Arizona Statewide Pre-Exposure Prophylaxis Provider Survey

Arizona Statewide Pre-Exposure Prophylaxis Provider Survey December 05 Report produced by: Spencer Schaff, MPH Candidate Graduate Assistant Arizona AIDS Education and Training Center Alyssa Guido, MPH Program Director Arizona AIDS Education and Training Center

Table of Contents Introduction... Project Timeline... Methodology... 5 Results... 6 Respondents... 6 PrEP Awareness Among Patients and Provider Initiated PrEP Discussions... 7 PrEP Knowledge... Education and Training... 5 Clinic Capacity... 6 Provider Directory... 9 Discussion... 0 Gaps in PrEP Awareness... 0 Recommendations... Limitations... Appendix... i Appendix A. Introductory Email... i Appendix B. Survey... ii Appendix C. Compiled Survey Data... vii List of Figures Figure. Survey Respondents By County.... 7 Figure. Number of Respondents That Have Had Patients Ask About PrEP... 7 Figure. Number of Respondents That Initiated Discussions About PrEP.... 8 Figure. Provider Experience with PrEP.... 8 Figure 5. Provider Experience with PrEP Disaggregated by County.... 9 Figure 6. Number of Patients Prescribed PrEP by County.... 0 Figure 7. PrEP Referrals.... 0 Figure 8. Provider Knowledge and Comfort with PrEP.... Figure 9. Familiarity with Current Research on PrEP Safety and Efficacy....

Figure 0. Comfort Discussing HIV Risk Factors with Patients.... Figure. Comfort in Determining PrEP Indications.... Figure. Required Labs for PrEP Initiation and Safety.... Figure. Comfort Prescribing PrEP to Patients.... Figure. Familiarity with Resources to Help Patients Pay for PrEP.... 5 Figure 5. Willingness to Participate in PrEP Clinical Training.... 5 Figure 6. Preferred Training Modality.... 6 Figure 7. Clinic Capacity to Provide PrEP Support Services.... 6 Figure 8. Medication Adherence Counseling.... 7 Figure 9. HIV Risk Reduction Counseling... 7 Figure 0. Ensure HIV Testing Every Months... 8 Figure. Ensure Clinical Follow-up and Monitoring Requirements Are Met... 8 Figure. Benefits Coordination to Assist PrEP Patients with Insurance and Patient Assistance Programs... 9 Figure. PrEP Provider Directory... 0

Introduction Arizona AIDS Education and Training Center (AETC) collaborated with the Arizona Department of Health Services (ADHS) HIV Prevention Office to administer an HIV pre-exposure prophylaxis (PrEP) assessment of health care respondents throughout the state of Arizona. The survey had main three goals:. Identify provider training needs around PrEP and their preferred training modality.. Identify potential gaps in respondents capacity to manage PrEP patients.. Identify respondents that are already prescribing PrEP that wish to be included in an online PrEP directory. The survey sought to identify gaps in provider knowledge and asked about provider preferences for training such as in-person training or online webinars. The survey also contained several questions related to clinic capacity to provide PrEP support services such as on-going HIV prevention counseling, medication adherence counseling and patient monitoring. Project Timeline August Reviewed literature on PrEP surveys previously conducted with providers Septemeber Developed survey with input from AETC faculty Developed list of providers to be surveyed October Piloted survey Contacted providers and clinics to aquire contact information Distributed survey to providers and clinics Novemeber Sent reminder emails and made follow-up phone calls to clinics Sent faxes to clinics that did not have contact email addresses December Analyzed and reviewed survey data Compiled report

