Expanding the PrEP Workforce in Primary Care

[00:21:10]

What Is Pre-Exposure Prophylaxis (PrEP)?

So what is PrEP? What is pre-exposure prophylaxis? It's the use of antiretroviral medications, and that is that medicine that is used to treat HIV by people who don't have HIV to protect them from acquiring HIV from either sex or from injection—for those individuals who participate in injection drug use.

Taken consistently, and I'm going to reemphasize the word consistently, PrEP reduces the risk of acquiring HIV from sex by 99%. And for those who participate in injection drug use by greater than 74%. It is recommended for adults as well as adolescents weighing greater than 35 kilos, that equates to 77 pounds who are at risk for acquiring HIV.

[00:22:17]             

Why Is Prep Needed?

So why are we having this conversation? Why is PrEP needed? Of the 31,800 estimated new infections in the United States in 2022, over 66%—so 77% were gay, bisexual, and other men who have sex with men. 22% were amongst people who reported heterosexual contact. And a smaller percent, 7%, were amongst individuals who inject drugs.

So we really need to realize the importance of PrEP to decrease the number of new infections that we're having in the United States. And of the ways that we were really encouraged to provide this and to, you know, focus in on this was the initiation of ending the HIV incentive that, you know, rolled out in 2019. And the overall goal was to reduce new infections by 75% in 2025, and by at least 90% in 2030.

And just think of where we are now. We are in 2025, and we have not reached this goal at all.

[00:23:46]

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

So it's important as I am in South Carolina, and probably many of you to realize that the South accounts for greater than 50% of all new infections within the United States. And this is really significant. So we're going to, you know, focus on some of the issues that we see within the South.

[00:24:10]

HIV in South Carolina

So HIV here in South Carolina. That's where I live. In 2021, 2022, we had 1532 new infections. It was slightly higher than previous years. And sadly, the incidents is disproportionately seen in certain racial and ethnic minorities. And as you can see on the one side, greater than 52% are Black, 24% were White, 11% Hispanic, and 12% unknown. So certain racial and ethnic groups are disproportionately impacted by HIV.

[00:24:58]

Ending the HIV Epidemic in the United States

And so, as we look at the ending the HIV epidemic to decrease those number of new infections, it's imperative that we realize the importance of prevention. And this is part of the things that we need to focus on, not only on diagnosing individuals, but getting them into treatment and getting them virally suppressed and responding to potential outbreaks, but also the importance of [inaudible] or also through syringe services programs.

I may need some help. My slide does not advancing. All right. Oh, it went a little bit too fast there. Okay, let's get back. Okay, next. All right. One more. One more.

[00:26:20]

PrEP Is a Key Prevention Strategy for Ending the HIV Epidemic in the United States

All right. Awesome. Thank you. So, you know, PrEP is key - is key prevention strategy for ending the HIV epidemic in the United States. The initial focus of the EHE initiative was to focus on priority populations. Priority counties were greater than 50% of new infections that occurred in 2016 and 2017. And so that priority, you know, we have South Carolina was 1 of those states. And it's really sad that we still are seeing many counties that are disproportionately impacted by HIV.

[00:27:09]

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

And so what is going on right now? What are we seeing as far as the US coverage of PrEP and those individuals who can benefit? You know, how are we truly, really getting to that population and those individuals? In 2022, only 36% of the 1.2 million individuals who could benefit from PrEP were actually prescribed PrEP.

And sadly, severely, severely, disproportionately addressed, by, you know, the - the coverage. So individuals who were White had a higher percentage of being prescribed PrEP vs those groups that are disproportionately impacted, such as Black and Hispanic Latinos. So we definitely have disparities between certain racial and ethnic groups. And these, sadly have been increased.

[00:28:15]

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

One of the ways that we can also look at, you know, the PrEP need is the PrEP-to-need ratio. And that number is lowest in the South. For those who may not have heard this term, you know, it's the ratio of PrEP prescriptions given compared to the new HIV infections. And so the lower the number, the greater the PrEP need. And sadly, 5 states that has the lowest PrEP-to-need ratio is in the South - is in the South.

