Challenges and Opportunities for Patients With HIV During COVID-19 - Episode 7
The impact of the COVID-19 pandemic on preexposure prophylaxis therapy for HIV and considerations for reengaging patients following a decline in utilization.
Mary Malek, PharmD, BCPS, AAHIVP: With the HIV risk assessment that we hold, we do this assessment for all our patients who are HIV negative, again for the homeless and transgender population. And, once we finish the assessment, patients are stratified into different groups, either high risk already on PrEP [preexposure prophylaxis], or high risk eligible to be on PrEP, or low risk, or even high risk and just not interested to be on PrEP. The results we've been seeing from this assessment have been very consistent. We do have about 45% of the population not at risk, which is fine, because people do take care of themselves. They use other methods of protection besides PrEP, and they are considered low risk. For that population, we stress education and awareness, because you might be at low risk today, but tomorrow you might change your activities, you might change the people you're meeting, and risk always changes. We give them the tools to understand what is PrEP and how to access it.
For patients who are high risk already on PrEP, for these patients, we continue assessing their adherence. Are they taking PrEP? Are they being consistent with it? Are they going to the doctor every 3 months for lab work? And we've been trying to support our members in that way, connect them to our nurse care coordinators to make sure they continue to access care.
The purpose of this assessment is to find patients who are at risk but not on PrEP, and we've been finding about 10[%] to 15% of patients fall into that group. For that group of patients, we educate them, and we connect them to getting access to a provider who can prescribe PrEP for them. It's been helping. Not all patients who say they are interested actually start PrEP, but we're trying our best to just keep that awareness out there. Today, maybe they're not interested, or they contemplate on it, but maybe in a few weeks or a month, they do become interested, and at least they have the resources, and they know to call us in order to get access to PrEP.
We've seen results that vary, but we've seen uptake from the assessment that we're doing of new patients starting PrEP because of that 1 phone call that we gave them, and we know that our providers do similar assessments with them. Hearing this same thing from multiple different perspectives hopefully will remind patients to see themselves at risk, because I think that is the hardest milestone to pass. It's just seeing that you are at risk. “Oh, yeah,PrEP works.PrEP is great, but it's just not for me.” A lot of patients see themselves that way, because they're so young and healthy.
Understanding risk and understanding that you are at risk is important. We see that in our other disease states, for example with diabetes. When you want to put somebody on metformin for prediabetes to prevent them from being diabetic, people don't see themselves at risk. They don't want to take metformin. Having an aspirin to prevent heart attack—a lot of people, again, don't want to do that.
Crossing that barrier to understanding that you are at risk is important, and that's what we try to clarify and show with our patients. There are some behaviors that might put you at risk, and there are tools to prevent HIV that we're so grateful to have now, and hopefully they are getting access to it.
Moti Ramgopal, MD, FACP, FIDSA: The PrEP therapy story is somewhat different from the HIV story because prior to the COVID-19 [coronavirus disease 2019], we have seen a lot of calls, requests to be seen for PrEP. Right after the COVID-19, those requests have dropped significantly. The patients who have been on PrEP have tried to stay at thePrEP, but we're beginning to see that they're fading away quite quickly. And a lot of refills, a lot of patients who were on PrEPbefore, have not called [about] the refills and have not followed through with refills.
And their excuse is that they're not engaged, involved as they were prior to COVID-19. But we're beginning to see a lot of new patients as well, and that's an interesting story. If we’re saying well, socially, they're not as active, [but] we’re still seeing new patients, there's a disconnect in that conversation. Some patients are in denial to some extent, and what's happening … with the PrEP patients is that we need to reengage them into care.
And they seemed to be a lot more challenging right now than the HIV patients. Not only is HIV prevention a challenge, but we've seen a really rapid uptick of syphilis, for the last few years we’ve still seen that in our office. I prescribed more penicillin injections today than I prescribed more HIV medications for new patients, quite easily. I mean, chlamydia, gonorrhea are still on the increase.
The PrEP patients are still sexually active and they're still acquiring infections that are associated with unprotected sex. And we are still encouraging those patients to stay on their PrEP, but we're clearly seeing that the COVID-19 pandemic has affected that population somewhat much more than the HIV population in the fact that retention and care, following up with visits and keeping patients compliant.
It's tough. It's difficult to ensure the continued care for these patients and is quite stressful to have to really go in beyond to do that. Because I'm a physician, we have nurse practitioners. We have COVID-19 patients. We see COVID-19 patients in the hospital. We do a lot of infectious disease follow-up in the office.
The PrEP story is drifting slowly to the back burner to some extent and is so much we can do as providers. But again, the onus must be on the patients. As much is the question is what are we doing for the patients, the question should be what are these patients doing for themselves to maintain the PrEP care? The conversation has to put the onus of responsibility back to the patients. For a time, we prescribe a medication to a patient, the onus of response will be on those patients.
Historically, when we look at HIV care and PrEP care, we put the burden of responsibility to the health care system. I believe that burden will have to shift completely to patients. There should be a high level of responsibility with these patients and their insurance carriers who are providing the care for these patients over time. We need to reemphasize the value of patients' ownership of their disease state or the risk that they're engaged in. There’s only so much health care workers can do.
But now we truly have to see a reengagement by people who are at high risk to be back on PrEP and to engage us. They should want to engage in us at this stage than for us to be looking for them because as it is, we are completely inundated with treating COVID-19 and treating so many other challenges with STDs, pneumonia, respiratory conditions. And IV drug usage is on the rise as we are seeing that in our infectious disease clinic.
Hepatitis disease on the rise again as we're seeing numbers increase. There's a lot of other challenges we begin to face. The question is what PrEP is, it's going to remain very difficult. Now the challenge has to shift to the patients. They must now step up to the plate and say I want to be more involved in the treatment than what providers are gearing and prodding them along.
The payers should have a database, as we do have a database. The patients who are on PrEP, they'll know. They can probably run a database and provide the patients with update for their PrEPmedication they're taking. And they can follow that. I mean, as insurance companies and organizations, they have massive infrastructure. The health care of patients are their responsibility [at the] end of the day, just as it is our responsibility, just as it is the public health responsibility.
Still, it's part of their responsibility. As insurance companies, they're receiving money every month to provide the health care services to patients. And they need to step up at this time to recognize the fact that here are a lot of disease states that are being pushed backward because COVID-19 has been on the front burner. And now, how do you now engage these other disease states and make patients still continue to be aware?
It has to be a massive education campaign. Through Facebook, through social media that patients need to become reengaged back in the care or falling out of care. And I think they should accept some of the leadership in this environment.