Family Planning Provider PrEP Toolkit

This Family Planning Provider PrEP Toolkit is a collaborative effort between HIVESan Francisco Department of Public Health Center for Learning and Innovation, (CBA), National CBA Provider Network Resource Center, National Clinical Training Center for Family Planning

This first draft is published at HIVEonline.org/PrEP4FamilyPlanning to both rapidly publish the information and simultaneously gather feedback.

We welcome your feedback here.

Introduction

PrEP (pre-exposure prophylaxis) for HIV prevention is highly effective and safe. PrEP works for women. The CDC estimates 468,000 U.S. women could benefit from PrEP. Of women who have been prescribed PrEP to date, there are significant racial disparities. Fewer Black women have received PrEP prescriptions. This is particularly striking in light of the U.S. HIV epidemic, where Black women are twenty times more likely to acquire HIV than White women. Black women have 1 in 52 lifetime risk of acquiring HIV. For information, resources and actionable steps to address disparities click here.

Forty percent of women access reproductive health care only, making family planning clinics a logical and efficient location for offering PrEP to women. PrEP services have been successfully implemented in a variety of family planning settings and in different ways. Even as additional training and infrastructure support are needed to fully implement PrEP in the family planning setting, PrEP clinic champions as well as PrEP user champions are emerging.

Family planning providers are uniquely skilled to offer options within a shared decision making model. Women tell us they want to hear about PrEP from family planning providers. Shared decision making focuses on women’s values and preferences – a way forward for supporting women as they balance competing priorities. Prevention of sexually transmitted infections, including HIV, is a core part of providing quality family planning services. While this toolkit is focused on cis women, we understand that people of all genders and sexual preferences (including gay/bi men) receive care in family planning settings.

This Family Planning Provider PrEP Toolkit aims to support PrEP implementation based on existing tools and resources.

Getting Started:

A PrEP clinic champion can lead the way to implement the necessary clinical and administrative protocols for smooth PrEP delivery. Are you a PrEP clinic champion? Would you like to be one? You don’t have to do this alone. There are trainings and clinical support resources available to you at no cost.

There is value in developing or finding PrEP user champions. Supporting user demand and integrating consumer feedback can make your job easier. Check out the following resources to find people and ideas:

Talking about HIV and PrEP:

HIV prevention counseling is best provided early and often.  People who are getting HIV and STI tests are ideal candidates for HIV prevention messaging. Consider adding  brief HIV prevention counseling (including PrEP) to HIV and STI testing: “Did you know that there is a new HIV prevention method called PrEP? It’s a pill that you can take every day if you are HIV negative to prevent HIV.” This brief counseling can be done by a peer navigator, medical assistant, nurse, physician assistant or doctor.

Who is eligible for PrEP?

There are tools available to support screening for PrEP.

  • Ask about recent possible HIV exposures: Anyone presenting to care with an HIV exposure within 72 hours, should be offered/referred for post-exposure prophylaxis (PEP).
  • Provider pocket card including PrEP eligibility
  • CDC PrEP guidelines and Provider Supplement outline PrEP eligibility
  • PleasePrEPMe.org PrEP Palm Card for women outlines women who may benefit from PrEP
  • Any person requesting PrEP/PEP can be considered eligible.
  • Women at risk for HIV do not always identify themselves as being at risk for HIV. As you incorporate HIV testing and prevention counseling into your family planning care, you may find women who self identify for PrEP and don’t meet standard eligibility criteria.
  • AltaMed video on of PrEP screening for providers
  • Check out the #HIVLoveWins Video Series for examples of patient-provider interactions around PrEP.

HIV Testing:

Before prescribing PrEP, a point-of-care or laboratory-based HIV test is required (CDC discourages using the oral fluid test for HIV screening in PrEP use); as well as ruling out acute HIV if there is a recent exposure. Many family planning clinics routinely provide HIV testing. Additional information on HIV testing is provided below.

PrEP Prescribing:

There are several options for being a PrEP champion. You can offer PrEP in your clinic. If you are not ready or unable to provide PrEP, developing a strong referral network with local PrEP providers is another option. Questions on how you can prescribe PrEP?

PrEP Follow-up & Adherence:

After a PrEP prescription has been filled, the next steps are follow-up and adherence. If you do not have capacity at your clinic to do follow-up and adherence counseling, consider being a screening and prescribing site and developing the warm handoff protocol to a local provider. Quarterly follow up visits include STI testing, renal labs, and counseling around daily pill taking.

Reimbursement (medical visit/s, tests, medication):

Developing reimbursement mechanisms and coverage for patient costs is an important part of a PrEP program’s sustainability plan. Many tools have been created to support the development of local and site-specific reimbursement plans.

Ancillary staff can support providers in the provision of PrEP. For example, a benefits or PrEP navigator can help in high-volume clinics to assure medication coverage, lab costs and paperwork are in order. Pharmacists can play an important role in working with the Gilead Medication Assistance Program. Another option for clinics is to consider 340B pricing and medication reimbursement as a sustainability model.

Patient-specific reimbursement resources are available.

Operations:

Developing a clinic flow for serving potential PrEP patients as well as longitudinal follow up includes staff at every level.  For example, front desk staff need to be aware that requests for PEP are akin to a request for emergency contraception and should be scheduled in the same fashion.

  • Staff roles and responsibilities can be tailored to your clinic’s resources and needs
  • Health departments may have resources to support PrEP and associated costs and/or navigation services.
  • Electronic medical records can provide opportunities to operationalize screening for PrEP as well as follow up visits.
  • Quality assurance measures related to PrEP should be integrated into the clinic’s evaluation plan.

Finally, consider providing patient resources with a mindful approach, tailored to clinic populations including language, reading level, and images.

Distinct Populations:

There are distinct populations at greater risk for HIV who may benefit from PrEP. More information on PrEP use during pregnancy and/or breastfeeding, can be found in this brochure. PrEP implementation for distinct populations is emerging. As specific tools for people who are substance involved or people who exchange sex are developed, we will add them here.

What did you think of our Family Planning Provider PrEP Toolkit? We welcome your feedback here.