PrEPing Patients for HIV Prevention

Although the number of new HIV infections in Boston has been declining, over 150 people were diagnosed with a new infection in 2018. Boston Medical Center’s PrEP Program thinks that number should be zero, and they are hard at work getting there.

The program provides pre-exposure prophylaxis (PrEP) to patients at risk of being infected with HIV. PrEP – as a daily pill – prevents the transmission of HIV. As the only PrEP program with dedicated PrEP navigators in the region, the goal of the program is not just to provide PrEP to eligible patients. Rather, they aim to reduce barriers to getting the medication, as well as lessen associated stigma.

“Many providers have concerns about stigmatizing patients from marginalized populations, but data shows that these same communities have traditionally received less medical care, and therefore may not have had access to the prevention efforts,” says Cassandra Pierre, MD, MPH, a physician in the Infectious Diseases practice. “We believe that’s it’s part of health equity to be sure that our patient population is getting access to prevention tools, that they’re being screened appropriately, and that they’re getting treatment that they need.”

To reduce barriers, the PrEP Program’s guiding principle is that PrEP should be prescribed in places where people are getting their care. Therefore, patients either ask their physician for PrEP or are identified in a primary care visit. This determination is made by screening for a variety of factors, including sexual preferences, substance use, and whether or not a person has a high-risk sexual network. Potential patients are also identified by the PrEP Program team, who flag patients throughout the hospital with positive sexually transmitted infection (STI) tests, particularly gonorrhea and syphilis, which is another identifier of someone at a potentially higher risk of contracting HIV.

“We also try to reach people who may not fit what we traditionally think of as risk criteria,” says Jessica Stewart, the PrEP program coordinator. “We know for instance that the lifetime risk for a Black woman for getting HIV, regardless of sexual or substance use history, is one in 48, which is high. This isn’t a group that you might think of as high risk.”

Once a patient is identified as a candidate for PrEP, they receive testing to ensure they are eligible for the medication, including an HIV test, other STI testing, and kidney function tests; these tests must be repeated every three months for patients on PrEP. Patients also receive counseling about risk prevention and what PrEP does and does not protect against, as well as instructions for use.

Outside of the STI Clinic, most providers who prescribe PrEP are in General Internal Medicine, as well various other locations including Obstetrics/Gynecology, Family Medicine, and Faster Paths. The PrEP program itself consists of Stewart and several dedicated PrEP navigators. Together, they provide case management services, reach out to patients after a prescription is given, help resolve pharmacy issues, and ensure patients receive the follow-up care necessary to keep taking PrEP. The team also works closely with Jessica Taylor, MD, in GIM, and Pierre, as well as two nurse practitioners in the STI Clinic who prescribe PrEP.

Over the years, the PrEP Program has also worked to ensure that PrEP is accessible for all patients, working with insurance companies, the company who makes Truvada, and federal programs to lower costs of both the medication and required testing.

Since BMC began prescribing PrEP in 2013 – one year after it went on the market – over 900 patients have been started on the medication. However, Stewart estimates that there are potentially still thousands of patients at BMC alone who could benefit from PrEP.

To expand their reach, the PrEP Program plans to increase marketing and partnerships with community organizations, as well as providers at BMC and other institutions. In addition, a best practice alert will soon be going live in Epic that will show providers the testing guidelines for HIV. These call for at least one lifetime test for everyone, and more frequent testing for those at high risk of infection.

Stewart and Pierre also note that patients and providers don’t always assess risk adequately. Therefore, there could be other places where patients could be flagged as potential candidate for PrEP, such as needle exchange sites and methadone clinics. They hope that a focus on PrEP will expand to these sites, as well as to other academic medical centers.

“There’s a pervasive cultural misconception that PrEP is for men who have sex with men,” says Pierre. “While that is one group who can benefit, we want to expand awareness for patients and providers about who PrEP is for. We want to help patients with any risk for HIV, not just those at high risk.”