PrEP Access in the United States: The Role of Telehealth
Uptake of pre-exposure prophylaxis (PrEP)—a preventive medication that reduces the risk of acquiring HIV through sex and injection drug use, has been slow, despite its high efficacy and recommended use for those at risk. Furthermore, disparities in access and use exist along racial, ethnic, and gender lines. The Centers for Disease Control and Prevention (CDC) estimates that in 2020 about 300,800 people were prescribed PrEP, representing only 25% of those with an indicated need for the medication.1 The use of telehealth to provide PrEP and associated services (“tele-PrEP”) is a trend that began before the COVID-19 pandemic but we find it has increased for some providers along with the growing use of telehealth generally. However, little is known about the tele-PrEP environment. This brief provides an overview of the tele-PrEP landscape, including how PrEP services (e.g., initial consults, lab work, prescribing, and ongoing monitoring) are provided and factors that facilitate its provision as well as barriers that remain. It is based on in-depth interviews conducted at the end of 2021 with representatives from the major national telehealth companies (those serving all or large portions of the U.S.) providing tele-PrEP and other select tele-PrEP programs. We also highlight two-state run programs – California and Iowa – and four community-based clinics that offer tele-PrEP programs. Collectively, the organizations included in this analysis are estimated to provide tele-PrEP services to over ten thousand clients. Key findings are as follows:
- Tele-PrEP programs have different operational models and financing structures, each with implications for patient costs and company/program revenue. In some cases, services are offered for free to clients but more than half of private companies interviewed charge a fee. Some, but not all, work to enroll uninsured and underinsured patients in assistance programs or insurance coverage. Programs and companies generated revenue through fees charged to clients or organizations who contract with the private companies, by operating as both the pharmacy as well as the provider, and also through the 340B drug pricing program.
- About half of respondents reported conducting visits primarily or exclusively via live video (i.e. using synchronous methods), one primarily uses asynchronous methods (e.g., via text, email, or delayed chat instead of phone or video), and about half use a hybrid approach.
- Laboratory services, a central component to PrEP initiation and related on going care, and prescribing patterns also varied. For example, some respondents primarily used home lab collection kits while others referred patients to in-person labs. In some cases, this was based on client preference, and in others, in response to legal barriers. Likewise, some providers primarily offer generic PrEP while others tend to favor prescribing branded drugs, a choice that was typically tied to program design.
- Some programs are primarily focused on PrEP provision, while others offer additional select services, and some provide PrEP as part of a comprehensive clinical program. All programs have a process for connecting people who are diagnosed with HIV to care and either can treat other sexually transmitted infections (STIs) or have linkages to STI care.
- Respondents offered a range of reasons for providing tele-PrEP. While the private companies stood to earn a profit from their PrEP programs, the predominant reason given for offering this services across all respondents was to provide wider access to PrEP and some tied this objective to reaching the national goal of “ending the HIV epidemic.” For some, tele-PrEP was viewed as a way to address specific access barriers, including stigma associated with PrEP and structural challenges, such as getting time off work or transportation to appointments.
- Clients served were mostly cisgender men who have sex with men, and in their 20s and 30s. Among interviewees who provided estimates, between 23% and 55% of patient populations were people of color. Insurance coverage distribution ranged significantly by tele-PrEP provider. Collectively, the national tele-PrEP companies included in the analysis served clients in all states, with most clients located in California, Texas, Florida, Georgia, and New York.
- Factors that facilitated tele-PrEP provision included multi-state licensing, developing partnerships with community-based organizations, use of marketing, and assisting uninsured clients with insurance enrollments. Respondents’ opinions varied as to whether synchronous or asynchronous communication better facilitated provision of tele-PrEP. Barriers included the challenge of working with insurance companies and Medicaid, laws prohibiting some aspects of telehealth, and retention.
- A spotlight on tele-PrEP provision in California reveals a changing landscape in the state. For example, the state policy environment is evolving to prohibit the use of step-therapy, which usually requires patients try a lower cost or generic drug before a more expensive or brand drug, and prior authorization for PrEP in many cases and to promote the use of home lab collection. The state tele-PrEP program is also undergoing structural changes. The focus on California is noteworthy given the largest share of PrEP users in the U.S. hail from the state.
Taken together and given the number of clients being served via this modality, we find that tele-PrEP offers an additional or alternative avenue for accessing PrEP services. However, little is known about how effectively tele-PrEP can be used to increase access and adherence overall or address disparities in PrEP use and how the client experience of tele-PrEP compares to in-person PrEP services. And despite it’s potential, access challenges to PrEP through tele-health remain: some populations are still being left out, particularly women and people of color, insurance barriers persist, certain policies can hamper uptake (e.g. multi-state licensing and credentialing requirements, coverage of home lab collection, etc.), and knowledge gaps about PrEP among both providers and individuals remain.