Rural Telehealth Programs Help Prevent HIV

Heather Boerner

November 08, 2018

DENVER — Keeping patients on pre-exposure prophylaxis (PrEP) for HIV prevention is always a challenge, but in rural parts of the country, it can be nearly impossible, said Donna McGregor, NP, from the University of Colorado School of Medicine in Aurora.

She described the situation faced by one of her patients here at the Association of Nurses in AIDS Care 2018.

The college student was taking the combination of tenofovir and emtricitabine (Truvada, Gilead Sciences) for HIV prevention, and drove for hours every 3 months so that McGregor could order the lab tests associated with PrEP. But he ran into trouble getting the Colorado Public Health Intervention Program (PHIP) to cover the cost of his labs and medications.

And then, "he just gave up" filling his prescriptions, she reported.

"He's 21 now," she said. "If he's 24 and living with HIV, I have failed at my job."

So McGregor and her colleagues decided to build a tele-PrEP system that uses the telehealth infrastructure at the University of Colorado and PHIP. They hope to serve 50 Coloradans in the next year who want PrEP but do not have easy access to or cannot afford care.

The 50-patient goal comes from the experience of the University of Iowa, which implemented a rural telehealth PrEP program about 2 years ago. When McGregor's team consulted the clinicians in Iowa 9 months ago, that program was serving 50 people using a combination of local lab work, HIPAA-compliant video sessions, and mail-order or in-person pharmacies.

The Iowa program is run by a pharmacist-coordinator and is currently funded by a grant from Gilead Sciences. But the Colorado program is designed to pay for itself, with reimbursement from public and private payers and PHIP, which covers the cost of lab work, office visits, and medication for people who earn less than $60,700 a year.

As the Colorado program developed, barriers to telehealth and rural healthcare emerged, McGregor and her copresenter, Lisa Lawrence, MSW, from the Colorado AIDS Education and Training Center Program, explained.

For one thing, only certain providers are authorized to provide PHIP services to low-income or uninsured people.

"Those providers are lacking in rural areas," said Lawrence. "Folks didn't have another way to pay for care or access the program."

For another, some states require a physical exam before PrEP can be prescribed. "That defeats the whole purpose" of telemedicine, McGregor pointed out. Colorado isn't one of those states, but it does require something more than an online intake form.

In addition, a provider has to be licensed in the state where the patient resides. People regularly travel from rural Wyoming to access care in Colorado, so tele-PrEP providers need to be licensed in Wyoming to provide their care.

And getting lab tests can be an issue for people who live in a "care desert" or who live in a small town and are concerned that if they go to a local clinic, word will travel. A local sexual health clinic initiative was abandoned because people living with HIV "in small towns would rather travel 2 to 3 hours for services than risk having their status known," Lawrence pointed out.

At-home testing kits are a great idea, but the University of Colorado currently has no method of paying for them. "You're reimbursed for medical visits and you're reimbursed for labs," McGregor explained. "Nowhere in our contract with PHIP are there funds to purchase goods like these tests."

They'll probably have to apply for a grant to pay for that sort of thing, she said.

But despite these challenges, the program at the University of Iowa has been a success, as have, for example, telemedicine programs run by the Veterans Administration and the ECHO Project.

"Don't be put off by all the rules and regulations" that affect care in rural areas, particularly telemedicine and telehealth, McGregor told Medscape Medical News.

"If they can do it, we can do it," she said.

Having a template for such a program makes the task less daunting, said Mary Anne Hoskins, RN, from the ASHwell Clinic in Austin, Texas, who attended the session specifically because her clinic is planning to develop a tele-PrEP program.

But there is another challenge, she noted: local providers. During the session, people shared story after story about rural healthcare providers who refused to test for HIV or prescribe PrEP because "we don't see those kinds of people," as one audience member from Mississippi put it.

Hoskins herself shared a story about a provider, a gay man in Austin, who "all but talked this woman out of PrEP."

"To tell her she didn't really need it made me insane," she said. "I'm thinking about how to get our providers ready for it."

The presentation drove home the next step providers should be taking to get PrEP to the people who aren't already in care or early adopters, said Kimberly Adams Tufts, DNP, from Dominion University in Norfolk, Virginia.

The "foundational concept" of access is still an issue. "We might be thinking that, in my metropolitan area right now, the health departments have all started to offer PrEP," Adams Tufts said. "Well, yeah, but what about the folks an hour or an hour and a half away?"

McGregor, Lawrence, Hoskins, and Adams Tufts have disclosed no relevant financial relationships.

Association of Nurses in AIDS Care (ANAC) 2018. Presented November 7, 2018.

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