Original Research

Accessibility and Uptake of Pre-Exposure Prophylaxis for HIV Prevention in the VHA

Fed Pract. 2018 March;35(suppl 2):S42-S48

References

1. Centers for Disease Control and Prevention. HIV surveillance report, 2016; Vol 28. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance -report-2016-vol-28.pdf. Published November 2017. Accessed February 12, 2018.

2. Centers for Disease Control and Prevention. HIV continuum of care, US, 2014, overall and by age, race/ethnicity, transmission route and sex. https://www.cdc .gov/nchhstp/newsroom/2017/HIV-Continuum-of-Care.html. Updated September 12, 2017. Accessed February 12, 2018.

3. Branson BM, Handsfield HH, Lampe MA, et al; Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.

4. US Food and Drug Administration. FDA approves first medication to reduce HIV risk [press release]. https://aidsinfo.nih.gov/news/1254/fda-approves-first-drug -for-reducing-the-risk-of-sexually-acquired-hiv-infection. Published July 12, 2012. Accessed February 14, 2018.

5. Fonner VA, Dalglish SL, Kennedy CE, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS. 2016;30(12):1973-1983.

6. Centers for Disease Control and Prevention, US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf. Published 2014. Accessed February 12, 2018.

7. Smith DK, Mendoza MC, Stryker JE, Rose CE. PrEP awareness and attitudes in a national survey of primary care clinicians in the United States, 2009-2015. PLoS One. 2016;11(6):e0156592.

8. Van Epps P, Maier M, Lund B, et al. Medication adherence in a nationwide cohort of veterans initiating pre-exposure prophylaxis (PrEP) to prevent HIV infection. J Acquir Immune Defic Syndr. 2018;77(3):272-278.

9. US Department of Veterans Affairs. 38 CFR Part 17, RIN 2900-AP44. Advance Practice Registered Nurses. Federal Register, Rules and Regulations. 81(240) December 14, 2016

10. Ourth H, Groppi J, Morreale AP, Quicci-Roberts K. Clinical pharmacist prescribing activities in the Veterans Health Administration. Am J Health Syst Pharm. 2016;73(18):1406-1415.

11. US Department of Veterans Affairs, Pharmacy Benefits Management Academic Detailing Service. VA academic detailing implementation guide. https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/VA_Academic_Detailing_Implementation_Guide.pdf. Published September 2016. Accessed February 12, 2018.

12. Veterans Health Administration US Department of Veterans Affairs, Veterans Health Administration, Office of Specialty Services, HIV, Hepatitis, and Related Conditions Programs. Pre-exposure prophylaxis (PrEP) to prevent HIV infection: clinical considerations from the Department of Veterans Affairs National HIV Program. https://www.hiv.va.gov/pdf/PrEP-considerations.pdf. Published September 2016. Accessed January 4, 2018.

13. US Department of Veterans Affairs, VA Mobile Health. Annie app for clinicians. https://mobile.va.gov/app/annie-app-clinicians. Published September 2016. Accessed January 4, 2018.

14. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. VA utilization profile FY 2016. https://www.va.gov/vetdata/docs/Quickfacts/VA_Utilization_Profile.pdf. Published . November 2017. Accessed March 5, 2018.

15. Van Epps P. Pre-exposure prophylaxis for HIV prevention: the use and effectiveness of PrEP in the Veterans Health Administration (VHA). Abstract presented at: Infectious Diseases Week 2016; October 26-30, 2016; New Orleans, LA. https://idsa.confex.com/idsa/2016/webprogram/Paper60122.html. Accessed February 12, 2018.

16. Centers for Disease Control and Prevention. 2016 conference on retroviruses and opportunistic infections, lifetime risk of HIV diagnosis by state: https://www.cdc .gov/nchhstp/newsroom/images/2016/CROI_lifetime_risk_state.jpg. Published February 24, 2016. Accessed February 12, 2018.

17. Elopre L, Kudroff K, Westfall AO, Overton ET, Mugavero MJ. Brief report: the right people, right places, and right practices: disparities in PrEP access among African American men, women, and MSM in the Deep South. J Acquir Immune Defic Syndr. 2017;74(1):56-59.

18. Wu H, Mendoza MC, Huang YA, Hayes T, Smith DK, Hoover KW. Uptake of HIV preexposure prophylaxis among commercially insured persons-United States, 2010-2014. Clin Infect Dis. 2017;64(2):144-149.

19. Schafer KR, Albrecht H, Dillingham R, et al. The continuum of HIV care in rural communities in the United States and Canada: what is known and future research directions. J Acquir Immune Defic Syndr. 2017;75(1):355-344.

20. Conrad C, Bradley HM, Broz D, et al; Centers for Disease Control and Prevention (CDC). community outbreak of hiv infection linked to injection drug use of oxymorphone—Indiana, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(16):443-444.

21. Ohl ME, Richardson K, Kaboli P, Perencevich E, Vaughan-Sarrazin M. Geographic access and use of infectious diseases specialty and general primary care services by veterans with HIV infection: implications for telehealth and shared care programs. J Rural Health. 2014;30(4):412-421.

22. US Department of Veterans Affairs, Office of Rural Health. Rural veterans’ health care challenges. https://www.ruralhealth.va.gov/aboutus/ruralvets.asp. Updated February 9, 2018. Accessed on February 12, 2018.

23. Centers for Disease Control and Prevention. HIV among African Americans. https://www.cdc.gov/hiv/group/racialethnic/africanamericans/index.html. Updated February 9, 2018. Accessed on February 12, 2018.

