A Decade of PrEP in Iowa | Celebration and Reflection

On July 16, 2012 the Food and Drug Administration (FDA) approved Truvada® as the first form of HIV pre-exposure prophylaxis (PrEP) in the United States. As we celebrate a decade of PrEP’s availability, it’s a great time to reflect on how far we’ve come in our efforts to expand awareness of and access to PrEP in Iowa while also acknowledging the work that still remains.

Where It Began

The Bureau of HIV, STD, and Hepatitis at the Iowa Department of Public Health (IDPH) began actively addressing PrEP awareness and supporting increased access in January 2017 when the HIV and Hepatitis Prevention Program expanded to include PrEP activities. The initial goals of the initiative were to:

• Increase awareness of PrEP as a primary care prevention strategy among prescribing medical providers in Iowa

• Provide technical assistance to medical providers interested in prescribing and managing PrEP

• Increase awareness of PrEP as a proven HIV prevention tool among Iowans who may benefit from biomedical HIV prevention

• Provide navigation and linkage to care services for Iowans interested in PrEP by assisting with benefits enrollment, insurance navigation, and identification of PrEP providers

• Create and maintain a central repository of information to assist providers and consumers

To support these goals, PrEPIowa.org was launched in 2017 to serve as the central repository of information and prescriber resources, offer a directory of known PrEP providers, and provide a pathway for consumers to request navigation services. Since its creation, PrEPIowa.org has reached over 73,300 Iowans.

All of this great work, from awareness campaigns to patient recruitment and linkage to care, has contributed to increased utilization of PrEP in Iowa.

• Rapid HIV testing and prevention projects have screened countless clients for PrEP indications, provided PrEP education, assisted with linkage to navigation services, and provided crucial access to low barrier labs.

• Navigation services have touched over 2,000 Iowans interested in learning more about or accessing PrEP, while also providing ongoing benefits navigation to individuals already engaged in PrEP care.

• The Iowa TelePrEP program, a first of its kind direct-to-consumer telemedical PrEP program implemented in partnership with University of Iowa Health Care, has provided safety-net and stigma-free PrEP services to over 300 Iowans.

• Regional Health Specialists working with the Bureau of HIV, STD, and Hepatitis have educated countless medical and social service providers on the availability and importance of PrEP and recruited prescribers to be listed on the PrEPIowa provider directory.

We’ve done a lot of great work and Iowans are better prepared to tackle HIV prevention today than they were a decade ago, in large part due to the efforts of this program and its partners!

And while PrEP is effective at preventing HIV, it’s also important to note that the benefits of PrEP go far beyond HIV prevention. We hear from clients often that PrEP has changed the way they approach their sexual health, increased their engagement in primary medical care, and decreased stigma related to HIV. This is why it’s so important for us to continue this work and take inventory of the opportunities we have to extend these vital services to more Iowans.

Understanding the Bigger Picture

All of these efforts are worthy of recognition as we celebrate the first decade of PrEP. Still, it’s also important to contextualize the progress we have made.

Coalition for Applied Modeling for Prevention. (n.d.). PrEP Populations Estimation Tool Iowa. https://prepind.shinyapps.io/prepind2/

The Coalition for Applied Modeling for Prevention (CAMP) provides estimates of persons with indications for PrEP through their web-based modeling tool for public health practice, which indicates that 4,180 Iowans might benefit from PrEP. The report further clarifies that 68% of these persons are men who have sex with men (MSM), 22% are persons who have opposite-sex partners (HET), and 10% are persons who inject drugs (PWID).

Iowa’s progress towards PrEP utilization coverage can be estimated by comparing CAMP’s estimation of persons who may benefit from PrEP with estimates of minimum PrEP utilization provided by AIDSVu.

When viewing estimates of persons using PrEP, it is important to note that AIDSVu data reflect a weighted estimate of the number of persons using PrEP; the actual number of persons using PrEP is higher. The data used to create these estimates are derived from an open sample of commercially available data, which excludes entities that do not make their data available to the system. Therefore, these data represent the minimum number of persons using PrEP within the reported timeframes.

Minimum number of Iowans using PrEP by year

Comparing these two estimates illustrates that Iowa has obtained at least 35% PrEP coverage as of 2020 (1,470/4,180) and that more work can and should be done to engage patients in PrEP care who would benefit from biomedical HIV interventions.

Opportunities for More

And thus the question we are left to answer as we celebrate a decade of PrEP is this: What are our opportunities to increase awareness of, access to, and use of PrEP for Iowans who may want or need it?

Recently, PrEP has evolved from the limited single drug option to now include generic and more affordable versions of Truvada®, alternate off-label on-demand dosing of Truvada®, a second oral medication (Descovy®), and a long-acting injectable version of PrEP (Apretude®). Along with the expansion of the PrEP toolbox, federal policies now require insurance payers to provide full coverage of at least one PrEP option and ancillary services without cost sharing to patients beginning in 2021. The combination of these changes means that PrEP is now more affordable than ever and new methods of administration may increase acceptability of PrEP among those who are averse to daily oral dosing.

The bottom line is that we now have more options and better coverage than we have had at any time in the past decade. This creates a real opportunity to increase engagement and further disrupt HIV transmission in Iowa. To do so, we need to focus our collective efforts on the following strategies:

1. Talk to everyone about PrEP. The Prevention Needs Assessment conducted by the IDPH in 2019 illustrated that 40% of respondents were unaware that PrEP existed, with female respondents being far less aware of PrEP than male respondents. Talking to patients, clients, and others within our networks can help elevate awareness of PrEP and increase interest among those who may benefit from it.

2. Center PrEP as a primary care prevention strategy. PrEP can and should be managed in Primary Care settings and there is no need to refer individuals in need of PrEP to specialty providers. Primary care providers should incorporate sexual health histories, routine HIV screening, and risk reduction counseling into practice to best support their patients.

3. Foster access to PrEP. Finding a provider willing to prescribe PrEP can feel like an insurmountable challenge to some patients. Providers who are able and willing to manage PrEP in their clinical settings should register to be listed on the Iowa PrEP Provider Directory to assist patients in locating them.

4. Support persons using PrEP. Eliminate barriers to PrEP access by not requiring a specific disclosure of activity or risk from patients. A request for PrEP should be reason enough to offer it, so long as the patient is not clinically ineligible for the medications. Recognize that risk changes over time and that for most, PrEP may be used in intervals rather than long term. Listen to your patients/clients and support them based on the reality of their circumstances.

Here in Iowa, we’ve done great work to make PrEP available and accessible. We’ve done this work in partnership with countless public health partners, community based organizations, community advocates, and Iowa’s innovative TelePrEP program. PrEP is changing lives, and we are doing our best to make sure that this innovative prevention strategy makes it into the hands of those who need it.

I hope we all take a moment to celebrate a decade of PrEP and congratulate ourselves on our accomplishments, and it is my sincerest wish that we come away from our reflections and celebrations reinvigorated to do this work and help stop HIV in Iowa.

Cody Shafer

Lead Prevention Services Coordinator

For more information on PrEP in Iowa, including newly updated prescriber resources, please visit www.prepiowa.org. For more information on other strategies to end the HIV epidemic in Iowa, please visit www.stophiviowa.org or www.stophiviowplan.org.