[00:28:56]

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

And again, when we look at that PrEP-to-need ratio, it has significant racial and ethnic disparities. We see that, you know, sadly, Black individuals are not being prescribed PrEP as they are 1 of the highest groups that is impacted by HIV. And we can see this in the PrEP-to-need ratio.

[00:29:22]

PrEP Use in South Carolina in 2022/2023

So what about South Carolina. PrEP use in South Carolina in 2022-2023, we had 104 PrEP users per 100,000 people. In 2023, 4679 people receive PrEP to reduce the chance of acquiring HIV. But then when we look at race and ethnicity, we are still seeing fewer PrEP users and higher new infections. So we really need to address this issue.

[00:30:05]

PrEP Deserts: Geographical Barrier to PrEP

So 1 thing that we need to look at is the geographic impact of PrEP and, you know, I want to introduce this term PrEP deserts. We've heard about maternal deserts, food deserts, you know, there's also the PrEP desert. And this describes a community with low access to and availability to PrEP services. Living in a PrEP desert, means having to drive longer distances of 30 to 2.5 hours to access PrEP. This is a barrier. And only 1 in 9 rural counties have organizations that provide PrEP. And sadly, living in a PrEP desert decreases the likelihood of PrEP use.

[00:31:02]

PrEP Deserts More Common in Midwestern and Southern Regions of US

We have more PrEP deserts in the South, in addition to the Midwestern regions. And when you look at the actual map, you know, individuals in the South having to drive over 30 minutes for a visit is much higher than, you know, individuals who have to drive 30 minutes in other regions of the country. And so this really supports the critical need for expanded pool of PrEP providers, especially within the most affected communities.

[00:31:42]

Who Can (and Should) Provide PrEP? You!

So, who should and who can provide PrEP—and that's you. Any primary care provider that is any MDs, family medicine, internal medicine, pediatrics, GYN, you know, all of those individuals can provide PrEP. Any individuals who work in the STI clinic can provide PrEP services, as well as those individuals who provide HIV care.

And also, you know, don't forget the individuals who work in substance use disorder treatment care facilities. All of these individuals have an impact on being able to provide PrEP services. Let's not forget some of our nurses and it really depends on where you are. Because again, if you don't have prescribing ability, you may not be able to provide that service. But then pharmacists in many areas, and I'm a former pharmacist, so I’d like to give kudos to our pharmacists out there, who can also be 1 of the individuals who can help us to impact the increased need in PrEP providing—PrEP providers. And then those individuals who work in community-based organizations. So let's not forget our community services.

[00:33:20]

CDC: PrEP Prescribers in the United States

So when we look at who is actually out there right now providing PrEP within the United States, we've seen some increase. But again, when you look at the West vs the Northeast vs the Midwest, the South, who has the greatest need for PrEP services, we just don't have enough individuals like you providing PrEP in this area.

[00:33:52]

PrEP Is Appropriate for Primary Care

And PrEP is definitely appropriate for primary care. You don't need to be an infectious disease clinician or HIV specialist to provide PrEP. Any licensed provider can provide PrEP. It can be and should be easily integrated into primary care practices similar to, you know, our regular prescribed preventative care. You know, we do prevention with metformin for pre-diabetes, statins for cardiovascular disease, and - and also oral contraceptives to prevent pregnancy.

And it's important that we realize making PrEP part of the primary care visit. Remember, most primary care offices and visits is that first contact that you have with your patients. And so that's the time where you need to make sure that one is aware and is knowledgeable of PrEP so that you can take care of the patients that you serve.

[00:35:05]

Introduction to PrEP Regimens

So, let's talk about some of the PrEP regimens that are out there.

[00:35:12]

          Poll 3

So we have a poll question. Have you prescribed PrEP? And that is number one:

1. Yes;
2. No; and then
3. If it's not applicable.

Hope the polls have been open.

Zachary Schwartz: Yeah, and we have a lot of results. So I think we can close the poll and see your results.

 Dr Stewart: All right. Oh my goodness. So I am glad we're having this conversation. So, 63% not applicable, and 15% yes, and 22% no. So we have some work to do.