24. Bush S, Magnuson D, Rawlings K, et al. Racial characteristics of FTC/TDF for pre-exposure prophylaxis (PrEP) users in the US. Paper presented at: ASM Microbe Conference 2016; June 16-20, 2016; Boston, MA.

25. Centers for Disease Control and Prevention. HIV risk behaviors. https://www.cdc .gov/hiv/pdf/risk/estimates/cdc-hiv-risk-behaviors.pdf. Published December 2015. Accessed on February 12, 2018.

26. Lehman JS, Carr MH, Nichol AJ, et al. Prevalence and public health implications of state laws that criminalize potential HIV exposure in the United States. AIDS Behav. 2014;18(6):997-1006.

27. US Department of Justice, Civil Rights Division. Best practices guide to reform HIV-specific criminal laws to align with scientifically-supported factors. https://www.hivlawandpolicy.org/sites/default/files/DOj-HIV-Criminal-Law-Best-Practices-Guide.pdf. March 2014. Accessed on February 12, 2018.

28. Backus L, Czarnogorski M, Yip G, et al. HIV care continuum applied to the US Department of Veterans Affairs: HIV virologic outcomes in an integrated health care system. J Acquir Immune Defic Syndr. 2015;69(4):474-480.

Increasing PrEP Use in Primary Care and Women’s Health Clinics

As of June 2017, physicians (staff, interns, residents, and fellows) accounted for more than three-quarters of VA PrEP index prescriptions. Among staff physicians, infectious diseases specialists initiated 67% of all prescriptions. Clinical pharmacists prescribed only 6%; APRNs and PAs prescribed 16% of initiations. This is unsurprising, as the field survey identified lack of awareness and specific training on PrEP care among providers without infectious diseases training as a common barrier.

The VA is the largest US employer of nurses, including more than 5,500 APRNs. In December 2016, the VA granted full practice authority to APRNs across the health care system, regardless of state restrictions in most cases.⁹In some states, this change in scope of practice (SOP) may allow for APRNs to become more involved in the prescribing of PrEP.

In 2015, the VA employed about 7,700 clinical pharmacists, 3,200 of whom had an active SOP that allowed for prescribing authority. In fiscal year 2015, clinical pharmacists were responsible for at least 20% of all hepatitis C virus (HCV) prescriptions and 69% of prescriptions for anticoagulants across the system.¹⁰ Clinical pharmacists are increasingly recognized for their extensive contributions to increasing access to treatment in the VA across a broad spectrum of clinical issues. With this infrastructure and expertise, clinical pharmacists also are well positioned to expand their scope to include PrEP.

To that end, the National PrEP Working Group worked closely with clinical pharmacists in the field and from the VA Academic Detailing Service (ADS) within the VA Pharmacy Benefits Management Services office. The ADS supports the development of scholarly, balanced, evidence-based educational tools and information for frontline VA providers using one-on-one social marketing techniques to impact specific clinical targets. These interventions are delivered by clinical pharmacists to empower VA clinicians and promote evidence-based clinical care to help reduce variability in practice across the system.¹¹ An ADS module for PrEP has been developed and will be available in 2018 across the VHA to facilities participating in the ADS.

A virtual accredited training program on prescribing PrEP and monitoring patients on PrEP designed for clinical pharmacists will be delivered early in 2018 to complement these materials and will be open to all prescribers interested in learning more about PrEP. By offering a complement of training and clinical support tools, most of which are detailed in other sections of this article, the National PrEP Working Group is creating educational opportunities that are accessible in a variety of different formats to decrease knowledge barriers over PrEP prescribing and build over time a broader pool of VA clinicians trained in PrEP care.

Ensuring High-Quality PrEP Care

One system-level concern about expanding PrEP to providers without infectious diseases training is the quality of follow-up care. In order to aid noninfectious diseases clinicians, and nonphysician providers who are not as familiar with PrEP, several clinical support tools have been created, including (1) VA’s Clinical Considerations for PrEP to Prevent HIV Infection, which is aligned with CDC clinical guidance¹²; (2) a PrEP clinical criterion check list; (3) clinical support tools, such as prepopulated electronic health record (EHR) templates and order menus to facilitate PrEP prescribing and monitoring in busy primary care clinical settings; and (4) PrEP-specific texts in the Annie App, an automated text-messaging application developed by the VA Office of Connected Care, which supports medication adherence, appointment attendance, vitals tracking, and education.¹³

Available evidence indicates that there is potential for disparities in PrEP effectiveness in the VA related to varying medication adherence. Analysis of pharmacy refill records found that adherence with TDF/FTC was high in the first year after PrEP initiation (median proportion of days covered in the first year was 74%), but adherence was lower among veterans in VA care who were African American, women, and/or under age 45 years.⁸ This highlights the importance of enhanced services, such as Annie, to support PrEP adherence in at-risk groups as well as monitoring of HIV risk factors to ensure PrEP is still indicated.

Targeting PrEP Uptake for High-Risk Veterans

Although the VA’s overarching goal is to increase access to and uptake of PrEP across the VHA, it also is important to direct resources to those at greatest risk of acquiring HIV infection. The National PrEP Working Group has focused on the following critical implementation issues in the VA’s strategic approach to HIV prevention, with a specific focus on the geographic disparities between PrEP uptake and HIV risk across the VHA as well as disparities based on rurality, race/ethnicity, and gender.