State Health Departments Implementing PrEP
PrEP Promotion: A Washington State Overview
Dave Kern
Dave Kern
Manager,
Manager,
Infectious
Disease
Prevention
HIV and
Adult Viral
Hepatitis
Prevention
Services
Washington
April 15,State
2015Department of Public Health
WASHINGTON STATE OVERVIEW
• Population
• 6.8 million (2011 estimate)
• New HIV diagnoses
• ~510 new cases / year
• Prevalent HIV cases
• 12,000+ persons living with HIV disease
• Concentration of disease
• Central Puget Sound (including Seattle) – 77 percent of new
diagnoses
• Trends
• Decreasing diagnoses and rates
WHAT WE KNOW
• Our epidemic is concentrated geographically and within specific
populations – gay / bisexual men in the Puget Sound.
• New HIV diagnoses and rates of HIV infection are declining.
• Coverage and saturation of HIV testing / screening is good – nearly 90
percent of persons living with HIV know their status.
• Viral suppression in the population of persons living with HIV is good –
nearly 60 percent are suppressed.
• To achieve the impact we want – a 50 percent reduction in the rate of
new HIV diagnoses by 2020 – we must continue to improve work along
the HIV care continuum and, at the same time, improve efforts to prevent
transmission to HIV-negative persons.
WHERE DID WE START?
• In partnership with our state’s HIV Prevention Planning Group (20112013), we mapped outcomes that influence direct transmission of HIV.
Priority outcomes include:
– Suppressed viral load among persons living with HIV
– Decreased STD incidence (GC and syphilis)
– Increased use of PrEP
– Increased use of nPEP
– Increased use of condoms
– Increased use of clean syringes
• OUTCOME THREE: Increase use of pre-exposure prophylaxis (PrEP)
among gay and bisexual men in Seattle and secondary urban areas
Secondary urban areas = Everett, Kent, Renton, Shoreline, Spokane, Tacoma and Vancouver
WHERE DID WE START?
• Our planning group recommended PrEP be a priority outcome for gay and
bisexual men in urban areas.
• Though supportive, the planning group expressed reservations about PrEP,
citing common concerns: misuse, unintended consequences, moral
objection to providing ART to HIV-negative persons while ART is not
available for all HIV-positive persons, etc.
• The planning group’s recommendation came after many months of
discussion and as a result of their commitment to meaningfully reducing
HIV transmission.
• Work with this community body was an important first step in our process.
WHERE ARE WE NOW?
• Based on planning group recommendations, all current HIV programming
connects to one or more of the 6 outcomes.
• Our PrEP promotion approach includes activities aimed at increasing
awareness, access and uptake of PrEP, primarily among gay / bisexual
men.
• Our approach is multi-faceted – community, public health, healthcare and
payers.
• 2014 focused on infrastructure and capacity building.
WHERE ARE WE NOW?
• Community engagement
– Community mobilization
– Community forums
– Health insurance outreach and enrollment  increase access to and
utilization of healthcare among gay / bisexual men
• Public health engagement
– DIS refer to PrEP all gay / bisexual men diagnosed with syphilis and / or
rectal GC (data are monitored – who’s eligible, who’s offered, who
accepts, etc.)
– Local health departments instituted local PrEP referral processes
– DOH provided training to all funded DIS and medical case
management staff
WHERE ARE WE NOW?
• Healthcare engagement
– Identify and publicize local clinicians willing to prescribe and manage
PrEP
– Hosted informal dinners for Seattle-based LGBT and ID providers
– Provided funding to Seattle-based doc to support PrEP program at Gay
City Health Project
WHERE ARE WE NOW?
• Healthcare engagement (continued)
– Established PrEP clinic at Seattle STD clinic
• Highly targeted for gay / bisexual men with syphilis and / or rectal
GC
• Funding covers medical, lab and drug costs
• In the future, will explore uptake and maintenance strategies (e.g.,
shift longer term users to PCPs?)
– Provide information and non-fiscal support to other healthcare
systems (e.g., guidelines, mentors)
WHERE ARE WE NOW?
• Payer system engagement
– PrEP DAP
– Medicaid / QHP enrollment of eligible persons
– Purchased insurance (premium payment assistance) for participants
without coverage (during open enrollment)
WHERE ARE WE NOW?
• PrEP DAP
– Launched April 2014
– Drug assistance program to reduce barriers associated with costs of
Truvada
– Currently, coverage is for Truvada only, not medical or lab costs
– Coverage for both co- and full-pay, depending on needs of the enrollee
– Not meant to replace individual’s medical home, but to defray
deductible and co-pay costs of medication
– To date, soft-touch launch of program
• Emails to providers (clinical, prevention and non-clinical care)
• Web presence
• Media
WHERE ARE WE NOW?
• PrEP DAP
– Eligibility criteria are fairly low threshold to not curtail early interest in
the program
• Risk – sero-discordant couples, gay / bisexual men who meet
certain risk criteria
• Residence – WA State only
• Healthcare provider engagement – Provider must complete part of
the application
• No income or requirement to use PAP
• No requirements for routine medical visits (though strongly
encouraged)
WHERE ARE WE NOW?