Methodology AETC reviewed provider PrEP surveys that could be accessed online, brainstormed survey questions with AETC team, and compiled a list of possible survey questions. Survey questions were selected based on the survey goals and input from AETC team. The initial survey was piloted with John Sapero, HIV Prevention Chief ADHS; Dr. Al Mohajer, Infectious Disease Specialist; Anca Georgescu, Infectious Disease Specialist; Shannon Smith Director, Special Programs; and Cesar Egurrola, Petersen HIV Clinical Care Coordinator. Based on feedback from the initial pilot, a second draft of the survey was piloted with the team above and several master s of public health students. The final survey consisted of 9 questions and included multiple choice and ranking questions. The survey was anonymous to encourage respondents to answer truthfully. Respondent zip codes were collected so responses could be disaggregated by location. The survey was distributed to a list of 55 health care providers throughout the state of Arizona plus the Director of Clinical and Quality Programs at the Arizona Alliance of Community Health Centers who forwarded the survey on to their provider list. The list of providers consisted of physicians, physician assistants and nurse practitioners. Respondents were identified through past AETC training participation, and therefore had expressed some interest in HIV education in the past or were already known to be prescribing PrEP. The survey was only sent to providers (physicians, physician assistants, nurse practitioners) and did not include nurses or social workers. However, in several cases the survey was passed on to other clinic team members such as pharmacists or clinic managers, who completed the survey on behalf of the clinic. The survey was also sent to the Director of Clinical and Quality Programs at the Arizona Alliance of Community Health Centers who sent the survey to their provider contact list. Providers were contacted via email directly, or through program coordinators and office managers. Some clinics requested the survey be sent via fax. Six providers were contact via fax. Of the six providers who were faxed, no faxed surveys were returned. It s possible those providers completed the survey online as the fax included an introductory letter with the online survey link. Providers at the following organizations were contacted about the survey: Arizona Alliance of Community Health Centers Indian Health Service o Phoenix Indian Medical Center o Whiteriver Indian Health Hospital Federally Qualified Health Centers o El Rio, multiple clinics o Chiricahua Community Health Center o North Country Community Health Center o Sunlife Community Health Center o McDowell Clinic Public Providers 5

o University of Arizona Petersen HIV Clinic o University of Arizona Campus Health o Yuma Regional Medical Center o Clinicá Amistad o Flagstaff Medical Center o Northland Cares Behavioral Health Providers o COPE o CODAC o Terros Private Providers o Scottsdale Healthcare o Honorhealth o Spectrum Medical o Pueblo Family o Camelback Mountain Medical o Arizona Pulmonary Specialists o First Family Medical The emails included an introduction and purpose of the survey, key information about PrEP, and a link to the survey (see appendix for survey introduction email). The survey was hosted by Qualtrics, an online survey software and insight platform. The survey was open for a total of one month. Providers received an initial email and two reminder emails. In total, 5 responses were received. The survey sample should not be viewed as a representative sample of all providers in the state. There is inherent bias in the sample as the providers were either part of the Arizona AETC contact list or the Arizona Alliance of Community Health Center Contact list. Results *Full survey questions available in the appendix. Respondents Of the 5 responses received, respondents completed the survey and 0 respondents provided their zip code. Respondents were asked to provide the zip code were they work. Responses were grouped by county based on the zip code they provided. Responses were received from providers in 6 counties: Maricopa, Pima, Pinal, Yavapai, Yuma and Coconino. One respondent did not indicate their zip code and one respondent stated that they work in many areas and listed the following counties: Mohave, Yavapai, Coconino, Apache and Navajo. The majority of respondents were from urban counties with respondents from Maricopa County and 9 respondents from Pima County. 6

N=5 9 5 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIPCODE FIGURE. SURVEY RESPONDENTS BY COUNTY. Providers were asked, What is the zip code where you work? PrEP Awareness Among Patients and Provider Initiated PrEP Discussions The first two questions of the survey asked about patient awareness of PrEP ( Has a patient ever asked you about PrEP? ) and provider initiated discussions around PrEP (Have you ever initiated a discussion about PrEP with a patient? ). Twenty-three (5%) of respondents indicated that patients had asked them about PrEP and (5%) respondents indicated that they had initiated discussions about PrEP with their patients. YES 8 8 NO 5 0 5 0 5 0 5 N = 5 Coconino Maricopa Pima Pinal Yavapai Yuma Many No Zip Code FIGURE. NUMBER OF RESPONDENTS THAT HAVE HAD PATIENTS ASK ABOUT PREP Provider responses to the question, Has a patient ever asked you about PrEP? Respondents are disaggregated by county. Figure displays results to the question Has a patient ever asked you about PrEP? disaggregated by the county where the respondent works. Of the respondents who indicated that a patient has asked them about PrEP, 8 respondents were from Maricopa County, 8 were from Pima County and provider each from Yavapai, Yuma and Coconino Counties. The provider who works in many counties also responded that a patient has asked him about PrEP. 7

