Family planning providers’ role in offering PrEP to women

Abstract

Pre-exposure prophylaxis (PrEP) provides a radically different HIV prevention option for women. Not only is PrEP the first discrete, woman-controlled method that is taken in advance of exposure, but it is both safe and highly effective, offering over 90% protection if taken daily[1]. While multiple modalities of PrEP are in development ranging from vaginal rings to injectables and implants, only PrEP with oral tenofovir/emtricitabine is currently FDA-approved.

The Centers for Disease Control and Prevention (CDC) estimates 468,000 women in the United States (U.S.) are eligible for PrEP, defined as having condomless sex in the prior 6 months with a man living with HIV, a man who has sex with men, or a man who injects drugs [2]. However, to date, only approximately 19,000 women have ever been prescribed PrEP, and that number appears to have stabilized [3, 4]. Moreover, while Black women in the U.S. are twenty times more likely to acquire HIV than White women and have 1 in 54 lifetime risk of acquiring HIV [5], disproportionately fewer Black women have been prescribed PrEP or know about PrEP [4, 6]. Latina women also have approximately four times the lifetime risk of acquiring HIV when compared to White women, but have received disproportionately fewer PrEP prescriptions [4, 5]. Who will take responsibility for PrEP implementation for women in the U.S.?

The case for PrEP provision at family planning clinics

Multiple groups have called on family planning providers to lead PrEP implementation for women in the U.S.. The CDC and Office of Population Affairs identify STI/HIV testing, treatment and prevention as a core family planning service[7]. The United States Women & PrEP Working group identified family planning’s critical role in PrEP implementation in their 2015 position statement [8]. The broader HIV prevention community frequently highlights the role of family planning providers in PrEP roll-out for women in the U.S. [9–11].

More important than organizations’ calls to action, data suggest women expect HIV prevention services at family planning visits. In focus groups with over 150 women from around the U.S. who reported increased vulnerability to HIV, participants identified family planning clinics as places where they saw “trusted providers,” and where they would want to learn about PrEP. Moreover, as early as 2013, women reported feeling “angry” at not having heard about PrEP from healthcare providers [12]. In a survey of approximately 2,000 women attending family planning clinics in Northern California, over 80% reported expecting to receive integrated sexual and reproductive healthcare, including comprehensive HIV prevention services, at the time of their visit [6].

Finally, family planning clinics may be the only way to reach some women and educate them about the first woman-controlled HIV prevention method. Forty percent of women in the U.S. exclusively access reproductive healthcare, including pregnancy and family planning care [13]. Title X providers serve a racially and ethnically diverse population. Of the 4 million family planning users served by Title X in 2015, 30% self-identified as non-White (Black or African American, Asian, Native Hawaiian or Pacific Islander, or American Indian or Alaska Native), 32% self- identified as Hispanic or Latino, and 13% were limited English proficient [14]. Title X clinics are one of the few places that uninsured immigrant women may access sexual and reproductive health services; many of these women experience increased vulnerability to HIV through their own or their partners’ sexual practices in the US and/or when traveling to areas of high HIV prevalence. Family planning clinics provide key access points for many women to learn about and obtain PrEP. By incorporating PrEP services into family planning care, family planning providers have the opportunity to meet women’s expectations, ensure women are aware of and offered comprehensive HIV prevention options, and reverse emerging disparities in PrEP access.

Lessons learned from family planning are highly applicable to PrEP implementation

Oral PrEP and oral contraceptives both involve individuals taking a pill daily for prevention. Both are dependent on adherence for efficacy and both have suffered from concerns about risk compensation [15, 16]. Just as family planning care provision requires regular assessment of changing pregnancy intentions and sexual practices, HIV prevention care requires regular assessment of changing vulnerabilities to HIV and risk perception [17, 18]. Just as family planning clinics have adopted a low-barrier approach to care through quick-start protocols, same-day PrEP provision is increasingly offered to facilitate clients’ initiation of PrEP. Similar individual, community, and structural determinants of health affect HIV infections and unintended pregnancies, demonstrating how incorporating each woman’s preferences, goals and context is crucial to service delivery [19]. Family planning providers have addressed these challenges for decades [20, 21], and are well-positioned to utilize their experience and skills to implement PrEP for women (Table 1).

TABLE 1.

Lessons learned from family planning to inform PrEP implementation.

