As the health care landscape evolves, providers must stay informed about impactful practices that improve patient access, outcomes, and health equity. Former White House physician Dr. Jennifer Peña, medical director at Q Care Plus (an Avita Care Solutions company), recently offered stakeholders tips for navigating the opportunities, challenges, and crucial considerations associated with PrEP. Read on for the webinar transcript, which explores how to promote PrEP to patients while supporting their sexual wellness, best practices for scaling telePrEP to underserved populations with limited resources, and more!
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*Transcript edited for length and clarity.
Dr. Jennifer Pena: Hello to everybody joining and thank you for the privilege of your time today. I’m grateful for this opportunity to share insights about PrEP and telePrEP and lessons learned from the front lines.
I’ve spent the last four and a half years working in telehealth, including for platforms focused specifically on sexual and reproductive health. It’s taught me about the huge need our country has to address access to health care gaps, especially concerning PrEP and HIV care. It’s motivated me to innovate on these models of telehealth. Let’s dive right into it with some basic PrEP stats. After that, we’ll get into PrEP care continuum basics, and then overview telePrEP and PrEP care.
Important PrEP stats
Dr. Jennifer Peña: Significant improvements in PrEP were made between 2012 and 2021. Over 300,000 people in the United States use some sort of form of PrEP today. CDC data shows that in 2020, about 25% of the 1.2 million people for whom PrEP was recommended were prescribed it. That’s compared to only 3% in 2015. This is a huge improvement, and the CDC has called for a further rapid scale-up of PrEP services. Doing so will help us reach individuals at high risk of HIV infection and reduce new HIV transmissions. It will also improve the potential cost-effectiveness of PrEP because if we achieve economies of scale, we’ll reduce the overall cost of PrEP provision and, at the end of the day, have a greater public health impact.
Again, it’s important to reiterate that there has been a significant increase in the number of PrEP users in the U.S., up 20% from 2021 to 2022. And we continue to see that trend, a consistent growth in PrEP use since 2012. There are some important things to note, however. The South accounted for 52% of HIV diagnoses but only 38% of PrEP users. There’s an access to care issue in terms of PrEP use.
In 2022, states that expanded Medicaid programs had an average PrEP use rate that was 1.4 times higher than states that did not expand Medicaid. In terms of PrEP use by gender and sex, among all the PrEP users in the U.S., 92% were male, and only 8% were female. This is despite the fact that women comprise 18% of new HIV diagnoses in terms of PrEP use by age. Teenagers and young adults aged between 13 and 24 had the greatest unmet need for PrEP among all age groups. A full 64% of all PrEP users were between 25 and 44 years of age.
The PrEP rate use per 100,000 people was highest in the 25 to 34 age group and lowest in the 55-plus age group, again showing there is still a need for outreach to those age groups on both ends of the extreme. In terms of PrEP use by race and ethnicity, the Black community represented 14% of PrEP users but 42% of new HIV diagnoses. So again, there’s still a big need in that population, as well as the Latinx community, which represented 17% of PrEP users and 27% of new HIV diagnoses, and white people, which represented 64% of PrEP users and 26% of new HIV diagnoses.
What’s interesting here, and it’s near and dear to my heart because I just moved back to Puerto Rico, is that Puerto Rico was listed along with the top five states with the greatest unmet need for PrEP, including Mississippi, South Carolina, Alabama, and West Virginia.
If we achieve economies of scale, we'll reduce the overall cost of PrEP provision and, at the end of the day, have a greater public health impact.
PrEP deserts
Dr. Jennifer Peña: Let’s talk about PrEP deserts, defined as geographic areas or communities with limited access to PrEP. This has several implications for HIV prevention and health equity. These PrEP deserts contribute to disparities in HIV incidence because those living in these areas don’t have as much access to PrEP. PrEP deserts also tend to coincide with areas where awareness and education about PrEP may be lacking. That’s on the patient and health care provider’s side. This lack of accessible PrEP services can reinforce misconceptions and biases.