• PrEP DAP
– Created and launched as a matter of program planning and
development, rather than a legislative or agency initiative
– Collaborative effort between DOH HIV prevention and HIV care /
treatment programs
– Built on the backbone of state’s ADAP program – eligibility processing
and pharmacy benefits management
– Funded exclusively with state general funds
• CDC, Part B / ADAP dollars and rebate dollars cannot be used (but
do free up state funds to support PrEP DAP)
WHERE ARE WE NOW?
• PrEP DAP
– ~$2M / year allocated for coverage of ~200 clients
• Conservative estimate figuring 50 percent of enrollees will be full
pay (WRONG!)
– System improvements and / or changes will be made as appropriate
– Staffing:
• 11 DOH staff tasked with some portion of PrEP DAP / promotion
– 6 prevention staff – ~1.85 FTE
– 4 care staff – ~0.65 FTE
– 2 surveillance staff – ~0.10 FTE
WHERE ARE WE NOW?
332 Applications Received
273 Active PrEP DAP Clients
41 Denied
18 Incomplete Applications
Gender:
• 7 are female (<3%)
• 264 are male (97%)
• 1 is other gender (<1%)
• 1 is Transgender (FtM) (<1%)
Ethnicity:
• 197 Non-Hispanic/Latino(a) (72%)
• 39 Hispanic/Latino(a) (15%)
• 37 No Answer (13%)
Race:
Insurance Status:
• 42 are uninsured (15%)
• 231 are insured (85%)
• 1 Alaskan Native/American Indian (<1%)
• 1 Native Hawaiian/Pacific Islander (<1%)
• 7 Other (2.5%)
• 7 Black/African American (2.5%)
• 13 Asian (4.8%)
• 15 Multi Race (5.5%)
• 18 No Answer (6.6%)
• 211 White/Caucasian (77.3%)
WHERE ARE WE NOW?
• PrEP DAP: Risk Factors (client declared)
– 27% have sexual / drug sharing partner(s) who is HIV+
– 80% identify as gay / bisexual man or other man who engages in
sexual activity and has one or more of the following conditions:
• 26% - Bacterial STI within the last year
• 26% - Exposure to an STI within the last year
• 64% - Ten or more partners within the last year
• 3% - Used meth within the last year
• 46% - Unprotected anal intercourse with partner of unknown hiv-1
status
Month/Yr
Clients Clients
Active Filling
4/2014
5
3
5/2014
11
6
6/2014
14
8
7/2014
24
11
8/2014
41
32
9/2014
64
43
10/2014
91
59
11/2014
109
56
12/2014
148
91
1/2015
188
144
2/2015
241
163
3/2015**
273
91
WHERE ARE WE NOW?
Costs* as of 3/15/2015
Drugs
Contractor set up costs
TOTAL
*no DOH Staff costs included
**as of 3/15/2015
$414,052.48
$ 20,660
$434,712.48
WHERE ARE WE GOING?
• In 2015, we plan to:
– Align existing and future PrEP promotion efforts with End AIDS
Washington
WHERE ARE WE GOING?
• In 2015, we plan to:
– Add multi-jurisdiction marketing / media PrEP promotion campaign for
communities and providers
– Add navigation / care coordination for PrEP users
– Work with local AETC to increase provider awareness, knowledge and
support for PrEP via HIV ECHO (telemedicine)
– Develop data collection system to monitor PrEP utilization (e.g.,
accessing and analyzing Medicaid and health plan data)
– Cultivate new partnerships with pharmacies to increase accessibility of
PrEP
– Explore options for covering medical / lab costs for PrEP DAP
participants
WHERE ARE WE GOING?
• In 2015, we plan to:
– Expand GCHP PrEP project to:
• Provide a PrEP “start up” clinic for individuals without insurance
and / or primary care providers
• Identify and cultivate other clinician champions
• Identify and market GCHP PrEP “start up” clinic to providers who
are willing to assume PrEP management after initial monitoring
• Work with participants to enroll them in insurance and primary
care
• Streamline the GCHP PrEP process to leverage other resources
LESSONS LEARNED / FINAL THOUGHTS
• PrEP isn’t a new and novel intervention anymore. It’s an essential tool in
the tool box. PH must find opportunities to promote its use.
• The collaboration between health department prevention and care /
treatment programs was integral to our success.
• A multi-faced approach allowed us to promote PrEP on multiple fronts
(community, public health, healthcare and payer engagement).
• We opted to integrate PrEP into the work of as many staff and programs as
possible rather than consolidating it into one team, i.e., PrEP as a tool, not
a program area.
• We remain curious and open to discovery.
CONTACT INFORMATION
Dave Kern, Manager
Infectious Disease Prevention
david.kern@doh.wa.gov
Richard Aleshire, Manager
HIV Client Services
richard.aleshire@doh.wa.gov.
Beth Crutsinger-Perry, ADAP
HIV Client Services
elizabeth.Crutsinger-Perry@doh.wa.gov