CBA PROMISING PRACTICES: PREP IN STD CLINICS

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1 PROMISING PRCTICES: PREP IN STD CLINICS CB Pre-Exposure Prophylaxis (PrEP) is a daily HIV medication regimen for HIV-negative persons used to prevent HIV infection. t this time, Truvada is the only drug approved for PrEP use. Consistent adherence to PrEP medication is essential for preventing HIV infection. The CDC projects that scaling up PrEP implementation among high-risk populations would reduce more than 48,000 new HIV infections over six years in the U.S. 1 Ideal candidates for PrEP include: HIV-negative persons in a serodiscordant relationship with an HIV-positive partner Men who have sex with men (MSM) who have had anal sex without a condom or have been diagnosed with a STD in the last six months Heterosexual men and women who do not regularly use condoms during sex with partners of unknown HIV status at high risk for HIV infection The CDC estimates that more than 1.2 million people nationally would benefit from using PrEP to reduce their risk of acquiring HIV. This includes roughly one in four (492,000) MSM and 0.4% (624,000) of heterosexual adults. 3 Injection drug users 2 For more information about PrEP as part of a system of prevention and supportive services, please see CI s Info Brief, Pre-exposure Prophylaxis (PrEP) for Health Care Providers. 3 STD CLINICS S SETTINGS FOR PREP CCESS Sexually transmitted diseases (STDs) have been consistently demonstrated as predictors of HIV infection in recent literature, with multiple studies in the past few years adding to that body of literature. In New York City, Pathela and colleagues found that one in 15 men who have sex with men (MSM) diagnosed with rectal gonorrhea (GC) or chlamydia (CT) and one in 20 MSM with infectious syphilis acquired HIV within one year of their STD diagnosis. 5,6 In collaboration with

2 CB dditionally, a study of women with STD diagnoses in Florida found that women with syphilis and gonorrhea infections were at increased risk for HIV acquisition. 7 STD clinics have multiple factors that position them uniquely to refer and/or prescribe PrEP to patients with STD diagnosis or other risk factors for HIV acquisition. These factors include the following: Clinical and laboratory capacity for pharyngeal and rectal testing for CT and GC Experience and expertise in taking accurate sexual histories Staff with skills in motivational interviewing and building rapport with clients in a culturally competent and non-judgmental manner nonymity for patients with concerns about sharing sexual orientation with primary care providers, or who are concerned about Explanation of Benefits from insurance companies being mailed to their homes vailability of fourth-generation HIV tests for acute HIV infection prior to initiating PrEP Health equity and disparities can be addressed in the STD clinic setting as well. The majority of people seeking care in public STD clinics are uninsured, which underscores the importance of STD clinics as a safety net serving populations that may not access health care elsewhere. 7,8 In a recent analysis of people who sought care in an STD clinic, 21% of male patients were Hispanic, 49% were Black, and 24% MSM. Fifty-seven percent of female patients were Black and 19% Hispanic. 8 s such, STD clinics can be a key location for reaching priority populations for HIV prevention. 9 PREP IMPLEMENTTION IN STD CLINICS On-Site Provision Miriam Hospital HIV/STD Clinic is the only publicly-funded categorical STD clinic in Rhode Island. s of 2013, all MSM receiving care at the STD Clinic are offered a brief educational session about PrEP by clinic staff. STD Clinic patients who are interested in PrEP are referred to the onsite PrEP Program, which also receives referrals from other community organizations, outpatient physicians, and current patients who are on PrEP. The clinic s six-part PrEP implementation plan aims to address health equity with a patient-centered approach. The six parts include: SCREEN FOR RISK BEHVIORS HIV/STD TESTING DISCUSS PREP FOLLOW-UP PPOINTMENT PRESCRIBE TRUVD QURTERLY FOLLOW-UP PPOINTMENTS T THE CLINIC

