Webinar: Implementing HIV Pre Exposure Prophylaxis (PrEP) in a Homeless Primary Care Clinic

Webinar: Implementing HIV Pre Exposure Prophylaxis (PrEP) in a Homeless Primary Care Clinic



hello and welcome to today's webinar implementing HIV pre exposure prophylaxis our prep and a homeless primary care clinic I'm Lauryn burner and I'll be the moderator for today's webinar presented by the national healthcare for the homeless Council with support from the health resources and services administration and the Bureau of primary health care this is a 60 minute presentation with the last 15 minutes reserved for Q&A there's a chat box below the presentation slides for participant questions and technical issues please type your questions or technical issues into the chat box at any time during the presentation a select number of questions will be answered at the end of the presentation during the Q&A session remaining questions will be logged and provided to the presenters for written responses after the webinar if you're having technical issues you may also call Caroline Gump and Berger at the counsel's office that number is six one five two two six two two nine two extension two two two for assistance a copy of the slide deck is available in the resources pod on the bottom right corner of your screen and materials in the recording will be available on our website Stan our presenters today are from the VA Greater Los Angeles healthcare system we have Elizabeth Gregg of family nurse practitioner a minase also a family nurse practitioner and Carrie Lin a pharmacist and thank you all for joining us I'll hand it over to you for today's presentation thank you so much for this really wonderful opportunity to share with this group the work that our quality improvement team has been invested in for the past year we are in actually joined by some of our other qi project team members today including sonja jefferson our social work representative NOAA Rayven Berg one of our internal medicine residents that work with us and we have our faculty advisors Brianna : and Lillian gelberg with us on the call as well we do anticipate one other person to join us and that will be Jennifer Coker who is our infectious disease specialist so hopefully she finds a way to be on the call at some point I also just want to really thank Hannah and Lauren for this opportunity and on our side Kerry and Lillian for their work getting this set up so without further ado let's get started so our objectives for this webinar of this afternoon are to provide a brief review of HIV and the development of pre exposure prophylaxis otherwise known as prep for HIV to review HIV acquisition risk factors that may be over-represented in the homeless population to provide up-to-date recommendations to initiate prep in the primary care setting and to describe the QI project in a primary care clinic serving homeless veterans which is where we are which is the West LA VA homeless patient aligned care team otherwise known as H pact so a brief review of the history of HIV the earliest cases have been tracked down to the 1930s and 40s and then there was a slow spread of the disease through Africa into other parts of the world lasting until the early to mid 70s during the 70s and 80s there was a rapid increase in infection rates and in the early 1980s of the rare cases of pneumonia cancer and opportunistic infections that were showing up in emergency rooms and primary care providers led to the identification and characterization of HIV and AIDS as I'm sure we all know those initial cases were always fatal by the late 80s the first antiretroviral medications had been developed and things began to look a little bit better for patients diagnosed by the late 90s we had improved therapies that could suppress the viral load to such an extent that allowed HIV to be considered a chronic disease and those who actually had access to treatment today in the United States about 1.1 million people live with HIV infection the CDC estimates that about a hundred and sixty-two thousand of those persons do not know that they have HIV and this is that information displayed through a nice infographic by the CDC the main takeaways here are that there are many people living with HIV who do not know their diagnosis and of those who do know their diagnosis only slightly over half are well controlled on medication or virally suppressed in 2019 the Health and Human Services launched an HIV initiative to eradicate HIV in the United States with a four prong plan for ending the HIV epidemic diagnosing HIV as early as possible treating HIV quickly and effectively protecting people at risk and responding quickly to clusters of new cases and this is why primary care has a very important part in this initiative about one and two people with HIV have the virus at least three years before diagnosis and about 70% of people saw a health care provider in the 12 months prior to diagnosis and failed to be diagnosed and about 87 percent of new HIV infections are transmitted from people who don't know they have HIV or are not retained in treatment per the CDC this is the current patterns for HIV transmissions the current predominant pattern in the United States is men who have sex with men however heterosexual men and women make up just under a quarter of new cases if we're to prevent HIV acquisition we cannot continue to view HIV as a concern only to the LGBT community and IV drug use along with other risk factors also account for about 10% of new transmission this is a slide of lifetime risk for HIV diagnosis by transmission group transmission group is the same information in a slightly different manner about who is at the highest risk related to behavior this is a slide that shows patterns for who is being diagnosed in the United States and just to make a little