Dr Rachel Melson (Swope Health):

So, to get started, what is PrEP? What is pre-exposure prophylaxis? So simply PrEP is the use of antiretroviral medications by people without HIV to protect themselves from getting HIV.

Now, PrEP is recommended for adults and adolescents that weigh at least 35 kilograms, who are at risk of getting HIV through either sex or even injection drug use. The FDA has approved 3 different medications for the use as PrEP. Two of these medications are taken as oral regimens and consist of 2 drugs combined in a single oral tablet used daily or as prescribed.

So the first medication is emtricitabine in combination with tenofovir disoproxil fumarate, also known as TDF. And you’ll hear me use that interchangeably throughout this webinar today. The other medication, again, is emtricitabine in combination with tenofovir alafenamide or TAF. And you may hear me use those interchangeably throughout this presentation. Of note, TAF is not approved for use by women or people who could get HIV through receptive vaginal sex.

The third medication is an injectable formulation. It’s called cabotegravir. It’s given every 2 months as an IM injection by a health care provider. And you’ll see it through this webinar as abbreviated as CAB or C-A-B.

[00:18:32]

Why Is PrEP Needed?

So why do we need PrEP? Well, PrEP is safe, and it’s an effective tool to prevent HIV. Unfortunately, even though it currently exists and is available, we’re still seeing a vast number of new infections every single year. In 2022 alone, that was over 31,000 new infections, which 67% of were among gay, bisexual, and other men who reported male-to-male sexual contact. 22% of those new infections were among people who reported homosexual contact, and 7% were among people who injected drugs.

Our goal is to reduce the number of new infections of HIV. To be able to do that, we have to be able to get PrEP where communities and persons need it most. The goal of Ending the HIV Epidemic is to reduce these overall new infections by 75% in the year 2025, and at least by 90% by 2030. And we’re hoping that we’re going to be moving in that direction. Again, having all of you here today is a testimony to your dedication to helping us end the HIV epidemic.

[00:19:48]

The South Accounts for ~50% of All New HIV Infection in the US

So, Missouri, Arkansas, Oklahoma are highlighted because they have disproportionately high rates of HIV, especially in rural areas, and relatively low PrEP uptake. The South in general accounts for 50% of all new HIV infections. In general, there are exact reasons why and where primary care providers can start providing PrEP and make the biggest impact in overall ending HIV.

[00:20:25]

Ending the HIV Epidemic in the United States

So the Ending the HIV Epidemic Program launched in the United States in 2019, again with its goal of overall reducing infections. The protocol or the purpose of the EHE was to diagnose all living people with HIV as early as possible in that process, to then treat people living with HIV rapidly and effectively to reach that sustained viral suppression or an undetectable status.

And then what we’re coming into this today is part of it being preventing new HIV transmissions by using proven interventions like PrEP. And then other programs like SSPs or Syringe Service Programs.

The final goal is to respond quickly to potential HIV outbreaks to get prevention and treatment services to, again, the people who need them most.

Overall, the goal is to really advance health equity by scaling up these key HIV prevention and treatment strategies to get them to our, again, our communities where the need is the highest.

[00:21:36]

PrEP is a Key Prevention Strategy of Ending the HIV Epidemic in the United States

So PrEP is a key prevention strategy, again, for this Ending the HIV Epidemic Program in the United States. They had an initial focus on these priority counties where they saw 50% of new HIV diagnoses, and then priority states that had a disproportionate burden of HIV, especially in rural areas. And that includes Arkansas, Missouri, and Oklahoma. These priority states or target states were supported by this program to implement testing programs, prevention strategies, and even treatment programs.

[00:22:14]

HIV in Arkansas, Missouri, and Oklahoma: 2022 Data

So despite our efforts in testing and prevention, we are still seeing a high amount of new HIV diagnoses every single year. So to give you some perspective on that, the new HIV diagnoses in just the year 2022, in Arkansas, were 305. Missouri was 512, and Oklahoma was at 394. Among these new diagnoses, there was an unfortunate disproportionate incidence among certain racial and ethnic groups, which you can see here on the slide.

Something to note, our hope is that these new infections are going down. But unfortunately, in some of these target states like Missouri, we are seeing a higher and higher reported cases. In 2024 was one of the highest years for Missouri yet. In 2024, Missouri reported 575 new HIV diagnoses.

[00:23:14]

US Trends in PrEP Coverage for People Who Could Benefit: 2019-2022

So this slide kind of goes through again, those US trends for PrEP coverage for people who could benefit. Again, we want to get this to the communities where the need is the most. In 2022, only 36% of the 1.2 million people who could have benefited from PrEP were actually prescribed it. PrEP has increased over time, but has been unequally across subgroups, and disproportionately you’ll see not given to certain race and ethnicity groups, and also predominantly provided in urban areas.

