August 16, 2017

6 Questions: PrEP and Primary Care

A pillar of the Primary Care Development Corporation’s (PCDC) work is capacity building — transforming primary care delivery through expert consulting, training, and coaching, as well as expanding primary care services to help prevent diseases.

A key player in this work is Brandon A. Harrison, a Project Manager and Trainer on PCDC’s High Impact Prevention (HIP) in Health Care team.

Brandon — who trains and provides technical assistance to health care organizations nationwide — recently implemented and supervised one of the country’s largest PrEP programs, based in New York City. PrEP, or Pre-Exposure Prophylaxis, is the use of anti-HIV medication that keeps HIV negative people from becoming infected.

As part of National Health Center Week, Brandon recently talked about who stands to benefit from PrEP, why misconceptions still linger, and how providers can best embark on creating PrEP programs.

PCDC provides free HIV prevention training and technical assistance to health care organizations — learn more and request our services.                                                                           


PCDC: Why should health care organizations expand access to PrEP?  

BH: Some clinics may just have one provider prescribing PrEP — so there’s a whole population of the clinic that might not know that the medication exists, or that they’re eligible to take it. And if it’s just one provider prescribing PrEP, then it’s typically just for their patient population and/or those that are identified as the highest risk for HIV.

So if we’re able to implement PrEP access throughout a clinic without barriers, such as having to see a specific provider, then we’re able to increase the number of PrEP users. The result is decreased numbers of people who are newly infected with HIV.

Since primary care providers see all types of patient populations, they can have the maximum impact in ensuring PrEP utilization.


What is PCDC’s role in supporting PrEP integration and HIV prevention within primary care?

First, we customize our training to providers’ needs. Because we’re able to provide that training for free, and since and providers’ time is limited, it’s really valuable.

Second, for those health care organizations implementing new PrEP programs, we’ve been able to help them write protocols and policies, assisting them in learning best practices from some of the organizations that have been implementing PrEP successfully across the nation.

Even for providers that are already prescribing PrEP, we’re able to provide them with technical assistance and identify ways to make their programs more streamlined and effective, based on the very best practices of other PrEP providers.


What do trainings entail?

Our most requested training recently has been our PrEP Implementation Training, which was created by Dr. Sarit Golup of Hunter College. It is a hands-on workshop-style training over two to three days, where we discuss PrEP and the components of a successful program.

Then we allow participants to write their own PrEP program, based on targeted populations, funding, clinic capabilities — all the components of what a PrEP program can look like. There are exercises and worksheets that really help guide conversation among participants and allow them to really process the training.

Another option is our PrEP Navigation Training, where we help our providers understand the system for prescribing PrEP — from financing and talking candidly about the medication, to preparing the patient for what to expect during their medical visit, and more.

We also have “PrEP 101/102”-style training, which essentially introduces the concept of PrEP to participants: what PrEP is, how it should be used, and who’s quote-unquote “eligible” for it.

In addition, we offer trainings for all staff and for providers. In fact, there are several upcoming PrEP Institutes and learning collaborations happening across the country, and we’re planning to do some work over the next few months in the southern region of the United States.

Wherever providers are on the spectrum — whether just learning about PrEP or needing to overhaul patient workflows — we can help.


How does your background shape your work at PCDC?

My past work in the clinic helps me to be in the participants’ shoes with implementing PrEP — understanding any barriers that they’re encountering, and helping them address those obstacles with best practices. It really helps to be relatable.


What are some of the larger national challenges with PrEP access?

Getting youth, transgender individuals, women and people of color on PrEP has been one of the biggest challenges. There’s still huge distrust in the medical system, still a belief among some that PrEP will give you HIV — fears that still linger decades after the Tuskegee syphilis experiment, which we always have to bring back into our conversations, especially when we’re talking about people of color in the medical system. This population faces wide barriers to accessing primary care and prevention services in general. Finding culturally competent care is also an issue.

Also, when PrEP first came to market, it was intended for everyone but marketed to gay men. So it’s still hard for women to adapt to the idea of taking PrEP. That it takes slightly longer to be effective in women’s bodies than it does in men’s may also prompt some women to say, “Maybe PrEP isn’t for me then.” We have to address those barriers and change our messaging around how and why PrEP works.

Outside of New York, there’s also a big issue with minors — a huge population of people, many of whom are sexually active but can’t necessarily access PrEP in many states. Because when the FDA approved PrEP, they approved it for adults without actually attaching an age range. It was a very gray area as to who and who shouldn’t take PrEP.

And in terms of paying for PrEP, minors either have to put it on their insurance — which means having a conversation with a parent, which may or may not be safe — or they have to pay for it themselves out of pocket, which can be very expensive. The pharmaceutical company will pay for the medication, but not for minors. So it’s hard to navigate those systems if you’re not in a place like New York, which does support PrEP for minors.


What would you say to a provider that is implementing a PrEP program, or considering doing so?

The easiest thing to do is to identify a “PrEP champion” — a small team of people, or just one provider and a nurse, who will be really versed in PrEP. It’s a way to start small.

Also, I highly recommend an all-staff training. Everyone in the building should know what PrEP is. That’s one of the easiest ways to get buy-in from the staff, to make them aware that the service exists. You wouldn’t want a patient calling to ask about PrEP, and have front-desk staff not know what it is, for example.

Finally, be sure to modify templates and use your EHR early on in implementation for monitoring of PrEP patients. These three pieces are important as you staff up and understand how PrEP is going to work at your site.