PrEP deserts also tend to increase stigma toward PrEP and perpetuate negative attitudes toward individuals at high risk for HIV. So, it’s important to identify these areas and focus on expanding and advocating PrEP services, education, and awareness. We must tailor outreach programs, engage with the community, collaborate with local healthcare providers, and improve insurance coverage and reimbursement support. All those things can help bridge the gap in PrEP access in these geographical deserts.
A lack of accessible PrEP services can reinforce misconceptions and biases
The continuum of PrEP care
Dr. Jennifer Peña: Let’s talk a little bit about the continuum of PrEP care. What does that mean? It’s a comprehensive approach that includes a range of services and interventions that help provide HIV prevention to high-risk individuals. The continuum of PrEP care involves the preclinical, clinical initiation, and follow-up stages of care.
At the preclinical end, we do a risk assessment, which involves assessing the patient’s risk factors for HIV. We provide education about PrEP and HIV transmission. Once you get into the clinical stage, you’re doing your PrEP screening and evaluation. Essentially, at this point, you’re assessing an individual’s eligibility for PrEP, testing for HIV and other STIs, and checking kidney function, overall health status, and eligibility for PrEP initiation. Then you move on to the initiation stage.
If you deem the patient eligible for PrEP, they are typically prescribed an oral pill containing a combination of two antiretroviral drugs. This step also includes providing information on proper medication use, potential side effects, and stressing the importance of adherence.
During the follow-up stage, there is ongoing monitoring and support. This isn’t a one-and-done deal. Once on PrEP, patients require regular follow-up visits. This may involve HIV or STI testing, monitoring for kidney function, assessing adherence, and addressing any side effects or concerns the patient might have. Follow-up also includes risk reduction counseling. We must encourage people to adopt and maintain other risk reduction strategies in addition to PrEP, such as consistent and correct condom use to prevent other STI acquisitions, regular STI testing, and the overall reduction of risky sexual behaviors.
This isn't a one-and-done deal. Once on PrEP, patients require regular follow-up visits.
Adherence, access, and affordability
Dr. Jennifer Peña: Bridging barriers is how you facilitate PrEP adherence. Knowledge and access are the first barriers. It’s essential for people to have accurate information about PrEP. It behooves us as clinicians to make sure we’re educating and raising awareness to address misconceptions that can impact adherence.
Access and affordability are also significant barriers. We must ensure folks have access to health care facilities, can obtain prescriptions, can afford the medication, and can get help if they have issues with insurance coverage.
We talked a little already about geographic locations and PrEP deserts. If patients don’t have access to PrEP close by, we need to help them find the nearest clinic or a telePrEP service that can service them. Stigma and discrimination surrounding HIV and sexual health can also discourage people from openly seeking PrEP services. We must reduce stigma and create supportive environments.
The presence of side effects also can be disconcerting to people. We must manage expectations with our patients and let them know that most of these side effects are temporary, and that very adverse, significant effects are rare. As health care providers, we can help patients address these side effects through appropriate support and education. We must develop good patient-provider relationships to establish open communication and trust.
Bridging barriers is how you facilitate PrEP adherence.
Key patient messaging about PrEP
Dr. Jennifer Peña: If I had to summarize my key message to patients about PrEP, it’s that PrEP is safe and effective, but only if you use it consistently and correctly. Adherence is important, and we have to ensure that patients stick with it, emphasize the importance of other prevention strategies, and encourage them to use condoms and test for STIs and HIV regularly. Routine testing is going to help us ensure patients remain HIV-negative and allows for early detection if breakthrough infections do occur.
We must encourage people to keep a regular cadence of follow-up while they’re on PrEP. This is important for many reasons, including that the monitoring allows us to continually educate patients, answer questions, and conduct appropriate screenings. If you have patients who are pregnant or planning to become pregnant, it’s important that they understand the implications of PrEP on their pregnancies. Explain that PrEP can be used safely during pregnancy and can help protect the baby against HIV transmission.
