State Health Departments Implementing PrEP Dave Kern Manager, HIV and Adult Viral Hepatitis Prevention Services Washington State Department of Public Health PrEP Promotion: A Washington State Overview Dave Kern Manager, 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? 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%) 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%)

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 3/15/2015 Drugs $414,052.48 Month/Yr Clients Active Clients Filling 4/2014 5 3 5/2014 11 6 6/2014 14 8 7/2014 24 8/2014 41 32 9/2014 64 43 10/2014 91 59 11/2014 109 56 12/2014 148 1/2015 188 144 2/2015 241 163 3/2015** 273 WHERE are we now? Costs* as of 3/15/2015 Drugs $414,052.48 Contractor set up costs $ 20,660 TOTAL $434,712.48 *no DOH Staff costs included **as of 3/15/2015

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 elizabeth.Crutsinger-Perry@doh.wa.gov