[00:36:04]

Current PrEP Options

So what are the current PrEP options? Currently, we have a long-acting injectable that is cabotegravir, also called CAB, that the injection is given every 2 months. Then we have 2 oral formulations that are 1 pill a day, emtricitabine (FTC) 200 mg that's combined with tenofovir/disoproxil fumarate, TDF, 300 mg. And then the other oral medication we have emtricitabine, FTC, 200 mg plus tenofovir/alafenamide, TAF, 25 mg, also 1 pill a day. So currently we have 2 oral medications that are daily medications and then the 1 long-acting.

[00:37:15]

FDA-Approved PrEP Regimens by Population

[Inaudible] if you could be on this particular chart, there's a red box. And for those individuals who are cisgender women as well as transgender men, our daily FTC/TAF is not recommended. But for all other populations, any of our formulations is a possible choice for us for providing PrEP for that particular population. And I'll talk a little bit more in the next couple slides.

[00:37:54]

PrEP FTC/TDF vs FTC/TAF

So as I mentioned, we have the 2 oral forms. We have FTC/TDF, as well as FTC/TAF. And when we look and compare the 2 as far as effectiveness, they're both just as effective over 99%. And then I just want to highlight for heterosexual men and women, FTC/TAF that particular effectiveness is not known. Again, is not recommended by the FDA because it's not been approved.

And then for our individuals who inject drugs our FTC/TAF, that information is not known. But remember, for those individuals who do inject drugs you can use the FTC/TDF, which is 74% to 84% effective. There is a generic that is available for our FTC/TDF right now. And there is not a generic available for our FTC/TAF.

I want to make mention some of the things that may concern providers as they look towards providing PrEP services to their patients. And there is some concern about bone and renal health. But those differences are very small, and those changes are usually very small. And so based on your patient population, oral medicine may be more effective or more, or better for your particular patient than the other.

Remember that our FTC/TDF does have an increase in bone issues as well as renal. But other side effects are negligible. There is some higher rates of triglyceride elevation and weight with our FTC/TAF vs our FTC/TDF. But these are things that, again, as we treat our patients, give them medications for other disease entities that we check that we give the best option possible for them.

[00:40:56]

PrEP CAB vs FTC/TDF

So I just want to mention, there has been, some studies, and it's the HIV prevention trials network study. Two studies that, 1, the 083 were done with men who have sex with men and transgender women, as well as the 084 that had cisgender women.

And this comparison is for FTC/TDF vs CAB, the injectable version. And it found that the injectable, the CAB had superior efficacy compared to the daily oral. And you think about it, you know, you're given a shot that lasts a few months vs someone who is having to take a pill every day, you know, there could be some issues with that. So, again, recognizing that this study did show superior efficacy in our injectable form.

Renal and weight was very small, but pretty much similar side effects between the 2. And there is no generic available in our injectable formulation. But again, there is a generic for our FTC/TDF. And then again, our FTC/TDF is a daily medication vs our CAB injectable, which lasts over a couple months.

[00:43:10]

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

I want to talk about our on-demand PrEP, which is another option. It is not FDA-approved but is recommended by the International Antiviral Society. And it is the opportunity for those individuals who, you know, may fit into this population, the cisgender men who have sex with men. You'll take 2 pills, 2 to 24 hours before sex. So you kind of have to know what's going to be happening over the next 24 hours. And this could be those individuals who may be on vacation and know that something's going to happen.

And then it will be 1 pill 24 hours after the first 2, and then another 24 hours after that, 1 more pill. So, 2, 1, 1. And you have to make sure that this individual or that you may prescribe this particular regimen for does not have hepatitis B, and that they will be adherent to this particular regimen.

[00:44:31]

PrEP Guidance: CDC

So this is a really busy slide. And so the bottom line is this is the CDC's guideline, for who is eligible for PrEP. All sexually active adults and adolescents should be informed about PrEP for prevention. And for anyone who asks about PrEP, should be able to acquire PrEP. It talks about, if you have a partner who has HIV or if you have 1 or more sex partners of unknown status, or you had a bacterial STI within the 6 months, the bottom line is everyone should have the opportunity to be offered and prescribed PrEP.

