Rupa Patel, MD, MPH recently provided expert testimony in the Michael Johnson court case, a Lindenwood University wrestler accused of infecting a sexual partner with HIV. We checked in with Dr. Patel to hear about her latest projects.
She is director of both the PrEP Program at the Washington University Infectious Diseases Clinic and the Global Health Scholars Pathway in Internal Medicine. Her interests include implementing PrEP (HIV pre-exposure prophylaxis) among young adult men who have sex with men and health advocacy surrounding sexual minority health.
Q. You are the director of the PrEP program at Washington University – are you finding that awareness of PrEP is changing in St. Louis? What challenges is the program facing this year?
PrEP is the concept of using medications to prevent HIV before exposure occurs. Today, PrEP is in the form of a daily oral single tablet that contains two anti-HIV medications in it. The university started a PrEP care program within the Infectious Diseases Clinic in 2013 because we saw that people could not easily find doctors who knew enough about PrEP to prescribe it.
We also identified that there was a lack of known places where people could go and speak freely about their sexual practices to a prescribing provider, a necessity for PrEP. (Without first assessing a person’s sexual risk for HIV, you cannot determine their eligibility or start the protocol to deliver PrEP.) In conjunction with initiating provider and community member education with known credible partners such as multiple community organizations, health departments, and the Midwest AIDS Training and Education Center, the Washington University PrEP program became an example of how to deliver PrEP care and started documenting the resources that it takes to start and maintain a PrEP care program. Our PrEP clinic has helped other providers to see how the clinic flows and the other logistics are managed.
I think PrEP awareness, use, and provider prescribing have all increased rapidly over the past 1.5 years. I think these are in large part because there was a large group of early adopter PrEP users who had positive experiences with their care and thus, there was efficient, yet natural peer-to-peer dissemination. Now that people are starting to seek PrEP, more providers are being asked about it.
This university program has taken an active role in working with the state and local health departments to promote PrEP by helping to initiate statewide PrEP taskforce meetings, a local PrEP St. Louis working group, and a state Health Department PrEP website. Very importantly, we have worked with the Midwest AIDS Training and Education Center to conduct a statewide provider PrEP awareness tour where we outlined the CDC PrEP Prescribing Guidelines and other tools and resources that could help clinics begin delivering services.
The challenge is to get the message out more broadly to people without adding any stigma to the message of HIV prevention. Everyone should know about PrEP and where to get more information about it in the St. Louis area, as well as other parts of Missouri.
Q. Tell us about any public health research you’re currently doing, and anything you’re planning for 2017.
A. We are planning to take a closer look at the PrEP care continuum at three clinics in the USA — we will examine who did not remain in care and why. We hope to investigate how insurance copayments and other factors, such as having a previously diagnosed previous mental illness, affect PrEP initiation and retention. We also want to document if there were any changes in renal function in PrEP patients in non-research clinic settings.
Additionally, we want to see if and how STD infections and condom use change over time while people are taking PrEP. We know there is increased STD testing related to PrEP care, but are there more infections out of proportion with the increased testing that is being performed.
Finally, we will explore pharmacy-based PrEP delivery models. We have opened one in St. Louis and we want to see how the PrEP care continuum appears in this setting.
We are trying to create an active dissemination plan where we use the local TV and radio stations in Missouri to send messages about PrEP as an HIV prevention tool that many have not yet heard about. And, again, that all people (or the general public) should be aware of it. We hope people who listen or watch will then pass on the message to their friends, family, acquaintances so that PrEP and HIV testing become an acceptable topic of conversation. This is an effort to destigmatize HIV testing and PrEP use.
We also want to direct people who have questions about PrEP to their local HIV prevention community organizations, their doctor, or to state or local health department clinics/prevention staff for more information.
Q. Has any of your recent work involved collaboration with other faculty scholars or community partners from other areas of expertise? If so, how has this multi-disciplinary approach impacted your process/findings?
Yes, we combined efforts with Aimee James, Charlene Caburnay, and Enola Proctor (from the Institute’s Center for Dissemination and Implementation and the Brown School’s Health Communications Research Lab) and found that young men who have sex with men wanted to receive PrEP messages through peers. People also wanted to know immediately (such as on a poster), after first learning about PrEP, that it was affordable if they did not have insurance.
Furthermore, we found that social phone applications were the way people were initiating the conversation on PrEP so that became an active dissemination tool (posting that you are on PrEP in the “about me” section of social media profiles). So we suggested that early adopting PrEP users ,who had expressed an interest in helping with community awareness, talk about PrEP with their peers and put it on their social media profiles. Some of those PrEP users went on to speak on the evening news and be interviewed by the St. Louis Post Dispatch.
With the help of Douglas Luke, we mapped out venues where condomless sex occurs in St. Louis among different subgroups of men who have sex with men. This allowed us to see the central venues in the different networks to identify the venues where the networks overlapped. These venues served as places to post PrEP awareness messages and were used to link people to PrEP to care. Knowing these venues allowed us to conserve resources for PrEP awareness messaging as posting messages on multiple phone applications is very expensive.
We have been working with Sarah Gehlert and Richelle Clark at the Institute’s Center for Community Partnership and Research to host community education evening events that involve local health departments, CBOs, academia, community members, pharmacies and other stakeholders as attendees and speakers.
With the help of Timothy McBride at the Institute’s Center for Health Economics and Policy, we quantified the effect of having any type of insurance coverage on the use of PrEP. People without insurance were over four times less likely to use PrEP within a three month period after having received the first prescription. This study included a sample of 200 patients from three diverse clinics located in three US states (Mississippi, Missouri, and Rhode Island). Quantifying how insurance coverage affects PrEP use has now set us up to model cost savings and HIV incidence reduction depending on PrEP use in Missouri and elsewhere. We hope these types of studies could eventually impact policies related to PrEP.
Working in a multi-disciplinary team is important to ensure that you are investigating the issue from all the different and possible angles, while also allowing everyone to use their valuable and different skill sets in order to accurately investigate the issue. Working with many people with different expertise at the Institute has improved and changed my original approach on several projects and has given a different depth to how study results can be applied to policy, population health, program planning, etc.
For more information on PrEP or HIV/AIDS prevention and treatment providers in the St. Louis area, visit the Washington University Division of Infectious Diseases website.