[00:23:58]

PrEP-to-Need Ratio Is Low in the US South

So there’s a way that we look at what the need is in certain areas of the country, and we call that a PrEP-to-need ratio. It’s very, very low in the US south, so that ratio of patients of PrEP users to the new diagnoses gives us an idea of what that unmet need is for each of those areas. We just don’t have enough PrEP getting to the people again who need it most. So this slide demonstrates the PrEP-to-need ratio. The lower the number, the greater the unmet need.

[00:24:41]

PrEP-to-Need Ratios Are Also Relatively Low in Missouri and Oklahoma

Well, there are states, as you saw on the previous slide, with much lower scores. The PrEP-to-needs ratios also may remain very low in states like Missouri and Oklahoma, again, especially in those rural areas.

[00:25:02]

PrEP-to-Need Ratio Has Substantial Racial/Ethnic Disparities

Unfortunately, despite the work that we have to provide equitable access to HIV PrEP, there’s still a substantially greater unmet PrEP need for Black and Hispanic individuals versus white individuals. What’s even more concerning is that we’ve seen that US medical professionals are actually less likely to prescribe PrEP to Black and Hispanic people, which continues to add to the substantial racial and ethnic and even geographic disparities that we’re seeing in PrEP.

[00:25:41]

PrEP Use in Arkansas, Missouri and Oklahoma in 2022/2023

So, again, giving you some numbers about our local areas through Arkansas, Missouri, and Oklahoma. This shows you how many users per 100,000 people are, again, being provided PrEP in Arkansas, which was 81 in 2023, Missouri 117, and Oklahoma at 91. Again, looking closely at this slide, you can see the disproportionate access between Black and Hispanic or Latino individuals and those of White individuals.

The percentage of PrEP users, especially in my home state of Missouri, again, 79.2% of those users were White, while only 4% were Hispanic or Latino, and 14.7% were Black. We have to do a better job of, again, getting PrEP to those who need it most, but also making sure that we’re providing equitable care and equitable access among whatever race or ethnicity group our patients are coming from.

[00:26:48]

PrEP Use by County in Missouri 2022/2023

The graphic represents the use of PrEP by county in Missouri, and I found this especially interesting because while the numbers for the PrEP-to-needs ratio were a bit higher for Missouri, you can clearly see on this map—I guess clearly see if you understand where the cities are located in the state of Missouri, but where we have our urban areas.

So, to the west, you’ll see the darker areas that are around the Kansas City area and kind of the central area of Missouri. That’s where we have Columbia and Jefferson City. Again, big big urban areas. And then, to the east, we have the St Louis area. Kind of down to the lower part of Missouri, you see one darker section, and that’s where we have some bigger cities. Again, like Joplin and Springfield. But most of Missouri is very, very rural.

And individuals in those areas have a very hard time connecting with providers who offer PrEP and prescribe PrEP. And remember, part of PrEP and a big part of PrEP is education. Many patients don’t even know that PrEP exists. And so, part of the problem is that if a patient is presenting for— they want to be checked for STDs. That is such an important time to be able to provide education about what PrEP is, and being able to tell patients that this is something that can help prevent HIV, and it’s an option for them if it’s something that they’re interested in.

I do that in just about every visit that I have for an STD check. And just simply say, hey, have you ever heard of HIV PrEP? Most of the time they say, no. I provide them that information. And regardless of where that conversation goes, if they agree to, you know, go down the road of looking to start on PrEP or they’re just leaving with more information. That’s one more person that knows that PrEP exists, and they can help us spread the word within our communities.

[00:28:52]

PrEP Deserts: Geographical Barrier to PrEP

So, again, as you can see on the map of Missouri, we have a lot of areas that we consider PrEP deserts or these geographical barriers to PrEP. It constitutes a community with low access and low availability of those PrEP services. So, again, especially in rural regions, we have patients that may have to travel 32 minutes to 2.5 hours for PrEP. Bringing PrEP to the primary care clinics, especially again in those rural areas, helps us close this PrEP gap, helps us provide PrEP in areas that traditionally haven’t had access.

So if you live in a PrEP desert, it overall decreases the likelihood of not only using PrEP, but even being offered PrEP. Among PrEP-eligible men, those living in PrEP desert, 38% of them were less likely to have used PrEP in the last 12 months, 25% of those individuals were less likely versus their nonurban dwelling peers, and 65% were less likely versus their suburban dwelling peers. Again, this is something that we can do to help diminish these PrEP deserts and open up PrEP to all persons.

[00:30:15]

PrEP Deserts More Common in Midwestern and Southern Region of US

So, PrEP deserts again have been become more common in western and southern regions of the United States. Again, this supports that need for an expanded pool of PrEP prescribers, especially within, you know, our most affected communities. Each region had a substantial number of individuals living in a 30-minute PrEP desert.

