Getting to Zero: Implementing PrEP and PEP in School-Based Health Centers
Download as PPTX, PDF2 likes292 views
The document outlines the implementation of PrEP and PEP in school-based health centers to combat HIV among adolescents in California, detailing the healthcare infrastructure required and best practices for education and accessibility. It emphasizes the importance of culturally competent staff and sex-positive approaches to engage youth effectively, with statistics indicating a significant percentage of new infections among young individuals. The presentation also highlights the necessity of ongoing patient support, including case management, lab testing, and medication follow-up, to improve adherence and health outcomes.
Getting to Zero: Implementing PrEP and PEP in School-Based Health Centers
- 1. Getting to Zero: Implementing PrEP and PEP in School-Based Health Centers Skye Timmons, MPH Kathie Rhodes, FNP Naomi Schapiro, PNP, PhD Jose Luis Robledo-Guereca
- 2. Presenter Disclosures No relationships to disclose Several slides are from Samali Lubega, MD • Bay Area North & Central Coast AIDS Education & Training Center (BANCC AETC)
- 3. Objectives Discuss the epidemiology and health inequities in the HIV epidemic for adolescents in California1. List best-practice HIV prevention strategies for adolescents, including education about PrEP and PEP, onsite labs, medication prescription and case management 2. Create a workflow for implementing PrEP and PEP in school-based health centers, including case management and needed infrastructure (labs, pharmacies, insurance coverage, patient follow- up) 3.
- 4. Disclaimer • La Clinica’s SBHCs have been working on educating staff and incorporating PrEP into the services we offer for approximately 2 years • Slow process, work in progress • Approximately 15 pts. started on PrEP, >5 pts. started on PEP • We are not the experts/perfect example, but we have created a system and started some patients on PrEP • Hopefully sharing our experience will help other SBHC start or advance their own PrEP access project
- 5. Who’s in the room? • PollEv.com/skyet766
- 6. PrEP & PEP • Pre-Exposure Prophylaxis (PrEP) • Truvada – 1 pill taken every day to prevent HIV • Post-Exposure Prophylaxis (PEP) • Truvada + another medication • Started within 72 hours of possible HIV exposure; taken every day for 28 days
- 7. HIV Update Worldwide • 36.9 million people living with HIV globally in 2017 • 1.8 million new cases of HIV globally in 2017 United States • 1.1 million people were HIV+ in the U.S. at the end of 2015 • Of those people, 15%, or 1 in 7, did not know they were infected • 38,739 people were diagnosed with HIV in the U.S. in 2017 • 21% of new infections in the U.S. were among young people ages 13-24 California • 132,000+ people living with HIV in CA in 2016 • 4,500 new HIV infections in CA in 2017 cdc.gov
- 8. HIV disproportionately affects men who have sex with men (MSM) cdc.gov
- 9. HIV disproportionately affects MSM of color cdc.gov
- 10. OAK LA SF acphd.org HIV & Women in California
- 11. HIV disproportionately affects women of color
- 12. Who can benefit from PrEP and PEP?