YES 9 8 NO 0 5 0 5 0 5 N = 5 Coconino Maricopa Pima Pinal Yavapai Yuma Many No Zip Code FIGURE. NUMBER OF RESPONDENTS THAT INITIATED DISCUSSIONS ABOUT PREP. Provider responses to the question, Have you ever initiated a discussion about PrEP with a patient? Provider responses disaggregated by county. Twenty-three respondents (5%) indicated that they had initiated discussions about PrEP with patients. Of those, 7 were from urban counties with 9 respondents from Maricopa and 8 respondents from Tucson. The respondents from Coconino and Yavapai Counties indicated that they had initiated discussions about PrEP along with the provider who listed many as the counties where he works. Twenty-two respondents indicated that they had not initiated discussions with patients about PrEP including all respondents from Pinal County. I have prescribed and/or currently prescribe PrEP for HIV 5 I refer patients to other providers who prescribe PrEP. 7 With more education and training, I would refer patients With more education and training, I would prescribe PrEP. I will not prescribe PrEP to my patients. 0 Other 6 N=5 0 6 8 0 6 Yes FIGURE. PROVIDER EXPERIENCE WITH PREP. Respondents were asked to select which statement best applies to them. The bar graph indicates the number of respondents that selected each statement. Respondents were asked, Which of the following statements best applies to you? and provided the six selections listed in the figure above. Fifteen respondents (%) indicated they were already prescribing PrEP; 7 respondents (6%) indicated they refer to other providers that prescribe PrEP, respondents (9%) answered that with more education and training, they would prescribe PrEP, and (9%) said with more education, they would refer patients to providers that prescribe PrEP. Six respondents (%) selected other and no respondents selected I will not prescribe PrEP to my patients. 8

Table. Answers Provided by Participants Who Selected Other. I have not had any patients in my clinic that would qualify for PrEP, but would prescribe it if it came up. I am a pharmacist with no prescriptive authority to prescribe PrEP. The physician that I work with prescribes PrEP. With more education and training I would consider prescribing PrEP; I would certainly refer pts. CODAC works with other community respondents including SAAF and county health department to encourage and support at-risk individuals I will prescribe PrEP to patients, but I have not had the opportunity since I received the education and training. Previously I referred the patient to another provider. I would prescribe PrEP if the right patient presented, but that has not happened yet. I have prescribed and/or currently prescribe ARVs for HIV prevention (PrEP). 5 6 I refer patients to other providers who prescribe PrEP. With more education and training, I would refer patients to other providers who prescribe PrEP. With more education and training, I would prescribe PrEP. 6 I will not prescribe PrEP to my patients. Other N=5 0 6 8 0 6 Coconino Maricopa Pima Pinal Yavapai Yuma Many No Zip Code FIGURE 5. PROVIDER EXPERIENCE WITH PREP DISAGGREGATED BY COUNTY. Respondents were asked to select which statement best applies to them. The bar graph indicates the number of respondents that selected each statement. Responses are disaggregated by county. Figure 5 disaggregates responses to the same question, Which of the following statements best applies to you? by respondent county. Respondents in Coconino, Maricopa, Pima, Yavapai and Yuma Counties indicated that they are already are prescribing PrEP along with the respondent who indicated that he serves many counties and the respondent who declined to give their zip code. Five respondents in Pima and Maricopa Counties and two others who failed to give their zip codes indicated that they refer patients to providers that prescribing PrEP. Thirteen respondents (9%) from Maricopa, Pima and Pinal Counties indicated they would be willing to prescribe PrEP with more education and training along with respondents who did not give their zip code. 9

7 6 5 0 N=5 5 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIP CODE to 5 6 to 0 >0 FIGURE 6. NUMBER OF PATIENTS PRESCRIBED PREP BY COUNTY. Respondents who indicated that they prescribe PrEP were asked, To how many patients have you prescribed PrEP? Responses are disaggregated by county. Respondents that indicated they currently prescribe PrEP were asked to indicate the number of patients they prescribe PrEP to. Four respondents in Maricopa and Pima Counties have prescribed PrEP to greater than 0 patients and respondents in Yuma, Yavapai and many counties have prescribed PrEP to 6-0 patients. One provider each in Coconino, Maricopa, and Yuma Counties have prescribed PrEP to -5 patients. % Community Based Organization % % 8% 9% 5% County STD Clinic Patient contacted me on their own I don't know Another health care provider Other FIGURE 7. PREP REFERRALS. Respondents were asked, By whom was your PrEP patient(s) referred? Respondents were able to check all answers that apply. Respondents were asked, By whom was your PrEP patient(s) referred? This question was a logic question and only the 5 providers who indicated that they currently prescribe PrEP were asked this question. The majority, respondents (5%) indicated that PrEP patients were referred from county STD clinics, respondents (8%) indicated patients contacted them on their own, respondents (%) indicated that another health care provider referred them and provider (%) indicated that a community based organization referred the patient. Additionally, provider (%) said they didn t know and respondents (9%) answered other and indicated other patients and partners of patients. 0

