PrEP: A Focus on Florida's Policies

Christopher Hahn

Human Immunodeficiency Virus (HIV) is a virus that weakens the host immune system through the destruction of T-cells, which is a major component in our body’s first-line defense against infectious material. HIV first appeared in the United States in the mid to late 1970s; however, it was presenting as very uncommon lung infections and cancers that were not normally seen in individuals with healthy immune systems. Scientists discovered the virus that was causing these health issues in 1983. It became known as Human Immunodeficiency Virus (The AIDS Institution 2011). According to the World Health Organization (2019), HIV is a major global health issue that has claimed over 32 million lives to date. Thankfully, due to advancements in treatment, people infected with HIV are able to live healthy long lives while taking antiretroviral therapy (ART). It is estimated that approximately 37.9 million people globally were living with HIV at the end of 2018. The World Health Organization (2019) has reported globally that between 2000 and 2018, new HIV infections fell by 37% and HIV-related deaths fell by 45%, with 13.6 million lives saved due to ART. Through the support of national HIV programs and health policies, a massive improvement was achieved. This paper will take a closer look at the United States’ clinical practice guidelines on Pre-expose Prophylaxis (PrEP) for the prevention of HIV set by the Centers for Disease Control and Prevention (CDC) as well as compare it to the state of Florida’s policies and goals to decrease the rate of HIV infection.

Pre-exposure Prophylaxis (PrEP) for HIV prevention is the concept of taking a pill daily to help reduce an individual’s risk of being infected with HIV. The current treatment is two antiviral medications, tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC), combined into one medication. The CDC conducted a meta-analysis of the current research published on PrEP’s safety and efficacy. This analysis gave rise to the CDC’s clinical practice guidelines for PrEP. The guidelines identify the target populations that have the highest risk of acquiring the HIV infection. The first group recommended to use PrEP is sexually active adult men who have sex with men (MSM). The next group is adult heterosexually active men and women who are at a substantial risk of HIV, and the last group is adult persons who inject drugs. The next section of the CDC’s guidelines discuss the need for screening and assessing patients’ risk of sexual HIV infection. In a survey completed by Smith, Finlayson, Oster, and DiNenno (2008), it was found that 76% of MSM reported seeing a health care provider during the past year. However, it was uncovered that health care providers did not ask and that patients did not report same sex practices (Bernstein, Liu, Begier, Koblin & Murrill, 2008). There was similar missing information in vital information for the other two groups. This led the CDC (2018) to state, “Clinicians should not limit sexual history assessment to only selected patients because all adults and adolescent age groups, both sexes and both married and unmarried persons are being infected”. The guidelines continued with initial laboratory testing and follow up for the patient. Initial testing includes HIV serology, renal function, hepatitis serology, and testing for other STIs. The CDC also recommended providing patients with resources for risk-reduction of behaviors when starting PrEP. Lastly, the patient is to follow up every 3 months for repeat HIV testing, pregnancy testing, creatinine clearance, and support for medication adherence as well as risk reduction behaviors.

The CDC’s guidelines provide a standard for preventing and treating HIV for clinical providers to follow. However, clinical practice is just one part of the solution. Another major part in decreasing rates of HIV infection is a state’s policy to implement changes to achieve that goal. In June of 2015, the CDC and the Health Resources and Services Administration (HRSA) published a guide for states to develop and implement an integrated HIV prevention and care plan, which was a legislative requirement for Ryan White HIV/AIDs Program Grantees. The idea for the states to develop a plan was to accelerate the progress of achieving the National HIV/AIDs Strategy’s (NHAS) three goals. The first goal is to reduce new infections. The second goal is to increase access to care and improve health outcomes for people living with HIV. The third goal is to reduce HIV related health disparities and inequities (National HIV/AIDs Strategy, 2018). Florida submitted their integrated HIV prevention and care plan for 2017-2021 to unify the state’s action against HIV.

