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Melanie Cole (Host): Preexposure prophylaxis or PREP is when people at very high risk for HIV, take HIV medicines daily to lower their chances of getting infected. Today, we’re talking about BMC’s PREP program. My guests are Dr. Jessica Taylor. She’s and Assistant Professor of Medicine in General Internal Medicine at the Boston University School of Medicine and Jessica Stewart. She’s the Program Coordinator for PREP at Boston Medical Center. Ladies, thank you so much for being with us today. it’s a great topic and really so interesting. So, Dr. Taylor I’d start with you. What is PREP? What is preexposure prophylaxis? Tell the listeners what that means.

Jessica Taylor, MD (Guest): Thank you so much for having us. So HIV preexposure prophylaxis or PREP is one strategy that people can use to decrease their chances of getting HIV. And what it means is that you can take one pill which contains two HIV medicines once a day. One pill once a day to decrease the chances of getting HIV.

Host: Jessica why would a patient choose PREP? Is it something the patient asks you about? You’re the Program Coordinator or do you tell them about it?

Jessica Stewart (Guest): We do a lot of education to providers and patients about what patient’s risks for HIV could be. And we offer it to anyone that wants an added layer of protection for HIV prevention in combination with condoms and safer sex practices.

Host: Well then Jessica, sticking with you, you mentioned you discuss it with patients that are at risk. Who is at risk?

Jessica: PREP is approved for groups that have always been at higher risk for HIV. So, men who have sex with men, anyone with an HIV positive partner, anyone who is using injection drugs, or has a recent bacterial STI. But it really is for a wider range of people. Someone who is maybe exchanging sex for commodities or people that are not able to negotiate condom use with their partners or if their partner has outside partners. So, we counsel patients and educate them about all of these different factors and then offer it to them and sometimes they are ready to initiate, sometimes they are not. And we try to get them to come back in to do another counseling session or test them for STIs and keep the conversation going.

Host: Well that segues beautifully. Dr. Taylor so when should the use of PREP be initiated? Are there some clinical protocols going on in the country right now to prescribe, support, monitor adherence? I know that’s a lot but then speak to us about prescription and when it should be initiated.

Dr. Taylor: You know I think right now the trend is to try to offer PREP as soon as a patient is ready for it and as soon as they and their provider agree that it’s the right choice for them. So, if a patient has a high risk of getting HIV infection and has done some baseline labwork and they and their provider agree that they are ready; we really like to start PREP as soon as possible and sometimes even on the same day.

Keys in terms of the baseline lab tests that we do are making sure that patients do not have HIV infection so an HIV test to make sure they are negative. Because of course if someone has HIV infection, we would offer them treatment for HIV which is different than PREP. And testing things like the kidney function, testing for other sexually transmitted infections as well as hepatitis, hepatitis B specifically. So, once that testing has been done and the patient and provider agree that they are a good candidate for PREP, we really don’t want to delay. And across the country we are seeing increasing interest in offering PREP on the same day of service or very shortly after patients ask for it.

Because we know that when patients come in asking for PREP, they’ve already identified their risk as being high and any delay in getting them the prevention that they need can put them at higher risk of HIV infection.

Host: Jessica how well does it work? Is there evidence of the safety and efficacy of this prophylaxis? What have you seen?

Jessica: PREP is a very powerful tool and works very well if it’s taken as directed. So, it’s a once a day pill and if you take it every day, it’s over 92% effective for those with a sexual risk. And for those who are using injection drugs and that might be their only risk, it’s over 70% effective.

Host: Wow. That’s really great to hear. So Dr. Taylor, is there anyone who shouldn’t be treated with PREP? Are there clinical contraindications for the institution of this drug?

Dr. Taylor: I think the primary concern is that people who have HIV infection, should not receive PREP. They should receive HIV treatment which would involve a combination of three drugs or a different regimen than what we use for PREP. So, I think that’s the primary contraindication or reason that someone should be treated with PREP. Otherwise, PREP is a very, very safe intervention. We do check patient’s kidney function and patients with very advanced kidney failure should not be treated with PREP. Patients with more moderate kidney failure may have additional opportunities coming down the road, but right now, those with kidney failure shouldn’t receive the medicine that we have approved for PREP which is tenofovir disoproxil fumarate emtricitabine.

I think the other piece that Jessica allude to is that PREP does involve coming in for testing and support around adherence. So, we want to make sure that we talk to our patients about that upfront and that they understand that the best data for this medication right now is in patients who take it every day. So, we want to make sure patients are prepared for that. And we are able to treat patients who historically might have not been offered PREP. So, for example women who are pregnant, we are able to talk to about the pros and cons of starting PREP and oftentimes offer it if it’s the right choice for them.

Host: So, Jessica along those lines then, tell us about some of the challenges that might affect successful PREP outreach and adherence as Dr. Taylor would say, and speak about BMC’s unique implementation strategies. How are you reaching out to people? How are you monitoring their adherence? Tell us about that.

Jessica: PREP is kind of a changing landscape. We’ve been implementing this program at BMC for the last four to five years and we’ve identified different problems throughout that time. So, I think initially we first saw it, this is an access problem if we just get on demand PREP access then we are able to offer it to patients same day through our DPH funded PREP clinic. That is no longer a barrier. Then we thought maybe it’s a cost issue because when this medication first came out it was very expensive and so we were able to enroll patients in cost assistance programs and help them get all of the follow up testing that’s required for PREP completely free through our STI clinic.