nomenclature pede wi d stands for people who inject drugs the biggest takeaway here is that there are racial and ethnic differences among diagnosis patterns well overall men who have sex with men diagnosis have remained stable white men who have sex with men have had a marked drop in diagnosis while african-american men have remained stable and there's been a marked increase in diagnosis among the Hispanic and Latino communities for risk factors for acquiring HIV it's a blood-borne virus the two most common current modes of transmission are through sexual transmission or IV drug use we are past the the place where people are getting HIV through blood donation for sexual transmission the highest risk groups are people who are not in a mutually monogamous relationship with a partner who has recently tested HIV negative and who do not regularly use condoms or barrier protection during sex with partners of unknown HIV status for IV transmission the risk is anyone who has injected any substance in the past six months doulas ever shared injection equipment the other group is people who have unprotected sex with a partner who have the above risk factors or occupational risks for medical providers although that is a very low risk for when we want to think about the HIV risk in the homeless community which is very near and dear to our hearts working with homeless veterans there are some very unique risk factors for the homeless community and they live at the intersection of multiple risk factors about 11 to 40% of homeless individuals identify as LGBT and surveys about 40% of homeless individuals report having engaged in survival sex at least once during their period of homelessness and survival sex is defined as a transaction transactional sex act engaged in by a person because of their extreme need it describes the practice of people who are homeless or otherwise disadvantaged in society trading sex for money food a place to sleep other basic needs or for drugs and again for the homeless community there's a special note there's been some research done in Los Angeles that suggests that the period of transition from homeless to permanent supportive housing produced provides an opportunity for intervention as that transition itself can increase rest risk factors for a sexually transmitted HIV protection as people begin to feel a little bit more relaxed and have privacy and have access to a safe place to beam about 25% of homeless individuals report low rates of barrier protection during a sexual act and about 30 to 50 percent of homeless individuals report using IV drug use at some points all of these things combined lead to home higher HIV rates in the homeless population study showed that homeless persons are 5 to 10 times more likely to have HIV than the stabili housed population invasive HIV infection homeless persons in the United States or the twenty two and ten percent and overall higher HIV acquisition rates among homeless persons who have substance use and mental illness and just for comparison the overall HIV infection rate in the United States is 0.3 percent so the rate of HIV infection among homeless persons going from two to ten percent represents a pretty significant increase in risk the next slide is about HIV prevention strategies as we've talked about a little bit there's barrier protection condoms dental dams clean needles programs needle exchange post-exposure prophylaxis tests which we will not be talking about in this presentation and then pre-exposure prophylaxis which we are talking about and routine STD screening and treatment at this stage I'm going to transfer the presenter to Carrie who's our pharmacist who will then review with you what prep is all right thank you very much so a little bit of background about prep itself it was approved by the FDA in July of 2012 it's a combination medication so it's two different medications in one tablet to not veer to propyl fumarate and emtricitabine just to be taken once a day and just another note about prep as that is now a grade a recommendation by the US Preventive task force but it's now a standard of care and should be offered to all at-risk individuals a little bit more background about prep is that it just really emphasize that it's the use of an antiretroviral medication for the prevention of HIV acquisition so it's indicated for those who are HIV negative and who are at risk of contracting HIV as far as you have indicated for our press it's important to assess the sexual risk factor that we mentioned before the two main risk factors for HIV acquisition are sexual behaviors as well as IV drug use so it's important to keep in mind certain methods for actually assessing sexual risk factors and that kind of includes the five keys which includes assessing more information about partners practices past history of STI protection against STI and as well as pregnancy plans it's also important to assess risk factors as far as drug use code so just to keep in mind that what we want to make sure is that we put questions in context really assessing at for example some of my patients have used drugs such as heroin have you used such drugs so just putting things into context like that to get more information assessing history of IV drug use specifically and getting kind of a timeline of that so in the last six months for example have you used any IV drugs and then what type of drugs are being used how it's being administered and then harm-reduction practices for example where they're getting their needles and what their practices are as far as the effectiveness of HIV prep it's been shown to be real it's very effective so the daily youth impress has been shown to be for multiple studies I've been done if you can see and as you can see a HIV acquisition has been reduced by more than 90 percent and for IV drug use HIV