It’s important for providers to encourage patients to have open and honest communication with sexual partners about PrEP use for HIV prevention, and it requires mutual support and shared responsibility in the prevention of HIV.
If I had to summarize my key message to patients about PrEP, it’s that PrEP is safe and effective, but only if you use it consistently and correctly.
TelePrEP: Convenience and cost savings
Dr. Jennifer Peña: Let’s talk about telePrEP. It’s the remote provision of services for PrEP using telehealth technology, and it can help improve traditional PrEP uptake and adherence. Most importantly, it helps with accessibility and convenience. TelePrEP is a game-changer for people who live in remote, underserved areas and have limited access to health care facilities.
TelePrEP also reduces patient stigma and privacy concerns. Many patients say they feel much more comfortable discussing their sexual health and PrEP needs in a private, secure telehealth environment instead of going into a brick-and-mortar clinic. TelePrEP also allows for a timelier initiation of PrEP care and allows folks to conveniently maintain regular follow-up visits and prescription refills through remote consultations.
TelePrEP can also offer cost savings. We’ll talk about reimbursement in a bit, but for patients, it reduces the need for in-person visits, transportation, and time taken off work. From the provider’s point of view, telehealth consultations can be a lot more efficient to schedule, which allows providers to see more patients and increase their cost-effectiveness.
It’s important to note that telePrEP is not a panacea. It won’t always be a perfect full replacement for in-person visits or clinical services. But as with other telehealth modalities and services, it can complement traditional models very well by offering expanded access and convenience.
TelePrEP is not a panacea. It won't always be a perfect full replacement for in-person visits or clinical services. But as with other telehealth modalities and services, it can complement traditional models very well by offering expanded access and convenience.
The telePrEP care journey
Dr. Jennifer Peña: In the telePrEP care journey, the patient gets an initial assessment and is scheduled for a consultation. This can be done through video, phone, a text-based consultation, or a hybrid of those modalities. Providers then assess a patient’s risk factors, discuss PrEP eligibility, and address any questions or concerns. Next, laboratory monitoring and testing can be done remotely or completed at a brick-and-mortar lab.
The provider discusses test results with the patient and offers follow-up recommendations. Next comes prescription medication management, where the provider electronically sends a patient’s prescription to the individual’s preferred pharmacy or via mail order. Finally, providers check in with the patient at an established cadence. During these check-ins, they evaluate medication adherence, discuss concerns, and adjust the care plan as needed. Not everybody’s journey is the same.
There are various types of telePrEP programs across the United States, but they all leverage technology platforms to provide remote access to PrEP services. There are national companies that focus on telePrEP, hospital system-based telePrEP programs, state-run telePrEP programs, and lab companies that provide telePrEP programs via at-home self-collection lab kits.
Not everybody’s journey is the same.
How pharmacy providers complement telePrEP programs
Dr. Jennifer Peña: Let’s talk about pharmacy providers and how they complement telePrEP programs. Pharmacy providers have a robust presence across the country and can help optimize patient PrEP access, adherence, and support.
There’s nobody better than a pharmacist to counsel patients on side effects and adherence, answer prescription insurance questions, or help with payment assistance programs. They tend to be subject matter experts in these areas.
It’s important that pharmacies collaborate with health care providers and prescribing providers from PrEP clinics to ensure a comprehensive, coordinated patient care approach.
Pharmacy providers have a robust presence across the country and can help optimize patient PrEP access, adherence, and support.
Challenges associated with telePrEP
Dr. Jennifer Peña: TelePrEP is not perfect. It has challenges, but there are also potential solutions. The first and foremost is limited access to technology. I’ve been joking around with our team that I’m in Puerto Rico, where it’s raining, so I might lose WiFi in the middle of this webinar. One of the main challenges with telePrEP is ensuring that individuals have access to the technology, like smartphones or computers, to participate in their telemedicine visits.
