HIV health care professionals and advocates have been struggling with how to reach the populations that could most benefit from pre-exposure prophylaxis (PrEP) and, when and if these patients access it, help them take their medication daily. A variety of new mobile-friendly online portals and apps are taking on two of the biggest barriers to getting people on PrEP: the lack of doctors who are willing to prescribe it, and the perceived—and often real—difficulties in obtaining it. People who use PrEP on a regular basis need four visits to a doctor every year, with an average of four hours, including time off work. Telemedicine apps and mobile-friendly platforms allow users to consult with (judgment-free) doctors, obtain PrEP, and even get lab tests (in some cases) without setting foot in a brick-and-mortar medical facility or pharmacy.
Overcoming Rural Barriers
In rural Iowa, telehealth is one solution. Launched in 2017, the University of Iowa’s TelePrEP program was the first in the nation to provide access to PrEP through secure video conferencing. Patients visit with a University of Iowa Health Care pharmacist using a secure, HIPAA-compliant app on a smartphone, laptop, or tablet. Users can get tests at a local lab or through Iowa’s network of public health providers. In most cases, meds can be delivered by mail.
Funded by the Iowa Department of Public Health, the TelePrEP service points out the lack of PrEP prescribers in many rural communities across the country. From the website: “We believe that every Iowan who wants/needs PrEP should be able to get it without having to spend a whole day in the car and without risking a loss of privacy.” Between February 2017 and October 2018, Iowa’s TelePrEP received 186 referrals and completed 127 initial video visits with clients. Ninety-one percent of clients with video visits started PrEP, and the retention rate for TelePrEP at six months was 61%.
Telemedicine can be helpful for high-risk populations in rural communities and for people in cities who don’t have time to go to the doctor—or, just like in rural areas, can’t find one who knows about or advocates for PrEP.
Direct-to-Patient Telehealth
Three direct-to-consumer platforms are available for obtaining PrEP, all developed to circumvent the obstacles keeping many people from getting on PrEP. They can also help users navigate the payment maze and, in many cases, find out how to pay little or nothing for the medication. Once on PrEP, customers can get SMS messages reminding them to take the medication and to renew.
One mobile-friendly telemedicine platform, PlushCare, is like an “online doctor’s office,” according to its chief medical officer. PlushCare offers end-to-end medical care, if needed, so a patient can come for PrEP and also get diagnosed and treated—through face time and messages with a doctor—for any other acute illnesses. It has 100,000 total users and 10,000 accessing PrEP. Unlike the similar platforms Nurx and Mistr, there is no in-home testing option, so users must physically go to a lab for HIV tests as well as ongoing testing while on PrEP.
Started as a telemedicine platform for women’s reproductive health, with 200,000 current patients on birth control, Nurx now offers HIV and kidney function home testing kits needed for PrEP, and additional testing kits for sexually transmitted infections (STIs). A Nurx spokesperson said one benefit of the platform is allowing patients to consult with doctors to determine if PrEP is right for them. Nurx also connects patients with a navigator team to assist with insurance coverage and payment-assistance programs.
Mistr is a mobile-friendly site exclusively for PrEP, and it’s marketed to gay-identifying men and other men who have sex with men. Since going live last year, Mistr now has more than 10,000 users on PrEP. Anyone wanting PrEP can log in and schedule all lab tests to be done at a local lab—or order an in-home testing kit—and have the results fed back into the Mistr system. A doctor reviews the results and consults with the patient through video chat. If you do want PrEP, the doctor sends a prescription to a partner pharmacy. Mistr will also send PrEP renewal and testing reminders. The founder of the company, Tristan Schukraft, said Mistr has a PrEP adherence rate approaching 95%.
All three platforms offer security through encrypted messages and log-in time-outs. Representatives from each company say health files are as secure as those in a doctor’s office, with software sometimes more advanced than in an office. All companies say they don’t sell health or financial information. However, with all digital platforms, data and privacy protection are important, especially so with sensitive health information. TheBody urges readers to read the privacy policy on any health-related consumer app you use where you will be disclosing your health status or prescription information. Companies will often send you a prompt when they’ve updated their user and privacy policy, and TheBody urges you to read that information.
How a PrEP App Can Address the Whole Patient
One more app for accessing PrEP and increasing adherence—E2PrEP—will be available in the fall of 2020, and a web-only version will be launched before the summer. Jesse Thomas, project director at Los Angeles–based RDE Systems, the company behind E2PrEP, told TheBody that the app won’t be direct-to-consumer, but rather, it will focus on “connecting local resources to priority populations, give them tools to better serve clients.” Those priority populations, Thomas said, are those with more than just a need for PrEP.
“There will be tools built in for navigators and counselors to follow up. These services can be mental health, housing, places where there are structural barriers,” Thomas said. “Current reporting systems present a fragmented view of the person. When you enroll a patient through a normal PrEP navigator, there’s one more database to track. And those data systems are not integrated and sometimes not user friendly or culturally appropriate. But we want to give integrated view across all systems, with proactive alerts. And we want to make it user-friendly enough to put patient and client in control of their information.
“E2PrEP takes on how to address all of a client’s needs,” Thomas said. “Maybe they’re not concerned with PrEP now because they lost their apartment, for example. We have worked on clinical and social services to address the whole person.”
The client-to-patient E2PrEP app is funded through several health departments and a grant from the Centers for Disease Control and Prevention (CDC).
Come for PrEP, Stay for Health Care
Like Thomas, John Huckaby, CEO of AIDS Foundation Houston, sees mobile tech as potentially game-changing in getting the most vulnerable populations on, and staying on, PrEP.
“The CDC analysis of those indicated for PrEP shows tremendous disparity,” Huckaby said. “We have had PrEP for five years, so why are we not seeing significant declines in HIV new cases? We know anecdotally when large population areas adopt PrEP by big numbers, it has an impact. Why is there a gap, still?”
Huckaby cites stigma and sex-shaming, the misperception of cost, and a need for more passionate PrEP advocates in the LGBTQ community. While trying to address those hurdles, Huckaby and AIDS Foundation Houston recently tried out one online PrEP portal—Mistr—to see whether customizing the app would bring in more potential patients to the foundation’s walk-in clinic.
“We liked many things [about Mistr]. It can be accessed in privacy, in a safe space, and users don’t have to go into a doctor’s office for an initial visit. You can process all paperwork online. You can consult with doctors online to review results and ask questions, and you can opt for home delivery.”
Beyond those benefits, Mistr allowed its PrEP navigators and other health care workers to begin an ongoing relationship with a client.
“Houston is a big, spread-out city, so having an online option is great for increasing engagement. Some patients just want PrEP. Others, maybe they learn that they test positive for an STI, and they will make appointments to see a counselor. So, it’s come for the PrEP, stay for the health care.”
AIDS Foundation Houston’s customized Mistr app went live Dec. 1, and word has spread through local social-media channels and a local gay publication. Soon they will reach out to college campuses in the area. So far, there have been 100 new registrations, meaning those who have enrolled to get to the point of ordering a home test kit. “That’s pretty phenomenal, considering the low-key rollout,” Huckaby said.