Barriers to HIV Prevention: More Than Just COVID-19

The COVID-19 pandemic has impacted the field of HIV prevention on almost every level since it began in early 2020. The sudden implementation of public health measures such as stay-at-home orders, universal masking, and social distancing of 6 feet in enclosed spaces impacted interactions with people seeking HIV testing and linkage to pre-exposure prophylaxis (PrEP). Although full and in-person offerings have resumed for many of these services, the lessons learned and strategies and techniques employed during the height of the COVID-19 pandemic have remained crucial for providing HIV prevention to vulnerable and priority populations. Here we discuss the nimbleness with which we adapted to our patients’ needs while working through the limitations imposed by the pandemic within our university-affiliated clinic in the Southeastern United States, as well as address the barriers to successful PrEP care that many vulnerable communities face on a daily basis. 

Rapid Adaptations
Many people with HIV present with complicated physical and mental health issues, as well as structural barriers to care that can be accentuated in Southern, Black, and Brown communities. By contrast, the majority of people currently receiving PrEP are otherwise healthy individuals requiring minimal interaction with the healthcare system. For some, PrEP is the only medication they are prescribed. The type of contextual barriers faced by patients with HIV at our university-affiliated HIV clinic in Birmingham, Alabama, should be mirrored among patients receiving PrEP services, but this is not the case. The difference between these 2 groups is due to the inability to effectively provide resources for individuals in need of PrEP who are uninsured or underinsured, especially in a state that has failed to expand Medicaid. This simplicity of care allowed our clinic to implement several alternative service delivery methods during the pandemic. For example, we facilitated a monthly bridge of PrEP medication for individuals whose quarterly appointments fell during the initial phases of stay-at-home orders, and our staff had the time needed to transition to providing care via telemedicine. Once it was up and running, telemedicine offered patients the flexibility to check in with their care team from the safety, comfort, and convenience of their home or another location. PrEP clinic coordinating staff worked to ensure that patients arrived for brief, necessary clinic visits for routine safety labs and that they understood the directions for connecting with PrEP medical providers during their appointments. Furthermore, to help ensure daily PrEP adherence, patients were encouraged to have their prescriptions and refills sent to a mail-order pharmacy to avoid trips to the pharmacy.

One of our most innovative and potentially transformative initiatives arose from a partnership with the state department of public health to provide at-home PrEP safety labs including HIV, multisite sexually transmitted infection, and creatinine testing free of charge. This initiative gives patients the flexibility to complete these labs prior to a scheduled visit with their medical provider. The testing kits are confidential, with results being shared only with the patient, provider’s office, and relevant health department staff. For patients being seen via telemedicine, this option provides a convenient way to complete the lab component of a PrEP visit from the safety and comfort of their home.

Recovering From Pandemic-Related Service Interruptions
In our HIV clinic, rapid, free, and confidential HIV testing is offered to any person seeking an HIV test for any reason. From just a finger-stick blood collection, a person can learn their HIV status in as little as 1 minute. By providing a quick, free test, linkage to HIV care or PrEP is sped up exponentially. 

Because of the public health measures implemented in March and April 2020, access to such HIV prevention services—including status-neutral linkage to care for HIV treatment and PrEP—was drastically reduced. As these services have ramped up to prepandemic levels and beyond, it remains to be seen just how deeply the shutdowns have impacted vulnerable populations, including communities of color, persons of lower socioeconomic status, and gender minorities, particularly in the Deep South, where rates of new HIV diagnoses are among the highest in the United States. Thus, it has never been more vital for HIV prevention outreach efforts to be prioritized in programmatic decisions. 

Where Do We Go From Here?
It is abundantly clear that COVID-19 is here to stay in some capacity. In line with the impact felt around the world from the pandemic, the impact and adjustments made within our healthcare systems—as well as areas where our current systems have fallen short—should challenge us moving forward to create positive and permanent changes. In general, the current PrEP patient cohort is stable and benefits from consistent, gainful employment; access to health insurance; and the ability to receive care via telemedicine and at-home testing alternatives. However, we know that this cohort is missing many people in need of HIV prevention services who are unable to access them. The pandemic only has exacerbated this gap. To expand the changes in service delivery brought about by the pandemic, it is imperative that future policy decisions and funding opportunities seek to bridge these gaps in equity. PrEP care decisions must account for the needs of those who are underinsured, uninsured, and/or unemployed, as well as people with other barriers to adequate care, including but not limited to access to stable Internet service, reliable mail delivery for mail-order prescriptions, and baseline knowledge and awareness of HIV prevention options. If we can effectively change based on these vital lessons learned during the height of the COVID-19 pandemic, our ability to “End the HIV Epidemic” by filling care gaps and ameliorate inequities may be actualized. 

Your Thoughts?
How have you adapted HIV prevention services in your clinical setting to overcome barriers imposed by the pandemic, and how have these changes helped to address barriers that already existed for priority populations? Answer the polling question and join the conversation by posting a comment.