We can test kidney function. Those test results will be in a day or two, hepatitis B status, have that result within a day or two, bring them back in a month and we can continue to address their sexual health.

I think talking about it normalizes it, it helps to deal with some of the stigma around HIV and it's also just so I was just like, did you know, do you know we have this medicine that prevents HIV and a lot of people are like, no, I didn't know that. And it's just an opportunity. Even if it doesn't apply to them, they can talk to their auntie, their cousin, their niece.

Your patients trust you. They know you have their best interests at heart. They know you're trying to prevent them from getting HIV and they tell you a lot of things. It's actually a very great relationship.

PrEP implementation in practice [0:00]

We all love what we're doing here and we do it because of the good that we're doing, the prevention that we're doing and it's actually a fun part of medicine.

Some of us have pretty burdensome days seeing 25, 30 patients a day and I light up when I see a PrEP patient on my schedule because again,

The paradigm is a little bit different. We're helping people with things that they really want help with and it's a positive interaction. You're giving people what they need.

Christian, let's talk about PrEP implementation. How are you starting this conversation or having this conversation with providers out there who aren't yet doing PrEP? Maybe they wrote one script but they're not really comfortable yet. What does that look like?

I have a particular provider in mind who's a little bit more senior than me, a little more white hair. And he came to our practice, he works at a downtown, really urban site and had two main barriers really. Number one is I don't see those patients or they're not in my population. And number two was, well this is an HIV thing, it's not my specialty. I don't know how to use those medications. So I worked with him and kind of mentored him a little bit and made him see first of all, these are your patients. If you've diagnosed syphilis or gonorrhea or chlamydia in the last six months, these are your patients. And then secondly, just after spending literally one hour with him going through the medications, that fear of the unknown for him just dissolved away and he's now an independent PrEP prescriber doing it and really enjoying it.

Educating newer providers on PrEP [1:39]

One of the things that I did, very brand-new provider who thought just like you just said, that's just not my patient population. And so we were on the phone and I asked her, I said, do you have an EMR system? She said, yeah. I said, can you go and push a button, drill down the data? She said, yeah, I can. And she was a genius at this, right? And she did all this while we were on the phone. I said, so tell me how many STIs you had in the last three weeks? She said, well, I had about 12. Wow. I said, that was your opportunity.

If you're having that many STIs within your population, then you've missed the opportunity to have a conversation about PrEP.

Our colleagues that they can help us a lot. I admire them so much and because what they do, it will be very easy for them is OB-GYN. They're already there. They're addressing STIs, especially in females that they didn't know that they can take advantage of PrEP.

Baseline testing before starting PrEP [2:32]

I think some new PrEP prescribers get a little hung up on all the different tests that they have to send. But really the general principle is if someone's been out there in the world for a while—off PrEP, perhaps—you got to reestablish that they're HIV negative.

Exactly, that is crucial.

Talking about lab work testing and make sure that somebody is HIV negative before we start or restart the process. Christian, can you tell us for new prescribers, what is the lab order look like? How they have to review them?

It's only a couple of things. And fundamentally we need to make sure the patient is HIV negative so that whatever HIV test you have access to, whether it's a rapid test or a fourth generation antigen antibody, which is usually a blood test, you make sure that they're HIV negative first. You want to test for other coinfections. So we usually test for hepatitis B. B is actually treated by some of the PrEP agents. So you need to know that and you basically need to know kidney function.

Awesome.

And that's essentially it. That's the basics.

Getting PrEP started in clinical practice [3:27]

So Alexea, what do you say to a primary care clinic that says, I don't have time for this. I can't learn something new in terms of implementation of PrEP.

Yeah, streamline the process and get everybody in the practice involved. I've been doing this so long that the LPN or the MA in my practice can identify a patient who would benefit from PrEP. So we have these wonderful EMRs the same way we're doing PHQ nines and GAD sevens. Every visit we can do at our annual exam or at a follow-up visit, just establish a rule. We need to get a sexual health history. You can have anybody do it. You can have the patient write it on paper. You can utilize patient entry into your EMR to answer the questions, are you sexually active? When you're sexually active, do you have sex with men, women, or both? Or what gender are your sexual partners? Don't forget about your patient's own gender identity to start with and then ask about condom use. What body parts do you use for sex?

Alexea, I heard you say this before, if you're struggling for language or what words to use, do you have sex with men, women, or both? Just start there.

Free of judgment. It assumes nothing and it gets you the information you need.

Introduction [0:00]

PrEP Implementation: Considerations for Latine and Black Communities [0:09]

So let me ask this question. So we got a task to do, and our task is to reach the communities who have not taken advantage of PrEP. And mostly that is our Black and Brown communities.

