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State Health Departments Implementing PrEPDave KernManager, HIV and Adult Viral Hepatitis Prevention ServicesWashington State Department of Public Health
PrEP Promotion: A Washington State Overview
Dave KernManager, Infectious Disease Prevention
April 15, 2015
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 (2011-2013), 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?
Gender: • 7 are female (<3%)• 264 are male (97%)• 1 is other gender (<1%)• 1 is Transgender (FtM) (<1%)
Insurance Status: • 42 are uninsured (15%)• 231 are insured (85%)
Ethnicity:• 197 Non-Hispanic/Latino(a) (72%)• 39 Hispanic/Latino(a) (15%)• 37 No Answer (13%)
Race:• 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%)
332 Applications Received273 Active PrEP DAP Clients
41 Denied18 Incomplete Applications
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
WHERE ARE WE NOW?
Costs* as of 3/15/2015Drugs $414,052.48Contractor set up costs $ 20,660
TOTAL $434,712.48*no DOH Staff costs included**as of 3/15/2015
Month/Yr Clients Active
Clients 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 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, ManagerInfectious Disease [email protected]
Richard Aleshire, ManagerHIV Client Services [email protected].
Beth Crutsinger-Perry, ADAPHIV Client [email protected]