There was a considerable range across regions in the proportion of PrEP eligible population that were living in a desert relative to the total regional PrEP eligible population. And you can see the statistics here on the slide in our bar graph. In the northeast it was 5.4%. To the west, it was 10.7%, and then Midwest it was around 12.8%, and in the South 17.1%. The corresponding proportions for a 60-minute dessert were in the northeast, 0.6% in the West, 4.8% in the Midwest, 3.8%, and in the South it was up to 6.2%.

[00:31:25]

Who Can (and should) Provide PrEP? You!

So who can and who should provide PrEP in their clinics? The answer is you. Any licensed prescriber can prescribe PrEP to people who don’t have HIV and are at risk of getting HIV through sex or injection drug use. Even in some states, we actually have pharmacists who can provide PrEP once prescribed by a clinician. PrEP providers include primary care providers, maybe providers who work at STI clinics or sexually transmitted infection clinics, HIV care providers, and even providers who work for clinics that provide substance use disorder treatments.

[00:32:12]

CDC: PrEP Prescribers in the United States

So we have still seen increases in overall PrEP prescribing since 2014 across these different provider types. You know, again, in general, in the United States, we’ve gone from in 2014, 0.7% providers providing PrEP up to 4.3%. While those numbers are still low, we’re seeing growth in those areas.

In the primary care population of providers, that went from 1.8% to 13.6%. And then for infectious disease physicians, that went from around 14% up to 34%.

Unfortunately, though, 93% of these providers were in urban areas. Again, leaving those in rural areas at a disadvantage in access. In an effort to expand access, pharmacists have expanded authority again in about 17 states to dispense PrEP and PEP independently, again, in those 12 different states, which is really exciting.

We have the greatest need overall for PrEP in the Midwest and the South. And again, we need more PrEP providers like all of you. So, we are, again, so thankful that you’re here today to talk about this important topic.

[00:33:37]

PrEP is Appropriate for Primary Care

So PrEP can be prescribed again by any licensed provider. The prescriber does not need to have an infectious disease background or be an HIV specialist. PrEP is preventative for HIV, and it can be readily integrated into primary care, as providers already are prescribing other preventative interventions, such as metformin for somebody with prediabetes and is at risk for diabetes. We provide statins regularly for those at risk for cardiovascular disease and, you know, other medications as well. In fact, making PrEP available in primary care settings as part of routine preventative health can improve access for all people who could benefit, and can help address existing disparities in PrEP use.

It’s so important to be able to integrate this into our primary care setting, so we can reduce the barriers of access for our patients. Making PrEP a part of that primary care visit, again, will help address disparities and our primary care providers working in our most affected communities can make the biggest difference.

[00:34:38]

Introduction to PrEP Regimens

So now, we’re going to transition into talking about PrEP-specific regimens.

[00:34:56]

Poll 3

Zachary Schwartz: Great. And let’s find out from the audience.

Have you prescribed PrEP?

1. Yes;
2. No; or
3. It’s not applicable to you.

Polls are open. Let’s have a look. And I think we can close the poll and have a look. It’s quite a split, actually. A lot of people saying no, they haven’t. So, that’s great that you are here to learn.

Dr Melson: Oh.

Zachary Schwartz: That was my mistake. Sorry.

[00:35:29]

Current PrEP Options

Dr Melson: Oh, that’s okay. It’s clicking the buttons at the same time. All right. So we have 3 different current PrEP options. So we’ve talked about these just a little bit before, but I want to go over them again. Again, PrEP is the use of these antiretroviral medications. So we have 3 different options. One is an injectable version. It’s cabotegravir or CAB. It’s an IM injection every 2 months. And so, this is a long-acting option.

We have emtricitabine tenofovir disoproxil fumarate or TDF. Again, that’s a once daily oral pill. And then we have TAF or tenofovir alafenamide. Again, a once daily oral pill.

[00:36:18]

FDA-Approved PrEP Regimens by Population

So I wanted to provide some information about the FDA-approved PrEP regimens by population specific. So there is one specific formulation, and that’s the TAF. It is not approved for cisgender women or transgender men. So just to keep that in mind when you’re looking at what to prescribe for your patients, that there is a limitation for TAF for cisgender women or transgender men.

However, TDF can be used for men who have sex with men, transgender women, cisgender men, cisgender women, or transgender men. And the same goes for injectable CAB.

[00:37:15]

PrEP FTC/TDF vs FTC/TAF

So PrEP is generally well tolerated. When we’re looking at TDF, you might see a slight effect in renal and bone health. There have been some reasons to believe that TAF might cause a little bit of weight gain or some lipid changes. But realistically, those are rarely clinically significant. But it is a reason why we draw labs for our patients and have them come in for in-person visits occasionally so that we can monitor those lipid changes, those weight changes, and monitor bone and renal health.

[00:38:01]

PrEP CAB vs FTC/TDF

So, in terms of efficacy, you know, we have great outcomes for cabotegravir and for our TDF regimens. This slide just kind of goes into overall safety and efficacy of those medications. Again, safe and effective across the board. And just in general, though, for cabotegravir, there’s some notably some superior efficacy compared to those daily oral regimens in the trials in which they were studied.

