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.

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.