This workshop will cover best practices for HIV prevention in adolescents with a focus on the implementation of Pre-Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP) in SBHCs. Join this workshop to hear an overview of the HIV epidemic among adolescents in California, best practices for determining eligibility for PrEP and PEP, instructions for labs and prescriptions, and suggestions for case management and training of all SBHC staff.

1. Getting to Zero:
Implementing PrEP and
PEP in School-Based
Health Centers
Skye Timmons, MPH
Kathie Rhodes, FNP
Naomi Schapiro, PNP, PhD
Jose Luis Robledo-Guereca

2. Presenter Disclosures
No relationships to disclose
Several slides are from Samali Lubega, MD
• Bay Area North & Central Coast AIDS Education & Training Center (BANCC AETC)

3. Objectives
Discuss the epidemiology and health inequities in the HIV epidemic
for adolescents in California1.
List best-practice HIV prevention strategies for adolescents, including
education about PrEP and PEP, onsite labs, medication prescription
and case management
2.
Create a workflow for implementing PrEP and PEP in school-based
health centers, including case management and needed
infrastructure (labs, pharmacies, insurance coverage, patient follow-
up)
3.

4. Disclaimer
• La Clinica’s SBHCs have been working on educating staff and incorporating PrEP into
the services we offer for approximately 2 years
• Slow process, work in progress
• Approximately 15 pts. started on PrEP, >5 pts. started on PEP
• We are not the experts/perfect example, but we have created a system and started
some patients on PrEP
• Hopefully sharing our experience will help other SBHC start or advance their own
PrEP access project

5. Who’s in the room?
• PollEv.com/skyet766

6. PrEP & PEP
• Pre-Exposure Prophylaxis (PrEP)
• Truvada – 1 pill taken every day to prevent HIV
• Post-Exposure Prophylaxis (PEP)
• Truvada + another medication
• Started within 72 hours of possible HIV exposure; taken every day for 28 days

7. HIV Update
Worldwide
• 36.9 million people living with HIV globally in 2017
• 1.8 million new cases of HIV globally in 2017
United States
• 1.1 million people were HIV+ in the U.S. at the end of 2015
• Of those people, 15%, or 1 in 7, did not know they were infected
• 38,739 people were diagnosed with HIV in the U.S. in 2017
• 21% of new infections in the U.S. were among young people ages 13-24
California
• 132,000+ people living with HIV in CA in 2016
• 4,500 new HIV infections in CA in 2017
cdc.gov

8. HIV disproportionately affects men who have sex with men (MSM)
cdc.gov

9. HIV disproportionately affects MSM of color
cdc.gov

10. OAK LA SF
acphd.org
HIV & Women in California

11. HIV disproportionately affects women of color

12. Who can benefit from PrEP and PEP?

13. cdc.gov
HIV disproportionately affects youth

14. • 1 in 4 new HIV infections
are in ages 13-24
• 84% of all new infections
among youth occur in
boys/men of color
• Over half of all new
infections among youth
occur in Black/African
American males
HIV disproportionately affects youth of color
cdc.gov

15. Who’s using PrEP in the U.S.?
cdc.gov

16. Building Youth-friendly PrEP/
Sexual Health Services
• 160 responses
• 85% ages 14-17
• 63% female, 33% male
• 1.3% transgender/genderqueer
• 85% heterosexual
• 53% sexually active

17. Wheredoyou/wouldyougotoaccesssexualhealthcareservices?
62%
community clinic
and/or
youth-only clinic

18. Iwouldtalktomydoctoraboutsexualhealthorotherquestionsrelatedtosex.
79%
Agree/
Strongly Agree

19. How often do yougetSTI testing?
64%
of sexually active
youth have never
been tested

20. I thinkI am at riskfor HIV.
85%
of sexually active
youth do not feel
at risk for HIV

21. Haveyouheard of PrEP?
69%
of sexually active
youth have heard
of PrEP

22. I wouldusePrEPif I could get it for free.
69%
of sexually active
youth would use
free PrEP

23. • Sexually active youth trust their providers, but aren’t getting tested for HIV
*What are we missing? How can we help them access HIV testing?*
• Youth DO NOT feel at risk for HIV but would consider using PrEP if accessible to them
• Sex positive approaches to PrEP may be more effective than risk-based
• PrEP is a health promoting tool for control, freedom, enjoyment, & health
PrEP is for youth

24. PrEP Education
• All staff educated about PrEP
• Culturally competent staff
• Introduce PrEP at all sexual health visits
• “Have you ever heard of PrEP, the one pill you take every day to prevent HIV?”
• Visual education (posters, handouts)

25. • Sex positivity is "an attitude towards human sexuality that regards all
consensual sexual activities as fundamentally healthy and pleasurable…”
• The sex-positive movement advocates for sex education and safer sex
Goals of sex positivity
• Increase patient safety
• Increase patient empowerment
• Reduce poor health outcomes
• Build partnerships with patients.
*Disclosure of sexual behaviors is NOT the goal
Gabosch, 2008
Sex Positive Approach

26. • Judgements on other people’s behavior
• Equating sexuality – or certain types of sex – with deviance, abnormality, or risk
• The belief that sex is:
• Inherently bad, dangerous, sinful, dirty, shameful
• Only permissible for procreation, marriage, and/or love
Glickman, 2000
Sex Negativity

27. A sex-positive health professional…
• Checks their own assumptions and biases
• Embrace our patients as assets and experts on their experience
• Centers the patient’s priorities in communication and decision making
• Practices self reflection, humility, & empathy
• Seeks ongoing training and development
• Responsive, relevant, respectful
• Remembers that pleasure is an important part of sexual health

