Pre-exposure prophylaxis, known as PrEP, is dramatically effective at preventing HIV infections. When taken correctly, the pill can reduce the risk of contracting HIV through drug injection by up to 74%, and through sexual contact by up to 99%.
But not enough people use it, health officials say.
Less than half of the Philadelphia residents most at risk for HIV actually take PrEP, according to the city's latest health data. Einstein Medical Center and the city's health department are seeking to change that with a new telehealth program, called Tele-PrEP, that connects patients with health care providers who can prescribe the medication free of charge.
"Our mission with the Tele-PrEP program is to provide accessible PrEP service to everybody," said Dr. Hussein Safa, the program's medical director. "For every background, every gender identity, every sexual orientation, regardless of even immigration status. It doesn't matter."
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Over the past decade, health officials have worked to remove the barriers that typically prevent people from accessing PrEP: lack of awareness, health insurance and stigma. In 2018, Einstein mounted an outreach campaign to educate prospective patients on HIV prevention, targeting the North Philly neighborhoods around the medical center. The next year, the federal government made PrEP free to the uninsured. With Tele-PrEP, patients now will have the means to access treatment from the privacy of their homes.
"There's still the stigma around being sexually active or around HIV," Safa said. "Some people feel hesitant to come in and talk about these things, to pick up a prescription from a pharmacy where they might feel like they're being judged. ... A big issue we encounter is people who are still on their parents' insurance (who are) worried about the consequences if someone finds out."
Tele-PrEP will work with patients to find treatment plans that work for them, Safa said. The service is hosted on Philly, Keep on Loving, the health department's hub for sexually transmitted infections and HIV prevention. The top of the Tele-Prep page offers two pathways. Users who aren't quite ready to book an appointment can start an online chat or talk via text to get further information. Those who are ready to proceed can schedule a video call with a doctor.
All patients must take an HIV test to confirm they're currently HIV negative, but they can stay at home for this part of the process, too. While patients are welcome to visit local clinics for the test, Tele-PrEP also offers a "discreetly packaged" HIV and STI test kit that is mailed to patients' preferred addresses. Once they've swabbed their gums and pricked their fingers for the blood samples, tests are mailed back to the lab for results.
After a televisit and negative test result, patients can receive their PrEP prescriptions, either via another discreet mailer or at a local pharmacy. Tele-PrEP will conduct three-month follow-ups to make sure the medication is working as intended, but those visits — like all the previous ones — are available online.
Safa said the program's grant money allows it to waive fees for the uninsured, as well as copays or lab fees for insured patients who can't afford the charges. This money also helps treat patients reluctant to use their insurance because they don't want the policy holder to find out.
By offering so many options, Tele-PrEP seeks to reach vulnerable populations that are typically underserved. Studies have shown that while the majority of patients using PrEP are white, HIV diagnoses are much higher among Black and Latino populations. In 2019, for instance, the CDC found that HIV rates among gay Latino and Black men were 5 to 10 times higher than rates among their white counterparts. Trans patients and women are also often overlooked, Safa said.
"Because of all the systemic issues of poverty and racism and oppression, these groups tend to be underinsured or uninsured," he said. "(They) don't tend to have easy access to the health care system. Sometimes there's also a lot of mistrust (after) they've interacted with the health care system and they've experienced a lot of trauma or judgement."
Safa is likewise hopeful the program will help reverse troubling trends seen since the COVID-19 pandemic began. The annual HIV in Philadelphia report found that HIV testing rates dipped dramatically in April 2020, shortly after the city's stay-at-home order, and while those numbers have gone back up, the health department still hasn't seen the same retention in care and viral suppression observed pre-pandemic.
"I think now as things are easing up, more and more people have been coming in for testing," Safa said. "In the last year or so, we've definitely caught a lot of undiagnosed STIs and even HIV. ... But I think definitely having the at-home test kit will increase that access."
Tele-PrEP has debuted just a few years away from a set of ambitious city-wide prevention goals. By 2025, Philadelphia aims to increase knowledge of HIV status, linkage to care and viral suppression to 95% among HIV-positive individuals. It also wants to decrease new HIV infections by 75%, and bring down rates of stigma and homelessness among HIV-positive individuals. Finally, the city is seeking to attain 50% PrEP coverage among those "indicated" for PrEP — meaning those especially at risk of HIV infection. According to the city, the most vulnerable populations include:
• Gay, bisexual and other men who have sex with men
• Black and Latina cisgender heterosexual women
• Youth 16 to 24 years of age
• Young adults aged 25 to 34
• Trans people who have sex with men
• People who inject drugs
• Sexual partners of people who inject drugs
• Needle-sharing partners
The city still has a ways to go on those goals, including the PrEP coverage. As of 2021, that number stands at 41.9%, but the picture is looking brighter than it did even a year or two ago, Safa said.
"Because (we wouldn't have been) addressing the issues that COVID has amplified, but I think now that is available, this is helping offer low barrier care," Safa said.
Now, Tele-PrEP just needs patients, and good word-of-mouth.
"I think if somebody has a good experience with us, they might tell other people in their community, you know, this is a good program," Safa said. "I'm really happy with the services I'm getting. I really felt heard and affirmed. (Then) more people will respect coming to us, and we can help get the people who need to be on PrEP on PrEP and lower the new rates of HIV diagnoses."
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