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PrEP starts vs. maintenance in times of COVID quarantine

  • 1.  PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-02-2020 11:12
    Hi AAHIVM friends!

    Just wondering what you're doing for patients on PrEP or who want to start PrEP in these times without recent HIV lab monitoring. 

    Personally, I'm screening for acute HIV, if negative, continuing PrEP and scheduling a one-month appt (hopefully). 

    Initiating PrEP (without recent HIV testing) though causes me some pause...what has been your experience and/or strategy?

    Thanks,
    Gina Simoncini
    Temple, Philly

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    Gina Simoncini MD MPH FACP AAHIVM
    Lewis Katz School of Medicine at Temple University
    Philadelphia PA
    @gina_simoncini
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  • 2.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-02-2020 11:48
    I am doing telemedicine with my PrEP patients, having patients get testing in the lab for HIV, RPR, etc, and having self-swabs for STI screening.  I am continuing to take new PrEP patients as well as continuing to follow current patients.  I have been successful in getting about 10 of the PCPs in my community health center also providing PrEP and with the guidelines I have distributed, they too will continue taking new patients and/or following existing PrEP patients.

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    Gary F. Spinner PA,MPH,AAHIVS
    Southwest Community Health Center
    Bridgeport, CT
    gspinner@swchc.org
    Gary.spinner@aya.yale.edu
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  • 3.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-02-2020 12:34
    Edited by Gryan Eroll Garcia 04-02-2020 12:41
    Hi. I also move all my PrEP and HIV positive stable patient on acute treatment via telemedicine. I do it all online, and I instruct patient to go to LabCorp or Quest for their labs. I have an HIV/PrEP navigator too to help me.

    I see my PrEP patients every 3 months with the routine testings, and HIV from initial, to 2-4 weeks, then 4-8 weeks until suppressed. All are telehealth. Depending on the situation, I have allotted, once a week clinic hours - for those patients that are needed to be seen in person.

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    Gryan Eroll Garcia
    Scottsdale AZ
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  • 4.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-03-2020 06:43
    Edited by Joel Ang 04-04-2020 08:35


  • 5.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-04-2020 07:26
    We are able to  perform almost all labs in house but we have stopped essentially all in person visits except emergencies and COVID related visits. We screen all patients by phone in advance then in a screening tent outside our office.  Inside we have consolidated services on one floor with a separate Influenza Life Infection unit and a non ILI unit with appropriately different levels of PPE.  All staff and patients are masked. This is a matter of patient, staff and community safety.  It is important that HIV providers as always also set an example from a public health perspective and that example now is that unless it is an emergency you should be staying at home. There is no treatment for this disease and our only hope as a nation is to flatten the curve to buy us some time and not overwhelm our hospital and ventilator capacity and to hopefully develop some treatment or vaccine eventually.  

    We are not having anyone on PrEP or HIV come in for lab monitoring.  We are managing most of our STD patients by telehealth as well.

    There are high risk conditions that need to be seen during this pandemic e.g. patients with aggressive cancers on chemotherapy.  I do not think that HIV and PrEP are in that category.  We all have plenty of patients who come in once a year or so for labs but have good adherence and are doing fine. We have plenty of patients who go back and forth to developing countries and have no lab monitoring while they are away. Compared to 30 years ago, our meds are very safe and effective now.  Adherence is still important and we can monitor that by phone and pharmacy refill data online.  Even the guidelines have changed to allow less frequent monitoring of labs in patients that are doing well.  I would argue that in this pandemic we should extend that to all patients.  I did my first telephone visit with a newly infected patient this week. She did come in for baseline labs and met with two of my staff that were on site but I was off site that day. We switched to self swab for all our STD testing (vagina, oral and rectal) several years ago and it has worked great. We are also going to start sending home HIV and STD test kits to patients to improve telehealth STD services.  Below is our current version of our telehealth STD services.

    I think the risks of in office visits and the message that sends to patients, staff and the public are potentially more harmful than the risks of waiting a few months for routine labs.  

    We have all been trained that we need labs and in person evaluations but times have changed and I think if you consider the safety and efficacy of our current meds and the risks to leaving the home now, we should be deferring labs in essentially all patients with HIV and on PrEP for now. 

    Be safe, 

    jon






    Jonathan Pincus MD
    Internal Medicine and HIV Services
    Codman Square Health Center
    637 Washington Street
    Dorchester, MA 02124
    Phone (617-822-8115)
    Fax (617-825-7118)
    codman.org








  • 6.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-05-2020 17:00
    Dear Jon,

    I'm a family nurse practitioner up at Lynn Community Health Center. I really appreciated your post. I prescribe Suboxone, PEP and PrEP, and treat HIV and HCV. In fact,

    I'm about to start my 4th week of telemedicine. We use Ochin Epic for our EMR and I've started to become more creative with remote care. MyChart allows you to send many screening instruments to patients and even send vital sign tracking sheets to patients. I've been prescribing many more blood pressure cuffs and my DM patients are actually learning out to self-titrate and learning true self-management.