[00:45:22]

Posttest 3

So let's go back to one of the questions that we asked previously. Which of the following individuals is not an appropriate candidate for PrEP?

1. 24-year-old cisgender woman recently diagnosed with gonorrhea;
2. A 30-year-old transgender man who reports sex with both men and women;
3. A 60-year-old cisgender recently divorced after 30 years of marriage, and now dating again; and
4. A 40-year-old woman who has been married for six years, reports four lifetime partners, and ask for PrEP and then; the last
5. All of these individuals are eligible for PrEP.

Hopefully, the polls have been open, and we'll see what responses we have.

Zachary Schwartz: Yeah, it looks like we've got enough results, so I think we can close the poll and show the results.

Dr Stewart: Alrighty. So as we can see from the last slide, hopefully. We missed a few people that all of these individuals are eligible for PrEP. So thank you. So another question. Go [inaudible] individual who asks for PrEP should be prescribed PrEP. Any individual who is sexually active should be informed about PrEP and given the opportunity to be prescribed PrEP. So all of these individuals are eligible for PrEP.

[00:47:34]

Case: Assessing PrEP Candidacy

So let's kind of look at again, you know, how do we access PrEP candidacy? You know, going back to that case, you're providing care for 34-year-old Black, heterosexual, cisgender woman who's been married for 6 years. She tells you that she's had 4 lifetime partners and is not engaged in extramarital sex. Her friend has begun PrEP, and she would like to know if she can start PrEP as well.

[00:48:09]

Posttest 4

So, going back to review of our previous couple slides, you know, how would you counsel this person about PrEP.

1. Explain that she's not a candidate, she's not at high risk of acquiring HIV;
2. Explain that she is not a candidate, but probe further to see if you can find a HIV risk factor that she is not sharing with you;
3. Refer to sexual health clinic the most appropriate place for obtaining PrEP; and
4. Provide PrEP now with educational support and answers to her questions.

Hopefully, the poll has been open, and we will see what responses we have.

Zachary Schwartz: Yeah, I think we have enough there. Slowing down. So, let's show the answers here. A little teaching I need to reinforce if needed.

Dr Stewart: Yes. So the majority of folks, you know, said provide PrEP now with educational support and answers to the questions. Again, anyone who asks, because you don't want to try to have to probe and - and figure out, you know, what is going on with them. You know, according to those CDC guidelines, all sexually active adults and adolescents should be informed about PrEP for prevention of HIV and anyone who requests it should be prescribed it.

[00:49:52]

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

So, bottom line, this is a busy slide, and we don't need to go into the weeds on this, but HIV testing needs to be done prior to initiation of PrEP. And there are, you know, differences in, you know, what tests you need to offer based on how that patient presents to you or that client presents to you. And so this talks about, you know, the individual who has not been on oral PrEP or PEP in the last 3 months. No injectable PrEP in the past 12 months.

The bottom line is you need to make sure that you have a negative. And the best test is the HIV antibody antigen plasma test laboratory, which is the fourth with the reflux. And that's a fourth-generation task and that is more accurate. And so again, you want to make sure that that individual is HIV negative.

[00:50:56]           

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

So, our next slide, you know, talks about that individual who has been on PrEP in the last 3 months. May have taken some time off, was on the injectable, and in the last 12 months, and so, again, may have missed that follow-up. Remember, I talked about consistency and how important that is. You would do a few other tests to ensure that patient is HIV negative. And 1 of those tests would include a quantitative or qualitative HIV-1 RNA assay. So you want to make sure that this individual does not have HIV.

[00:51:41]

How Long Does PrEP Take to Work?

So 1 of the questions that many individuals who we prescribe PrEP to, you know, so I started off PrEP, how long before I am protected? And sometimes you can't give a great answer depending on the way that that individual—or the what parts of their body that they use in addition to which formulation you're using.

So, for daily oral PrEP, for receptive, anal sex bottoming, the maximum HIV protection is after about 7 days of consistent daily use. And for individuals who participate in receptive vaginal sex and injection drug use and maximum HIV protection is reached about 21. Again, consistent, 21 days of daily use. For insertive anal sex topping or insertive vaginal sex, there's no data on that. And for individuals who are using the injectable formulation, there's no data available for that as well.

