How One Pill Helps Slow the Spread of HIV
Bill Fantini: One pill, made from a combination of drugs that already were being prescribed for people infected with HIV is showing a better than 90 percent rate of preventing the spread of the virus even in cases of unprotected sex with partners who have HIV.
I’m Bill Fantini with Einstein Perspectives. Welcome to this chat with two representatives of the Immunodeficiency Center at Einstein Medical Center Philadelphia. Laura Martindale is HIV Prevention Coordinator and John Rose, Community Prevention Navigator. First off, what does the Immunodeficiency Center or IDC do?
Laura Martindale: The IDC is a specialty clinic for HIV positive people. It links them into primary care and/or specialty care for the HIV. We have a number of providers; we have medical doctors, nurse practitioners that see about 900 patients every year.
Bill Fantini: What exactly do the two of you do at IDC?
Laura Martindale: We are specifically working on HIV prevention, that is working with people who are HIV-negative and trying to keep them HIV-negative and providing services in the community as well as within the facility. IDC actually provides services for HIV-positive patients. We are working together with them but we are actually serving a different community so I need to make that distinction.
Bill Fantini: So, you have patients that are both negative and positive in testing for HIV?
John Rose: That is correct.
Bill Fantini: You said that you have about 900 patients. How do patients come to you?
John Rose: Our patients come to us from all over. Our patients come to us from inside of the hospital. They’re referred to us from our emergency department. We get referrals from health centers. We have relationships with other hospitals near us where we also take patients. Most importantly they come from the neighborhood.
Bill Fantini: One of your concerns is preventing high risk patients from contracting HIV. How do you that?
John Rose: We’ve thought of a number of ways to do it. One of the things that we did in 2015 was, we expanded our testing program, what was happening in our emergency department, to routinely test patients as they entered our emergency room. That was a success because we were able to not screen people based on risk but moreover just make it eligible for all people. This took away some of the stigma and put us in touch with more people. As our program developed, we talked to a lot of people so obviously we were able to diagnose a lot of people. We were able to engage a lot of people back into care who had fallen out of care.
But, we also spoke to a lot of people whose tests were negative. What we found out in many instances where they really dodged a bullet, a very serious bullet. We would talk to them about their practices. In a non-judgmental way we try to engage people to tell us exactly whether or not they use condoms and maybe the number of partners they had, how many times had they been tested. We got a lot of information. With that information, we work with our IT team to develop reports that could capture patients who were not only tested for HIV but also tested for other STDs. We know there’s a link between the STD and HIV. You get an STD, you’re more likely to get HIV if you come in contact with it.
So, these patients were on our radar and we reached out to them. We received the reports, we talked to them on the phone and we developed a protocol where now we’re in the community.
Bill Fantini: Explain, please, what PrEP stands for?
Laura Martindale: PrEP stands for pre-exposure prophylaxis. It is a prevention for HIV before someone gets into contact with it. In addition to doing the routine HIV testing that’s going on in the emergency department, we are also talking to everybody about sexual health and wellness. We’re working with a lot of different doctors to also incorporate these conversations into their everyday talks with their patients to see what’s going on in life, what kind of sex are they having, and identify potential risks that way as the entry point to start talking about PrEP.
Previously the IDC was providing PrEP services on a very small scale with only a couple of providers. What we’ve been able to do in the first six months of our PrEP program is to train more than 200 medical providers in PrEP basics, what is PrEP, how are we doing it, what is our workflow going to be like? We’ve made that pool larger and expanded access for people who are interested in PrEP. We have a lot of providers who are now doing that.
Bill Fantini: Now, in order to take PrEP, they do have to be HIV negative—is that correct?
Laura Martindale: That’s correct, and PrEP actually is … It is a daily medication. It’s one pill once a day to prevent HIV.
Bill Fantini: How well does it work? What is the rate of risk of getting HIV in patients who take PrEP?
Laura Martindale: It works very well when it’s taken, and it does have to be taken every day. When it is taken every day, it’s more than 90 percent effective in preventing HIV.
John Rose: I can also add that there have been studies, one in particular the Partner Study. That study, Partners of Discordant Couples, meaning one partner has HIV and the other doesn’t, and in the study where the people were having sex with each other, condom-less in some cases, there were no reported transmissions of HIV. I believe there were thousands of participants in this study. What we know is that the efficacy of it is great. The value of it is great to people because it becomes another tool in their toolbox to prevent HIV in addition to condoms. This project is new and we are just beginning to sign up patients and monitor them over long periods to see whether or not the treatment was effective.
A lot of it has to do with adherence. The pill works but relied on the patient’s adherence. As my colleague stated, it’s a one pill a day regimen that has to be taken every day, consistently. This is not a holiday pill or something you take just when you’re going to have a sexual experience over a weekend or on vacation. This is a very serious protocol that probably involves a change in mindset into how you monitor your health and take care of yourself.
Bill Fantini: How much does it cost?
Laura Martindale: PrEP is covered by all insurances to different degrees. It is covered 100 percent by all Medicaid plans and for those plans that are private that someone might have a copay for their medication there is a copay assistance card that will cover the entire cost of the copay so that the patient does not have any cost for the medication itself. For those who have no insurance, there is an assistance program that is provided from the pharmaceutical company that will cover the entire cost of the medication as well. It is very well supported and no one should be paying any kind of a copay for the actual medication.
What we are really working on also is trying to get as many provided aware and comfortable with PrEP itself so that they are able to offer this prevention in a number of different clinics, through primary care, through the adolescent teen clinic and also through the women’s health OB/GYN providers so that it can be accessed anywhere.