I'm curious what are you guys doing that's unique and different to attract this patient population but not just attract them, but to keep 'em within the PrEP continuum? What are you doing?

PrEP, pre-exposure prophylaxis.

Get outside of the four walls of your clinic. We have outreach out at the pride festivals out in the bars and the clubs and billboards. So, we are visible out in the community and that is an open hand to say, come on, come on in.

Dr Ramers is now an employee of Gilead Sciences. In this video, he reflects on his prior personal experience and perspectives as an actively practicing physician.

We also have nighttime hours.

Yes, me too.

Yeah.

That flexibility, nighttime hours. And then I will say COVID took a lot of things away from us, but it also gave us some things.

It gave us telemedicine.

The ability to do a phone call. When someone doesn't show up for their scheduled appointment, my medical assistant can just get 'em on the phone and that's not a missed appointment anymore. It becomes a telehealth appointment.

PrEP Implementation in the Latine Community [1:16]

I would say for the Latinx community, you just said it, it applies to both, but when we talk about trust, one of the ways that I've been able to garnish trust in that community is…

…making sure that my enrollment forms or my new patient packets are in Spanish, and that I hire people who can speak their language; for me, that has garnished the trust within my Chicago area. When patients know that I went the extra mile to do that, they do come. And so that's been very helpful for me.

Language is so critically important. If you can have bilingual staff, it makes such a difference.

Also understanding a little bit of the cultural background.

For us Latinos, it is not very common to go and do something to prevent.

That cultural anchoring is so critical. I think stigma, we throw that term around a lot, but it does really mean a different thing to different communities. And I have many Latino patients that are just so ashamed of themselves, mostly because of their religious upbringing or their family machismo or marianismo that they've been kind of living with their whole lives. And you can just feel it in the way they talk to you. So just being open to that as well.

And sometimes those patients, they'd rather to drive one hour to a satellite clinic because they don't want them to get seen.

Allow them to do that. It's because they're fearful. Sometimes the family doesn't know their sexual preference. Sometimes the family, they didn't even know they're sexually active.

Yeah, yeah.

PrEP Implementation in the Black Community [2:56]

I think we're all aware that the African-American population has been disproportionately affected amongst new HIV infections. How does your practice engage with the African-American community?

I think, you know, address the elephant in the room, and it doesn't matter what you're talking about when you're speaking to a person of color who is seeking healthcare. We have historically been on the receiving end of inferior treatment, disparate treatment, and we have to talk about what happened historically and acknowledge that there's a medical mistrust even if it's coming from your brother and sister.

And so our community is like, well why is everybody all of a sudden giving us everything? They never gave us anything. What's the motive? And so I can, you know, really safely, and truthfully say the motive is to reach our community because we are disproportionately affected. We're having the most prevalence of new cases, and I don't just say you, I don’t just say me, I make it about all of us and explain, this is a shared experience and it's not personal to you. It's not a judgment for who's sitting in the seat with me. It's about what zip code do you live in, where do you socialize, where are you dating, what do you know about the people that you are dating? And so depersonalizing it.

Somebody is really looking at us at a group and saying, this is something that is disproportionately affecting this group and there's something we can do about it and let's make this change. Let's make change happen.

You’ve got to gain your patients’ trust, regardless of what you look like [4:36]

What do you suggest to tell providers who may not look exactly like the patient in front of them? Have you confronted that challenge?

Absolutely. Absolutely. Trust, right? And so you got to gain your patient trust, regardless of what you look like. And part of gaining that trust is being open and honest. I get what you wrote, but I don't understand it. Help me to understand it. You're talking to a patient who does identify straight, but yet they have sexual encounters with men. Having that open and honest relationship with that patient will allow that patient to be open to you.

And so, I seek to understand. That's very important for me.

With humility it sounds like.

You got it.

How to adopt a person-centered approach [0:00]

So we're talking about person-centered care and PrEP. Patricia, what does that mean to you?

To be not a cookie-cutter provider or not a cookie-cutter clinic, you have to individualize care.

I love that, that it’s not cookie cutter. Certainly none of our practices look identical and they don't necessarily look like our partners who are doing primary care.

And so just giving people different ideas of what PrEP would look like and just talking about the different types of patients and the wide variety of people you can take care of when you're providing HIV prevention care is so important to think about.

One of the things that I've done in my practice is I've really made an effort to meet each of my patients where they are. No matter whether they are on that continuum, I try to meet them.

That concept of meeting people where they are, it really requires us to get out of our own heads and really try to have that empathy. I am not a 20-year-old undocumented person walking into the clinic with that fear, but I have to try to empathize with that person and really kind of put myself in their own shoes. And it really helps you be a better clinician that way.