28. Safe spaces for all patients
• Visibly sex positive, welcoming space for people who are black, brown, queer,
bigger bodied, have varying abilities/disabilities
• Representative artwork and signage
• Non-judgmental reading materials
• Trained staff
• Sex positivity
• LQBTQ+ inclusion and competency
• Trauma informed care
• Cultural humility
• Intake forms - all genders and sexualities,
pronouns, preferred names
• Ask name and pronouns at each visit

29. 9
PrEP 101

30. Labs
• Prescription for Truvada (PrEP) requires lab testing
• Before first Rx: 4th gen HIV test, BMP, GC/CT (throat, rectal, urine), RPR, Upreg,
HBsAg/sAb/cAb, HCV Ab (+HIV viral load if sxs of possible acute HIV infection in past
month)
• Rationale:
• If client is already HIV positive, need more/different combination medication for
treatment, to prevent resistance
• Medication can affect kidney function – test before and periodically while using
• Hepatitis B: important to know status to address treatment if previously undiagnosed, to
monitor liver function before PrEP and while using PrEP, and to vaccinate if uninfected and
not already immune
• Hep C: important opportunity for diagnosis and treatment, and to monitor liver function
before and while using PrEP

31. Labs
Refill prescription for Truvada (PrEP) requires lab testing
• Every 3 months while on it: 4th gen HIV, GC/CT (throat, rectal, urine), RPR, Upreg
• Every 6 mos: BMP (basic metabolic panel)
Best practice for labs:
• On site lab testing whenever possible
• Urine, throat/vaginal/rectal swabs
• Consider offering self swab option
• On site blood draws
• If no phlebotomy on site, make arrangement with nearby lab for easy access and
confidentiality

32. Medication
• Need negative HIV lab result before eRx sent to pharmacy (should be done ASAP
after results received)
• Rx Truvada (Tenofovir 300mg and Emtricitabine 200mg) 1 tablet orally every day
• 1 month supply initially
• Follow up: 3 month supply if insurance allows
• Gilead limits to 1 month supply at a time

33. Medication
• Need to know about the pharmacy you are sending Rx to
• Do they stock it regularly?
• Confidentiality?
• Insurance coverage?
• Do they have free delivery if pt. prefers not to pick up in person?
• Delivery to home, clinic, PrEP navigator, different pharmacy location
• Oakland example: Community, a Walgreens specialty pharmacy

34. Medical follow-up
• Follow up visit 1 week after labs – assure lab results back, eRx submitted, assess for
pharmacy and insurance issues
• Ideally patient has already received and started Truvada
• Side effects?
• Adherence challenges?
• Non-judgmental approach
• Truvada is just one tool in the patient’s/provider’s toolkit to help prevent HIV
• Address condom use, communication with partners, boosting self-worth/self advocacy for
good sexual health
• Provide condoms/lube

35. PEP (Post-Exposure Prophylaxis)
• If patient thinks they may have been exposed to HIV within the past 72 hours, screen
for risk status (see AETC Pacific Clinical Essentials for criteria)
• They could be offered PEP (post-exposure prophylaxis)
• Must be started within 72 hours of exposure, the sooner the better
• Must take every day for 28 days
• Labs: 4th gen HIV – result not needed to prescribe
• Preferred regimens: Truvada + Tivicay or Biktarvy
• Follow up in 1 week (lab results, adherence, side effects)
• After 28 days, consider/offer transition to PrEP depending on ongoing risk status

36. Adherence by week:
Week 4 = 54%
Week 8 = 47%
Week 12 = 49%
Week 24 = 28%
Week 36 = 17%
Week 48 = 22%
Reasons for missed doses:
Away from home (32%)
Too busy (28%)
Forgetting (26%)
Change in routine (18%)
Adherence
JAMA

37. Supporting Adherence
0 20 40 60 80 100
Online forum (n=25)*
Videos (n=31)*
Website information (n=41)*
Weekly check-in messages
Daily pill-reminders
Percent
Very helpful
Somewhat helpful
A little helpful
Not at all helpful
JAMA

38. Case Management
• PrEP navigator model
• Initial consultation
• Registration for non-patients
• Referrals to other clinics if necessary
• Scheduling/cancelling appointments
• Assessing insurance status/coverage
• Helping apply for patient assistance program if insurance won’t cover
• Gilead Patient Assistance Program
• Communicating with pharmacy
• Monthly appointments for medication pick-up and check-in
• Delivery of medications
• La Clinica PrEP/PEP phone line
• Community outreach events with HIV testing, condoms & lube, PrEP/PEP ed. & consultation
• If PrEP navigator is not possible for your clinic, train a staff member to help
• Pharmacy and insurance
• Case management is key to helping overcome multiple barriers to pts. starting and staying on PrEP

39. PrEP/PEP Resources
• Staff & patient education
• PleasePrepMe.org
• https://www.cdc.gov/hiv/risk/
• Consultation resources for providers
• National PrEP Line: 855-448-7737
• 6am-5pm PST, 7 days/wk
• cdc.gov/hiv/prevention/research/prep
• AIDS Education and Training Center (AETC Pacific)
• Kaiser pts. – educate and connect with local
Kaiser PrEP Navigator

40. Brainstorm Time
• How could your SBHC start or improve PrEP and PEP infrastructure at your SBHC?
• Staff training, materials, education, case management, etc.
• Who could you partner with? Who could be a champion of PrEP and PEP for your
SBHC?
• What is one tangible thing you can do to support patients’ access to PrEP and PEP?

41. In Memory of Those Who Passed

42. Questions?
Thank you!
Skye Timmons, MPH: stimmons@laclinica.org
Kathie Rhodes, FNP: krhodes@laclinica.org
Naomi Schapiro, PNP, PhD: nschapiro@laclinica.org
Jose Luis Robledo-Guereca: jrobledo@laclinica.org