8 minute read
Clinicians: You can Help End the HIV Epidemic in Philadelphia
Kathleen A. Brady, MD
Brian Hernandez
Afrah Howlader
Olivia Kirby, MPH
Drexel Shaw, MPH
Mars Potros, MPH
Evan Thornburg
Tanner Nassau, MPH Anna ThomasFerraioli, MPH
BY Philadelphia Department of Public Health, AIDS Activities Coordinating Office (AACO), Ending the HIV Epidemic Team members:
As part of a national effort to reduce new infections of human immunodeficiency virus (HIV), the Philadelphia Department of Public Health (PDPH) has established an ambitious ‘Ending the HIV Epidemic (EHE) Initiative’ to achieve the following goals: reduce new HIV infections by 75% to less than 118 new infections per year by 2025 and by 90% to less than 47 new infections by 2030. At the start of the initiative in 2017, there were an estimated 470 new infections in Philadelphia.
To achieve these goals, the EHE initiative has created four main strategies:
1. Diagnose all people with HIV as early as possible.
2. Treat people with HIV rapidly and effectively to reach sustained viral suppression.
3. Prevent new HIV transmissions by using proven interventions, including pre-exposure prophylaxis (PrEP), non-occupational post-exposure prophylaxis (PEP) and syringe services programs (SSPs).
4. Respond quickly to potential HIV outbreaks to get needed prevention and treatment services to people who need them.
These four strategies work together to reduce the incidence of HIV over time. Medical advancements in HIV care and prevention, such as anti-retroviral therapy (ART) and PrEP, are critical parts of these strategies. With input from the community, Philadelphia has developed its own EHE Community Plan, which is available in English and Spanish at ehe.hivphilly.org.
Local clinicians, regardless of their specialty, can contribute to Ending the HIV Epidemic by:
1. Learning more about HIV epidemiology, testing, treatment, and prevention options available in Philadelphia.
2. Informing all sexually active adults and adolescents that PrEP can protect them from getting HIV.
3. Normalizing and destigmatizing HIV and sexual behavior by discussing these topics in an open-ended, non-judgmental manner.
4. Prescribing PEP to patients for whom it is clinically indicated.
5. Learning about strategies to reduce barriers to HIV prevention and care.
6. Being a champion for health equity.
HIV in Philadelphia
In 2019, 446 Philadelphians were newly diagnosed with HIV. As in previous years, there were significant disparities in the rate of HIV diagnoses by sex at birth, race/ethnicity, and transmission routes. Non-Hispanic Black and Hispanic Philadelphians carry a disproportionate burden of HIV, with rates of new diagnosis that were 3.4 and 3.2 times greater than the rate among white Philadelphians, respectively. Men who have sex with men (MSM) had rates that were 26.5 times greater than those who acquired HIV through heterosexual contact and people who inject drugs (PWID) had rates 10.1 times greater than among heterosexuals.
There were 18,621 people living with diagnosed HIV (PLWDH) in Philadelphia in 2020. The plurality of Philadelphians living with HIV were assigned male sex at birth (72.1%), non-Hispanic Black (63.7%), age 50 or older (54.8%), and MSM (38.9%). There remain significant needs for improvement in receipt of medical care and HIV outcomes. Among PLWDH with evidence of care in the past 5 years, 78.2% received care in 2020 and 67% were virally suppressed.
EHE Activities and How Philadelphia Clinicians Can Help
Improve Access to PrEP
Philadelphia’s EHE Community Plan outlines a goal for 50% of people with a PrEP indication to be prescribed PrEP by 2025. One strategy PDPH is employing to achieve this goal is to increase access to PrEP for priority populations. PDPH’s activities to implement this strategy include expanding PrEP clinical-community partnerships (like low-threshold sexual health centers) and expanding PrEP access through the offer of same-day PrEP.
The Centers for Disease Control and Prevention’s most recent clinical practice guidelines for pre-exposure prophylaxis (PrEP) focus on increasing PrEP use by people who could benefit from it. There are two new recommendations: (1) prescribe injectable cabotegravir as PrEP for sexually active adults (approved by the FDA in 2021) and (2) inform all sexually active adults and adolescents that PrEP can protect them from getting HIV. In addition to these new recommendations, providers are encouraged to offer PrEP to anyone who asks for it, regardless of self-report of behaviors that are considered risk factors for HIV acquisition. All medical disciplines and specialties are encouraged to prescribe PrEP, including primary care providers. Providers can help end the HIV epidemic in Philadelphia by discussing sexual behavior with patients in a non-judgmental and open-ended manner, and by informing sexually active adults about PrEP.