PrEP Knowledge The next section of the survey focused on overall knowledge around current PrEP guidelines. Figure 8 below illustrates responses to the question, To what extent do you agree or disagree with the following statements? I am familiar with current research on PrEP safety and efficacy. I am comfortable discussing HIV risk factors with my patients. I can determine if PrEP is indicated for my patients. I know the resources available to help patients pay for PrEP. N= I know the required labs for PrEP initiation and management. I am comfortable prescribing PrEP for my patients. FIGURE 8. PROVIDER KNOWLEDGE AND COMFORT WITH PREP. Respondents were asked, To what extent do you agree or disagree with the following statements? Answer selections were based on a 5-point Likert scale ranging from strongly disagree to strongly agree. All respondents answered they feel comfortable discussing HIV risk factors with patients. Ten respondents (%) answered they disagree or strongly disagree with the statement I am familiar with current research on PrEP safety and efficacy with (5%) indicating that they agree or strongly agree with the statement. Eight respondents (8%) answered they disagree or strongly disagree with I am can determine if PrEP is indicated for my patients, 0 respondents (%) were unsure and (5%) indicated that the agree or strongly agree. Twenty respondents (5%) responded they disagree and strongly disagree to the statement I know the required labs for PrEP initiation and management and 6 respondents (6%) answered disagree or strongly disagree to the statement I am comfortable prescribing PrEP for my patients. Only respondents (8%) indicated that they know the resources available to help patients pay for PrEP. Strongly Disagree Disagree No opinion or Uncertain Agree Strongly Agree 7 7 8 8 9 7 8 0 9 8 7 5 5 9

8 0 6 5 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIP CODE N= Disagree/Strongly Disagree No Opinion or Uncertain Agree/Strongly Agree FIGURE 9. FAMILIARITY WITH CURRENT RESEARCH ON PREP SAFETY AND EFFICACY. Responses are grouped into categories: Disagree/ Strongly Disagree, No Opinion or Uncertain, Agree/ Strongly and disaggregated by county where the respondent works. This next section will look at these questions by county response. As illustrated in Figure 9, ten respondents (5%) that responded, disagree/strongly disagree to being familiar with current research on PrEP safety and efficacy were from Maricopa, Pima and Pinal Counties. Six respondents (5%) from Maricopa and Pima Counties answered that they had no opinion or uncertain. The remaining respondents (60%) in Coconino, Maricopa, Pima, Pinal, Yavapai and Yuma Counties agreed or strongly agreed that they are familiar with current research on PrEP safety and efficacy. 7 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIP CODE N= Disagree/ Strongly Disagree No Opinion or Uncertain Agree/ Strong Agree FIGURE 0. COMFORT DISCUSSING HIV RISK FACTORS WITH PATIENTS. Responses are grouped into categories: Disagree/ Strongly Disagree, No Opinion or Uncertain, Agree/ Strongly and disaggregated by county where the respondent works. Figure 0 shows that all respondents (00%) that responded to this survey question answered they either agree or strongly agree to feeling comfortable discussing HIV risk factors with patients.

9 9 6 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIP CODE N= Disagree/ Strongly Disagree No opinion or Uncertain Agree/Strongly Agree FIGURE. COMFORT IN DETERMINING PREP INDICATIONS. Responses are grouped into categories: Disagree/ Strongly Disagree, No Opinion or Uncertain, Agree/ Strongly and disaggregated by county where the respondent works. Figure depicts responses to the statement I am able to determine if PrEP is indicated for my patients. Eight respondents (8%) from Coconino, Maricopa, Pima and Pinal answered that they strongly disagree or disagree with this statement. Eight respondents (8%) from Pima and Pinal Counties were unsure/no opinion. The remanding respondents (60%) agreed or strongly agreed with the statement.

5 8 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIP CODE N= Disagree/ Strongly Disagree No opinion or Uncertain Agree/ Strongly Agree FIGURE. REQUIRED LABS FOR PREP INITIATION AND SAFETY. Responses are grouped into categories: Disagree/ Strongly Disagree, No Opinion or Uncertain, Agree/ Strongly and disaggregated by county where the respondent works. Figure depicts responses to, I am familiar with the required labs for PrEP initiation and management. Twenty respondents (50%) from Maricopa, Pima, Pinal and Yuma Counties answered that they either disagree or strongly disagree with this statement. Three respondents (8%) from Maricopa and Pima Counties answered with No opinion or uncertain and respondents (5%) answered they agree or strongly agree with the statement. 0 7 8 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIP CODE N= Disagree/ Strongly Disagree No opinion or Uncertain Agree/Strongly Agree FIGURE. COMFORT PRESCRIBING PREP TO PATIENTS. Responses are grouped into categories: Disagree/ Strongly Disagree, No Opinion or Uncertain, Agree/ Strongly and disaggregated by county where the respondent works. Figure addresses respondents comfort level with prescribing PrEP to patients. In total, respondents (5%) from Maricopa, Pima, and Pinal Counties answered that they are not comfortable prescribing PrEP for their patients. Three respondents (8%)