[00:52:55]

PrEP in Practice

So, how do we get PrEP into practice?

[00:53:04]

Patient Testimony: Video 1

I would love for you all to hear actually testimony from Michael Chancley, and you know, he's going to talk about how PrEP impacted his wellbeing and in this next couple of slides. So I'm going to play the video.

[00:53:27]

“ How Has PrEP Impacted Your Well-being?”

Michael Chancley (PrEP4All): Typically outside of routine HIV testing, which was rapid testing at community-based organizations, I didn't engage the healthcare system. So 1 of the things that starting PrEP did was actually got me to engaging 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 rather 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.

[00:54:34]

Mechanisms to Improve Conversations About PrEP

Dr Stewart: Awesome. So how can we improve our conversations about PrEP. PrEP needs to be normalized as a prevention option for anyone who is sexually active or plans to be. It's important that we initiate the conversation and have that build. As Michael said, you know, build that report and trust within that patient–provider or patient–clinician relationship.

You know, provide person centered care. You know, make sure that you're making that shared decision-making between you and the provider or you the client or patient and that provider or individual who is providing that care.

Promoting cultural competency and humility and, you know, avoid that stigmatizing language. One of the ways to improve conversations also is to make sure that you set up a safe space. Promote representation of racial and ethnic minority and transgender people that display signals of acceptance. Wear pride pins on your clothing or, or talk about and have, you know, your staff and individuals display pronouns on their ID tags and making sure that sexual health is part of the regular health in that person's whole health.

[00:56:12]

Tips on Taking a Sexual History

And, you know, just a few tips on taking that sexual history, because if you don't have that conversation about the sexual history, you have no idea whether that individual can benefit from PrEP, or is afraid to even talk about it.

You want to promote a comfortable and nonjudgmental environment. Don't assume—don't make any accusations or assumptions about gender, gender identity, or pronouns or sexual orientation. And, you know, avoid asking unnecessary information that will turn individuals off, you know, asking them their number of partners or frequency of sex. You know, instead ask, "Are you having sex? Do you want to be having sex? What type of sex or what body parts are you using?"

[00:57:06]

Patient Testimony: Video 2

So let's turn to Michael and see how he experienced the non-judgmental approach.

[00:57:18]

“Importance of Nonjudgmental Approach”

Michael Chancley: 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'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, I've had providers who may pass judgment if they find out I engage in condomless sex.

And 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 DoxyPEP 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 thinking about what resources you could provide to make sure that someone is engaging with their sexual healthcare in a way that's patient-centered and healthy.

[00:58:47]

Tools for Overcoming Implicit Bias

Dr Stewart: No, that is great. And, you know, Michael talked about some really important things. We need to really meet our patients where they are and, and avoid being judgmental. We forget that implicit bias exists and that's that unconscious attitudes perspective or stereotypes that we all have in some way.

In some ways that we can really address this is to be culturally humble admitting that you don't know certain things about one's culture or ethnicity, and be willing to learn. And that's really important.

Another way is to, you know, making sure that you're culturally competent. And that really is like a training. It's just mastery and humility. Making sure that you cultivate that person-centered care. We need to really meet our patients and our clients where they are.

[00:59:59]

Representation Matters

And let's not forget that representation matters. It has been proven that individuals who care for you, who look like you, who care for individuals, who have that concordance of race or ethnicity, they do better. So racial concordance between patients and healthcare, clinicians can improve communication, increase trust, and adherence to medical recommendations.

[01:00:29]

Patient Testimony: Video 3 and 4

So let's turn to Michael again and talk about how, you know, he values that relationship with a supportive PrEP provider.

[01:00:44]

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

Michael Chancley: Sometimes when your insurance changes, you have to build a rapport with a 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 1 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 re-engage in PrEP care. 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 - 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 who I can like, actually talk about my sexual health not just open a door that's 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 next 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 screen."

Dr Stewart: Yes. And - and it's important that we not forget that sexual health is part of overall health. So let's hear from Michael again.