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To assist providers who want to learn more, PDPH has a PrEP technical assistance (TA) team, which provides content-based assistance through educational materials, evaluation of provider services, quarterly PrEP provider meetings, and a monthly “PrEP Update for Providers.” This newsletter provides the latest PrEP news and features policy updates, new PrEP resources, and information on upcoming conferences/webinars. Sign up to receive the newsletter by emailing PreventHIV@philly.gov.
Provide PEP
HIV post-exposure prophylaxis (PEP) is anti-retroviral medication given to an HIV-negative person who may have been exposed to HIV within 72 hours of the exposure to prevent transmission of HIV. PEP is indicated if, within the prior 72 hours, a person had condomless sex or shared syringes or other injection equipment with a person known to have HIV or whose HIV status is unknown. Despite the effectiveness and strong recommendation for usage of HIV PEP from the Centers for Disease Control and Prevention, many Philadelphians are not aware of PEP, who it’s recommended for, and where to access PEP in the city.
PDPH has released an RFP for the development of a Philadelphia PEP Center of Excellence (PEP COE), where any Philadelphian can access this vital medication when necessary. Expected to be fully operational by summer 2022, the program will include a 24-hour call line and a brick-and-mortar PEP COE. The call line will allow Philadelphians to speak to a health care provider to assess eligibility for PEP and arrange for after-hours access to a starter dose if needed. The COE will provide comprehensive PEP services according to the national guidelines for prescribing PEP, as well as navigation services to assistance with paying for PEP.
A licensed medical provider with prescribing privileges in good standing can prescribe PEP to anyone meeting the exposure criteria. For the most updated PEP prescribing guidelines for clinicians please refer to National Guidelines to Prescribing PEP at: https://www.cdc. gov/hiv/clinicians/prevention/pep.html
Reduce barriers to HIV prevention and care services
Patients experience many individual and structural barriers when trying to engage in HIV prevention and care services. Patients cite barriers that include limited resources to pay for services, lack of appointment availability at times or locations that are accessible to them, lack of access to transportation, insecure and unsafe housing, and lack of adequate behavioral health services.
To reduce barriers, PDPH has funded several clinics and health centers across the city to provide low-barrier HIV prevention and care services for Philadelphians. Strategies used to reduce barriers include offering flexible appointment times or walk-in capacity, leveraging multiple funding sources to ensure access to services regardless of insurance status, and revising policies to ensure flexibility amid the COVID-19 pandemic. Telemedicine appointments continue to be an essential point of care for many. Providers are also participating in health equity initiatives with PDPH, with the goal of ensuring more equitable access to HIV prevention and care service (regardless of their race, gender identity, sexual identity, and drug use), quickly linking patients to care, and offering immediate Anti-Retroviral Therapy (iART), which is defined as starting HIV treatment within 96 hours of the initial diagnosis.
PDPH supports programming to improve HIV outcomes through the Philadelphia Regional Ending the HIV Epidemic (EHE) Collaborative. The Collaborative is currently working to help providers expedite HIV treatment availability through the iART Working Group.
Enhancing Equity Practices and Working to address HIV Stigma
Historically, marginalized communities have been neglected and mistreated when seeking HIV prevention and care. This mistreatment allows HIV diagnoses to remain consistent and pervasive in stigmatized and marginalized communities. Through the work of the PDPH’s HIV Health Equity Special Advisor, the agency has implemented policies, practices, and program requirements that aim to rework inequitable systems that stand in the way of successful HIV prevention and care.
Because systems change begins at home, PDPH established its own HIV Health Equity Policy, which are explicit internal guidelines to support health equity practices throughout the system of HIV prevention and care. Funded programs undergo a Health Equity Assessment, with assessment results used to design health equity action plans. The action plans and associated program performance reporting are being used to evaluate processes and outcomes, and to continuously improve systems.
PDPH is also tackling low health literacy in HIV prevention and care programs by requiring low literacy assessments, providing low literacy/low color perception resources, reimagining how we depend on and require consumers to use technology, and preemptively making language and ASL translation quick and easy to access, as well as implement.
Philadelphia clinicians can contribute by becoming champions for health equity and equitable access to services in their own organizations. They can do this by participating actively in their own organizations’ health equity efforts or by advocating for new or expanded equity efforts in their organizations. Clinicians can learn more about advancing health equity by exploring the American Medical Association’s Center for Health Equity resources. Also, providers can advocate for and be mindful of literacy, technology use, and language access needs that may be less discussed but still widespread barriers to equitable health care access. Multiple resources are available through the CDC, HRSA, and the National Library of Medicine.
Clinicians, thank you for all you do to care for vulnerable Philadelphians every day. Let’s act now to end the HIV epidemic in Philadelphia. •
