Since 2016, many accredited prescribers of s100 HIV medication, sexual health specialists, general practitioners (GPs), nurse practitioners, nurses in New South Wales, Queensland, Victoria, South Australia, Tasmania, Western Australia and the Australian Capital Territory have been involved in making pre- exposure prophylaxis (PrEP) available through clinical PrEP implementation trials and people self-importing PrEP. Since 1 April 2018, tenofovir disoproxil* and emtricitabine (TD*/FTC) and its generic versions have been available in Australia for human immunodeficiency virus (HIV) PrEP at subsidised cost and can be prescribed through the Pharmaceutical Benefits Scheme (PBS) by any GP or specialist (1).
Making PrEP easily accessible to all Australians where they live requires local medical practitioners and authorised nurse practitioners to be aware of, and comfortable with prescribing, PrEP. Therefore, GPs’ knowledge, acceptance and ability to provide PrEP are instrumental to optimising PrEP access and use.
ASHM’s online learning module Introduction to PrEP Prescribing as well as other PrEP resources for clinicians are designed to upscale their knowledge and skills: PrEP resources.
The prescription and provision of PrEP clinical and laboratory monitoring are straightforward for GPs and other clinicians. However some providers who are less experienced in serving populations at high risk of acquiring HIV and sexually transmissible infections (STIs) (e.g. men who have sex with men, transgender and gender-diverse people, Indigenous Australians, women involved in sex work, people whose partners are at high risk for HIV/STI, and people who inject drugs) may wish to consider establishing relationships with experienced and accredited HIV s100 prescribers, HIV clinics and sexual health centres, that can provide information and support if required and may be able to do so via Telehealth. Initiatives such as telementoring (2) and innovative Information and Communication Technology (ICT) solutions offered
by eHealth NSW (3) are good examples of how communication technologies can support new PrEP prescribers in remote areas where traditional sexual health services may be limited.
When starting PrEP services, providers should also establish:
- appropriate referral pathways to ensure that specific needs of PrEP users are adequately provided (e.g. regular HIV and STI testing, the management of chronic hepatitis B infection, treatment of hepatitis C and possible abnormal liver and kidney function - see Clinical Assessment for more
- communication with local pharmacies to ensure uninterrupted refills of PrEP scripts. In rural and remote Australia, clinicians are advised to establish pathways with clinicians and pharmacies in metropolitan areas to help provide clinical support and provide an uninterrupted postal supply of PrEP medications.
An important approach to successful PrEP implementation is to engage representatives from HIV community-based organisations working with relevant populations in the delivery of PrEP (see Resources page for Australia’s State and Territory-based AIDS Councils). AIDS Councils can assist with PrEP promotion
and education and, depending on their capacity, may also be able to assist with behavioural screening and adherence support. Similarly, support can be useful from community-based organisations working with culturally diverse communities, to ensure equality of access to PrEP.
When embarking on PrEP prescribing, providers should also consider the capacity of their practices to accommodate new patients and maintain follow-up every 3 months while taking PrEP. Several approaches may be helpful in dealing with these changes to practice:
- Careful planning of clinic appointments to allow sufficient space for PrEP initiation and regular follow-up visits
- Where resources allow, automating most steps in the patient pathway, to reduce the patient registration- to-PrEP prescription time
- Task shifting including having clinical nurse specialists, or trained nurses with clinician supervision in charge of PrEP-related services where possible
- Developing systems and procedures for recording and monitoring PrEP
Finally, clinical practices that are planning to build up their PrEP patient population can consider developing a customised communications plan for PrEP demand creation, including media channels and communication strategy which will be used to drive local PrEP awareness and use, with input from relevant local community-based organisations and sexual health services.
References
1. Australian Government Department of Health. The Pharmaceutical Benefits Scheme. Recommendations made by the PBAC - December 2017. Positive recommendations. Available at: http://www.pbs.gov.au/ info/industry/listing/elements/pbac-meetings/pbac-outcomes/recommendations-pbac-december-2017 (last accessed 24 August 2019).
2. Wood BR, Mann MS, Martinez-Paz N, et al. Project ECHO: telementoring to educate and support prescribing of HIV pre-exposure prophylaxis by community medical providers. Sex Health 2018;15:601-5.
3. NSW Government eHealth. Rural eHealth Strategy. Available at: http://www.ehealth.nsw.gov.au/programs/clinical/rural (last accessed 24 August 2019).