acquisition has been reduced by more than 70 percent so if you can see this is a list of studies that have kind of looked at how effective HIV prep youth has been as far as contraindications for the use of crepes one of the contraindications is the inability to successfully take a daily medication so adherence to the medication is pretty important some studies are looking at kind of the as needed method but right now it's fda-approved for daily use so this is what we emphasize is that that adherence is good for this medication hiv-positive individuals that would be a contraindication to the medication as I noted earlier it's only for HIV negative individuals at risk renal function defined of creatinine clearance less than 60 milliliters per minute is a contraindication for prep as well as HIV exposure within the last 72 hours and at that point you would want to evaluate for pets that we briefly mentioned earlier just also of note on the adherence for example in our clinic where we work with homeless veterans and patients this is where we just might want to monitor more frequently just to ensure that these patients are adherent to the medication other kit considerations to keep in mind for prescribing prep is noting to test for hepatitis B infection because this medication can also be used to treat hepatitis B so we want to know what the status is of that infection we want to know pregnancy plans including if patients are currently pregnant plan to become pregnant plan to conceive with one's partner or our breastfeeding just note that this medication is safe in pregnancy observational studies up to this point have not found increased risk in birth defects and it's kept track in an antiretroviral of pregnancy registry at this point but it is safe to use in pregnancy and just keep in mind that Truvada is part used as part of combination therapy for HIV treatment in pregnant individuals this table here just kind of shows a summary of guidance for prep use just to kind of put together a lot of the things that we've mentioned and we'll mention it closely reflects the guidelines that are laid out by the CEC as well so just a couple of things to note from this table is that they talked about a high number of sexual partners being a risk factor just know that this isn't actually truly defined this isn't a specific number that's ever really been defined for certain and then just generally noting that we generally monitor for labs and definitely HIV status every three months and then STI we monitor every six months and then can vary depending on risk this is a little bit more about monitoring for on prep therapy so if you can see at baseline we monitor multiple different labs and then every three months as I mentioned is how we most frequently monitor and then every six months depending on risk and then hepatitis B would be yearly and just to know – why that's important as I mentioned that Truvada is also used to treat hepatitis B so if a patient already has hepatitis C and we don't know and then we stopped prep that can cause a hepatitis B flare so that's the concern with hepatitis B as far as discontinuation of prep Sarah P and when that would be indicated so a new HIV diagnosis would certainly be a reason to discontinue prep as I mentioned it only for HIV negative individuals so that you would want to stop prep and Link the patient to an HIV specialist at that point self discontinuation of prep or prep is no longer indicated we would want the patient to make sure that they have they have an HIV test at the end just to make sure and really just clarify the reason for discontinuation prep is essentially not indicated when there are no longer risk factors for HIV acquisition so just really making sure to the patient understands that what those risk factors are and make sure that they don't have those anymore as far as side-effects go of prep the most common short-term side effects they usually only lasted for a few weeks most common side effects include headache and nausea less common side effects are the GI related side effects of diarrhea abdominal pain and then sometimes some myalgia decrease creatinine clearance as you saw from the monitoring screen and what we mentioned before we do monitor kidney function while on prep therapy but it is noted often that there is a small decrease in renal function which typically does reverse if prep is discontinued also there's a little bit of a little bit of a concern for bone mineral density loss so approximately 1% decrease with no increased risk of fractures and this also reverses when prep is discontinued as far as prep use in the community goes of more than 1 million people that are at high risk for contracting HIV only about 10% are currently receiving prep at this time so as you can see there's a lot of room for improvement for a capture of these patients to improve prep uptake insurance generally does cover prep therapy but it's still expensive at about two thousand dollars a month but it's also important to note the cost benefits of being on prep therapy so the lifetime medical cost of an HIV if one becomes HIV infected at age 35 rounds out to be about $300,000 and medical cost aids by avoiding one HIV infection comes out to be about 230,000 so just know that this is a prevention tool and it belongs in primary care screening for risk factors and initiating prep is the standard of care at this point in time and now I'm going to turn it over to Emma to talk a little bit more about our qi project in our clinics Hey so I'm just gonna zoom it in a little bit now to the work that we've been doing specifically at our site to increase access to prep so just a little background on who we are we are in West Los Angeles we are in the Veterans Administration health system and we are specifically and represent the homeless patient aligned