Population Health and HIV PrEP
Douglas Krakower, MD: As for trying to achieve the quadruple objective of [Institute for Healthcare Improvement], there are many ways to improve both patient experience and outcomes, as well as clinician experiences, satisfaction and outcomes. I think we have to recognize that PrEP [pre-exposure prophylaxis] at the moment is relatively complicated from the point of view of the medical aspects. There’s a lot of follow-up. For example, right now, for people taking oral PrEP based on CDC guidelines, which were just updated last week, the idea is to have someone come in quarterly for their adherence. , their medications and their tests. It’s really important from a safety perspective, but it’s a burden on patients and providers. I think we need to think about ways to safely demedicalize PrEP to some degree so that it is more accessible. We meet patients where they are, because people have full lives and they can be otherwise perfectly healthy, and so we don’t want to overburden them to the point that they don’t choose to continue the PrEP or initiate it in the first place.
Same thing on the clinician side. I think we need to find ways to give clinicians tools to make HIV testing, PrEP conversations, prescribing, and follow-up much easier for them and their staff. This could relieve busy clinicians of other healthcare professionals who can do much of the work with clients and patients to ease some of the burden on the clinician prescribing it. We can think of ways to use the electronic health record and automated tools to help remind clinicians of patients who may be at increased risk for HIV based on their electronic health record history. For example, if they have ever had sexually transmitted infections, this would be a way to get them thinking about talking about PrEP.
In terms of monitoring, if you have large numbers of people on PrEP in a panel of clinicians, we really need population health management tools, whether it’s staff, where they can offload with a nurse, physician assistant, or other professional who can work on following up with people after the initial prescription and making sure they have what they need in terms of laboratory care, adherence counseling, and to get their questions answered. This can really positively impact the Quadruple Aim of everyone’s experience and results.
I think we need to think about innovative ways to bring PrEP to people where they are, including dispensing it completely from the healthcare system. It’s already underway with the idea of telemedicine for PrEP, or tele-PrEP, where you can have people from any jurisdiction in the country accessing PrEP centrally with virtual visits, testing home laboratory or maybe local tests, but it avoids having to take a day off for example, and come to the clinic 4 times a year. There are many ways to innovate and improve the Quadruple Aim Lenses [Institute for Healthcare Improvement].
There are a number of population health challenges in terms of who might be eligible for or taking PrEP. The first is to raise awareness about PrEP, especially in communities where rates of new HIV infections have been high, such as the southeastern United States, and where PrEP use has been lower than in other regions, and particularly among black and Latino populations. I think some of these challenges can be addressed with well-designed public health campaigns where people are made aware of PrEP in the wider community. I think there have been misconceptions that PrEP is only for certain populations. We’ve heard from research we’ve done that cisgender women have heard that PrEP is only for gay men, for example, and we know that’s not true at all. In fact, PrEP is underused among cisgender women. We need to think of ways to inform the public that this is a benefit to them so that they can access it.
I think we also need to facilitate access instead of asking people to go exclusively to health care facilities where some people are otherwise healthy and don’t see a health care provider regularly. Others may have faced stigma and discrimination or judgments from health care providers regarding sexual health care. People may not want to see clinicians for things like PrEP. So if we can think of creative ways to use community organizations to implement PrEP in the future, I think those would be ways to improve access more broadly at the population level.
Once people are using PrEP and they’re engaged, I think having access to paraprofessionals who aren’t necessarily the clinician prescribing PrEP can also improve the number of people we can support on PrEP. For example, at the hospital where I work, there is a pharmacist who has been very motivated to work with the population using PrEP in the primary care clinic. It’s a large, busy primary care clinic, and there are a number of primary care providers who prescribe PrEP to their patients. But having the pharmacist as the central person who has expertise, maybe a little more time to manage the group, and also using the electronic health record to track people, those are ways you can really scale at the population level without overburdening clients or healthcare professionals managing PrEP.
Thinking about ways to use telemedicine for PrEP is a really creative way to do it also for people who are in rural areas, or frankly, people who just prefer to do things virtually. The COVID-19 pandemic has given people the opportunity to try new ways to access and use health care. While I don’t think the entire world will be virtual in terms of healthcare, in the indefinite future there is no doubt that some people and some aspects of healthcare can be delivered more effectively and efficiently using fully telemedicine or perhaps a combined-hybrid model. PrEP, I think, is a really good way to do that.
There are already academic, public health, and private organizations that have strong tele-PrEP programs that have been running for several years now. These have not yet been studied as rigorously as I would like to know the results, but I feel from speaking to people who have engaged in them that these are excellent opportunities for scaling up PrEP at the population level to more people. Colleagues of mine here in Boston are conducting studies with colleagues in the South to see if a tele-PrEP model keeps people engaged and adherent to PrEP compared to a standard in-person model. Over the next few years, we will also learn much more about some of these innovative approaches to delivering PrEP.
In terms of programs that can help make PrEP more effective for patients and for healthcare system providers, I think having a team-based approach is a great way to approach PrEP. There’s the prescribing clinician, but there are nurses, pharmacists, physician assistants, a whole host of people on the team who may have different levels of expertise and different amounts of time.
For example, in terms of adherence counseling, research has shown that using cognitive behavioral methodologies can be really effective in helping people address adherence issues, but a primary care clinician with a broad patient panel may not have time to do this. This involves hiring nurses who may be trained in some of these methods, or behavioral health specialists, and even peer navigators who can speak at a peer level with someone using PrEP about their experiences and how they overcame challenges to access PrEP. , incorporating into their lives some of the social considerations of PrEP use in terms of disclosure to partners, peers and family. I see the future and the present, frankly, uses a team approach.
At one of the places where I work, we have an excellent nurse who basically manages the PrEP program, except for the prescription and refills, and does an excellent job. This person has acquired all the expertise as a specialist as an infectious disease nurse, and so switching to PrEP is really quite simple. She is able to handle many more patient cases than I alone. Using team-based approaches and integrating these with technology tools, such as using population health management tools from the electronic health record, are ways to escalate that more effectively. I think it has been useful to me personally in our establishment. I know I’m not always at the clinic. I do research as well as clinical care, and even the busiest clinicians have been pulled in so many directions with everything they are asked to do, so we have to unburden ourselves and work as a team to make sure that is scalable and sustainable.
Ryan Bitton, PharmD, MBA: Strategies for managing PrEP use have evolved over the years. Initially, some plans had pre-clearance, others did not. They’re at the point where there’s not a lot of pre-clearance; PrEP is a pretty standard of care recommendation. There really is no utilization management for some of the therapies. Things like generic Truvada are available without prior authorization with a $0 copayment I assume for most plans including ours. There are obviously several therapies. Some of the other therapies may have prior authorization and requirements around a generic-Truvada-first type of policy. If Generic Truvada doesn’t work, which I don’t know if we see failure in this population, Truvada failure may not be the problem, but the contraindication or intolerance or reasons for which you would not like to use generic Truvada, there are allowances to enter other therapies.
Transcript edited for clarity.