At this time, for cabotegravir, it looks like it says, you know, there’s no generic available. And the nice part, again, about cabotegravir is that it’s not daily. So, you’re doing an injection once every 2 months.

[00:38:54]

On-Demand Oral FTC/TDF PrEP: Another Option for Cisgender Men Who Have Sex With Men

So you might hear patients or other prescribers talk about on-demand PrEP. And so, on-demand PrEP is a regimen that’s timing-based around when somebody plans to have sex. I want to note, as we go into this slide, that on-demand PrEP is not FDA approved, but it is recommended by the IAS and USA guidelines. But it’s not recommended for patients that might have an HPV coinfection. Those who might have difficulty adhering to that dosing schedule. So, making sure that they’re taking it on that 2-1-1 schedule, and for populations at risk of HIV through vaginal exposure.

So to be able to provide that 2-1-1 PrEP, you would have the patient take 2 pills of the TDF 2 to 24 hours before sex. And then, after sex, they would take, within 24 hours, the next dose, and then 48 hours after that.

[00:40:05]

PrEP Guidance: CDC

So I know this slide is a little busy, but I want to try to simplify it for you. PrEP should be discussed with all sexually active adults and adolescents. And really, the general rule of thumb is anybody who asks for PrEP should be offered it regardless of disclosed risk factors. And that’s for several reasons.

Often, sexual health and conversations around other risk factors like IV drug use are stigmatizing. And often, patients come to your clinic settings feeling judged. And so, patients may not be as upcoming about what their risk factors actually are. And so, the rule of thumb is that if you ask for PrEP, you get PrEP. All pathways lead to discussing or at least prescribing PrEP.

So, you know, if somebody says that they’re not currently having sex or they may just have one considerable monogamous partner at that time, that’s not a reason for deterring somebody in getting access to PrEP, again, because they may not understand what their risks are. They may not feel comfortable disclosing those risks. And, you know, they might just want to feel protected in case their situation changes.

And so, again, all pathways, no matter what way you look at it, leads to at least a discussion about PrEP and potentially even prescribing that if that’s the discussion where that lands and that’s what the patient decides.

[00:41:39]

Case: Assessing PrEP Candidacy

All right. So we are back to the question that we kind of kicked off our polls earlier in the session with Zachary. So you are providing care for a 34-year-old Black, heterosexual, cisgender woman who’s been married for 6 years. She tells you she’s had 4 lifetime partners and is not engaged in extramarital sex. Her friend had begun PrEP, and she’s interested and wants to know if she can start PrEP as well.

[00:42:10]

Posttest 3

All right. So, here we are. How would you counsel this person about PrEP? And I’ll just kind of go through these as you answer.

1. So explain she’s not a candidate, she’s not at risk;
2. Explain that she’s not a candidate, but probe further to see if you can figure out what risk factor that she may not have shared with you;
3. You could refer her to the sexual health clinic, which you tell her is the most appropriate place for obtaining PrEP; or
4. Provide PrEP now, with educational support and answers to questions.

Zachary Schwartz: Okay. I think the answers have slowed down a bit, so let’s close the poll and see the results. It looks like most people, 60%, would do it right now. Some people would wait and probe further first. Do you want to talk about that, whether that’s right or wrong?

Dr Melson: Yeah. So, again, as we saw on the previous slide, anybody who asked for PrEP should have access to PrEP, right? This question is meant to challenge our assumptions and really make us check our internal biases and how we approach patient care. Even if you don’t think that this person is at risk of HIV acquisition, it is not appropriate to tell them that they can’t have PrEP at this time. Again, the CDC guidelines say that any person who requests PrEP should be provided PrEP. And again, all sexually active adults and adolescents should be informed at a minimum about PrEP for prevention of HIV acquisition.

So it’s important to provide those options for our patients. Again, challenge our assumptions. This patient is being proactive and is interested in PrEP. So if they want it, we’re going to offer it. There’s no need to probe further, and there’s no need to refer out. You may notice, as you gain more rapport with patients through this process, that you will get more information. Maybe after a while, they’ll feel more comfortable potentially disclosing something that they didn’t before.

But probing further before a patient is ready to share that information with you can help or can keep patients from feeling comfortable. It might leave them feeling judged. It’s important to meet patients where they are. And if they’re not ready to disclose that information, it’s not important. Right now, they’re asking for PrEP, so let’s provide that education. Answer the questions they might have, and let them decide if this is what they feel is right for them.

[00:44:49]

HIV Testing Before PrEP Initiation: No Oral PrEP or PEP in Past 3 Mo and No CAB IM PrEP in Past 12 Mo

So before starting PrEP, we want to do HIV testing. So you can use, if available in your clinic, a rapid point-of-care test, but it’s preferred to use the fourth-generation HIV test through lab work or serology. And so, once we get that lab test, we’re going to just kind of go through this algorithm together.

