Background: Following the FDA approval of Truvada for Pre-Exposure Prophylaxis (PrEP) in July 2012, Callen-Lorde Community Health Center (CLCHC) implemented what would be one of the first and largest PrEP programs in the United States.
Description: In 2015, CLCHC delivered 1,050 PrEP prescriptions to patients interested in HIV prevention. An average of 87 patients were prescribed PrEP each month. 77% of patients self-referred for PrEP,14% transitioned to PrEP after completing post-exposure prophylaxis, 4% continued PrEP after participation in a demonstration project, and 5% reported being in an open and/or serodiscordant relationship as a reason. PrEP clients were 18-77 years, with 43% between 28 and 37 years; 32% < 27. The racial distribution was diverse: 58% White/Caucasian, 12% Black and 22% Hispanic/Latino ethnicity. PrEP was accessed via private insurance (57%), public insurance (26%) and by uninsured patients (17%) utilizing medication assistance programs.
Lessons learned: Upon implementation of the program there was high demand for PrEP. Medical staff required dedicated training to manage complex and constantly changing insurance requirements. Uninsured patients had to be linked to medication assistance programs or low/no cost health insurance plans. Insured patients encountered challenges due to high copayments, insurance denials or mandatory mail order delivery programs. Some programs delivered medication to our clinic, which necessitated ongoing tracking and distribution by our staff. The impact on clinic flow was minimized by sharing the tasks of the PrEP visit with a team of providers, testers, nursing and PrEP specialists. New protocols were developed, including one that facilitated patient self-swabs for STD screening. Patient navigation was a key aspect of our program, as was interdepartmental cooperation.
Conclusions/Next steps: As scale-up of PrEP continues, clinics considering implementing PrEP programs need to be prepared for high demand and proactively put systems into place to facilitate patient access, including strategies to deal with complex insurance issues, tracking of patients and quality assurance.

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