- 13. cdc.gov HIV disproportionately affects youth
- 14. • 1 in 4 new HIV infections are in ages 13-24 • 84% of all new infections among youth occur in boys/men of color • Over half of all new infections among youth occur in Black/African American males HIV disproportionately affects youth of color cdc.gov
- 15. Who’s using PrEP in the U.S.? cdc.gov
- 16. Building Youth-friendly PrEP/ Sexual Health Services • 160 responses • 85% ages 14-17 • 63% female, 33% male • 1.3% transgender/genderqueer • 85% heterosexual • 53% sexually active
- 17. Wheredoyou/wouldyougotoaccesssexualhealthcareservices? 62% community clinic and/or youth-only clinic
- 19. How often do yougetSTI testing? 64% of sexually active youth have never been tested
- 20. I thinkI am at riskfor HIV. 85% of sexually active youth do not feel at risk for HIV
- 21. Haveyouheard of PrEP? 69% of sexually active youth have heard of PrEP
- 22. I wouldusePrEPif I could get it for free. 69% of sexually active youth would use free PrEP
- 23. • Sexually active youth trust their providers, but aren’t getting tested for HIV *What are we missing? How can we help them access HIV testing?* • Youth DO NOT feel at risk for HIV but would consider using PrEP if accessible to them • Sex positive approaches to PrEP may be more effective than risk-based • PrEP is a health promoting tool for control, freedom, enjoyment, & health PrEP is for youth
- 24. PrEP Education • All staff educated about PrEP • Culturally competent staff • Introduce PrEP at all sexual health visits • “Have you ever heard of PrEP, the one pill you take every day to prevent HIV?” • Visual education (posters, handouts)
- 25. • Sex positivity is "an attitude towards human sexuality that regards all consensual sexual activities as fundamentally healthy and pleasurable…” • The sex-positive movement advocates for sex education and safer sex Goals of sex positivity • Increase patient safety • Increase patient empowerment • Reduce poor health outcomes • Build partnerships with patients. *Disclosure of sexual behaviors is NOT the goal Gabosch, 2008 Sex Positive Approach
- 26. • Judgements on other people’s behavior • Equating sexuality – or certain types of sex – with deviance, abnormality, or risk • The belief that sex is: • Inherently bad, dangerous, sinful, dirty, shameful • Only permissible for procreation, marriage, and/or love Glickman, 2000 Sex Negativity
- 27. A sex-positive health professional… • Checks their own assumptions and biases • Embrace our patients as assets and experts on their experience • Centers the patient’s priorities in communication and decision making • Practices self reflection, humility, & empathy • Seeks ongoing training and development • Responsive, relevant, respectful • Remembers that pleasure is an important part of sexual health
- 28. Safe spaces for all patients • Visibly sex positive, welcoming space for people who are black, brown, queer, bigger bodied, have varying abilities/disabilities • Representative artwork and signage • Non-judgmental reading materials • Trained staff • Sex positivity • LQBTQ+ inclusion and competency • Trauma informed care • Cultural humility • Intake forms - all genders and sexualities, pronouns, preferred names • Ask name and pronouns at each visit
- 29. 9 PrEP 101
- 30. Labs • Prescription for Truvada (PrEP) requires lab testing • Before first Rx: 4th gen HIV test, BMP, GC/CT (throat, rectal, urine), RPR, Upreg, HBsAg/sAb/cAb, HCV Ab (+HIV viral load if sxs of possible acute HIV infection in past month) • Rationale: • If client is already HIV positive, need more/different combination medication for treatment, to prevent resistance • Medication can affect kidney function – test before and periodically while using • Hepatitis B: important to know status to address treatment if previously undiagnosed, to monitor liver function before PrEP and while using PrEP, and to vaccinate if uninfected and not already immune • Hep C: important opportunity for diagnosis and treatment, and to monitor liver function before and while using PrEP
- 31. Labs Refill prescription for Truvada (PrEP) requires lab testing • Every 3 months while on it: 4th gen HIV, GC/CT (throat, rectal, urine), RPR, Upreg • Every 6 mos: BMP (basic metabolic panel) Best practice for labs: • On site lab testing whenever possible • Urine, throat/vaginal/rectal swabs • Consider offering self swab option • On site blood draws • If no phlebotomy on site, make arrangement with nearby lab for easy access and confidentiality
- 32. Medication • Need negative HIV lab result before eRx sent to pharmacy (should be done ASAP after results received) • Rx Truvada (Tenofovir 300mg and Emtricitabine 200mg) 1 tablet orally every day • 1 month supply initially • Follow up: 3 month supply if insurance allows • Gilead limits to 1 month supply at a time