3 CB t the Immunology Center, cost barriers are mitigated by close follow-up with patients and presence of an on-site financial advocate who helps to navigate the insurance process. This is advantageous because it is highly effective in preventing HIV and engages people in continued prevention practices. Potential challenges are possible risk compensation, side effects, and cost especially for the uninsured. Starter Packs Denver Metro Health Clinic is the largest STD clinic in the Rocky Mountain region, with significant funding from the City and County of Denver to provide STD testing, care, and treatment to residents of Denver County and the surrounding area. The clinic implemented a same-day, on-site starter pack program for persons interested in PrEP, to study its effectiveness in improving service delivery to persons at high risk for HIV infection compared to the standard protocol of referral to STD services. Eligibility for the same-day starter pack is based on the CDC s PrEP Guidelines, with a particular focus on MSM with a history of a syphilis, rectal chlamydia, and/or rectal gonorrhea infection within the past three months. The same day starter pack includes STD/HIV testing, PrEP counseling, and a 30-day prescription. PrEP candidates are contacted the following day with results of HIV testing that indicate whether a patient is ineligible for PrEP and should stop taking the medication. Patients are called by the study coordinator a week after starting PrEP to assess side effects and adherence, and return to the Infectious Disease clinic within two weeks of starting PrEP for a visit with a provider. ctive Linkage ctive linkage to PrEP is similar to the model that is employed for patients newly-diagnosed with HIV. The STD clinic staff or Disease Intervention Specialists (DIS) identifies candidates for PrEP, counsels the patient about PrEP, provides insurance counseling or connects the patient directly with an insurance counselor and PrEP services in another clinical setting. Chicago Department of Public Health works in close partnership with Howard Brown Health Center s very successful PrEP program through using this approach. DIS from the health department, as well as the Partner Services Specialists at Howard Brown Health Center, work closely with the PrEP Navigators to (1) identify potential PrEP users, (2) ensure that PrEP users are fully informed of their options to access PrEP including at their facility, and (3) help PrEP users identify methods to pay for PrEP medications. PrEP Navigators also work with the patient population particularly vulnerable to HIV infection by enrolling them into a specialized Medication dherence and Medical Retention support program. Passive Referral Not all STD clinics have the capacity to prescribe PrEP and conduct the laboratory and clinical follow up that is required. Passive Referral to PrEP is one in which the STD clinic staff or DIS identifies candidates for PrEP, counsels the patient about PrEP to help them make an informed decision, and provides them with possible clinics where they can access PrEP themselves.

4 CB Regardless of which method is used, STD clinic staff should have access to the most recently updated and accurate information concerning PrEP, including clinical sites that are providing PrEP in their local health jurisdictions. National efforts are underway to incorporate PrEP provider directories into existing databases to streamline some of these efforts. In the meantime, STD clinics and health department programs should work with their HIV prevention programs to identify PrEP providers in the community. ONLINE DIRECTORIES OF PREP PROVIDERS LREDY EXIST IN SOME RES. 10 CLIFORNI ILLINOIS NEW YORK STTE OHIO OREGON RHODE ISLND WSHINGTON PREP RESOURCES FOR STD CLINICS STD clinics have access to many resources for implementing passive or active referral programs, or for implementing PrEP clinical services in their settings. CI can provide free to STD clinics and other health care organizations for PrEP implementation. For more information, visit hivcbacenter.org. The National Coalition of STD Directors (NCSD) is a key resource for STD programs seeking peer-to-peer support and other capacity building assistance. For more information, visit NCSDDC.org.

5 CB References CDC developed detailed Clinical Guidance for PrEP 2, and a corresponding Clinical Provider s Supplement 11 with checklists and templates for use in clinical settings. Project Inform developed a helpful consumer-facing tool that can be provided to patients who are unsure about PrEP at the time of clinic visit, or who are offered passive referral to PrEP. This chart is available in English and Spanish. dditional resources for Health Care Providers are listed in the CI Info Brief, Pre-exposure Prophylaxis (PrEP) for Health Care Providers 3 recent publication details recommendations for HIV prevention with PrEP in STD Clinics: Hoover K., et al. Human Immunodeficiency Virus Prevention With Preexposure Prophylaxis in Sexually Transmitted Disease Clinics. Sex Transm Dis. 2016; 43: Yaylali E., et al. Impact of Improving HIV Care and Treatment and Initiating PrEP in the United States, (bstract 1051). Conference on Retroviruses and Opportunistic Infections Boston. 2 US Public Health Service. Pre-exposure Prophylaxis for the Prevention of HIV Infection in the United States: Clinical Practice Guideline CI Global. Information Brief: Pre-exposure Prophylaxis (PrEP) for Health Care Providers. CBresourcecenter/InfoBrief/PrEP-Info-Brief_Final.pdf 4 Smith, D., et al., Vital Signs: Estimated Percentages and Numbers of dults with Indications for Preexposure Prophylaxis to Prevent HIV cquisition -- United States, MMWR, : p Pathela P, et al. HIV Incidence among men with and those without sexually transmitted rectal infections: estimates from matching against an HIV registry. Clin Infect Dis 2013; 57: Pathela P, et al. The high risk of an HIV diagnosis following a diagnosis of syphilis: population-level analysis of New York City men. Clin Infect Dis 2015; 61: Peterman T, et al. Risk for HIV following a diagnosis of syphilis, gonorrhea or chlamydia: 328,456 women in Florida, Int J STD IDS 2015; 26: Hoover, K., Parsell, B., Leichliter, J., et al. Continuing need for sexually transmitted disease clinics after the affordable care act. mj Public Health. 2015: The White House. National HIV/IDS Strategy for the United States: Updated to July al-resources/national-hiv-aids-strategy/nhas-update.pdf 10 Project Inform. Getting Yourself Prepared for PrEP (in English/Spanish) US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection In the United States: Clinical Providers Supplement