An innovative telepharmacy service in Iowa offers convenience and discretion while delivering the benefits of preexposure prophylaxis (PrEP) to people in rural parts of the state who are at risk for HIV infection.
Angela Hoth, clinical pharmacist for University of Iowa (UI) Health Care and Project Manager for TelePrEP, described the program as “a public health-partnered, virtual pharmacist telemedicine model to provide HIV prevention within Iowa.”
“What that means,” she explained, “is that we partner with public health to identify people who may benefit from PrEP.”
The Iowa Department of Public Health’s 2017 HIV surveillance report stated that 125 Iowans were newly diagnosed with HIV infection that year and 2,790 were living with HIV.
Federal guidelines recommend PrEP—in most cases, a daily oral fixed-dose combination regimen consisting of 200 mg of emtricitabine and 300 mg of tenofovir disoproxil fumarate—for patients at substantial risk for HIV infection. A PrEP indication was approved in 2012 for Truvada, Gilead Sciences Inc.’s emtricitabine–tenofovir disoproxil fumarate combination product.
According to the Centers for Disease Control and Prevention (CDC), consistent use of PrEP can reduce the risk of HIV infection by up to 92% in people at highest risk for infection. CDC last summer awarded a 4-year, $2 million grant to help expand the TelePrEP program.
Hoth said UI Health Care, the Iowa Department of Public Health, and community representatives in southeast Iowa began collaborating on the TelePrEP project during August 2016.
“We wanted to somewhat ‘demedicalize’ PrEP—take it out of the [traditional] health system, put it into the public health system, and make it as seamless as possible, ... so people are just able to access PrEP, do the labs, get the visits, and really not take a huge chunk of time out of their lives,” she said. “We saw our first patient on February 14 of 2017. And we’ve been slowly growing since then.”
Many TelePrEP candidates are identified when they visit a public health department facility to be screened for HIV infection and sexually transmitted diseases.
During that visit, Hoth said, patients who are at risk for HIV infection can meet with a “PrEP navigator” who answers basic questions about PrEP and insurance coverage for the preventive.
“And then the person will talk to a pharmacist ... by video,” Hoth said. She said people interested in PrEP can use a computer or a smartphone app and participate in the visit from home or go to a health department site and use videoconferencing technology for the visit.
Hoth said feedback from patients shows that they like the convenience and privacy of the remote service and the option for daytime and evening video appointments.
An initial video visit typically lasts about 30 minutes, during which the pharmacist compiles a detailed medical, medication, allergy, and sexual history. The pharmacist also describes the PrEP regimen and answers the patient’s questions about the medications.
Subsequent video visits usually last 5–10 minutes. Hoth described those sessions as “checking in to see if anything has changed and then doing a sexual history and a risk assessment, potentially, and monitoring the medication.”
About 100 Iowans participated in TelePrEP from February 2017 through April 2018, according to a poster presented in October at the Infectious Diseases Society of America’s 2018 IDWeek forum, held in San Francisco.
Ideally, Hoth said, patients initiate PrEP through the telepharmacy program and then have a “warm handoff” to a primary care provider who assumes responsibility for prescribing and managing the preventive regimen.
But some patients don’t have a primary care provider. Others aren’t comfortable discussing PrEP with their usual healthcare provider and may lack access to a nearby provider of PrEP. So the TelePrEP team will continue to manage the patient’s therapy indefinitely, if necessary, Hoth said.
Laboratory testing is an important part of that management.
The labeling for Truvada states that patients should be screened for hepatitis B and HIV infection before initiating PrEP. After starting PrEP, patients must undergo HIV testing at least once every three months and kidney function monitoring as clinically appropriate. Regular testing for sexually transmitted infections that can facilitate HIV-1 transmission is also recommended.
According to initial data presented in October, all TelePrEP candidates had completed required baseline and subsequent HIV testing on schedule, 98% had completed all required serum creatinine testing, and 92% had completed scheduled testing for syphilis. Completion rates for recommended testing for chlamydia and gonorrhea were 71% or 95%, depending on the type of sample needed for the tests.
Hoth said keeping up with required testing can be a challenge for rural Iowans, because laboratories and clinicians to order tests may be many miles from the person’s home.
To overcome that barrier, the TelePrEP team is collaborating with Emory University in Atlanta to evaluate whether participants can successfully use a home test kit.
Hoth said these TelePrEP participants receive their kit by mail, collect their own blood samples and swabs, and mail them back for testing.
Hoth said patients occasionally complete the initial video visit and then decline to start PrEP.
“They’ll think about it, and then they’ll decide, ‘Maybe this isn’t something that I really need at this point in my life.’ And then we just make sure they have contact information if they do change their mind in the future,” she said.
She said feedback from participants indicates that TelePrEP is successful because it makes taking PrEP simple and facilitates communication among members of the healthcare team.
“They don’t feel like they have to constantly repeat themselves,” she said of the participants. “They’re not having to give three or four sexual histories because they’re talking to three or four different people. We share the information, and they consented to that information being shared.”
Hoth said the PrEP regimen is well tolerated; as of November, no TelePrEP participants had reported an adverse event that led them to discontinue the preventive.
Although the cost of medications is a potential barrier to initiating and maintaining a PrEP regimen, Hoth said her patients’ biggest concerns are the lack of insurance coverage for laboratory tests and insufficient access to healthcare providers who will prescribe and manage PrEP.
She said most patients use Gilead’s copayment card to cover the medication costs. The company in September increased the annual maximum value of the Truvada copayment coupon card to $7,200, up from the previous maximum of $4,800.
[This news story appears in the March 15, 2019, issue of AJHP.]