Philadelphia’s Activities Coordinating Office (AACO), a department of the Department of Public Health, recently put out a request for proposals (RFP) to establish a telemedicine program for HIV prevention services, specifically pre-exposure prophylaxis (PrEP.) Slated to be part of AACO’s sexual health info platform PhillyKeepOnLoving.com, the Philadelphia TelePrEP Program, will facilitate access to PrEP for all Philadelphia residents no matter their insurance status, according to the RFP. The award will fund an 11-month contract.
Boosting the use of PrEP is a key component of the City’s Community Plan to End the HIV Epidemic in Philadelphia (EHE). AACO’s RFP and the future telePrEP program will be in line with the EHE goal that by 2025, 50% of people with an indication for PrEP, meaning they are considered at risk of HIV, will be prescribed the medication and 100% of people in need of post-exposure prophylaxis (PEP) will be prescribed accordingly.
One of AACO’s requirements of those looking to apply: telePrEP services have to be accessible via online portal to anyone living in Philadelphia who’s indicated for PrEP, including the demographics hardest hit by HIV. Other must-haves for the entity that executes the telePrEP program include the provision of urgent care for people with acute HIV or sexually transmitted infections (STIs), provision of PrEP and PEP as appropriate, and engagement in project evaluation.
AACO envisions that people will access the telePrEP program as such: the potential patient will see a digital ad for telePrEP, click on the ad and be directed to the Philly Keep On Loving telePrEP landing page. Then, the potential patient sends their contact information in order to speak to a PrEP navigator. The PrEP navigator discusses PrEP options and insurance with the patient, carries out a sexual health assessment and sets up an appointment with a clinician. The patient mails in a self-collection lab kit ahead of meeting with a clinician, though the patient will have the choice to be tested at a lab if they prefer. The patient then meets with the clinician to talk through their test results, PrEP dosage and frequency of use. Finally, the patient receives their PrEP medication via mail-order, with an option to retrieve their prescription at a pharmacy.
In the RFP, the AACO team highlights the potential benefits and challenges to the telePrEP program. Aspects of PrEP administration most suitable for telemedicine include determining the risk of HIV and indications for PrEP; advising about the risks and benefits of using PrEP; assessing and advising about adherence to taking the medication; aiding in lab or at-home HIV and/or STI testing and prescribing PrEP.
Another potential benefit of telePrEP, according to AACO, is the elimination of distance and work scheduling issues that may deter some people from seeking out PrEP in physical medical establishments.
“Telemedicine has become another tool in our arsenal to fight HIV rate,” said Deja Lynn Alvarez, director of community engagement for World Healthcare Infrastructures. “There are a lot of people including trans people who have a hard time with adherence to their medications or adherence to their doctor’s appointments because of their living situation, or lack of transportation. We’ve seen an increase to adherence to both medications and appointments with telemedicine. Increasing people’s ease of access to PrEP is only going to help with that.”
The lessening of stigma-fueled discrimination that some people tend to experience entering a doctor’s office could be another pro. “TelePrEP, particularly with the option of laboratory specimen collection at home, is also expected to address confidentiality concerns or the barrier of stigma that prevents some people in Philadelphia from seeking PrEP care in person,” the RFP reads.
Alvarez said that she believes that marketing PrEP to people of color, MSM and “high risk” people is not the right way to go. “If you work in the medical field, particularly the public health field like I do, you see a lot of cases of heteroseuxual people who are not necessarily sleeping with a lot of different people, but it only takes that one person who may have slept with one other person that didn’t know [they had HIV]. I think we should be marketing this medication to everyone and anyone who’s having sex.”
Philadelphia’s 2020 EHE Community Plan indicates that at least 18,798 people in Philadelphia are living with HIV. The demographics hit the hardest by HIV include gay, bisexual and other men who have sex with men (MSM); Black and Hispanic cisgender heterosexual women; young people 13-24 years old; young adults 25-34 years old; transgender people who have sex with men; as well as people who inject drugs, their sexual partners and people with whom they share needles.
AACO approximates that about 300,000 HIV-negative Philadelphians are at risk for HIV, and an estimated 8,200 HIV-negative Philadelphia residents have an indication for PrEP. Of the PrEP indication group, 5,080 people are MSM, 970 are people who inject drugs and 2,150 are straight, as per the RFP. Although indications are racially diverse, higher percentages of people of color are indicated for PrEP in all risk categories. AACO cites CDC data showing that roughly 3,637 people were taking PrEP in Philadelphia in 2019, revealing a gap in PrEP usage of 4,563 people.
“If PrEP had been available two decades ago we would have screamed it from rooftops,” said José de Marco, founder of Black and Latinx Community Control of Health. “I am really happy the AIDS Activities Coordinating Office is taking this initiative to make prep accessible to the communities at high risk for HIV infection. Access really does matter.”
While a telePrEP program has its advantages, it would also not be without challenges, the AACO team acknowledges, including patients not knowing that PrEP is an option for HIV prevention, being unable to pay for PrEP or not knowing about payment options.
De Marco too pointed out some pitfalls to the telePrEP model. “There could be high hurdles reaching everyone that needs PrEP,” they said, “especially those doing survival sex work, [experiencing] homeless, and addiction issues. Telemedicine is great but I am thinking about people without internet access. But this initiative is a beginning to ending the HIV epidemic.”
AACO does indeed acknowledge those roadblocks in its RFP — that people facing homelessness or housing insecurity may not have access to smartphones, computers or wifi, have a place to store their meds or even have privacy to talk about their history via phone. Telemedicine would not necessarily be optimal for people who require a physical exam to determine an STI diagnosis or who need an injectable treatment that has to be administered by a healthcare professional.
Obstacles to accessing PrEP on a facility level, i.e., on the part of the healthcare provider, the RFP says, include a lack of knowledge of PrEP medication and protocols; insufficient knowledge of or misinterpretation of PrEP indications; discomfort with talking about sexual health and HIV with patients; a shortage of same-day or convenient appointment times and ignorance of patient assistance resources for people who are underinsured or have no insurance.
AACO requires the TelePrEP program to be implemented in three phases over the course of nine months: phase one is pre-implementation in partnership with AACO, which includes recruiting program personnel and establishing a year one work plan, among other tasks; phase two is trial implementation and phase three is full implementation.
Proposals for the Philadelphia TelePrEP Program will be accepted until 5 p.m. on Jan. 21, 2022. According to AACO’s RFP, department personnel hope to select an applicant by Jan. 31, and start the contract by Feb. 1. Proposals must be submitted through Philly’s online application process eContract at this link: https://philawx.phila.gov/econtract/, using the opportunity number 21211215114550.