Prior to the approval of Truvada as PrEP, health departments feared there would be a rush of affluent gay men demanding access to Pre-Exposure Prophylaxis (PrEP)-the use of antiretroviral medication to prevent the infection of HIV-to abandon condom use altogether. In so doing, they would create greater health disparities among vulnerable populations like young gay and bisexual men, Black and Latino gay and bisexual men, and transgender women who are often disenfranchised. However interest in PrEP outside of clinical trials across the country has been very limited. Gilead, manufacturer of Truvada, reports only 2,319 prescriptions filled for Truvada as PrEP from January 1, 2012 (prior to FDA approval in July 2012) to September 30, 2013 in the United States, which currently has an estimated 50,000 HIV infections each year.
The slow acceptance of PrEP as a viable option demonstrates an incredible need to educate potential PrEP users and prescribing providers. Demand may grow as more scientifically accurate and non-stigmatizing education reaches the broader public, making individuals aware of this new HIV prevention tool. However, this situation gives health departments the opportunity to strategize innovative ways to develop effective PrEP education and access programs that could significantly raise bars of the HIV care continuum. We would all like to see the rate of HIV transmissions and individuals testing positive go down, while continuing to raise the bars for newly identified positives, linking them to effective long-term care, and ultimately viral suppression. All prevention interventions need to be offered to and understood by the public as part of our efforts to raise the bars of the HIV care continuum.
Examples from the Field
When Truvada was approved in 2012, five health departments were engaged in PrEP programming. According to NASTAD’s 2014 National HIV Prevention Inventory Module 3: Analysis of Health Department HIV Prevention Programming in the United States, the number has increased by nearly 60% to eight. A number of these health departments are being very strategic and innovative in their PrEP programming. For example:
- New York: Created a plan to end the AIDS epidemic in New York State by 2020. This aggressive plan is a harm-reduction model focused on utilization of PrEP for non-condom users and promotion of Treatment as Prevention (TasP) for all infected individuals.
- Washington: Established an innovative medication access program modeled after the state’s AIDS Drug Assistance Program (ADAP) using state funds, ensuring communities in need can get the medication for free.
- Massachusetts: Engaged with the state’s community health centers (CHCs) and the advocacy community to move clinical research to authentic program implementation by creating unique access programs and education for each CHC’s diverse populations.
Some health departments are leading the charge and there is an opportunity to further incorporate PrEP education and interventions into their overall prevention programs across the nation. These opportunities include:
- Educating individuals both inside and outside the health department about PrEP and other biomedical prevention tools.
- Examining existing funding (i.e., CDC prevention grant PS12-1201) and identifying opportunities for PrEP education to be incorporated into existing prevention plans.
- Conducting outreach and educating providers catering to key populations (e.g., young Black and Latino gay and bisexual men and and transgender females) to establish an access network.
- Leveraging existing disease intervention specialist (DIS) and case management programs to support greater access to PrEP. For example, Ryan White case managers are skilled in navigating insurance and patient assistance programs (PAPs). They could possibly provide support or training to users and the providers to increase access to insurance or PAPs.
NASTAD is hosting a series technical assistance consultations this fall to examine the challenges that PrEP implementation presents for health departments and work to identify best practices for PrEP education, community involvement, provider education, and supportive services to aid individuals in gaining access to this important prevention tool. We will highlight the findings from these discussions and successful state examples in future blog posts, so stay tuned.
We want to hear from you! Is your jurisdiction using PrEP as a prevention strategy? What challenges and successes are you seeing? Share your thoughts by leaving a comment below.
In the meantime here are a few resources related to health departments and PrEP:
Additional PrEP educational materials and resources can be found here: