In 2014, Gov. Andrew Cuomo opened the discussion to End the AIDS Epidemic in New York State by the year 2020 (EtE 2020). The goal is to reduce new HIV infections statewide from 3000/year currently to under 750/year by 2020 with a 3-part plan:
1. Find and test all those who remain unaware of their current HIV status.
2. Link HIV positive people to medical care to treat and decrease their HIV viral load (amount of virus in blood) so that they do not transmit HIV to others.
3. Provide “Pre-Exposure Prophylaxis” (PrEP), a once a day pill for HIV prevention to people at high risk for HIV.
For almost 30 years, Trillium has worked to achieve 1 and 2 above. Since March 2013, we have been building #3 -PrEP.
Trillium’s PrEP program is a multidisciplinary effort. “Team PrEP” is an energetic group that includes providers, registered nurses, clinical pharmacists, health educators, outreach staff, mental health staff, treatment adherence staff, insurance navigators, care managers, on-site laboratory and pharmacy, and our health informatics and marketing teams. Central to the effort is an in-house “PrEP Expert,” funded by the New York State Health Department.
We have enrolled 228 patients in the program with 211 currently active (retention rate 93%); the second largest PrEP program in New York State. An added benefit is that 60% of PrEP patients have enrolled for primary care at Trillium and have access to a program for LGBT people developed under a grant from the Greater Rochester Health Foundation.
PrEP is a high impact, state-of-the-art HIV prevention program that is aligned with EtE 2020. We try to take an energetic approach to both the medical care and marketing. “Word of mouth” is the referral source for 50% of our patients, so we try to create a good patient experience in a welcoming environment. Trillium’s mantra is “Barrier Free Care.” We strive for short wait times from the patient ‘s first contact until the patient is seen and enrolled. We do on-the-spot enrollment, if the patient is ready. We can dispense drug in advance of the necessary insurance approvals or manufacturer’s subsidies. To meet the demand, we increased provider capacity in mid-2015 adding a family nurse practitioner and family physician that have “open access” appointments for same day PrEP consultations.
Internal referrals come from Trillium’s syringe exchange program and grant-funded HIV prevention and testing programs that target high risk HIV-negative men and women, including people of color.
In the spirit of innovation, Team PrEP combines some of our marketing and outreach efforts. For example, outreach staff work with our health educators to implement a targeted, embedded outreach initiative. Called “Feet on the Street,” we target bars, nightclubs, house parties, and other events where high-risk men who have sex with men are connected and present. Our staff is representative of the target populations, and is part of the communities and cultures most at risk for HIV. This allows for cultivating relationships that enable navigation into PrEP services when patients are ready. In 2016, we launched a “PrEP app” for mobile devices to better communicate with patients digitally, and we use multiple social media platforms to connect with people.
PrEP services are discussed at every community based HIV or STD screening encounter, with over 2,000 encounters/year. Individuals interested in PrEP services are connected directly to our PrEP Specialist via a “warm-handoff,” or as soon as possible if initial contact is made after hours.
As a result of our successes, the NYS Health Department has invested further in Trillium by funding a Tele-Health PrEP program (“Tele-PrEP”). This 4-year effort, launched in 2016, will make PrEP available in rural areas where there are no providers offering PrEP services. PrEP patients in these 8 counties will be recruited through our 2 regional outreach and service offices in Geneva and Bath, NY that provide services for 150 patients with HIV and include a grant-funded LGBT Health Program that reaches up to 1000 at risk people/ year with health information and HIV testing. Our 2017 Tele-PrEP goal is 200 active patients.
Currently, 70% of our PrEP patients are gay, white men. If EtE 2020 is to succeed, we will need to enroll more young men of color who have sex with men who make up 50% of new HIV infections. In late 2015, Team PrEP expanded with the merger of Trillium and The MOCHA Center, a local agency promoting health in LGBT people of color. We believe that MOCHA’s cultural competence, combined with Trillium’s medical and marketing infrastructure can meet our 2016 targets (excluding Tele-PrEP) of 450 patients enrolled with 35% men of color who have sex with men. The merger extends our reach further through their Buffalo office. Other MOCHA programs include “Vogue Tuesdays” and participation in the culturally unique “Ball Community.”
Research has shown that 13 people on PrEP will prevent one new HIV infection. The Monroe County Health Department estimates that there are up to 50 new HIV infections in the county yearly. Therefore, we need to enroll 650 PrEP patients/ year to “finish the job.”
In a January 8 Washington Post editorial, Dr. Anthony Fauci, Director of the National Institutes of Health delivered a call to action, saying that PrEP, while reducing HIV risk by more than 90%, is “vastly underutilized” and that 30% of primary care physicians are unaware of PrEP.