Dr. Chartier is the Deputy Director and the National Infectious Diseases Officer for the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs (HHRC). Ms. Gylys-Cowell and Dr. Lowy are Data Analysts for the HHRC Data and Analytics Group and Data Analysts for the Health Services Research and Development at VA Puget Sound Healthcare System. Dr. Beste is a Staff Physician and the Director of the VA National Liver Disease Database at VA Puget Sound Healthcare System, the Director of the HHRC Data Analytics Group, and Assistant Professor of Medicine in the Division of General Internal Medicine at the University of Washington in Seattle. Dr. Van Epps is a Staff Physician in the Geriatric Research Education and Clinical Center, Division of Infectious Diseases at Louis Stokes Cleveland VAMC and an Assistant Professor in the Department of Internal Medicine, Division of Infectious Diseases at Case Western Reserve University School of Medicine, both in Cleveland, Ohio. Dr. Ohl is an Investigator at the Center for Access and Delivery Research and Evaluation at Iowa City VA Health Care System and an Associate Professor in the University of Iowa Department of Medicine. Dr. Maier is a staff physician in the Infectious Diseases Section of the VA Portland Healthcare System and an Assistant Professor, at Oregon Health and Sciences University in the Division of Infectious Diseases, both in Portland. Correspondence: Dr. Chartier (maggie.chartier@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
During the calendar year 2017, the PrEP Working Group met monthly and in smaller subcommittees to develop the strategic plan, products, and tools described earlier. On World AIDS Day, a virtual live meeting on PrEP was made available to all providers across the system and will be made available for continuing education training through the VA online employee education system. During 2018, the primary focus of the PrEP Working Group will be the continued development and refinement of provider education materials, clinical tools, and data tracking as well as increasing veteran outreach through social media and other awareness campaigns planned throughout the year.
Annual assessment of PrEP uptake will evaluate progress on the primary implementation target and areas of clinical practice: (1) increase number of PrEP prescriptions overall; (2) ensure PrEP is prescribed at all VA facilities; (3) increase preciptions by noninfectious diseases provider; (4) increase prescriptions by clinical pharmacists and APRNs; (5) monitor quality of care, including by discipline/practice setting; (6) increase PrEP prescriptions in facilities in endemic areas; and (7) increase the proportion of PrEP prescriptions for veterans of color.
In 2019 and 2020, additional targeted intervention and outreach plans will be developed for sites with difficulty meeting implementation targets. Sites in highly HIV-endemic areas will be a priority, and outreach will be designed to assist in the identification of facility-level barriers to PrEP use.
Conclusion
HIV remains an important public health issue in the US and among veterans in VA care, and prevention is a critical component to combat the epidemic. The VHA is the largest single provider of HIV care in the US with facilities and community-based outpatient clinics in all states and US territories. The VA outperforms the US nationally across the HIV care continuum.28 However, PrEP uptake within the VHA has been modest since FDA approval of TDF/FTC for PrEP with variability, particularly across geographic regions and urban and rural settings.
The VA seems to be performing better in terms of the proportion of PrEP uptake among racial groups at highest risk for HIV compared with a US sample from retail pharmacies, which may be, in part, driven by the cost of PrEP and follow-up sexually transmitted infection testing.24 However, a considerable gap remain in VHA PrEP uptake among populations at highest risk for HIV in the US.
With the investment of a National PrEP Working Group, the VA is charting a course to augment its HIV prevention services to exceed the US nationally. The National PrEP Working Group will continue to develop specific, measurable, and impactful targets guided by state-of-the-art scientific evidence and surveillance data and a suite of educational and clinical resources designed to assist frontline providers, facilities, and patients in meeting clearly defined implementation targets.