Lesson Learned	Evidence	Application to PrEP
Activities In Clinical Encounters
Ask women; listen to women; share decisions	In contraceptive care, women prefer a shared-decision making approach [28].	Listening to women’s preferences and desires may support uptake of PrEP and other HIV prevention methods.
Discuss side effects	Anticipatory guidance improves continuation rates and patient satisfaction of contraception [29].	PrEP counseling about short and long-term side effects, particularly as new data emerge, may support adherence.
Provide contingency counseling	Contraceptive contingency counseling is associated with decreased rates of unintended pregnancy at 6 months [30].	For PrEP, clinic-based programs that facilitate appointments, refills, and access to short courses of drugs (including PEP and emergency contraception) when non-adherence occurs can all be part of contingency planning. Proactive discussion of potential adherence and access issues may empower patients and increase uptake.
Screen for violence	Discrete contraceptive methods such as intrauterine devices can assist women in exercising reproductive rights and avoiding reproductive sabotage [31].	As a woman-controlled method, PrEP offers the first discrete HIV prevention option.
Activities Targeting Community and Structural Barriers
Identify unique interventions for sub-populations	Family planning has innovated care for adolescents [32], women postpartum [33], women post-abortion [34], and women with complex medical conditions [35], improving health outcomes in particularly vulnerable groups.	PrEP needs implementation strategies for specific populations, including pregnant and breastfeeding women, women planning conception, sex workers, young women, women who inject drugs, transgender people, among others. Embracing diverse HIV prevention methods and implementation strategies may facilitate care of women most vulnerable to HIV.
Expand the method mix	Worldwide, one additional contraceptive method made available to half the population correlates with a 4-8% increase in contraceptive use [36].	Women have diverse preferences, needs and goals with respect to pregnancy and HIV prevention methods. Expanded methods and dosing may increase women’s utilization of HIV prevention options.
Train providers	A randomized trial of evidence-based provider training on counseling about and insertion of long-acting reversible contraception reduced unintended pregnancy rates at 1 year [37].	Clinicians’ lack of knowledge about PrEP and beliefs about sexual practices impede women’s accessing HIV prevention methods [38].
Provide effective, accessible and inexpensive prevention methods	The CHOICE Project demonstrated when cost and access barriers were removed, women chose the most efficacious and long-acting contraceptives. Pregnancy rates were reduced and abortion rates were less than half the national and regional rates [39].	To facilitate uptake of HIV prevention methods, financial and access barriers must be removed.
Activities Promoting Health Equity
Identify & investigate disparities	Sixty-nine percent of pregnancies in Black, 56% in Latina, and 42% in White women are unintended [40]. Black and Latina women have lower satisfaction and more frequently experience racism in family planning encounters [41]. Providers have been found to recommend certain contraceptives more frequently to poor Black and Latina women [42].	Similar trust issues and racial profiling are also likely to exist with PrEP provision. Acknowledging inequities and patient experiences in the context of a long history of racism, and investigating ways to best address stereotypes within systems and ourselves, may counteract disparities.
Develop trust	Quality interpersonal care during contraceptive counseling is associated with contraceptive continuation at 6 months [43].	While PrEP implementation is still in its infancy, focus groups in U.S. women reveal that they are “angry” at not hearing about PrEP, and want to learn about it from trusted providers. Barriers to PrEP implementation already exist as women feel betrayed by the healthcare system [12]. Shared decision-making with a focus on women’s preferences and desires may facilitate trust.

Challenges to integrating PrEP into family planning care

Family planning visits are busy clinical encounters that address multiple health priorities in limited time. Integrating a new service into this environment can feel daunting, particularly when PrEP provision may require navigation for clients who are under or uninsured, and more frequent lab testing and follow-up than other family planning services [22]. Even screening for HIV vulnerability can seem an overwhelming task, given that there are no validated questions that accurately assess a woman’s HIV risk in the U.S.

In addition to structural challenges, providers and clinic staff require training on both medical provision of PrEP (which while not overly complicated, requires familiarity) [23], and in counseling on a variety of HIV prevention options. While many family planning providers agree that PrEP provision is in their scope of practice, they want more training [22, 23].

It is equally important to acknowledge the changing landscape of healthcare and the limited resources family planning providers, clinics, and organizations face, thus adding new services may seem impractical at best. However, to restrict services now more than ever is to diminish the comprehensive approach to women’s healthcare, and may result in even further restrictions.

Pearls from early adopters

Despite these barriers, some family planning clinics have already integrated PrEP into their services, and identified ways to overcome challenges. The motivation to be early adopters is multifactorial, but anecdotally, seems to rest on a fundamental belief in the mission of providing comprehensive sexual and reproductive healthcare to women, and in particular, providing a diversity of prevention options to women that best meet their needs [22].

Lessons learned from early adopters of PrEP provision in family planning care include:

• Identify a clinic champion: this person may be a clinician, administrator, counselor, or advocate; regardless of their role, clinic champions serve to motivate and lead by example. These individuals may or may not be PrEP experts, but they develop relationships to obtain answers to others’ questions, and over time, often become local PrEP experts.