Organizations and clinicians must provide inclusive solutions and alternative options to people without these technologies. You might have to leverage phone consultations for some patients versus WiFi-based care if the patient has no access to the Internet. Digital health literacy is huge. Some patients may have limited familiarity with telemedicine platforms, so we must provide user-friendly interfaces and clear instructions to help people feel confident about using these technologies.
We also must stress confidentiality in telehealth, especially as it relates to sexual health and PrEP. This means managing encrypted platforms and secure physical examinations and lab testing.
TelePrEP allows for the timely filling of prescriptions, but we must collaborate with our pharmacy partners to ensure prescriptions are being filled efficiently, including mail-order services and local delivery.
We also often encounter reimbursement issues for telemedicine services, and some providers face a challenge in receiving the appropriate compensation. We must advocate for equitable reimbursement policies and collaborate with payers to establish coverage guidelines.
Finally, establishing good provider-patient relationships can be a little tricky in telehealth. We must teach our providers to listen actively and provide clear patient communications to make telemedicine visits as friendly as possible.
TelePrEP is not perfect. It has challenges, but there are also potential solutions.
Considerations for implementing a telePrEP program at your organization
Dr. Jennifer Peña: To run successfully, organizations’ telePrEP programs require integrated workflow techniques and change-management skills. First comes a readiness assessment, in which you consider your organization’s ability to establish a telePrEP program. Do you have the appropriate tech infrastructure, staff capacity, licensure, and demographics? Does your team need training? What’s your patient population going to look like? And, of course, there are legal and regulatory requirements.
Organizations must make sure from the beginning that their leadership team has bought into the idea of starting a telePrEP program and are part of the strategic planning and decision-making process. There must be a coalition between the clinical team and leadership to garner success. You must have a detailed roadmap for your telePrEP integration, define your goals and KPIs, and stick to them as you monitor outcomes.
It’s critical to determine the scope of your telepractice, including the modality of care you’re going to use and your target patient population. Establish achievable timelines and keep your organization in check by carefully monitoring your progress.
This next consideration tends to be a touchy subject across telehealth platforms in general: Organizations must foster cross-functional collaboration across teams, especially when it relates to IT product teams and clinicians. This is an essential relationship in telePrEP programs because so much of the product and IT support is crucial for appropriate care delivery. We must teach these teams how to translate engineering into clinical speak and vice versa. That can be challenging but also rewarding. Consider fostering mentorship programs and peer-to-peer learning opportunities.
Organizations must make sure from the beginning that their leadership team has bought into the idea of starting a telePrEP program and are part of the strategic planning and decision-making process.
The technology behind compliance and continuous improvement
Dr. Jennifer Peña: I cannot stress enough the importance of regulatory and legal compliance, especially in a post-PHE (public health emergency) environment. You must have a strong compliance cohort that ensures you’re compliant with relevant regulations because these vary state by state and are changing rapidly. The compliance cohort must stay updated with federal, state, and local regulations related to your programs. Telehealth, privacy, security, and reimbursement are all crucial components.
You also need to ensure your program is regularly evaluated for continuous improvement. That doesn’t only mean program effectiveness and patient satisfaction but also clinical outcomes and quality. Quality assurance assessments are paramount. Data drives outcomes. Ensure that your platform allows your team to access data easily and continuously, so you can implement necessary adjustments for process improvement.
You must have a strong compliance cohort that ensures you’re compliant with relevant regulations because these vary state by state and are changing rapidly.
Workflow changes that accommodate telePrEP
Dr. Jennifer Peña: Here are some workflow changes to consider when implementing telePrEP appointment scheduling. Make sure to adjust the scheduling system to accommodate telemedicine visits. Include tech time because glitches happen. Consider virtual waiting rooms to ensure people have sufficient time to maneuver across the platform. Send patients appointment reminders to reduce no-show rates. Send pre-visit instructions for easy access to the platform.
Also, perform tech checks, check connectivity speed, and test that patients can easily log in. It’s amazing how efficient the process can be if you follow these easy steps. Don’t forget to create a seamless intake and registration process. This process should be easy and streamlined. Collect data ahead of the appointment. Consider allowing for patient self-reported registration, or have a medical assistant help you collect registration information ahead of time.
