States Take Action to Expand Access to PrEP Through Telehealth
September 08, 2020 | Tequam Worku
Nearly 1.2 million Americans are currently living with HIV, and 14 percent are not aware that they have it. HIV has remained a persistent problem in the United States with specific populations making up a growing number of new diagnosis in recent years. In 2018, 42 percent of new diagnosis were Black/African American. In the same year, men who have sex with men accounted for 69 percent of the total number of new diagnoses across the nation.
In 2019, the Trump Administration launched the Ending the HIV Epidemic: A Plan for America (EHE) to reduce new HIV infections by 90 percent by 2030. State and local jurisdictions are developing their own EHE plans. The EHE initiative has largely focused on four key strategies: Diagnose, Treat, Prevent, and Respond to potential outbreaks.
Evidence-based preventive strategies include improving access to pre-exposure prophylaxis (PrEP) services to those for whom it is appropriate. PrEP is an anti-retroviral drug to prevent HIV infection among people at risk of exposure. Federal guidelines recommend that PrEP be considered for people who are HIV negative but have had unprotected sex in the past 6 months, those who inject drugs, or people who have been prescribed non-occupational postexposure prophylaxis (PEP) and report continued risk behavior.
The EHE initiative set a goal to increase the estimated percentage of individuals with indications for PrEP who have been prescribed PrEP to 50 percent by 2025, as the national average as of 2018 is 18.2 percent.
Expanding Access to PrEP
Cost and the stigma related to HIV have been found as reasons for low PrEP uptake, along with disparities in access and retention among marginalized populations. In July 2019, the PrEP Access and Coverage Act (H.R.3815) was introduced in the U.S. House of Representatives that aimed to expand access to PrEP to by addressing structural barriers to cost.
The bill also aimed to initiate a public education campaign to raise awareness about PrEP among high-need and disproportionately affected communities. Several states (including New Jersey, Utah, and New York) have also proposed and/or passed legislation to ensure insurance coverage of PrEP and/or to allow pharmacists to prescribe and dispense it. In addition to efforts addressing cost-related challenges, states can also employ innovative approaches—such as telehealth—to expand access to PrEP services to those in need.
Federal and State Action to Expand Telehealth and TelePrEP
Telehealth refers to the use of technology to increase the delivery of healthcare services. The current expansion of flexibilities to increase the utilization of telehealth during the COVID-19 response presents an opportunity for health centers to provide PrEP related services remotely.
On March 27, Congress approved the Coronavirus Aid, Relief, and Economic Security (CARES) Act which included the removal of restrictions from federally qualified health centers and rural health clinics and thus making them eligible to provide telehealth services and waiving restrictions on Medicaid coverage of telehealth services for its beneficiaries. Building on guidance from the Centers for Medicare & Medicaid Services most states across the country (e.g. California, Massachusetts, Michigan, and Vermont) have expanded flexibilities and removed restrictions on telehealth services.
TelePrEP is the use of telehealth to provide PrEP-related services to patients. It provides a convenient means for high-risk patients—particularly those who may be experiencing transportation challenges or who live in a community with provider shortages—to receive PrEP services. TelePrEP may also help improve drug adherence through consistent engagement with providers. Some states, including Iowa and Louisiana, piloted models for leveraging telehealth to improve the delivery of PrEP.
As a case example, the Iowa Department of Public Health, in partnership with the University of Iowa, developed a state-wide TelePrEP program to improve access to PrEP in the state. Three-fourths of all HIV cases in the state are from the rural parts with geographical barriers to accessing PrEP-related services. The TelePrEP program helps bridge this gap by allowing patients to use secure video conferencing to connect with a qualified pharmacist through an app on a smart phone, tablet, or laptop.
Pharmacists can prescribe PrEP and provide counseling without requiring a physical exam. The program reached 100 patients in its first year and received 250 referrals in the second year. Other states are using models like PlushCare, which is an urgent care telehealth platform available in 31 states. PlushCare started offering PrEP related services through telehealth three years ago. Through this platform, patients can meet virtually with a physician to receive orders for PrEP-related tests and prescriptions as well as reminders for follow-up visits.
The HIV epidemic continues to be a health issue that affects a significant number of Americans. State and territorial health agencies can play an important role by leveraging new telehealth flexibilities to expand access to PrEP. ASTHO will continue to highlight new and innovative strategies states can implement in their efforts to end the HIV epidemic in their jurisdictions.