So, you know, if a patient is reactive and that point of care test or you get the fourth generation back, it’s a hard stop. You stop there. You need to follow your, you know, internal organizations or regional linkage to care protocols. You’re going to want to order that confirmatory testing, if not already available, and discuss with the patient that they’re not eligible for PrEP at this time.

Something I always like to make mention of when having these conversations about testing is that when you are doing point-of-care testing, making sure that you’re using the words reactive. Until we get that confirmatory testing, we don’t want to talk about it being a positive result. It’s a reactive result, and we need to do some further testing to confirm if that HIV is actually positive and do some testing for determining if there’s a viral level.

So if you get a negative or nonreactive result, then you’re going to determine if they’ve had any sort of recent exposure, or if they have any signs or symptoms of an acute HIV infection. If they answer no, that they don’t have any signs or symptoms, then we just continue down this pathway of getting to providing PrEP for this patient. If they have any signs or symptoms of HIV, then we’re going to want to look further and determine the need for doing a plasma HIV fourth-generation assay again. If it’s reactive or positive, then you’re going to go down that linkage to care protocol. If it’s nonreactive, then you can continue those PrEP discussions.

Something important to also note is that RNA testing is really, really great to add on if there is potentially, you know, a recent PrEP or HIV exposure, or maybe they’ve potentially recently used PrEP, but haven’t been on it more recently, or maybe they’ve been on PEP or postexposure prophylaxis recently. Adding that RNA testing on whenever possible is great because it can help us avoid resistance from an acute or undiagnosed infection.

[00:47:36]

HIV Testing Before PrEP Initiation: Has Received Oral PrEP or PEP in Past 3 Mo or CAB IM PrEP in 12 Mo

So, this slide goes over similar to what we discussed before, but this is our HIV testing before PrEP initiation on somebody who’s had oral PrEP or PEP in the past 3 months, or maybe has had a CAB injection for PrEP in the last 12 months. So, again, starting with that HIV testing, we want to determine if they have any sort of reactive antibodies and if that HIV RNA is detected. Again, that would be a positive result if they have positive RNA and you want to follow those linkage to care protocols.

If they have negative results or nonreactive results, you want to continue down your pathway to potentially get them started back on those PrEP regimens. Now, if maybe you had a positive antibody test in the clinic or maybe a point-of-care test that was reactive but you get that confirmatory test and that HIV RNA is not detective, you want to continue down the pathways of, you know, sending specimens to reaffirm that that HIV RNA is, in fact, not detected before starting PrEP.

[00:48:49]

How Long Does PrEP Take to Work?

So a big question that we get from patients is, okay, I’m starting this today, but how long does it take to work? So we have some answers and not some answers. So, with daily oral PrEP, we know that for receptive anal sex or also called bottoming that the maximum HIV protection is reached at 7 days of daily use.

For receptive vaginal sex or injection drug use, that maximum HIV protection actually takes a little bit longer at 21 days. So making sure that you’re disclosing that to patients. I typically, regardless of who my patient is, I tell them both numbers, the 7 days for receptive anal sex and then the 21 days for the receptive vaginal sex and the injection drug use. Regardless of what you think that they’re using this PrEP for, it’s best to give all of that information.

For insertive anal sex or topping or insertive vaginal sex, there’s really no specific data on when it’s going to get to its most effective level. Similarly, though, with our PrEP injections, that are done every 2 months with CAB, there’s not specific data available about when it’s going to get to that maximum effect. There are some recommendations of using an oral lead in of oral medication while they’re starting on the injectable PrEP, and you do that to overlap that first injection by 7 days to allow that time for the PrEP injection to reach its protective levels. However, this isn’t a requirement for cabotegravir or CAB. But it is a recommendation and could give some patients some more comfortability knowing that they’ve been on that medication for a certain amount of time, and knowing when they could have reached that maximum HIV protection.

[00:50:44]

PrEP in Practice

All right. So we are going to talk about PrEP in practice.

[00:50:53]

Patient Testimony: Video 1

And we have a couple of videos that we’d like to share with you. So the first patient testimony is answering the question, how has PrEP impacted your well-being?

[00:50:51]

How Has PrEP Impacted Your Well-being?

Michael Chancley Jr (PrEP4All): We got outside of routine HIV testing, which was rapid testing at community-based organizations. I didn’t engage the healthcare system. So one of the things that starting PrEP did was actually get me to engage with medical providers on a routine basis. So not only did it help me with, you know, embracing my sexual health, you know, getting routine STI screenings, routine HIV screenings, but also being able to get referrals for other services, whether it be making sure I’m regularly checking my blood pressure, any referrals for mental health services, other, you know, dermatology.