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    Morgan Mako, APRN, FNP-C, AAHIVS
    Lynn Community Health Center
    280 Union Street, Floor 2
    Lynn, MA 02128
    mmako@lchcnet.org
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  • 7.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-03-2020 08:24

    I'm sorry. I should have been more specific.

    Where I am, I have a stay-at-home order for my region. Are still requiring patients to have labs done during this time? People are not *supposed* to leave the house unless to procure life sustaining items.

    My question really is: how are you handling monitoring HIV tests for patients on PrEP or initiating PrEP, but should not leave the house?

    I am doing tele/video visits, but not sure what to do with the lab portion. Are you requiring that they have the lab done prior to prescription or are you delaying HIV testing?

    Thanks,
    Gina

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    Gina Simoncini MD MPH FACP AAHIVM
    Lewis Katz School of Medicine at Temple University
    PhiladelphiaPA
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  • 8.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-03-2020 08:48
    Hi Gina, 
    I guess it depends on what your State and local guidelines are regarding leaving home.  In my town of New Haven and in my state of Connecticut, we are advised to stay home unless we have certain criteria, which includes patients who need medical care.  Other than my HIV patients who are seriously immunocompromised, i.e., CD4<200, I am still having patients leave their home to get labs, immunizations, etc.  You might want to check you local and State guideance, but I would suspect getting needed medical care would fall under what is allowed.  You might find it easiest to call  your local lab to see if they are open for business. I would want to make sure someone on PrEP remains HIV negative.  A few days or so beyond the 90 days is OK with me, but I would be reluctant to continue without getting needed labs.  Ken Mayer is giving a talk on TelePrEP  that should be useful for all of us.

    Webinar: PrEP in the Time of COVID-19

    Details

    Starts at: April 14, 2020 6:00pm ET
    Ends at: April 14, 2020 7:00pm ET
    Free Admission


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    Gary F. Spinner PA,MPH,AAHIVS
    Southwest Community Health Center
    Bridgeport, CT
    gspinner@swchc.org
    Gary.spinner@aya.yale.edu
    ------------------------------



  • 9.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-04-2020 15:35
    If PrEP patients are under shelter-in-place orders, and don't live with a serodiscordant partner, they are likely not having much sex--if any.

    So we should be asking PrEP pts what their sexual activity is, if any.  If none, perhaps we should counsel them to discontinue their PrEP until they foresee becoming sexually active again.  This would obviate the need for routine labs--and possible exposure to SARS-coV-2 by entering testing facilities.  

    In this scenario, we'd also need to counsel pts on how & when to restart their PrEP well before they anticipate becoming sexually active again.

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    Jeff Taylor
    Palm Springs CA
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  • 10.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-09-2020 23:16
    Hi, Gina!!!! 

    Missing you my friend! I will give you a short answer..I get your question. We have acquired some at home HIV test kits!! I have PrEP patients with symptoms consistent with COVID19, so ah...no labs for you! We just started putting together our list, then they will be mailed to the patients. Patients will have to screen shot the results send them, then they can get their script. 

    Stay safe, and I think I owe you something..email me when you have a minute.

    Michelle

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    Michelle Ogle
    Bronx NY
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  • 11.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-06-2020 02:15
    I agree with Dr. Pincus and some others here that this is an exceptional time and we need to change the way we approach everything we are doing. Obtaining labs should only be done for urgent/emergent cases (i.e., preventing hospital admission) to limit exposures as much as possible; I operate under the assumption that ALL of my patients are COVID-19 positive as this is the safest way to proceed at this point in time.

    PrEP refills are neither urgent nor emergent. The risk of acquiring HIV while an individual is adherent to PrEP as we know is INCREDIBLY low (referring primarily to rectal exposures) and driven by transmitted resistance and/or repeated (high) viral exposures which are not common, and we are putting our patients at risk of COVID-19 acquisition when asking them to leave their home and obtain labs. That being said, if there is concern for poor adherence AND potential exposure to HIV, or acute HIV then it is resonable to have a patient stop PrEP and obtain labs (of course trying to do this with least amount of human interaction/exposures as possible).

    I have been able to obtain labs via home health for some patients (not always covered, requires skilled need as well), again only being for urgent/emergent cases that would prevent hospital admissions, I have not yet done this for any of my patients on PrEP or with HIV. 

    Hope you all stay safe and healthy!! 