John Rose: One of the driving forces behind our initiative here at Einstein is that we know that 75 percent of the patients taking PrEP currently are white. When we talk about that number in relation to the epidemic as it stands today, while people of color represent 14 percent of the population they account for nearly half of all new infections. It’s stunning when you think about where the need for this prevention method exists and what Einstein’s role in ensuring that people who we serve in our hospital are able to take part of it. That really is what’s driving us. We do consider it a social justice issue and we are aware of it and we are talking to people and engaging them in trying to figure out what may be barriers. We talked about insurance, we talked about adherence, and whether or not people trust this medication based on some of the things we talked about, the Partner Study, what we know from the data we’ve collected and seen and whether or not they trust it enough to take it because it really is a life-saver.
Bill Fantini: How available is PrEP in Philadelphia?
Laura Martindale: There are quite a number of locations where people can get PrEP throughout Philadelphia. We are just actively now trying to expand the possibilities. Every day we are trying to get more and more providers on board for prescribing and all of the health centers also are providing PrEP, as well as private locations. There are other hospitals that provide it. We are not unique in that way. It is widely available. Not as widely as we would hope for but that’s what we are shooting for.
Within Einstein there are also a number of locations that we are trying to expand so that they feel more comfortable being able to support their patients that are taking PrEP.
John Rose: The availability exists but the uptake in communities of color does not necessarily correlate with that. That’s where I believe Einstein may, you know, be looking at this in the right direction because after all we consider ourselves the specialists in the treatment and care of HIV and the prevention of it. We have a huge team of people who are dedicated to it. We read about it. We keep up on it. We are very aware of the uptake issue. It’s no good if people aren’t taking it. That’s what we’re focusing on.
Laura Martindale: For us, I mean, we are really gauging success also on number of people who are referred, number of people who are offered PrEP. We have now so many more providers who are comfortable in doing that that it’s happening a lot more.
John Rose: Currently when I speak to people, most people tell me that they’ve never heard of it before and this initiative seeks to change that.
Laura Martindale: We have created systems where it’s quite simple for people to get an appointment and come in for PrEP and then also be seen at a primary care facility and get any other health situations dealt with at the same time as well.
John Rose: PrEP is a prevention measure. It stops HIV so we would also, hopefully, be around to see HIV prevalence rates decrease in communities that are high hit by HIV.
Laura Martindale: We really recommend that people do seek care in a location that’s convenient to them, if it’s somewhere that’s close by where they are staying or where they are working, because we’ve found that if people are going too far for care it’s difficult, they drop out, it’s not convenient so it’s not going to work out. When we get referrals we really do work with them to find where is the closest location that would be convenient for them to get care just to ensure that they are able to make it to their follow-up.
Bill Fantini: Just to be clear, they don’t have to go to the provider every day to take the pill, is that correct?
Laura Martindale: No, absolutely not. Once we have started someone on PrEP we will follow up with them after the first month just to see how everything is going and to make sure that the medication is not harmful to the body. Then, we do every three month follow-ups just to check in and again do monitoring.
Bill Fantini: What other services does the Immunodeficiency Center offer?
Laura Martindale: We try to offer a very comprehensive range of services. We offer everything from mental health, counseling, psychosocial support, nutrition. We recently started a medication assisted treatment program as well. We have walk-in services, also Hep C linkage.
Bill Fantini: How can people contact IDC?
Laura Martindale: We’ve got a couple of different contacts. There is a telephone that is answered continuously, if someone calls and leaves a message. The number is 215-456-3465. Again, that is services for people who are looking for an HIV provider. For those looking for prevention services and interested to find out more about PrEP, the number is 267-785-0892. I also did want to share a resource with you. Online there’s a website where you can find the nearest PrEP location to you by putting in your ZIP code. The website is www.pleaseprepme.org. Let people know who are not within our service area range.
John Rose: I wanted to talk about PrEP on the Outside. It’s Einstein PrEP on the Outside, which is my role in the community. The number for that would be 215-456-3587. The purpose of PrEP on the Outside is that we will come to community, we will show up at your health fair, we can engage you at a church even or a social. We have designed about an hour-long presentation that covers very easy to digest information about HIV, prevalence rates of HIV infection in the communities and we actually try to make the presentation fit the community that we’re in with the prevalence rates. We also reach out to barber shops and beauty salons.
Bill Fantini: You’re also at the local library, right?
John Rose: We have one near us at Logan, it’s on Shelton Avenue. We are hoping to make this information accessible. PrEP is here, and we wanted to be accessible to people and we’d like to see people get all the facts. One of the things that people tell us in the community is they’re somewhat skeptical of medicine, period. There has been and is distrust of the medical establishment in black communities. This is really in large part to do with the relationship between blacks and medicine. It’s really not without merit. People have a suspicion of things and they need clarification. They need the facts. We have the facts and we can provide the clarification. It’s not just PrEP. You know, when we’re in the community we’re talking about everything, everything sexual. PrEP is just one of those things but we’re actually telling you where to get an HIV test, we’re talking to you about hepatitis C prevention and we’re talking to you about other STDs. We’re understanding of the fact that PrEP may not be for you, it doesn’t fit into your lifestyle, but maybe talking and counseling and we can make those referrals as appropriate.
Bill Fantini: Thank you both for sharing your time and expertise with us. That was Laura Martindale, HIV Prevention Coordinator and Jose Rose, Community Prevention Navigator at the Immunodeficiency Center at Einstein Medical Center, Philadelphia. I’m Bill Fantini, thanks for listening.
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