PrEP was kind of got me in the door with engaging with medical providers. And because, you know, once you have a provider who offers you great service, then it’s kind of a great way to engage even around like the vaccines with mpox and COVID. Honestly, if it wasn’t for me and Gary Jean with PrEP care, I probably would not have started engaging with the medical provider. It kind of got me engaged with the healthcare system.

[00:52:14]

Mechanisms to Improve Conversations Around PrEP

Dr Melson: So it’s so encouraging to see people who become more engaged just again with their overall health, not only as PrEP being a lead into that, but also for patients who maybe were led to PrEP by engaging in their health. So it’s really beautiful to see how that can come full circle for patients.

So, you know, mechanisms to help improve those conversations about PrEP with your patients. So just normalizing overall sexual health discussions, like any other aspect of care, you want to use trauma-informed approaches, a respectful approach. Asking permission before discussing sensitive questions, making sure that you’re using shared decision-making for patients, you know, providing that education, answering questions, really working on building that trust between the patient and provider.

And then, doing your best to avoid stigmatizing languages, and set up places in your clinic where patients can feel safe, promoting representation of different racial and ethnic minority groups and transgender people. And displaying signals of acceptance. You know, I have this whole—I don’t know if you can see past the slides, but I got a lot of bling on my badge here, just to small little ways of showing I got rainbows and she, her pronouns and a little PrEP pin. All different ways to really show that you are supportive of your patients and creating a safe environment.

[00:53:53]

Tips on Taking a Sexual History

So I wanted to give you a few tips. Just because taking a sexual history can be an uncomfortable conversation to have for some people. And you want to make sure that you’re promoting comfortable and nonjudgmental, not only the language that you use, but the environment that you’re in. Never, ever, ever, ever, ever assume gender, gender identity, pronouns, sexual orientation of patient or their partners, or types of sexual activity.

Honestly, if you create an opportunity to just use—you’re asking the same questions for every patient in a way that’s trauma-informed and nonjudgmental. You’re going to make—your patients are going to be able to feel that that this is just routine for you. This is the same question you ask everybody. It takes the stigma out of the responses.

So, you know, avoid asking, you know, certain unnecessary information like number of partners, frequency of sex. Instead, say something like, are you having sex or do you want to be having sex? What type of sex? Or maybe what body parts are used in your sexual activities?

[00:54:58]

Patient Testimony: Video 2

So, we got another video to go over with you, and it just really highlights the importance of that nonjudgmental approach.

[00:55:07]

Importance of Nonjudgemental Approach

Michael Chancley Jr: I think it’s important that for any provider that you know what the patient wants. I’m coming in for a very clear reason. And obviously, I want to value your expertise because, you know, you’re a provider, and I trust that you’re an expert, but I’m also an expert in what I’m coming in for. So, you know, I’ve had providers who may pass judgment if they find out I engage in condomless sex.

And, you know, nobody wants to go into a healthcare environment and feel judged for their decisions, especially when there are health resources to help me navigate that, you know. So once you know that this is the kind of sex that I engage in sometimes, meet me with a solution that’s nonjudgmental and not dictating what I should do, but instead presenting options. So looking at options like making sure I’m vaccinated for hepatitis, making sure that I’m being adherent to PrEP, you know, talking to me about other options like Doxy-PEP or getting the mpox vaccine.

So, you can lose all of those opportunities to provide a patient with resources and education when you decide to be judgmental or, you know, dictate the type of sex that you believe that they should be having for health reasons or ethical reasons. So, instead, just kind of, like, leaving your judgment at the door and really—well, thinking about what resources you could provide to make sure that someone that’s engaging with their sexual health care in a way that’s patient-centered and healthy.

[00:56:36]

Tools for Overcoming Implicit Bias

Dr Melson: So, again, some really great things to reflect on there. We want to offer just some tools for you to leave with about overcoming our own implicit biases. And so, what that is, is implicit bias or unconscious attitudes, perspectives, stereotypes that everybody holds on to. We all have these, and they include race, gender, and sexuality. You know, biases can impact who gets offered PrEP. Again, Black and Hispanic patients are less likely to be prescribed PrEP.

Why is that? We have to be more proactive and offer PrEP and examine our own assumptions. And that’s using techniques like cultural humility and cultural competency. And so, really focusing on figuring out what your own biases are can help you in that process.

[00:57:24]

Representation Matters

Something else important is representation. Representation matters. It builds trust. When patients see providers who understand or reflect their own identities, they’re more likely to engage in care and adhere to prevention. And so, making sure that we provide that representation as best we can in our clinic settings is so important to help increase communication and trust and overall adherence.

[00:57:50]

Patient Testimony: Video 3 and 4

All right. So our next videos are about what value do you attach to your relationship with a supportive PrEP prescriber.

[00:57:58]

What Value Do You Attach to Your Relationship With a Supportive PrEP Provider

Michael Chancley Jr: Sometimes, when your insurance changes, you have to build a rapport with the new provider in your network. And I’ve had good providers and I’ve had bad providers. And the good providers were the ones who were not only just nonjudgmental but actually enthusiastic. You know, I had one provider, she kind of broke the ice because, you know, I was nervous. I had been out of PrEP care for maybe about 6 months. So I was trying to reengage in PrEP gear, so it kind of made me nervous to go ahead and embrace her.

And she actually cracked a joke. She was like, oh, you’re getting back on PrEP. You know, I know pride isn’t—I know Atlanta Pride is next month. And so we both, like, just fell out laughing. But it was like, oh, okay. This is someone whom I can, like, actually talk about my sexual health. And that just opened a door to talking about other things. She was able to—you know, that was the first time that I learned about an anal pap smear. So now, even though she’s no longer my provider because I’m not with that network anymore, now it empowers me to be able to go to my provider and say, hey, I want to get an anal pap smear. Or, hey, I want to make sure that I’m getting a full STI screening.

So when you have a provider who’s enthusiastic and really educates you with facts and proper information, it empowers you to go to the next provider and advocate for yourself. So, even if I’m not getting the right service because someone has shown me what good service looks like, I’m able to go to the next provider and know, hey, my past experiences have been with accessing PrEP, and I want the same quality of service as I move forward with accessing that. And I don’t think I would have been able to do that without a provider who really showed me what good PrEP care looks like.

[00:59:42]

Potential Solutions for PrEP Engagement/Access Barriers

Dr Melson: I love listening to these videos because again, it just speaks to how much that relationship is impacted when we provide that nonjudgmental, trauma-informed approach with our patients and really make them feel comfortable about discussing their needs and their sexual history.

So, a couple of solutions just to help with overall PrEP engagement and access barriers. You know, offering PrEP same day we know increases uptake. And so, when that’s possible for your patients, when you feel like you have the labs and the information available to you to make that decision starting that same day, whenever possible, is so important.

Having a PrEP navigator, a champion that can help support making sure patients follow up for labs and check in on insurance needs for getting the PrEP medications covered, and then just even following up with patients and offering, you know, different types of appointments or just overall removing barriers to access is so important. A huge shout-out to my HIV prevention nurse, Elise Kelly. She is just an amazing resource for our patients and a huge advocate. And just having that kind of person on your team is really important to make sure that patients maintain their access to PrEP.

And one final thing before I get off the slide again, using telehealth as well. You know, being able to get those labs and start patients on medications is important. But if you don’t have to see them in person, using telehealth is so great to be able to break down some of those barriers that people might have with their social determinants of health, like transportation and other issues like navigating around a work schedule.

[01:01:19]

PrEP Champion/Navigator: Promoting PrEP Uptake and Persistence

So, just briefly, I wanted to go through, again, just having a PrEP champion or navigator can really help with not only promoting PrEP uptake, but having patients, you know, maintain engagement in being on PrEP and retaining them in care. So having somebody that they can call, that they can go to. Again, my HIV prevention nurse, she is so great. She provides, you know, direct phone numbers to our patients, and is really important and not only helping connect patients to care, but she helps train our providers. She helps be a resource to our providers in our clinic settings to make sure that we have providers who feel comfortable and empowered to have these conversations with patients.

[01:02:00]

Same-Day PrEP Initiation: A Strategy to Improve Access

Again, just some strategies to help improve access. Same-day initiation is so important. You know, we all know that when a patient is in front of you presenting for care, that’s the most powerful time to get them started in any sort of treatment process, whether that’s Hep C treatment or HIV treatment or engaging them in PrEP. And so, making sure that if we can do that, that we do.

Some reasons not to do that same day PrEP is, you know, if we can’t figure out the payment options, we don’t have the right labs in place. Or maybe there’s an issue with their medical history, like renal disease, or they’re having that possibility of a recent exposure. Having some constitutional symptoms that make you worried about an acute HIV infection. Or, again, if they lack the ability to be contacted for abnormal lab follow-up. Really, navigating through what that looks like for patients before starting PrEP is really important for their success.

[01:02:58]

Creating Change: Education of Patients and HCP Is Key to Addressing Inequalities in PrEP Uptake

You know, primary care is HIV prevention. By making PrEP routine in our practices, we are reducing disparities. We are building trust, and we are saving lives. It is so important to have more and more healthcare providers engaged in addressing these inequities to PrEP uptake. Again, it’s so powerful that all of you are here. We need more and more providers providing that education to our patients, more representation of our patients, including, you know, Black healthcare providers, Hispanic or Latino healthcare providers as trusted community sources of knowledge.

We want to make sure that we’re disproving myths about HIV and reducing stigma, sending positive messaging about sexual health, and supporting different prevention messaging for our patients. And again, just discussing those different PrEP options to promote that patient-centered care. If your patient is presenting and they want access to PrEP, let’s figure out how we can provide that to them.