Michael Chancley: 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, this, my past experiences have been with accessing PrEP, and I want the same quality of service as I move forward with accessing it." And I don't think I would've been able to do that without a provider who really showed me like, what good PrEP care looks like.

[01:02:39]

Potential Solutions for PrEP Engagement/Access Barriers

Dr Stewart: Awesome. So what are some of the solutions? You know, we talk about the issues. You know, we need to really talk about some of the solutions to increase PrEP engagement and access. One is through PrEP navigation. Two is the use of telehealth, and then 3, that same day PrEP initiation.

[01:03:02]

PrEP Champion/Navigator: Promoting PrEP Uptake and Persistence

So, you know, we have current challenges. When we talk about different clinicians, you know, being willing to offer the service. If you don't have the personnel to really get it into PrEP management and to keep individuals in the care and keep them engaged, then you lose opportunity. And then you have to have buy-in, you know, buy-in from the - the whole leadership. And then you have to make sure that you're able to retain those individuals and keep them engaged and keep them on PrEP.

One of the solutions is to designate that PrEP champion, that PrEP navigator. It strengthens communication and leadership. It uses that proactive approach to increase PrEP navigation and retention. And then you have the opportunity to train other providers and PrEP coordinators to really meet the needs of the patient.

[01:04:03]

Same-Day PrEP Initiation: A Strategy to Improve Access

And then, of course, you know, if you have the opportunity, if we can get people as soon as they walk into that door, get them started on PrEP and keep them on PrEP, then that takes away 1 of the other barriers. Reasons to consider the same day PrEP is, you know, to increase, number 1, that retention, and give them that first prescription soon as they walk - they're able to get that soon as they walk into the door. It increases that PrEP access and delivery by decreasing the number. You know, you don't want them to have to come back and receive a - a prescription.

Remember, we have geographic deserts of PrEP, and if they can't get back, because they have to travel long distance, this is a way to be able to address that really difficult issue. Some reasons not to try to do the same day PrEP service. If you have barriers such as lack of payment options, can't provide that continuity of PrEP, you may not have laboratory services. And then when you look at our patients, if they have a history of renal disease or, you know, they have that possibility of acute HIV infection, you don't want to get them started on PrEP that day. You want to do further testing and then making sure you have an ability to follow them up if you have abnormal lab result. If you don't, then you may not want to use same day PrEP initiation in those particular cases.

[01:05:43]

Creating Change: Education of Patients and HCPs Is Key to Addressing Inequities in PrEP Uptake

So here we are, you know, how can we create change? Number 1, we need to educate our patients as well as our healthcare providers to be able to address the inequities and PrEP uptake, you know, provide that community-based education to raise awareness, to combat that implicit and unconscious bias, and to instill trust, as Michael talked about so importantly, instill the trust in the healthcare system.

Have more individuals who look like the patients who are - are disproportionately impacted by HIV, such as our Black and Latinx individuals. Have them as healthcare providers, and they can be that trusted source of knowledge and of care. Address those unfound beliefs about, you know, risk compensation that feed reluctance to receiving PrEP and have positive messaging to patients via social network and social media to improve that knowledge and attitudes and reduce the stigma that exists within our communities and also within individuals themselves.

Support preventative messages for HIV and STIs through monitoring and testing and discuss all available options to promote that patient-centered care. Remember, we have different formulations for patients to be able to use, to provide that protection from HIV, and you want to make sure it matches what that patient needs. And Michael talked about that a number of times in his video.

[01:07:30]

Break Down the Barriers

And we need to break down these barriers. You know, PCPs have a key role in expanding PrEP access and uptake. You know, making sure that we increase the awareness education training. Again, address implicit bias and stigma, you know, expand Medicaid. We've seen that there's many areas who have expanded their Medicaid, and those areas, those states have had an increase in individuals who have been able to access PrEP.

Unfortunately, out of the 10 states that have not expanded Medicaid, South Carolina where I live is 1 of them. Consider transportation needs. Remember those issues with transportation and that geographic barrier that we have. Expand clinic hours. Making sure we meet our patients where they are, and then employ our PrEP champions and navigators and engage community workers. Those individuals within the community who can help us to help our patients and our clients be able to not only get on PrEP, but stay on PrEP.