care team which is geared specifically towards providing primary care in an interdisciplinary housing first model geared towards veterans who are homeless or have been housed for less than a year our particular site is the largest in Los Angeles of three different sites we serve 2200 homeless veterans and it is a teaching and academic clinic and so there in addition to our 58 full-time permanent staff we there are also 26 trainees from a variety of disciplines and our group our qi group is a group of trainees from a variety of disciplines we mentioned pharmacy Social Work medicine and nurse practitioners are all represented as well as a number of faculty advisors for supports we recognize in fall 2018 we kind of came together and we recognized that despite being and above average risk population of both veterans and homeless veterans specifically prep was being prescribed at very very low rates and we suspected that it was being under prescribed so we looked at why this might be and we found a number of both cultural and structural factors the most glaring was that prep prescribing privileges were actually restricted to infectious disease department and relied on a specialty referral to be initiated and actually maintained so other factors that we saw were other structural supports such as workflows and other calls for management as well as a lack of routine screening and identification of eligible patients so the goals we set for this project were to obtain prescribing privileges for primary care providers and pharmacists within the home of patient clinic to increase identification of patients who are eligible for prep and ultimately to initiate prep therapy and 10% of eligible patients who were not already on it by February of 2020 you can see here a little bit more of an expansion of our exploration of causal causal factors involved in in this under prescribing and we found a few different trends so when a couple of the things that I wanted to highlight is is a kind of lack of perceived risk on the part of patients and providers and I think that that's related to and also perpetuates a lack of screening and and I think one of the things that kind of informs that both in the VA and in general is a perception that we spoke to briefly earlier that HIV is really kind of a disease and is only relevant to the MSM community particularly in populations that may use injection drugs or may use the services of sex workers or be sex workers themselves of course we know that there are in fact many other risk factors that can make people susceptible to infection and we also found a number of other of other barriers some of which were historical such as such as a kind of concern and apprehension about the safety of the medication about the cost discomfort with prescribing and discomfort with asking questions around sexual and drug health here you can see a bit of an overview of our qi process in this just goes into depth a little bit of some of the ways that we worked to address some of these barriers and I believe you will have this light so I won't get into detail with this but it's here for your reference just as an overview in terms of how we looked at addressing some of the system barriers we worked closely with infectious disease and specifically with Jim Fulcher who was from that department and eyes on this call now and and we work to identify a standardized training that primary care providers could complete in order to be approved by our pharmacy department to prescribe Truvada for prophylaxis we also identified another problem which was that recommended testing requires regular HIV and STD testing but we did not have either point of care HIV test rapid test or gonorrhea chlamydia swabs in the clinic so we were able to have the lab approve rapid processing of HIV tests so that patients who hadn't had labs done before their appointments would still be able to get their prescription in a timely manner as well as enabling self patient subcollection of gonorrhea and chlamydia swabs at the laboratory and then we've done a have in progress and have started as well a number of changes in our electronic medical records GPRS some of these tools involve working to adapt an automated reminder it's one of the functionalities that the VA EMR has and this is also creates a trackable a trackable health factor that enabled us to track risk factors and prescribing and we're also working to develop and adapt order sets as well as templates for templates for progress notes and and then we have as well a dashboard that pulls data based on icd-10 codes to enable us to identify patients who may be at risk and eligible for prep and we've been working to improve that dashboard particularly in capturing injection drug use as a risk factor we also have done a number of interventions in addressing more of the cultural barriers so we found just through kind of preliminary informal surveys that there was actually a pretty low awareness that perhaps even existed among our broader staff and so we have done some trainings aimed at increasing awareness of that and also at helping to disseminate understanding of what factors may put somebody at risk so that staff members even outside of the person prescribing can help to educate patients and to identify those who may be at risk for prescribers we did a little bit more in depth training and we concentrated on developing skills and and sharing pertinent questions for sexual and drug history taking including developing and distributing a pocket tool to help providers can remember what questions to ask and then we also did some training around kind of perceptions of what the scope of repres cribbing is really emphasizing its role as prevention rather than a specialty care to aimed at enhancing comfort of providers there's a little bit of a mystique