Good record-keeping is also essential. You’ll need a strong electronic health record (EHR) system and templates to document tools like dot phrases. Make it easy for providers to document encounters. Templates allow your organization to ensure that all important visit components are accounted for, which makes the process more efficient.
It’s critical that your EHR is integrated with your telehealth platform. Aim for click reduction for providers. You don’t want your providers to have five platforms open. You want to try to consolidate and integrate those platforms.
You should also integrate your e-prescribing software into your EHR platform. That’s the best way to coordinate care with your pharmacies and make sure prescriptions are being filled correctly and efficiently. The same goes for your laboratory. Create established lab workflows, collaborate protocols with local laboratories or self-collect options at home, and make sure that specimen collection is done seamlessly. Communicate and document test results and state-mandated reporting when needed.
Aim for click reduction for providers. You don't want your providers to have five platforms open. You want to try to consolidate and integrate those platforms.
Addressing health equity gaps
Dr. Jennifer Peña: There are obvious implications for health equity when it comes to telePrEP. But even though telePrEP helps us address health equity gaps, it also can exacerbate them if we’re not doing things correctly. As we discussed, you must ensure patient access to technology. Don’t create more barriers for individuals if they don’t have these resources. Get creative and leverage the phone or other solutions if needed.
We must make efforts to address the digital divide and empower digital health literacy. Don’t miss an opportunity to educate your patients. Leverage social media, blogs, videos, influencers, and step-by-step guides. We also need to offer culturally and linguistically appropriate options to accommodate diverse populations. Hire a diverse staff, train for cultural competency, and use language interpretation services.
Don’t forget your marginalized and stigmatized populations, such as people with substance abuse disorder and ethnic minorities, who face additional barriers in stigma when seeking PrEP. Some people might not have coverage for telePrEP programs, and we should explore alternative payment options for these individuals. Build trust and relationships with your patients because, at the end of the day, fostering good communication will help you succeed.
We must make efforts to address the digital divide and empower digital health literacy. Don't miss an opportunity to educate your patients. Leverage social media, blogs, videos, influencers, and step-by-step guides.
PrEP Q & A session
What are the implications for different modalities of telePrEP care, for example, asynchronous versus synchronous, especially in a post-pandemic landscape?
Dr. Jennifer Peña: I love this question because the PHE recently ended, and since then, there have been many changes in telePrEP and telemedicine in general. As an organization, pick a modality that serves your patient and provider populations best. Choose a model that you’re going to implement. Follow the steps we just discussed.
You can choose to use a hybrid model. In fact, I would argue that you should allow for fluidity and flexibility because, in my experience, hybrid models tend to offer the most comprehensive services. Also, think hybrid when it comes to communication technology (for example, internet vs phone services).
When it comes to choosing your modality, check the state-by-state regulations. I cannot stress this enough: Every state has its regulations regarding what’s deemed appropriate for the delivery of telehealth care. Some states still require synchronous encounters with patients, and others don’t. Some states require synchronous encounters for a certain number of appointments or at the initiation of the telemedicine encounter.
Think about the pros and cons for your organizational and business model goals. If you’re a business that wants to scale quickly, you might want to look at asynchronous models of care because those allow for quick scale. They also enable the capture and analysis of good data and metrics.
What does self-collection for labs look like? Is it generally accessible and easy for patients to do?
Dr. Jennifer Peña: There has been so much work done by companies producing self-collection lab tests, and it’s wonderful to see. That kind of service is badly needed in PrEP deserts where patients don’t have as much access to brick-and-mortar labs.
Traditionally the patient will get a kit in the mail. It will come with instructions on how to collect the sample. After it’s collected, the sample is repackaged and sent back to a laboratory for processing, and the results are translated back to the prescribing provider. Then the provider reaches out to the patient to review the results.