- 33. Medication • Need to know about the pharmacy you are sending Rx to • Do they stock it regularly? • Confidentiality? • Insurance coverage? • Do they have free delivery if pt. prefers not to pick up in person? • Delivery to home, clinic, PrEP navigator, different pharmacy location • Oakland example: Community, a Walgreens specialty pharmacy
- 34. Medical follow-up • Follow up visit 1 week after labs – assure lab results back, eRx submitted, assess for pharmacy and insurance issues • Ideally patient has already received and started Truvada • Side effects? • Adherence challenges? • Non-judgmental approach • Truvada is just one tool in the patient’s/provider’s toolkit to help prevent HIV • Address condom use, communication with partners, boosting self-worth/self advocacy for good sexual health • Provide condoms/lube
- 35. PEP (Post-Exposure Prophylaxis) • If patient thinks they may have been exposed to HIV within the past 72 hours, screen for risk status (see AETC Pacific Clinical Essentials for criteria) • They could be offered PEP (post-exposure prophylaxis) • Must be started within 72 hours of exposure, the sooner the better • Must take every day for 28 days • Labs: 4th gen HIV – result not needed to prescribe • Preferred regimens: Truvada + Tivicay or Biktarvy • Follow up in 1 week (lab results, adherence, side effects) • After 28 days, consider/offer transition to PrEP depending on ongoing risk status
- 36. Adherence by week: Week 4 = 54% Week 8 = 47% Week 12 = 49% Week 24 = 28% Week 36 = 17% Week 48 = 22% Reasons for missed doses: Away from home (32%) Too busy (28%) Forgetting (26%) Change in routine (18%) Adherence JAMA
- 37. Supporting Adherence 0 20 40 60 80 100 Online forum (n=25)* Videos (n=31)* Website information (n=41)* Weekly check-in messages Daily pill-reminders Percent Very helpful Somewhat helpful A little helpful Not at all helpful JAMA
- 38. Case Management • PrEP navigator model • Initial consultation • Registration for non-patients • Referrals to other clinics if necessary • Scheduling/cancelling appointments • Assessing insurance status/coverage • Helping apply for patient assistance program if insurance won’t cover • Gilead Patient Assistance Program • Communicating with pharmacy • Monthly appointments for medication pick-up and check-in • Delivery of medications • La Clinica PrEP/PEP phone line • Community outreach events with HIV testing, condoms & lube, PrEP/PEP ed. & consultation • If PrEP navigator is not possible for your clinic, train a staff member to help • Pharmacy and insurance • Case management is key to helping overcome multiple barriers to pts. starting and staying on PrEP
- 39. PrEP/PEP Resources • Staff & patient education • PleasePrepMe.org • https://www.cdc.gov/hiv/risk/ • Consultation resources for providers • National PrEP Line: 855-448-7737 • 6am-5pm PST, 7 days/wk • cdc.gov/hiv/prevention/research/prep • AIDS Education and Training Center (AETC Pacific) • Kaiser pts. – educate and connect with local Kaiser PrEP Navigator
- 40. Brainstorm Time • How could your SBHC start or improve PrEP and PEP infrastructure at your SBHC? • Staff training, materials, education, case management, etc. • Who could you partner with? Who could be a champion of PrEP and PEP for your SBHC? • What is one tangible thing you can do to support patients’ access to PrEP and PEP?
- 41. In Memory of Those Who Passed
- 42. Questions? Thank you! Skye Timmons, MPH: stimmons@laclinica.org Kathie Rhodes, FNP: krhodes@laclinica.org Naomi Schapiro, PNP, PhD: nschapiro@laclinica.org Jose Luis Robledo-Guereca: jrobledo@laclinica.org
Editor's Notes
- #5: we are not doing everything we want to yet NAOMI – let’s not give exact numbers, e.g. say < 10 PrEP and <? PEP – might be more by now?
- #6: I know someone who is HIV positive. I know someone who passed away from HIV. I have worked with a young person who is at-risk for HIV. I have talked to young people about PrEP and PEP. I have worked with young people who are on PrEP and PEP.
- #7: Raise your hand if you are willing, for each of the following statements NAOMI: IF we have internet for computer we can do PollEverywhere.com so folks don’t have to raise hands
- #8: Sub-Saharan Africa, which bears the heaviest burden of HIV and AIDS worldwide, accounts for 66% of all new HIV infections. Other regions significantly affected by HIV and AIDS include Asia and the Pacific, Latin America and the Caribbean, and Eastern Europe and Central Asia -important to consider worldwide statistics because people immigrate to the US, especially immigrants from Central America in CA -In 2017, CA was the state with the second highest number of new HIV diagnoses after Florida
- #9: Rates of HIV are down overall, but stable to rising among MSM -in this presentation we’ll be focusing on sexually transmistted HIV because they make up over 90% of US infections
- #10: Rising among black and Latino patients. Falling among white patients. Black patients have HIV more than white and latino combined (in total number of patients), but only make up 12% of general US population!
