We thank Wong and Klausner for their positive remarks regarding our research. We share their enthusiasm for telemedicine as a way to facilitate greater uptake of preexposure prophylaxis (PrEP) in low-access areas. In fact, we are currently conducting a clinical trial, as part of the Adolescent Medicine Trials Network for HIV/AIDS Interventions, to assess the effect of providing a telemedicine option on PrEP uptake and maintenance in care.1,2 Structured by a theory-based smartphone app, the intervention seeks to facilitate tailored access to PrEP care for adolescents in the rural US South. Separately, pilot testing of our home care system designed to supplement standard PrEP care found the approach to be both feasible and preferred by a majority of participants.3 These results are supported by a number of studies that found high interest in and acceptability of home care for PrEP.4,5
We also agree with Wong and Klausner’s assessment that the costs of laboratory testing and clinical care are a critical barrier to bringing telemedicine PrEP to scale, and we second their call to provide resources to support these efforts. One minor clarification: the authors note that telemedicine PrEP can “eliminate the impact of geography on access.” Our data indicate that individuals are not necessarily skilled at identifying what might make them a good candidate for PrEP, with issues ranging from not understanding that sexually transmitted infections are an indication for PrEP to being overly optimistic regarding future condom use.6 If geographic access also influences access to clinicians or wraparound prevention services that guide individuals toward PrEP care when appropriate, then simply covering the financial burden of telemedicine PrEP will not fully resolve access disparities.
Last, we note that there is a remarkable diversity of interventions that address each level of the PrEP care continuum.7 Covering the cost of laboratory tests for telemedicine is one of many worthy investments. Given the rapidly changing provision of PrEP, development of a national PrEP surveillance system could provide critical data for ongoing evaluation. This might facilitate assessment of the overall value and impact of PrEP support interventions as they translate from research to program.
ACKNOWLEDGMENTS
This work was supported by the National Institute of Mental Health (R01MH114692) and the Adolescent Medicine Trials Network for HIV/AIDS Interventions (Protocol 159) from the National Institutes of Health (U19HD089881). The work was facilitated by the Emory Center for AIDS Research (P30AI050409).
Note. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
CONFLICTS OF INTEREST
A. J. Siegler is a coinvestigator on a grant funded by the Gilead Foundation. All other authors have no conflicts of interest to report.
REFERENCES
- 1.Siegler AJ, Brock JB, Hurt CB et al. An electronic pre-exposure prophylaxis initiation and maintenance home care system for nonurban young men who have sex with men: protocol for a randomized controlled trial. JMIR Res Protoc. 2019;8(6):e13982. doi: 10.2196/13982. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Siegler AJ, Brock JB, Kelley CF Pilot test of a PrEP telemedicine system for young, Black MSM in the rural US south. Poster presented at: Conference on Retroviruses and Opportunistic Infections; March 6, 2019; Seattle, WA.
- 3.Siegler AJ, Mayer KH, Liu AY et al. Developing and assessing the feasibility of a home-based PrEP monitoring and support program. Clin Infect Dis. 2019;68(3):501–504. doi: 10.1093/cid/ciy529. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.John SA, Rendina HJ, Grov C, Parsons JT. Home-based pre-exposure prophylaxis (PrEP) services for gay and bisexual men: an opportunity to address barriers to PrEP uptake and persistence. PLoS One. 2017;12(12):e0189794. doi: 10.1371/journal.pone.0189794. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Stekler JD, McMahan V, Ballinger L et al. HIV pre-exposure prophylaxis prescribing through telehealth. J Acquir Immune Defic Syndr. 2018;77(5):e40–e42. doi: 10.1097/QAI.0000000000001621. [DOI] [PubMed] [Google Scholar]
- 6.Lockard A, Rosenberg ES, Sullivan PS et al. Contrasting self-perceived need and guideline-based indication for HIV pre-exposure prophylaxis among young, Black men who have sex with men offered pre-exposure prophylaxis in Atlanta, Georgia. AIDS Patient Care STDS. 2019;33(3):112–119. doi: 10.1089/apc.2018.0135. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kelley CF, Kahle E, Siegler A et al. Applying a PrEP continuum of care for men who have sex with men in Atlanta, Georgia. Clin Infect Dis. 2015;61(10):1590–1597. doi: 10.1093/cid/civ664. [DOI] [PMC free article] [PubMed] [Google Scholar]