• Don’t recreate the wheel: many resources have been developed to train staff, advertise to clients, and educate clients about PrEP. Key resources for family planning clinics are listed at the Family Planning Provider PrEP Toolkit (https://www.hiveonline.org/prep4familyplanning/).

• Provide post-exposure prophylaxis (PEP) as another opportunity to expand comprehensive HIV prevention services: for clients who had an exposure in the prior 72 hours, PEP is not only a highly effective HIV prevention method, but an opportunity to see if daily medication use is feasible and attractive as a prevention method. Transitioning from PEP to PrEP without a break in prophylaxis is simple and recommended by CDC guidelines. For some clients, this will be an attractive option; for others, PEP alone may be preferable. Providing multiple HIV prevention strategies is an important way to meet the diverse needs of more family planning clients.

• Bundle PEP and PrEP services with pre-existing clinical care to streamline follow-up: clients presenting for emergency contraception can also be asked about PEP eligibility, given similar time constraints for effective prevention. For clients using injectable contraception, HIV testing for PrEP, as well as PrEP prescriptions (every 3 months), can conveniently be coupled with contraceptive visits. Finally, some PrEP visits may require only lab tests with phone follow-up, minimizing unnecessary clinic visits.

• Develop and call on allies in the HIV community: HIV prevention advocates and experts are eager to support PrEP rollout through training, consultation, and partnerships in clinical care and research. These allies may be supportive not only in the realm of HIV prevention, but also in the fight for comprehensive reproductive healthcare [24, 25]. Developing allies outside of the strict confines of women’s health providers may be critical to protecting women’s healthcare in general.

• If a new HIV diagnosis is made, explore opportunities for improvement: consider asking women newly diagnosed with HIV in your clinic if they had heard about PrEP. Look back at the client’s interaction with your facility, and identify points where a discussion of PrEP or comprehensive HIV prevention methods may or may not have occurred. Simple case reviews can be motivating to staff and can facilitate identification of a PrEP champion and initiation of PrEP programming. Furthermore, ensuring clients newly diagnosed with HIV receive a warm hand-off to HIV providers can facilitate relationships with allies in the HIV community.

• Be prepared to welcome new clients: many family planning clinics note that offering PrEP services has attracted new clients, particularly cisgender men and transgender people. This influx provides an opportunity to examine how to best provide sexual and reproductive health services to clients across the gender spectrum, tailoring specific services to the needs of diverse populations. How to best provide PrEP to these groups in the family planning setting is unknown, but family planning providers can rely on emerging implementation experience from clinics already providing services to these populations [26, 27].

Identifying your role in PrEP implementation for U.S. women

Integrating PrEP services into family planning care does not require PrEP provision on day one. Rather, some clinics may start by offering information about PrEP – when taking a sexual history, when doing HIV or STI testing, or in waiting rooms or in clinic bathrooms. Ideally, clinics providing only information would also identify a PrEP provider in the community where patients can be referred for PrEP provision. If clinics can’t identify a provider, national directories of PrEP service providers such as PleasePrEPMe.org and PrEPlocator.org are published online and updated frequently. Over time, clinics can develop relationships with those providers to facilitate warm handoffs of patients, as well as potentially request trainings for clinic staff. Many jurisdictions around the country are developing navigation programs to help potential PrEP clients connect with providers, assure coverage for medical services, access medication, and support adherence to medications and clinic visits. Navigation services have proven cost-effective and may further facilitate PrEP provision in family planning clinics located in areas of high HIV incidence. Finally, some clinics may be ready to launch onsite PrEP provision, and can continue to inform best practices of PrEP provision for women. Robust PrEP programming may require additional staffing, funding strategies such as utilization of 340B pricing (a US federal government program that requires drug manufacturers to provide outpatient drugs to HRSA-supported health centers, Medicare/Medicaid Disproportionate Share Hospitals and some other safety net providers at significantly reduced prices), and advocacy for additional funds to support PrEP service provision, particularly in regions of the country where family planning centers are the only means of accessing comprehensive sexual and reproductive health care.

Conclusion

Despite real and perceived barriers to integrating PrEP into family planning care, providing PrEP services, ranging from education to onsite provision, is not only possible, but an important component of providing high-quality sexual and reproductive healthcare to women. Moreover, family planning providers not only have many of the necessary skills, but are leading experts in offering sexual and reproductive health prevention options to women. Looked at another way, the consequences of inaction are profound and may result in 1) increasing disparities as women of color continue to carry the burden of HIV among women in the U.S. 2) increasing distrust as women realize that they were not provided with comprehensive HIV prevention services, and 3) increasingly siloed sexual and reproductive healthcare for women.

With our commitments to improving sexual and reproductive healthcare and to health equity, family planning providers are uniquely qualified to advance implementation of PrEP for women. As a community, it is our responsibility to provide comprehensive sexual health services to women, including HIV prevention.