1. Iowa TelePrEP: Delivering PrEP through Telemedicine and Public
Health Partnerships
Michael Ohl, MD MSPH
Division of Infectious Disease
University of Iowa College of Medicine
Center for Access and Delivery Research and Evaluation (CADRE)
Iowa City VA
April 6, 2018

2. Disclosures Funding from: Gilead Sciences, Inc.
Iowa Department of Public Health (IDPH)
VA HSR&D

3. Outline PrEP delivery in rural United States Iowa TelePrEP Model
Iowa TelePrEP Study
Replicating TelePrEP in Rural Settings

4. TelePrEP Team at U of Iowa & Iowa DPH
Pat Young, HIV & Hepatitis Prevention Program – Program Director, IDPH
Angela Hoth, PharmD MPH TelePrEP Coordinator, UI
Cody Shafer, EIS/PrEP Coordinator, IDPH
Dena Dillon, PharmD, UI

5. Rural Populations are Small & Dispersed
Rural USA:
97% of land area
18% of population
6% of people with new HIV diagnoses
American Community Survey: 2015.

6. Rural and Small Urban Areas Matter HIV Incidence in the Upper Midwest
Location
HIV Annual Incidence*
Chicago metro area
903
Illinois, not Chicago
569
Iowa
136
Nebraska 93
Wisconsin**
100
Minnesota***
168
North Dakota 24
South Dakota 28
Total, rural/small urban
1,118
*Source: CDC and state surveillance; AIDSvu.org;
** Excluding Milwaukee
*** Excluding Minneapolis / St. Paul

7. Public health clients with PrEP need in IDPH STD & HIV Programs
County public health / STD clinics (N=58)
Disease Intervention Specialists / Partner Services
Integrated Testing Services (HIV testing)
5,596 PrEP-eligible public health clients in 2016
1,057 (19%) rural

8. IDPH STD & HIV Testing Programs
2016 data
HIV risk factors among rural public health clients with PrEP indications, N=1057
46% MSM
23% PWID
3% MSM and PWID
28% high-risk heterosexual

9. Vignette
42 year old MSM (non gay/bisexually identified) in a primary relationship with a female. MSM contact occurs infrequently with inconsistent condom use. He lives in a rural community with population 2,000. Travels 75+ miles to access rapid HIV screening services in a public health clinic on a regular basis - bypassing clinics nearer his home.
PrEP is recommended during his last HIV testing encounter, but he is reluctant to discuss PrEP with a provider due to privacy concerns.

10. Rural PrEP Barriers Stigma / privacy concerns Distance
Rural provider shortages

11. Where do we start?
“Start where you are. Use what you have. Do what you can.” – Arthur Ashe

12. Iowa TelePrEP Development, 2017
Partnerships: IDPH, UI Health Care, Community Representatives
Resources: IDPH programs, UI HIV care team, telehealth platforms, existing public health STD clinic / lab network
Stakeholder Interviews: Users, Public Health, Health Care
Rapid Prototyping: with Johnson County Public Health

13. The Iowa TelePrEP Model More than Telemedicine
Public Health Screening and Referral
Marketing
Telephone
Navigator
In-home Vidyo® Visit
Provider Outreach
Medication by Mail
Local labs

14. Pharmacist Collaborative Practice TelePrEP Service
Protocol driven
USPHS/CDC guidelines
Approved by UIHC Pharmacy & Therapeutics Committee
Collaborative practice agreement
Formal relationships between MDs and PharmDs
Registry-based population management
Behavioral counseling
States with Collaborative Practice Laws

15. Public Health Partnered – Local Labs
Statewide public-health- affiliated sites
Blood draws
Self-swab for extragenital GC/CT screening
Refer clients with + STD screens to DIS / local public health for treatment

16. Barriers and TelePrEP Interventions
Rural PrEP
Barrier
TelePrEP Intervention
Stigma / privacy concerns
In-home video visits
Discrete medication mailing
Distance to PrEP providers
Local labs
Mailed medication
Provider Shortages
Pharmacist collaborative practice / task shifting

17. Local TelePrEP Pilot: Feb 2017 – Jan 2018
115 referrals (53% PH, 37% self, 10% HIV clinics)
73 clients with telehealth visits
67 PrEP starts
76% retained in TelePrEP at 6 months

18. Local TelePrEP Pilot: Feb 2017 – Jan 2018
Median age 31 (18-60)
93% men, 7% women
Race / ethnicity: 77% white, 9% black, 7% Latinx, 4% multiracial, 3% Asian
Insurance:
73% commercial
18% uninsured
5% Medicaid
4% Medicare

19. Local TelePrEP pilot: Feb 2017 – Jan 2018
13 clients (18%) with 18 new STD diagnoses
syphilis 5 (2 early)
gonorrhea 5 (4 extragenital)
chlamydia 8 (7 extragenital)
1 Pregnancy
Vaccines series initiated
Hepatitis A 29
Hepatitis B 9
HPV 11

20. TelePrEP Initiation and Retention Study Gilead N-US-276-4448
Screen clients for PrEP
indications in public health
Control
Regions
TelePrEP
Regions
Community
Provider Referral
(Control Regions)
TelePrEP
Referral
Initiate PrEP anywhere
within 30 days?
4 IDPH Regions
Retention in PrEP at 6 months?

21. TelePrEP Initiation and Retention Study Gilead N-US-276-4448
Cohort Flow
Study Aims
Compare PrEP Initiation within 30 days in Control vs. TelePrEP Regions
Compare PrEP Retention at 180 days
Enroll PrEP-Eligible
Clients in Public Health
N = 240
Baseline Survey
Day 30 Follow Up Survey
? PrEP Initiation Anywhere
Day 180 Medical Record Review
? Retained in PrEP

22. TelePrEP – sustaining no-cost visits for clients
Visit fee-for-service (subject to state telehealth laws)
Truvada® margin through 340B pharmacy dispensing
Public health programs and Iowa State Hygienic Lab to offset lab costs

23. Implementation - Lessons Learned
Monitor “opt-out” automated electronic health information sharing in EHR
Variable implementation of self swab protocols for extragenital STD screening
“Critically distant” labs?
Social network referrals are key for rural clients with greatest privacy concerns

24. Iowa TelePrEP - Conclusions
Innovation can be combinatorial: Technology secondary to systems redesign and network creation through partnerships
Pharmacist collaborative practice overcomes PrEP barriers related to provider shortages in rural areas
Contact:
TelePrEP: