Multidisciplinary Roundtable

The Multidisciplinary Approach in HIV Prevention, PrEP Uptake

Jeffrey Kwong, DNP, MPH, ANP-BC

In this roundtable discussion, Jeffrey Kwong, DNP, MPH, ANP-BC, interviews John J. Faragon, PharmD, BCPS, BCGP, AAHIVP, Damon Jacobs, Rasheeta Chandler, PhD, RN, FNP-BC, Jonathan Appelbaum, MD, and Princy N. Kumar, MD, about the role of a multidisciplinary approach in promoting HIV prevention and preexposure prophylaxis uptake.

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Jeffrey Kwong:

Hello, everyone, and welcome to Consultant 360's multidisciplinary round table discussion on HIV prevention. Our topic today is on increasing PrEP uptake and the importance of a multidisciplinary approach in HIV prevention. I'm Jeffrey Kwong. I'm a nurse practitioner and professor in the division of advanced nursing practice at Rutgers School of Nursing in Newark, New Jersey, and a practicing clinician at Gotham Medical Group in New York City. I'll be serving as the moderator for this episode.

Joining me today are several experts in the field of HIV prevention. I'll go around and introduce them individually. I have Dr Rasheeta Chandler who is a nurse researcher and family nurse practitioner. She currently is an associate professor at Emory University's Nell Hodgson Woodruff School of Nursing in Atlanta, Georgia. Also joining us is Dr Princy Kumar, who's an infectious disease physician professor of medicine and microbiology, and chief of the Division of Infectious Diseases and Travel Medicine at MedStar Georgetown University Hospital. She's also the senior associate dean for students at the Georgetown University School of Medicine in Washington DC. Next, we have Dr John Faragon, who's a pharmacist at Albany Medical Center in Albany, New York, and the regional pharmacy director for the Northeast/Caribbean AIDS Education & Training Center. We also have Mr. Damon L. Jacobs, who is a licensed marriage and family therapist and HIV prevention specialist in New York City. And Dr Jonathan Appelbaum is a physician, and professor of internal medicine at the Florida State College of Medicine in Tallahassee, Florida.

To provide context for our audience, I'll give you a little bit of background information. In the US, it's estimated that over 30,000 new HIV infections occur annually in spite of the availability of effective prevention options, such as HIV pre-exposure prophylaxis. Recognizing the importance of reducing new HIV infections in the US, the Department of Health and Human Services launched the Ending the HIV Epidemic campaign, also known as the EHE Initiative, with the overall vision of reducing new HIV infections in the US by 90% by the year 2030. One of the key pillars of the EHE Initiative is increasing access to HIV prevention services and increasing the number of clinicians offering PrEP.

So for the focus of this discussion, my question to the panel is what can colleagues in your professional role, be it a primary care provider, mental health professional, pharmacist, nurse practitioner, or infectious disease specialist, what can do to support or contribute to increasing access to PrEP and supporting individuals who may benefit from PrEP? Why don't we start with Princy. As an ID specialist, can you share your perspectives?

Princy Kumar:

From my perspective, PrEP should be offered by primary care providers, nurse practitioners, and PAs, all in the primary care goal. The more routine we make it, the better it's going to be because right now the recommendations are that we discuss PrEP with anybody who's sexually active, with anybody who's sexually active, then offer it to people at high risk. So from the very beginning, the conversation should start with anybody who's sexually active. So we are not thinking, "Oh, are you at risk? Should you be getting PrEP?" We need to make it a part of our general conversation with any person who comes to us for care.

Jeffrey Kwong:

Great, thank you. And I guess on that note, maybe we'll move to Jon Appelbaum. As an internist and primary care provider, how do you see PrEP fitting in and what can primary care providers do?

Jonathan Appelbaum:

Yeah, I can't agree more with my colleague, Princy. If we depend upon just STI clinics and infectious disease docs, we're going to miss a huge swath of the population. It has to be rolled out to primary care. And I think the statement that you read, Jeff, I think you mentioned about what role can physicians play, and I think physicians play a role, but I think it's the entire health team that really has a role here in getting PrEP out. The data on PrEP, PrEP has been around for 13 years now. It was approved in 2012. It's been a horrible job of getting it out to people. And there are many millions of folks out there in the United States that could and should be on PrEP or at least have access to it.

Jeffrey Kwong:

Great. Thank you so much, Jon. And how about Rasheeta from a nursing perspective?