[01:04:05]

Break Down the Barriers

And finally, we just want to make sure that we’re breaking down those barriers. You know, primary care providers have a key role in expanding this PrEP access and uptake. And it’s our job moving forward to increase awareness, increase training of other providers in our organization, addressing those biases and stigmas that impact our patient care. You know, working towards expanding Medicaid, considering all of those social determinant needs for our patients, and really working together to be able to get access where it’s needed most.

[01:04:38]

PrEP Certification

And with that, I think I’m turning it back over to Zachary to talk about PrEP certification and some final closing questions.

Zachary Schwartz: Yes. Thank you so much. There’s an excellent program prepared by our partner, HealthHIV, to help anyone become a certified prevention provider. You can see the information on the website here. And I believe there’s a link in the resources tab, so I encourage you to check that out.

Now, while Dr Nelson—Melson, excuse me—is looking over the many great questions you’ve asked us, let’s follow up with the questions that we’ve asked you and see if things have changed after this presentation. So here’s our next question.

[01:05:19]

Poll 5

For those providing patient care, with how many patients do you now expect to discuss PrEP with in a typical week? Now, that you’ve listened to this presentation, how many times do you expect to discuss PrEP? Is it:

1. Zero;
2. 1-5;
3. 6-10;
4. 11-25; or
5. 26-50.

Polls are open. Let’s vote. All right. We have a good number of answers. Let’s close the poll and have a look. Looks like a number of people are choosing 1-5 or 6-10, so that’s good to see.

[01:06:00]

Posttest 1

Let’s move on to our next question. Now, going forward, I plan to have a significant role in expanding PrEP uptake in my local community. So this is the same question we asked you before, but now we’re asking forward looking. Now that you’ve had this education, do you now plan to have a significant role in expanding PrEP uptake in your local community? If you strongly disagree with this statement, answer A. If you strongly agree with this statement, answer E, and see where the needle lies now that the session is done.

Okay. Let’s close the poll and have a look. See, we have a lot of people choosing strongly agree now, almost a third. So that’s good to see.

[01:06:55]

Posttest 2

And now our next posttest question. How much do you disagree or agree with this statement now that you’ve heard from Dr Melson? I have clear steps I can take to overcome barriers to PrEP among racial and ethnic minorities in my practice. Do you strongly disagree with this statement? If so, press A. Do you strongly agree with this statement? If so, press E. Or are you somewhere in the middle?

Polls are open. Please vote. And we’re going to leave the poll open, actually. I can see that most people are choosing strongly agree, so that’s good to see. I’m going to leave this poll open for a little bit and move things over to Dr Melson to continue to answer the questions that have been coming in.

[01:07:45]

Q&A

Dr Melson: Yeah. Great. Thank you so much. And I know we’re short on time, so I’m going to briefly go through some questions that were put in our Q&A.

The first one by Marcus, he asked about any data on PrEP use by SOGI and sex preference. And so, the short answer to that is, yes, there is data on that, but it’s somewhat limited. We often rely on self-reported identity in clinical surveys, and that can make it more complicated.

The CDC and something called AIDSVu or A-I-D-S-V-U. If you Google that, you can find some really, really great information about data around people’s uptake with PrEP. In general, like, the bottom line is more inclusive data collection is needed. But what we have shows clear disparities in PrEP access and use across gender identity, sexual orientation, and behavior.

And so, the next question from, I think, it’s Davina or Davina, maybe. It shows PrEP can be used for adolescents. Is parental consent required? Oh, that’s such a big topic.

And so, the answer depends on the state laws regarding minor consent for sexual and reproductive health issues. So, you know, adolescents can legally consent to PrEP, but clinicians really do need to check their states’ minor consent laws and consider potential confidentiality barriers, and maybe the insurance or the pharmacy systems.

And the last question that I saw in there was about the requirements for HIV monitoring from Marcus while on PrEP. So there’s some really great resources about this, but just to briefly go through it, when you’re doing baseline testing, everybody needs an HIV test. And it’s recommended to do that fourth-generation test. You want to check a serum creatinine, hepatitis B and C serology, and then checking for the STDs gonorrhea, chlamydia, and syphilis.

Doing a pregnancy test when appropriate, and then getting a lipid panel if you were going to start them on TAF. And then every 3 months, you continue HIV tests, syphilis, gonorrhea, chlamydia every 6 months. You want to check, again, that creatinine clearance or that renal function. Every 12 months, you add in another test for lipids if they’re on TAF. And then every 12 months again, checking those Hep C serologies.

When stopping PrEP, again, you want to kind of repeat the same things when you started. You’re doing HIV test, renal function test, syphilis, gonorrhea, chlamydia, and then again offering testing anytime somebody requests it, similar to when prescribing PrEP. If somebody wants hep C, HIV, gonorrhea, chlamydia, syphilis testing, regardless of risk factors or disclosure, we want to make sure that we’re offering that.