A conversation about improving PrEP uptake in New York City with Emma Kaplan-Lewis, M.D., clinical quality director for HIV, hepatitis and sexual health services at NYC Health + Hospitals

The preexposure prophylaxis (PrEP) uptake at one New York City primary care clinic was more than triple the rate of the clinic’s entire health system, thanks to specially designed electronic medical record tools that prompted providers to initiate conversations about HIV prevention with patients, according to a recent case study published in NEJM Catalyst.

A team of researchers, led by Emma Kaplan-Lewis, M.D., clinical quality director for HIV, hepatitis and sexual health services at NYC Health + Hospitals, who is an HIV provider at the pilot site, studied the effects of the software on PrEP increase and compared its effectiveness to PrEP uptake rates across the NYC Health + Hospitals health system. She and her team found that uptake at the pilot site was 20% (15 out of 76 patients)—triple the rate of the whole system, which was 6.8% (1,207 out of 17,724).

Kaplan-Lewis recently sat down with Managed Healthcare Executive to discuss the results of the study, why it was a success and what it can tell us all about the current state of HIV prevention in the United States.

This interview has been edited for length and clarity.

MHE: What populations are the most impacted by the HIV epidemic, and why is PrEP underutilized by these populations?

Kaplan-Lewis: The highest prevalence and incidence of new cases of HIV are in Black and Hispanic men who have sex with men, transgender people (either male or female) and cisgender women of color.

There are a lot of different reasons for PrEP being underutilized. I think the major things are systematic and structural racism and inequity. Nationally, there is a lack of access to clinics and providers. In the south, for example, where there are a lot of new HIV diagnoses, or in Medicaid non-expansion states, there’s limited or no insurance coverage, wait lists for medication or long distances to a provider.

Even within resource-heavy urban areas, there’s still significant stigma in terms of seeking sexual health care or anything related to HIV.

Some providers are uncomfortable talking about sex, which is unfortunate, and so the conversations don't always happen.

MHE: What are some hurdles to implementing PrEP care within primary care and OBGYN clinics?

Kaplan-Lewis: I think a lot of it is about competing priorities. There's so much pressure on all types of providers, like “how many patients are you seeing?” and “are you helping the system meet the bottom line?”—even though it doesn't impact the provider’s compensation.

A lot of PrEP prescribing happens in the specialty care setting because infectious disease providers are more familiar with the medication, but people don't necessarily want to go to an HIV clinic for preventive care because that may add a layer of stigma.

In Ob/Gyn practices, the ‘Gyn’ practice versus the ‘Ob’ practice is quite different, but it's often the same providers. They may be rushing off to the operating room or handling a high-risk pregnancy, so HIV or sexual health conversations may fall to the bottom of that list of priorities.

I also think there is a lack of familiarity and comfort with medication. There are some Ob/Gyns and PCPs who are total PrEP champions and there are some that just feel very uncomfortable talking about it or have never seen it.

MHE: Can you provide an overview of the study and the methods that were used?

Kaplan-Lewis: This project and the paper we wrote up were built on the background efforts that we've been doing across our system to expand PrEP access in primary care and Ob/Gyn in general.

Prior to this project we did the PrEP ECHO series. The ECHO model is a web-based teaching model that’s used in health systems. We were able to use the data we gathered during the series to develop the PrEP express lane, which is a templated note in the electronic medical record that provides clinical suggestions when talking to patients about PrEP.

The listening tour was key for learning what was specifically needed to design this, and it included staff of all levels and patients. Providers and patients both stated the need for prompts so that patients know that they can get PrEP here.

One of the other components was a PrEP status metric, where if I have a schedule of patients, it can tell me different information about them. If a patient has had an STI in the past year, they are put into a higher risk category, where maybe they should be prioritized to at least discuss PrEP.

The last tool was PrEP Discussion SmartPhrase. One thing that kept coming up was providers saying, “I am having these conversations but so many people don't want PrEP,” and “how do I capture that?”

Sometimes people need five or six conversations to think about starting PrEP, and we were tracking it to see if this discussion was happening more in certain populations and less in others.

MHE: The PrEP uptake increased 20% at the pilot site compared with the other site. Were you expecting this much success at the pilot site?

Kaplan-Lewis: Yes and no. The numbers are small, so that's important to keep in mind, but I would say it validates what I see in my practice—that having a documented conversation does seem to impact people's uptake of PrEP across the board.

For example, I do it by asking the patient, “do you have any sexual health concerns?” If there are, we talk about them. I ask if they’ve ever heard of PrEP. Sometimes they’re super well informed and sometimes they have misinformation and we talk about it and fill it in.

It's normal to have sex. We want to make sure you're doing it safely or have the tools to do it as safely as possible.

MHE: In the study, it was found that across all demographics, only men who have sex with men were more likely to start PrEP, regardless of documented discussion. What do you think that this says about PrEP and, more broadly, HIV education in the United States?

Kaplan-Lewis: There is a much higher awareness of PrEP among men. This is an inadvertent side effect of the initial PrEP campaigns that targeted gay and bisexual men, which is great, but it was sort of at the expense of other populations who could also benefit from PrEP.

For example, the risk for cisgender women or cisgender men is different. I see a lot of cisgender women in my practice, and it's not their own risk behavior; it's their partner's risk behavior that puts them at risk. They may have one sexual partner, but I've seen so many new diagnoses among women because either their male partner had other partners or their partner never got tested.

MHE: You listed “celebrate success” as the last step for clinics considering implementing a PrEP program. Why is this important?

Kaplan-Lewis: Most people go into a health-related field because they want to help people, but we are, at every level, bombarded by various initiatives to do things quicker.

There is so much work behind even minuscule successes and celebrating those milestones along the way motivates ongoing effort way more than anything else.

Having that morale and keeping it refreshed is the key to keeping something sustainable, even if it’s just a shoutout at the morning huddle.