Rasheeta Chandler:

So again, I would agree with all of my colleagues. And I know this is provider-centric, but we have to think about this being a person who's influenced by the community as well. I would say that providers, yes, we need to make it routine, it doesn't need to seem as if it's kind of an appendix to your regular care. But I say that there should be innate provider prompts or reminders to recommend or offer HIV testing and PrEP options. So HIV prevention options like PrEP need to be done by any provider or promoter.

So a woman, and particularly Black women, because I deal with a lot of Black and brown women, and the fact that we're not included and our voice seems to be muted a lot of times in this space, I'm very sensitive to that. So that includes, and giving some examples, whether it's in our clinics, including community-based clinics, nonprofit clinics, but also some creative things where people are doing PrEP education in hair salons, trusted evidence-based technology resources, some of the work that I'm doing. And then starting younger, school health personnel. So I think we've all touched on elements of how we can get this out. We haven't done a good job, as Jon mentioned, of getting this out. And it may not always just be in the traditional settings.

Jeffrey Kwong:

Absolutely. John Faragon, as a pharmacist, what role do pharmacists play in promoting or supporting individuals?

John Faragon:

So I think there's a lot of work that can be done by pharmacists to increase access to PrEP. There are pharmacies everywhere. And that's a place where I think certainly we can encourage people to go on PrEP. One of the things that some places have done and some states have done is what we call collaborative practice agreements, where you may actually have a physician or a provider who actually allows the pharmacist to actually prescribe PrEP to a patient if they come into their pharmacy. Those collaborative practice agreements I think sometimes are very helpful because they set up a clear role of what the pharmacist can do based on the information that they have for that individual patient. And obviously, there's going to be follow-up with the primary care provider or whoever they have that practice agreement with, but I think that's one way to do it. They've done it in a lot of clinics in New York State, they have these collaborative practice agreements where pharmacists actually act as independent providers in some areas.

So I don't know if anybody saw this, but there are some recent articles on this. It was a letter in the New England Journal, it's called Free the PrEP, and they talk about making PrEP even potentially over the counter. I think that's probably pushing it a little bit because I think people really do need training on... Not all pharmacists are going to be able to understand all the nuances of PrEP. But I think for people who are trained in it and have specialized training, I think pharmacy and local pharmacies are perfect places for access for identifying patients who need PrEP and also getting them on at least oral PrEP. I think injectables are a whole nother topic. But at least for oral prep, I think it's an option for patients.

Jeffrey Kwong:

Great. Thank you.

Princy Kumar:

I think Jeff, if I could just, it's just demystifying PrEP. And really it's to demystify PrEP, that it's something that's over the 13 years we have learned it to be safe, learned it to be effective. And that's the key is to get people to recognize that there's nothing special about PrEP, that all of us can prescribe PrEP.

Jeffrey Kwong:

Absolutely. Damon, from your perspective as a mental health professional and provider, how can mental health professionals play a role in either supporting or promoting PrEP from your perspective?

Damon L. Jacobs:

Well, mental health providers and advocates play a significant role in teaching and supporting PrEP in the way that we often deal with the ambivalence that people feel about taking action and being proactive about their sexual health. So oftentimes people's not taking PrEP isn't because of the medicine or access, but it's because in their minds, they don't perceive themselves to be at any kind of risk or danger of encountering HIV. If they do feel like that's a risk, they're not necessarily feeling like they're empowered enough to take steps toward protecting themselves from HIV. And that's where in the mental health sphere we want to really think about working in a collaborative relational harm reduction framework.

I think preventing a virus is psychologically very different from treating a virus. We're not talking about this top-down model of expertise. I am not the expert in your life. But given an opportunity, if I'm working with someone at risk of HIV, I'm going to want to ask them, "What are your hopes? What are your dreams? How can I help you in feeling good and getting what you want from your life, not the other way around?" And I feel like mental health workers are in a very unique position to be able to work with that framework to have greater health outcomes.

Jeffrey Kwong:

Great. Thank you so much. I think each and all of you have contributed and articulated the importance of how PrEP is something that is truly a team-based effort and that each and every one of us can help contribute to expanding access and supporting individuals who may benefit from PrEP. So thank you for your time today. And for those of you who'd like to learn more about HIV PrEP, there are a variety of resources available, including CDC's HIV Nexus Clinician Resource website, that's N-E-X-U-S. There is the National Clinical Consultation Center PrEP Line, as well as regional AIDS education and training centers located across the US. Thank you for viewing this video. And working together, we can help end the HIV epidemic.

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