Discussing adherence [1:28]

When I have a new PrEP patient, I talk about the good, the bad, and adherence is one of those topics, and I brought it up to their attention. This is an investment in your health. I take away that paternalistic approach…and I'm like, this is teamwork. I'm going to do my best. But I want you also to put your reminder for the appointment. I'm going to make sure that you continue on PrEP, but this is for you. This is not for your sexual partner, this is not for so and so. This is for you.

For me, I tell my patients that we're partnered in care, just like you all said, we no longer are doing paternalistic medicine. You are making an informed decision to protect your health and your well-being for the long term. I'm in it with you, but I can only do my part.

Keeping people in care [2:18]

They’re here. They sacrifice commuting time, time from work, loss of income, all of these things to see me face-to-face for 20 or 30 minutes, like you said, give it 110%, give it everything you can. So utilizing rapid tests, so we at least have an HIV-negative test in the office that day, calling them before their visits. Did you get your labs? OK, if you didn't, which lab are you going to? I can fax the orders, I can send electronic order, just get the blood work in process.

And then when people are falling out of care, those phone calls, those text message reminders, I have patients take out their cell phone in the exam room with me. Let's see what's on your calendar. What’s preventing you from getting in here?

For me, it is my African-American men who are more likely to fall out of care. We don't call my locations “clinics.” I try to destigmatize it as much as I can. We call it “Wellness Home.” We streamlined the whole PrEP process, because we tried to make it an in and out situation. I recognize in this one population that they want to be in and out. And for me, keeping them in care meant me relooking at my model. So for practices who are looking to do this, understanding what a PrEP visit is and teaching your patient that this is just a PrEP visit and streamlining that process so that they can get in and get out. That has helped me understanding that these visits are very special and they need to get in and get out.

It takes a humility to, to put ourselves in their shoes and just realize that it's hard to get in every three months for some people. So I think accommodating them in the ways that we possibly can. I mentioned before that if someone doesn't show up, the first thing that our medical assistant is doing is getting 'em on the phone. So you haven't lost that visit. You continue to engage them. Engaging and keeping people in care looks a lot different for different people. And sometimes it's messy and that's the real world, but you want to always give that opportunity to re-engage. So just understanding that having longer hours is helpful for people. Converting over to telemedicine, it's all about flexibility. Allowing people to come in and do their labs on their own time when it's good for their schedule. That's kind of how we engage in people.

Importance of discussing sexual health [0:00]

Thinking about sexual health, historically speaking, topics like this has been frowned upon. Topics like this have been historically ignored,

And due to those reasons, we see the disparities we see today in HIV prevention, treatment, in STIs. That's the reason why I think also sexual health is important,

Because if we don't challenge the status quo today, nobody is going to do it. We need to bring up these conversations every day in every single visit we see these patients.

So, y’know, for me, it's normalizing sex. It's normalizing those conversations because people are having sex, your patients are having sex, and if you as a provider are ignoring that whole aspect of their care, you're not doing them any favors and you're not providing total patient care.

Discuss sexual health in practice [1:07]

So, what does this look like for you? What does it look like in your clinic? How do you bring up those conversations?

Just trying to get people to relax, and say hey, yes, we’re gonna talk about sex, ya know, and you may ask them “OK, so let's talk about sex” and they’re like oh, so we’re gonna go there. Oh yes! We’re gonna go there, let’s go there, let’s talk about it!

We’re gonna go all the way there.

I've got some pretty probing questions, and that's one of the things I say too, is to make sure that they know that the questions I'm about to ask are questions that I ask to every single person that comes in. There's no judgment behind those questions. There's no assumptions behind those questions. These are the questions I ask everyone.

Very similarly, I bring these conversations around I am passionate about primary care, and the whole idea about primary care is prevention, and that's why I bring it up—what's important for me today is the person in front of me, and to provide a good primary care to you, it's important for me is that I talk about all parts of your body, so I provide the best care for you, and if we identify additional resources and support you need, that's what I'm here for.

I think the most important questions to ask is are you sexually active? Are you having sex? And once you establish, OK, yes, this is a sexually active adult. OK, so then the next question is, are you having sex with men, women, or both? So if that unlocks that they may be a man having sex with other men, then we know when you think about HIV transmission, how that's linked, right? So that gives us information. If it's a man who is having sex with other women, then we can also get information as it relates to, OK, so well then next steps. Tell me more. So then the third question would be, condom use. So if they say sometimes or never, then I know that also that because there is a period of time where they may not be using

protection, then STI acquisition is likely. And then the last question I would ask is surrounding any STIs they've had in the past.

These stories, they make me think about what happens when we don't talk about sex. And it's exactly for these reasons. Someone who needed access to PrEP, who otherwise may have contracted HIV…

Guideline recommendation for HIV prevention [3:35]

It's interesting how some providers can make assumptions about patients’ sexual practices, and for whatever reason, people seem to think that older people are not having sex. And so I met this gentleman for the first time because he kept coming in requesting frequent STI testing. And my prevention team, he got on their radar because of the frequency of as to which he was coming in to get the test. And so when I met him for the first time, I started asking questions, like, we've already talked about the five P's, walking through some of those questions.

And so I started out by asking him is he sexually active? And then my next question to him is, do you have sex with men, women, or both? And so he said, that's really interesting. No one's ever asked me that question. And I'm like, OK, well look, well tell me more. Let's talk a little bit more about that.

And so he kind of laughed about it and whatnot, but he said, yes, I have sex with men. I said OK. And what he shared with me was that he has multiple partners but sometimes he uses condoms with the partners who he's comfortable with, but he doesn't always use condoms with other partners. And so from there, that gave me a lot of information, because that's the reason why he was coming in to get the test is because he was worried about getting an infection. And so there we were able to move forward with other resources and make sure that he was aware of other things such as PrEP.

Introduction [0:00]

Sexual Health: Sharing From Experience [0:10]

In my NP program, I don't think we ever really discussed taking a sexual health. We did a history and physical. We did a physical exam and glossed over…

Glossed

…right you're not going to practice your pap smear or your anal pap or whatever in a learning environment.

You're going to wait and do that in your clinical rotation.

But I don't think that conversation was ever actually had.

Isn’t it crazy?

And I came out, you know, into practice and was probably pretty terrible at it. .

Yeah, most definitely. I mean, it's more and more common I think now to have this be a part of medical school curriculums, but it's definitely far and few in between where we have that. Right, so people, we're learning this in practice, we're learning this by floundering, by getting it wrong. Yeah

But there are definitely ways in which we can bring up these conversations that create safe spaces.

When we think about creating space, we also have to make sure this important word called confidentiality. Right? Really verbalizing that, verbalizing the words that whatever we are talking about today, it's absolutely confidential. It's not going to leave these 4 walls. It's between you and me. Right? Once people hear that, it's that trust building.

Mhm

Sharing From Experience [01:29]

I had one of my patients and I was, was going through my normal thing and I love her and we have a really great relationship. And I was like, so how many sexual partners have you had in the last 3 months? And you know, I'm still just over here just typing away and chatting with her. And she goes, I really don't know. And I said, ballpark it for me. Give me a number. And she was like—I said, or don't, I mean we can skip it if you want. And she was like, I don't know, maybe 10. And then she said, that probably makes me a ho, doesn't it? And I was like, no, it means that somebody's having fun and as long as we're being safe, I could care less, you know? And so, it's those kind of conversations where they're already prejudging themselves.

And I'm like, my morals are not your morals. What I consider right, wrong, or indifferent doesn't apply across the board. So, I don't care how I feel or what I live by, what code I live by. That doesn't mean that that reflects over to you or you or you. And I think that's a big deal too, especially in—like I said, I grew up in that area where religion is very, very prominent. So, I think kind of removing your own thoughts about what's okay.

Right. I'm just a firm believer in there's so much data that's out there, but how are we using that data? How are we humanizing that data in such a way where it makes sense, to not only you, that you are now being called to action because of the data, but also making sure that the patients understand the data so that they can make informed decisions about their health as it relates to the data.

So there's a lady that recently came in to see me, Black female. We were having conversations surrounding her sexual health and helping her to understand the likelihood of her acquiring HIV because she's in Louisiana, she's a Black female in Louisiana. And my statement to her was, well, did you know that in 2022 that the Louisiana Office of Public Health reported that Black heterosexual women were number two in HIV new cases?

And she was like, what? I was like, yes. So now that she has this information, now we can say, okay, so let's talk about how we can keep that from happening. I'm not saying that that's going to happen to you, but it's important for you to know that it’s possible based on the data that we have available.

One thing that's coming to mind right now with this conversation is thinking about what are the risks of not talking about sex? What are the potential harms that we could be in many ways causing our patients by not bringing up these topics that we know are so critical and so crucial?

It makes me think about this one scenario I had where a patient established care with me. Male presenting, female identifying in his 80s, was still going by he/him pronouns pretty much his entire life, but had really identified as a female for the last 30 years of his life and did not even think that it was possible to affirm his gender. And so had never even considered changing pronouns for instance, because had never found a safe space to talk about those things. And it wasn't until we opened up a sexual health conversation that I found out any of that information, right? That I learned that his gender identity was something other than a sex assigned at birth.

Take that moment and take that breath and make sure that that patient knows that they've been seen today. Like, not seen as in, since yeah, you've sat in my office and you had a visit today, but that you were heard, you were valued, and you were seen.

Right, right.