As reported by the Florida Health Department (2016), Florida’s plan identified six major cities - Jacksonville, Tampa/St. Pete, Orlando, West Palm, Ft Lauderdale, and Miami - with the highest impact from the spread of HIV. According to the CDC’s Surveillance Report (2014), the state of Florida was the third highest state in rate of HIV infection per 100,000 at a rate of 26.9. The state of Florida’s overall goal is to have an annual 2% reduction using 2014 as a baseline. Florida created objectives to achieve the three goals set by the National HIV/AIDs Strategy. To ensure progress towards the first goal of reducing new infections through ensuring universal access to and availability of PrEP especially for at-risk communities, Objective 1.2 was developed. To achieve this goal Florida proposed developing toolkits and resources to assist clinics; developing a statewide inventory of providers that are able and willing to prescribe PrEP; expanding use of PrEP navigators; exploring non-traditional ways to purchase PrEP medications; and lastly, providing education to healthcare providers and the public. Since implementing the plan in 2016, Florida has taken the actions proposed above. The State’s health department website has a link to a directory of providers in your area that will prescribe PrEP. According to the Health Department, Florida continues to lead the nation in the number of HIV tests conducted at over 1,400 publicly funded and registered sites. The health department also reported in 2016, the Counseling, Testing and Linkage (CTL) data team recorded over 360,000 HIV screening tests with about 60% of these tests conducted at sites using rapid test technologies ( Florida Health Department, 2020). Florida has seen improvement since the implementation of these multiple policies, with the rate dropping 4.8 points to the new rate of 22.1 per 100,000 in 2018 (CDC, 2018). However, they have not met their overall goal of achieving an annual 2% reduction, which would be a rate of about 19 per 100,000 in 2018.

When reviewing the annual CDC HIV surveillance reports (2018), Florida’s HIV infection rate was down to 21 per 100,000 in 2017, which was on track with their goal of 2% reduction. Then, as reported earlier, the rate jumped back up in 2018. This might suggest a need for more innovative methods to spread awareness and provide easier access to PrEP. One way is to work collaboratively with other states that have an equally high LGBTQ population and lower rates of HIV infection. One example is the state of California, with a rate of 11.1 in 2018, which is 50% less than our rate of HIV infections. California is a very progressive state, which might be one contributing factor to their low rate. On the other hand, their “Getting to Zero” plan could be playing a major role as well. The “Getting to Zero” plan is the state required prevention and care plan for HIV, which focuses not just on providing the medication, but also on creating a medical home that is welcoming for all individuals. California is a great example of being trailblazers in this ever-evolving war against HIV. The state of California just passed a new law, S.B. 125, which will allow pharmacist who undergo special training to be able to provide 60-day supplies of PrEP, as well as doses of post-exposure prophylaxis, or PEP, without a prescription. (Zraick & Garcia 2019). That level of innovation is the key to success against HIV. Another potential idea is partnership with companies or programs, which could eliminate the barrier of access to PrEP. One example is the new company called Nurx. Nurx is a company with a mission to transform healthcare by providing vital medications and test quickly and with compassion. One of the tests and medications provided is HIV/STI and PrEP. A customer can get a virtual consultation, complete the test at home, have a physician review the test results, and then receive a 90-day supply of PrEP all from the comfort of their home. Collaboration between states and companies like Nurx would allow these tests and medications to become more accessible to all, while allowing the state to put focus elsewhere. The theme of all these ideas is that of collaboration, which is fundamental to fight against HIV.

HIV is continuously mutating, making it difficult to create a cure with medication or a vaccine. The way to win this fight is to stop the spread of the virus through awareness and prevention. Our newest weapon of PrEP has shown its efficacy to prevent the spread; however, it is useless if individuals are not taking it. Florida is taking necessary steps to lower the rate of HIV infections and is making progress. From this review, it has become clear that innovation and teamwork will be the key factors in our success to end HIV.

Citation

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