around HIV medications coming from kind of the early days of HIV treatment and that's been extended to Truvada for prophylaxis but really isn't warranted it's a very safe medication and it's a very easy one to prescribe and so to enhance that kind of providers confidence in prescribing this medication we also did pretty Cyril training in the risk side effects contraindications and monitoring similar to what we went over today in a little bit more detail we also have been working on developing workflows for the clinic and that's been somewhat at addressing kind of the whatnow factor when something's not currently being done frequently in a clinic a lot of times staff will identify that it needs to be done but they don't know how to execute it so for most disciplines that simply involves creating a pathway to facilitate a warm handoff to somebody who can prescribe and order testing and then for prescribers it gives a little more detail and how to outline and for scheduling staff when to schedule etc and in terms of helping with kind of in generating enthusiasm and overcoming some of the stigma and discomfort around its association with you know sex and drugs we identified some discipline champions who have been indispensable in helping to promote this project and we've also had been very fortunate and having a high level of buy-in from our management team and data identified from the dashboard I mentioned before has been helpful in generating that urgency you can see here one of our workflows identifying different disciplines roles in in the process of initiating prep and in terms of our next step we as I mentioned still some of these tools particularly in the medical record and the workflows are in process we have a new batch of trainees coming in it will be standardized for all of them to be trained in prescribing prep and and approved as part of their onboarding going forward we're hoping to expand the RN and LVN role in the clinic protocols as well as disseminate prescribing from primary care for homeless patients to our women's health clinic our substance use clinic and ultimately to our broader primary care clinics so we'll open now for questions thank you so much if folks could go ahead and type in questions into the chat box down there we'll take a couple of minutes to go through those I do want to note that there was a comment added to our chat box from Kristin also from the VA Greater Los Angeles health care system that coupons are available for prep to help address that cost and they are available through the pharmacy yeah yes so one of the things that we didn't really address here is cost and that's because at the VA cost is a very different issue it's it's kind of an all-in-one situation in the broader community there are a lot of resources for helping to cover some of that cost and we've included a few resources here as Kristin mentioned pharmaceutical companies for this medication Gilead and also for a lot of medications can often provide coupons for discounts for patients who are uninsured there's also I think we mentioned many insurance companies actually cover it now and I believe Medicaid does as well and Gilead has also made a commitment to providing free or reduced cost prep to thousands of people in the next few years and so particularly when we're thinking about working with the homeless and vulnerable there are a lot of resources that are available for our patient population it just requires a little bit of digging and Gilead has definitely had some not positive press recently and so and this is their way to try to gain back some goodwill and also we do anticipate some generic versions coming on the market and this may also be their attempt to get you ready to engage with them on their products before that happens thank you there's another question that came in asking if you could share the patient engagement rate following perhaps medication adherence lab testing follow-up and notion unfortunately we don't really have a good data yet it's a little too early in our implementation process who collected data on that I will say just quickly you know missing appointments or having poor medication adherence considered a contraindication to initiating prep I think you know we we spoke to how important that is but I think that it's also important with the homeless population to to have a little bit of flexibility with that understanding that they often have chaotic life and having a follow up shortly after an intended 110b okay and I think I think we mentioned that the medication well it's indicated for daily use can actually be very effective with as few as four doses a week so not being able to come on time for every single appointment isn't necessarily an absolute contraindication and just to reiterate our policy for prescribing practice that we never gave longer than a 90 day fill for and we don't put refills on that so it's part of our protocol to really just did not provide any further refills until we're able to make contact with the patient correct yes so that the rationale for for having frequent follow-up and not having a large supply for patients who have spotty adherence is the concern for for contracting HIV and then developing resistance if you continue to take the medication not knowing that you haven't so providing this short supply can really help to reduce that risk thank you um there's also a question if you could clarify the baseline labs that are done to indicate prep yeah so let me go back to that slide okay so this light this light here slide 23 kind of goes over all of the labs that we look at it baseline so HIV HPV a Hep C renal function spi pregnancy tests if applicable so if you business kind of what we look at at baseline and then every three months we reassess a lot of these labs again to you six months is when we start