[01:08:49]

PrEP Certification

And so for those individuals who are interested, there are some ways that you can learn how to be a certified PrEP provider. And so, please make note of HealthHIV, HIV prevention certified provider certification program. It's an online self-pace, CME-accredited certification program composed of seven 60-minute modules in HIV prevention, detailing the pertinent clinical and practice information that clinicians need to know to effectively employ HIV prevention interventions.

[01:09:36]

Poll 4

And so for those providing PrEP care, how many patients do you expect to discuss PrEP within a typical week?

1. Zero;
2. B. One to five;
3. Six to 10;
4. 11 to 25;
5. 26 to 50;
6. Greater than 50; and
7. Not applicable.

Let's open up the polls and see what we come up with.

Zachary Schwartz: Great. I think the answers are slowing down. So let's close the poll and have a look.

Dr Stewart: Right. Okay, we still got some, not applicable. One to five, 24%. Six to 10, 19%. 11 to 25, 12%. And still small number that are over 50. So hopefully, you know, we will - if we - when we have this next webinar, everybody be able to discuss PrEP to all their patients as part of the health and - health of the patient, as well as the health of the community.

[01:11:04]

Posttest 1

So going forward, I plan to have a significant role in expanding PrEP uptake in my community.

1. Strongly disagree;
2. Disagree;
3. Neither agree or nor disagree;
4. Agree; and
5. Strongly agree.

Let's open up the polls.

Zachary Schwartz: Okay. I think the polls have slowed down, so let's have a look. Lot of people in agree and strongly agree. That's good.

Dr Stewart: Great. Awesome.

Zachary Schwartz: I think we can move on, yeah, to the final question.

[01:11:54]

Posttest 2

Dr Stewart: Alrighty. I have clear steps I can take to overcome the barriers to PrEP amongst racial and ethnic minorities in my practice.

1. Strongly disagree;
2. Disagree;
3. Neither agree nor disagree;
4. Agree; and
5. Strongly agree;

Let's open up the polls and see what we got here. All right. Got more agree and strongly agree. Thank you. Thank you. Thank you.

[01:12:41]

Question and Answer Session

Zachary Schwartz: Great. Well, I want to - we're going to ask some questions in the background. But while we're doing those questions, I wanted to thank  Dr Stewart and thank everyone here for - for joining in. We only have time, I think for maybe 1 question,  Dr Stewart. I'm scanning through these. A lot of people thanking you for these questions. I see 2 themes. One is asking about encouraging PrEP for straight men and women, and convincing Black folk that someone on PrEP is not overly sexually active, but they're actually being responsible. So there's a question about, or a statement about - about that difference.

And also a question we got earlier about, will the guidelines gear towards, say, mention state that PrEP is appropriate for cisgender women because they say that the guidance is gearing towards men who have sex with men or transgender people? I don't know if you want to comment on either of those things.

Dr Stewart: Yeah. So I'll quickly comment on that. You know, the important thing, and 1 of the things that I really want to emphasize is this, that having that, that conversation about PrEP to everybody. And that's why primary care individuals, individuals in different spaces, you know, need to have that conversation with everyone who walks into the door, whether they're, you know, cisgender females, whether they're, you know, a man who have sex no matter what you, you know, where you find your pleasure ensuring that everyone has access to PrEP. We have to, you know, continue to, you know, change that narrative especially for Black women.

You know, we are, you know, disproportionately impacted, as far as women is concerned with HIV and most of the marketing initially was for, you know, men who had sex with men and especially White men. And so changing that narrative, and so many organizations are out there now trying to market more towards cisgender females as well as, you know, making sure we look at those men who are - have heterosexual sex as they - their form of pleasure. You know, everyone - everyone needs - if you're having sex, then you need to have the opportunity to protect yourself and to get on PrEP. And 1 of the ways is through having those conversations with everyone normalizing it with everyone who walks into your door, everyone that you come in contact with, and giving them the opportunity to make that informed decision.

[END OF TRANSCRIPT]