- #12: -Black/African American women only made up 13.7% of the total female population in the US -In Alameda county, heterosexual contact (and transmission to women) is still much larger than other west coast metropolitan areas. Epidemic mirrors the south more than other west coast cities.
- #13: CDC estimates of lifetime risk of HIV. Among MSM: 1 in 4 risk in Latino MSM, 1 in 2 risk in Black MSM! But when accounting for absolute numbers, just as many women as MSM need to be on PrEP. Which of these groups, if any, have you seen taking PrEP?
- #14: Rates rising among young adults. -In Alameda County, 20-29 year-olds are 2-3 timesmore likely to be diagnosed with HIV -SBHCs can have a huge impact because we can educate and hopefully start young people on PrEP before they’re in this high-risk age range
- #15: Slides 7-14, probably too many – some duplicative, though
- #16: Skew access to risk
- #17: Nice slide!
- #19: Genderqueer/Trans = 2 strongly agree, 2 neutral
- #24: Youth agency over health and wellbeing
- #25: Start with health ed and providers, move toward everyone (including front desk, medical assistant, mental health clinicians, clinic supervisors) Definitely bring up at all STI testing/treatment visits and Emergency Contraception visits Ideally at all sexual health visits Have a poster and/or handouts on the wall of the exam room, waiting room, and/or bathroom
- #26: LEE What do you know about sex positivity? How would you define it?
- #27: Brenly How do we reinforce these concepts in our work? Who is left out of sexual redemption? -> Clarify difference between shame as part of kink and sex negative shame -> Judgmental approach to other peoples' behaviors.
- #28: LEE
- #29: Brenly Important to have a visibly sex positive, queer, fat, disabled -friendly space. Artwork that is representative Reading materials that can educate on sensitive topics in a non-judgemental way Intake forms that allow for gender and sexuality variations Waiting rooms that are comfortable for all bodies Exam rooms that are comfortable for all bodies Staffing who are trained in sex positivity, LGBTQ inclusiveness, trauma informed care
- #30: Now that we've convinced you that PrEP is an important and valuable HIV prevention tool to offer at your clinic, I am going to go through some practical details...
- #31: Hand out AETC Pacific Clinical Essentials handout Not having capacity to do all labs on site is a big barrier for young people Inconvenience of having to go elsewhere, concerns about confidentiality, insurance and parent consent issues Hep B: Truvada active against Hep B as well as HIV. Risk Hep B could become resistant or flare when Truvada discontinued Hep C: increased risk from receptive anal sex without condom HIV viral load: would show early infection before 4th gen HIV test positive
- #32: Hand out AETC Pacific Clinical Essentials handout No having capacity to do all labs on site is a big barrier for young people Inconvenience of having to go elsewhere, concerns about confidentiality, insurance and parent consent issues
- #33: Confidentiality is a big deal with adolescents and pharmacies. Many pharmacies are not sensitive to/careful about it Comes up with pharmacy staff and also through insurance billing/info
- #34: Confidentiality is a big deal with adolescents and pharmacies. Many pharmacies are not sensitive to/careful about it Comes up with pharmacy staff and also through insurance billing/info
- #36: There are many barriers to starting PEP in time (access to provider, pharmacy, insurance)
- #37: From a study published in JAMA 2017 among 15-17 yo MSM “Safety and Feasibility if Antiretroviral Preexposure prophylaxis for adolescent men who have sex with men aged 15 to 17 in the United States”
- #38: PleasePrEPMe.org is a website that allows English and Spanish speakers in all 50 states to learn about PEP and PrEP through written information and/or live chat, text and telephone support with experienced PrEP navigators. It also has a provider directory to link people interested in starting PrEP or PEP with providers in their area.
- #39: Case manager needs to have flexibility to be able to clear time to help in timely manner NOT provider, MA or front desk staff unless they have protected time for this (eg someone who can cover) Potential good candidates: health educator, clinic supervisor (depending on your clinic)
- #40: PleasePrepMe.org (basic education info/videos and Bay Area provider directory) AIDS Education and Training Center (AETC Pacific): free online training + resources
- #41: PrEP provider toolkit
- #42: PrEP provider toolkit
- #43: PrEP provider toolkit