    Best, 
    Josh 

    Josh Khalili MD, AAHIVS 
    UCLA Extensivist Physician 
    Ambulatory HIV Specialist 
    Clinical Instructor of Medicine

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    Joshua Khalili
    Los Angeles CA
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  • 12.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-07-2020 08:23
    affected disproportionately by HIV and every other chronic disease.  The need to continue to offer care, which includes when needed- obtaining laboratory services, receiving immunizations against pneumonia, and maintaining needed prevention services such as PrEP needs to be continued.  I am seeing greater numbers of patients than ever through telemedicine, but am unwilling to make assumptions that my at-risk patients may have less sex or less HIV-risk in this time of pandemic.  I continue to be as vigilant in screening  for STIs as always.  I discuss with all of my patients the need to practice social distancing, to use frequent hand washing,   I don't want to make assumptions that I do any less for my patients than before.

    ------------------------------
    Gary F. Spinner PA,MPH,AAHIVS
    Southwest Community Health Center
    Bridgeport, CT
    gspinner@swchc.org
    Gary.spinner@aya.yale.edu
    ------------------------------



  • 13.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 04-06-2020 17:29
    Edited by A.C Demidont 04-06-2020 17:37
    Hi Gina,
    This is solely informational and not meant to direct your patient care in any specific way.
    There is a fair body of literature on ways to approach HIV/STI testing when patient can't regularly attend office visits.  
    Touger and Wood published a nice review: Current HIV/AIDS Reports (2019) 16:113–119 https://doi.org/10.1007/s11904-019-00430-z and they discuss testing options.  
    The Iowa DPH published: Iowa TelePrEP: A Public-Health-Partnered Telehealth Model for HIV Pre-Exposure Prophylaxis (PrEP) Delivery in a Rural Stateexually Transmitted Diseases. 46(8):507–512, AUGUST 2019. They collaborated with local and commercial labs in their program and were very successful.  They are exceptionally nice people and always helpful if you reach out. 
    Jacob Person and Tim Lahey from Dartmouth presented a nice posted at IDWeek last year on how their PrEP navigators assisted with assuring screenings were being done in their distance PrEP program.
    Also, the nice article in JAMA: MacGowan RJ, Chavez PR, Borkowf CB, et al. Effect of Internet-Distributed HIV Self-tests on HIV Diagnosis and Behavioral Outcomes in Men Who Have Sex With Men: A Randomized Clinical Trial. JAMA Intern Med.2020;180(1):117–125. 
    Orasure Technologies has a webinar regarding Innovative Strategies for HIV screening during COVID scheduled for Wednesday at 1pm which is being recorded https://orasure.zoom.us/webinar/register/WN_FhJTANePSs6KrWd07A8TyQ
    The National STD Curriculum has great posters in various sizes for free if you are looking to create a "drive-by" self-swabbing suite:  National STD Curriculum
    .  Such nice posters.  There are also programs which have created QR codes that link to videos from pharyngeal self swab.  I'd be happy to point you in the direction if you like. 

    There are many programs in New England which have developed TelePrEP with complimentary Express STI screening programs which require zero provider interaction and still allow patients to complete STI screening/HIV testing and receiving PrEP.  

    Obviously, the routine lab testing requirements at start and follow up are solely based on which PrEP regimen a patient is currently being prescribed.

    Lastly, I have read through many of the responses and would suggest that we have the expectation that patients will stop having sex when they are supposed to be social distancing and that PrEP is less necessary now would not be what has been suggested by the NYC Department of Health nor other Departments of Public Health. https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf

    HIV prevention is always a public health emergency.  The HIV pandemic has killed upwards of 35 million people worldwide and continued biomedical HIV prevention efforts can be a sign that things can change from a very sad and challenging time (during the beginning years of the HIV pandemic) as providers, patients and families struggle through as SARS-CoV2 changes all of our lives.



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    A.C Demidont, DO AAHIVS
    Principal Medical Scientist, HIV Prevention
    Medical Affairs, East (CT,MA,RI,NH,VT,ME and Upstate NY)
    Email: ac.demidont@gilead.com
    cell: 203.299.6076
    ------------------------------



  • 14.  RE: PrEP starts vs. maintenance in times of COVID quarantine

    Posted 05-13-2020 16:05
    Our facility moved to essentially 100% telemedicine.  We had the luxury of having a state DOH built and sponsored PrEP telemed clnic already up and running for over year.  So there were well established practice models.  Our specific system had rolled out a telePrEP PrEP clinic about 10 months ago already.  Labs remained open.  Most new patients were willing to have labs done.  Existing patients, assuming we were able to document self reported adherence, many prescribers felt comfortable in extending PrEP 30 days and scheduling labs in a month's time.  That month has now expired, our system is returning to largely normal function and most of our patients have been retained on PrEP.  

    Our larger challenge now is the large number of patients who have lost health insurance.  As an HIV pharmacist I can often obtain drug access but labs access has become a challenge.

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    John Brissette
    New Orleans LA
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