Implementing an HIV PrEP Program through a Local Health Department in a Non-Medicaid Expansion State

Background:  Since the release of national guidelines for HIV pre-exposure prophylaxis (PrEP) in 2014, providers have experienced multiple challenges in implementation of PrEP services for at-risk patients, especially in non-Medicaid expansion states. We developed and assessed a pilot PrEP referral program for patients presenting for STD care at a public health department clinic in North Carolina.

Methods:  We initially convened a PrEP Task Force, consisting of state and local public health officials and key providers in Durham, NC, to identify resources and priorities for PrEP implementation in the community.  The county STD clinic developed an internal referral process to a Federally Qualified Healthcare Center clinic co-located in the health department facility; external referrals were also available to providers in nearby academic medical centers.  We analyzed data from the first 11 months of the pilot program in order to characterize the patients referred for PrEP, the care cascade for PrEP, and early challenges to implementation.

Results:  Since May 2015, 86 patients have been evaluated in the STD clinic for baseline HIV/STD/hepatitis screening and referred for PrEP by HIV educators.  Most are men who have sex with men (76%); 21% are male or female sexual partners of HIV-infected persons. While 45% are insured including 12% on Medicaid and 1% on Medicare, 55% have no health insurance coverage.  Although 47% made appointments for PrEP with a prescribing provider, only 27% initiated and continued PrEP, and 8% have discontinued PrEP after initiation.  Barriers reported by patients include stigma, motivation, and cost of visit co-pays. 

Conclusions:  An HIV PrEP program can be implemented for high-risk persons in an STD clinic by leveraging existing local public and community health resources.  However, despite availability of on-site services, there are still barriers to PrEP delivery including lack of insurance coverage and individual reasons that affect the care cascade for PrEP.