looking at renal function STI if not needed more frequently so this slide here kind of shows what we look at at baseline there's also these sites should be available to you and there's also a a number of resources online I recommend looking at the CDC they have a very clear protocol so we're prescribing and monitoring which Parker colleges yeah this this closely reflects if not completely insensitive ADP and I would say yes and the slides are in their resource pod I know a couple questions have come in about that so those are on the bottom right corner of your screen and they will also be sent around along with the copy of the recording in a few days there's another question asking if you have any thoughts to share on getting buy-in from prescribers in an area where HIV rates are relatively low I mean I think the the biggest tool the biggest feather we have in our cap right now is that it's a u.s. preventative task force grade a recommendation to screen it both you know this is a preventative disease at this point but you have to ask your patient some questions that not all providers are really comfortable asking the CDC numbers show about twenty five percent of new infections are heterosexual men and women and well the individual risk for an individual man or woman may heterosexual man or woman may be low compared to that risk for a man who has sex with men there are a lot more straight people in the world than there are homosexual people and so twenty five percent of new infections are heterosexual infections and so this is about re-education for providers that this is not just a concern for the LGBT community and that people have risky sex in multiple ways and you know you have to ask for it I mean I think the key thing right is really understanding what the realistically the risk is for the specific patient so if you're in an area that has low HIV rates overall that may or may not be true for a particular sub population so when you look at the MSM community the reason that rates are so high in that community has a little bit to do with the with the style of transmission but it mostly has to do with epidemiology and that that is a small and sexually isolated community that because it had it had a was where the community initiated its spread and now has endemically high rates that can be true as well in homeless and drug use and communities and then the other thing that I would say is that it's really really important in any population to assess the risk of infection including sexually transmitted infections with all infection really and if truly that patient is at low or no infection then you know I don't see the need to convince prescribers to give them prep but as long as that screening is really happening I think it's being one thing I mean I think last about Ryan White funding anybody knows the answer to that I was just checking that out it looks like Ryan White funding does not currently cover prep unfortunately however I think as you mentioned there are a lot of other strategies that can be used to mitigate some of the cost concerns there we have a few more minutes so if folks have any additional questions please continue to type those into the chat box I have a quick question for you as well kind of going off of some of the discussion about getting buy-in I was wondering if you could talk a little bit more about some of the the training that you did for primary care providers around prescribing and increasing that comfort level sure one of the things that we really focused on was that the contraindications for this medication are very very small and so when providers when we first began to talk to our colleagues about bringing this to primary care there think there was a lot of concern and anxiety about what extra work this might mean for prescribers and so a lot of our work was on education of what the drug was and how simple it really is to prescribe and where and the monitoring is not monitoring that requires a lot of extra stuff either and so our our real emphasis was on this is not going to take a lot more of your time the follow-up and assessment shouldn't take much of your time either and this is just a very very safe drug you're not really needing to worry about serious side-effects you don't have to worry about really tracking up and making sure that bad things are not happening and then the other part of that was on how to really get a sexual an injection drug history in a way that feels natural for you as a provider and actually invites the the patient to be truthful and forthcoming to you and not everyone has that skill set and so we did create some very you know so some very specific wording to provide to providers that they could try it out and see what worked for them and the it was adapted from this slide about asking the sexual history that was shared with you in this presentation one conceptual framework that we really wanted our primary care providers to incorporate was within our clinic we talked a lot about harm reduction and you know this is one additional tool that we can use for persons who inject drugs with say a narcan prescription referrals for needle exchange we can offer them prep or for those with risky sexual behaviors you know in addition to talking about condoms or contraception or STI screening we can additionally offer them prep so we're trying to really include this as one tool in our toolbox for prevention based on behaviors I think one of the great things about about prep also is that and I think that providers and primary care providers love to offer people solutions and I think a lot of people feel uncomfortable asking about sexual behaviors if they don't have a clear reason in their mind that that might change their management this I think can really also be a way to motivate providers to ask about sexual risk