And there’s also the education piece. So identifying who is eligible and making sure patients know they are eligible and are asking for it and also providers are aware of patient’s HIV risk and who would be eligible and making sure it’s being offered to their patients. And sometimes it might take one offer and they are ready to initiate PREP and sometimes it might take six or seven and it’s just like I said, keeping that conversation going and making sure patients are coming back and going through the counseling sessions with us to understand their true risk of HIV.

And as far as the adherence component. Like with any medications that you have to take every day, that’s always going to be a struggle. Sometimes with this patient population they have other factors that might affect their adherence so, socioeconomic factors, changes in insurance, they might move, we have a lot of people that come here seasonally. So, college students, things like that that will need to find a PREP provider in another state, and we can help with all of that. We have a team of navigators that work with patients on getting them linked to primary care, insurance or cost assistance programs and that really makes us unique at BMC because we have a lot of resources to help patients and meet them where they are at and kind of help them engage in their own care both PREP care and otherwise so that they can come to us if they need anything and not have any barriers and just discontinue on their own.

Dr. Taylor: One major challenge that we’ve seen to offering PREP to more patients is that it can be very hard for an individual person to judge their own HIV risk. So, we often find that people who have a very high number of HIV risk behaviors believe that their own HIV risk is low. And I think it’s really important that as providers and as teams offering PREP, we help people understand an accurate picture of their HIV risk and that really highlights the importance of doing a thorough sexual history and doing a thorough injection related risk history in all of our patients and that includes if they come through primary care, as they come through our addiction programs, as they pass through our emergency department, it’s really our job to help patients have an accurate sense of what their HIV risk is.

And likewise, I would say we care for many patients who might not believe that PREP is for them. So, PREP has historically been marketed to predominantly men who have sex with men. And that’s a very important group that we want to continue to offer PREP to. But I think we also take care of a lot of patients who don’t fall into that category who would benefit from PREP and really haven’t seen marketing that has been directed towards their community.

So, one of our major goals here at Boston Medical Center is to make sure that we are offering PREP in a way that is inclusive and really acceptable to all patients who might benefit.

Host: Dr. Taylor are there any unique aspects of the BMC program you’d like to highlight?

Dr. Taylor: I think one thing that has been a barrier to many patients over the years is that PREP has historically often been offered in sexually transmitted infection clinics, STD clinics or in Infectious Diseases programs. And our patients who are interested in PREP do not have an infection and in fact want to continue to not have HIV infection. So, those locations have not always felt comfortable. And so, one thing that we’ve done is developed a PREP program with a primary care here in general internal medicine at Boston Medical Center that allows our primary care patients to get their PREP care either with their own PCP, primary care provider or with another provider within primary care so that they don’t even have to leave the floor where they are comfortable, where they are used to coming to get their preventive healthcare and where they really have a medical hold. And we think that’s one thing that’s been very helpful and unique in making PREP more accessible and more comfortable for our patients.

Host: Jessica what would you like the listeners to know as you are the Program Coordinator for PREP? What would you like them to know about reaching out and questions you’d like them to ask and who they should look to for this kind of advice?

Jessica: We just want them to come to us if they might be interested in PREP or have someone that will be interested in PREP and we can help with any barriers that we identify of that they identify. We don’t want cost to be an issue or appointment times. So, yeah, they can just come to us if they are interested and call us directly, call the STI clinic, ask their primary care provider and we will help them.

Host: Dr. Taylor I’d like just ask you to give us your last word on Boston Medical Center’s unique approach to the PREP program and what you would like listeners to know.

Dr. Taylor: I would say that PREP is an incredibly powerful potent tool to decrease people’s chances of getting HIV. It is not a tool that acts by itself. So, as Jessica mentioned, it goes along with for example, condom use, using clean injection equipment, talking to partners about HIV risk, but it is an incredibly important tool. And I think it’s a good tool for a lot of people that might not be thinking about PREP yet.

So, within our program, we’ve tried to make PREP available and acceptable like we said, to anyone who has high risk of getting HIV, and we also have really learned a lot about navigating some of the barriers that come up. And those include cost barriers, issues around appointment scheduling so for example, we offer evening appointments in our STD clinic, issues around prior authorizations, issues around connecting folks to both PREP and primary care in the same location. So, a lot of the things that might come to mind if you are sitting at home and thinking about PREP as being a problem; we might be able to work through for you and likely can. So, I’d really just encourage anyone who is interested to get in touch with us or ask their primary care provider to get in touch with us and we would love to talk about the pros and cons of starting PREP in their case.

Host: It’s great information and what a great program. Ladies, thank you so much for joining us. And that wraps up this episode of Boston MedTalks with Boston Medical Center. Head on over to our website at www.bmc.org/prep for more information on the PREP program and to get connected with one of our providers. If you found this podcast as informative as I did, please share on your social media, share with your friends and family because what a great program this is and it’s such great information to learn from these experts as we are all together. And be sure to check out all the other interesting podcasts in our library. There’s a bunch of them. Until next time, I’m Melanie Cole.