Self-collected labs often destigmatize the testing process because patients feel less apprehensive than entering a brick-and-mortar lab. It’s a great way to bridge the access to care gap.
What would motivate a patient to access PrEP via telehealth instead of a brick-and-mortar clinic? Are there traits or demographics that make a patient a better candidate for telehealth?
Dr. Jennifer Peña: When it comes to what motivates people to access PrEP via a telehealth platform versus visiting a brick-and-mortar clinic, the first considerations are convenience and accessibility. TelePrEP programs empower people to access PrEP from the comfort of their own homes or any location of their choosing. It’s beneficial for patients with busy schedules, limited mobility, or living in underserved areas without enough health care facilities.
Privacy and destigmatization are important drivers as well. TelePrEP allows patients to discreetly discuss their sexual health and PrEP needs. Some people are uncomfortable having those sensitive topics face-to-face with a provider. At the end of the day, telePrEP can actually enhance engagement between patients and providers.
People who are tech literate might be more comfortable with using telePrEP, but that doesn’t mean people who don’t have high tech literacy can’t be taught to do it.
Can you speak to the role of provider cultural competency when it comes to making patients feel comfortable with taking PrEP and adhering to it long-term?
Dr. Jennifer Peña: Cultural linguistic competency is a passion project of mine. That refers to providers’ ability to truly understand and respect cultural beliefs, values, and the diversity of practices in the populations we serve. That doesn’t mean we need to know them. That means we must be open to learning about them.
This contributes to building patient comfort and adherence to PrEP. Building trust is important and creates an environment where patients and providers feel heard, respected, and valued. It addresses stigma and discrimination, too, because it helps providers recognize that patients might feel uncomfortable sharing their sexual orientations or gender identities. They might not be as willing to share high-risk behaviors.
If you validate patients’ backgrounds and talk to them in their languages, you communicate in a way that helps reduce care barriers for them. Make sure you’re truly giving this some thought as you’re building your program. What is the patient cohort you’re targeting? Ensure there’s a concerted effort to honor cultural context when you’re creating patient educational materials and when you’re hiring and training your staff.
A recent CDC report shows that the rate of new HIV diagnoses is down, but that the Black and Latinx communities are falling behind in this trend. How is PrEP outreach to patients facing racial disparities crucial to the overall national effort to end the HIV epidemic by 2030?
Dr. Jennifer Peña: Many of the considerations we talked about throughout the presentation address this issue. For example, here in Puerto Rico, there is a lack of access to care and PrEP services, whether brick-and-mortar or telePrEP. When you look at PrEP deserts, often, their populations tend to be made up of racial minority communities. Improving access to care in those geographical areas will inevitably lead to an improvement in getting those communities better care.
We also just talked about cultural competency. Again, I’ll speak to a perfect example here in Puerto Rico, where Spanish is the predominant language, and there’s a cultural bias against HIV care and PrEP care. It’s going to take a lot of community education to get past that bias, and it starts at the provider level. Our providers must be culturally competent and help translate that into our patient populations.
Even though telePrEP helps us address health equity gaps, it also can exacerbate them if we're not doing things correctly.
About Jennifer M. Peña, MD, FACP
Dr. Peña is a board-certified internal medicine physician who has demonstrated an unwavering commitment to patient care throughout her career. Before transitioning from active-duty service in the U.S. Army in 2019, she served as a White House physician during both the Obama and Trump administrations and as a primary physician to the Vice President of the United States. With expertise in digital and telehealth, Dr. Peña is currently a Medical Director for Q Care Plus, an Avita Care Solutions company that offers telehealth access without stigma, utilizing technology to deliver compassionate care and eliminate health barriers.
Dr. Peña is also a physician consultant for URAC, a Fellow of the American College of Physicians (ACP), a member of the ACP Digital Health Advisory Group, the ACP’s representative on the American Telemedicine Association’s Advisory Group in Eliminating Healthcare Disparities and Inequalities, and a member of the Puerto Rico Telehealth Working Group.