and have a frank discussion about sexual risk because really it does impact management and and there are things that we can do to reduce that risk in terms of prep but also in terms of other risk management interventions and just to branch off a little bit more about the training that we provided so that came kind of in the form of the pocket cards that we created for them as sort of a quick reference but a little bit more formally at the VA we have we already actually had a built in prep training as part of just some of the continuing education resources that we have for VA employees already so we essentially went through that in a staff meeting and guided them through that to kind of help them complete that training and it's a really good training that already existed that a lot of it we just basically disseminated to the clinic but the pocket card serves as a good kind of quick reference for them just to remember to and those materials exist in the in the world and the cdc has a lot of material Health and Human Services how it has a lot of material so those of you who are thinking about how you might bring this into your clinical settings you know we stole lots of stuff but stuff exists in the world the CDC is a wonderful wonderful resource for for trainings and it really is it's a it's about getting people over the hump of defining HIV as only an LGBT concern one last thing that I wanted to speak to on that subject and this is in some ways a little beyond the scope of this presentation and even if our training but one of the concerns that we encounter here is there are unfortunately there's a pretty high rate of sexual harassment at the VIS stuff and so some staff have concerns about initiating conversations about sexual behavior because of that I think that one of the benefits of the really clear training about how to get a good sexual history is that it normalizes those questions in a way that isn't about curiosity that isn't about you know having a you know and recrossing conversation in any way it really just is about clinically excessive assessing risk factors and I think that that can be a really valuable skill for a lot of clinicians thank you so much another comment came in mentioning the importance of also looking at the implications on transgender patients and looking at some of those statistics and included a link to a fact sheet by the CDC so thank you so much for sharing that we'll try to make sure that that also gets listed with the resources for this webinar that is also covered in an upcoming sark sheet that the council will be releasing on prep that is currently under review so hopefully that will be coming out in a few weeks so stay tuned on that thank you for that consideration I did this is Lillian gelberg I wanted to say that I'm just delighted with the incredible work our interprofessional trainees and team have done on this quality improvement project and they picked crack because it's in importance to our population and the mandate the US Preventive Services Task Force to implement this in all of our primary care clinics and I would say that the interprofessional nature out of the work just made it a fantastic project from start to finish you know that every aspect of interprofessionalism was involved in creating this project and I'm just really proud of our trainees and our faculty thanks Willie and it sounds like a really great project and thank you another question comes in relating to insurance coverage I know that you mentioned it's a little bit different for the VA but if you have any insight you'd like to share about insurance coverage for prep that would be great most commercial and most Medicaid insurance has cover it and I think we can only anticipate that it will be covered even wider with the US Preventive task force grade a recommendation as well as the Health and Human Services initiative the issue is for issuers less for our patient population if you have very little money this is actually a medication that is easier to get with a very low out-of-pocket cost or no out-of-pocket cost it's for persons who are a higher income and have a you know a commercial insurance that the out-of-pocket copay may be quite high and that's also where Gilead has agreed to do some patient stuff but for our patient population cost should not be an issue it just may require a little bit of digging into how to connect them with the prescription yeah as they mentioned it really is cost-saving to prescribe this medication if you are within a system where your HIV care will be paid for by the same people who will pay for your HIV prevention so the exempt the advantage of working within safety net systems is that that is the case in private insurance that can be externalized meaning that the issues down the road are not going to come back to bite whoever's choosing to pay for the medication now so that's where we see kind of more of the gap thank you so much it looks like that is the last question that has come in I wanted to thank you all again for presenting today and sharing the great work that you've done around quality improvement and perhaps in the VA in LA I know I definitely learned a lot including kind of how many folks are seeing their provider in the year before diagnosis and thinking about ways that we can be proactive in that thank you all for joining and listening in on today's webinar and engaging with the content again the presentation materials and a link to the webinar will be available on our website at n HC HC org in the next couple of days a survey for evaluating today's presentation will also open in your browser at the close of this session so please fill that out so we can hear your feedback we really appreciate your time today and is that this webinar is closed thank you

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