had no opinion or were uncertain and respondents (58%) answered, agree or strongly agree with the statement. 7 6 9 6 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIP CODE N= Disagree/Strongly Disagree No opinion or Uncertain Agree/ Strongly Agree FIGURE. FAMILIARITY WITH RESOURCES TO HELP PATIENTS PAY FOR PREP. Responses are grouped into categories: Disagree/ Strongly Disagree, No Opinion or Uncertain, Agree/ Strongly and disaggregated by county where the respondent works. Figure illustrates provider s knowledge of resources available to help patients pay for PrEP. Eighteen respondents (5%) from Maricopa, Pima, Pinal and Yavapai Counties answered that they are unfamiliar with resources available. Six respondents (5%) from Pima and Pinal Counties answered that they have no opinion/uncertain and six respondents (0%) from Coconino, Maricopa, Pima, Yuma, and the provider working in many counties answered they agree or strongly agree with the statement. Education and Training Respondents were asked if they would attend a PrEP clinical training, respondents (59%) responded Yes, respondents (7%) answered Maybe, and 6 (5%) answered No as seen in Figure 5. 6 YES NO MAYBE FIGURE 5. WILLINGNESS TO PARTICIPATE IN PREP CLINICAL TRAINING. Respondents were asked, Would you attend a PrEP clinical training (either online or inperson?) 5

% In-person training % % 7% Webinar Self-guided online course 7% % Clinical consultation with HIV expert Written materials FIGURE 6. PREFERRED TRAINING MODALITY. Respondents were asked, What is your preferred training modality? Figure 6 shows respondents preferred training modality. Respondents were given the option of making multiple selections. Twenty-six respondents (7%) answered that they would prefer an in-person training, 9 respondents (7%) said self-guided online course, 8 respondents (%) answered webinar, 8 respondents (%) answered clinical consultation with HIV expert, 8 respondents (%) indicated they prefer written materials and provider (%) answered other. The answer response provided in the other category was this, I have already been doing PrEP training to others. We are a Ryan White clinic and so have NOT been able to see HIV-negatives. Clinic Capacity Medication adherence counseling 0 5 HIV risk reduction counseling Ensure HIV testing every months 7 9 Ensure other clinical follow-up and monitoring requirements are met Benefits coordination to assist PrEP patients with insurance and patient assistance programs 0 7 Yes. We provide this service at our clinic. Maybe. We could provide this service with more training. No. We would need to refer PrEP patients elsewhere for this service. N= I don't know. FIGURE 7. CLINIC CAPACITY TO PROVIDE PREP SUPPORT SERVICES. 6

Respondents were asked about their clinic s capacity to provide support services for PrEP initiation and management. As shown in Figure 7, 0 respondents (9%) indicated their clinic could provide medication adherence counseling, respondents(59%) indicated their clinic could provide HIV risk reduction counseling, 7 respondents (66%) responded they could ensure HIV testing every months, respondents (56%) answered could ensure other clinical follow-up and monitoring requirements are met, and respondents (%) are able to provide benefits coordination to assist PrEP patients with insurance and assistance programs. Yes. We provide this service at our clinic. 7 7 Maybe. We could provide this service with more training. 7 No. We would need to refer PrEP patients elsewhere for this service. I don't know. N= 0 5 0 5 0 5 Coconino Maricopa Pima Pinal Yavapai Yuma Many No Zip Code FIGURE 8. MEDICATION ADHERENCE COUNSELING. Figure 8 illustrates clinic s capacity to provide medication adherence disaggregated counseling by county. Nineteen respondents (5%) from Coconino, Maricopa, Pima, Yuma, Yavapai and the provider that works in many counties, answered, yes and are able to provide this service in their clinic. Five respondents (%) in Maricopa, six (5%) in Pima, and two (5%) in Pinal answered they could maybe provide this service. Five respondents (%) from Maricopa and Pima answered they would need to refer PrEP patients elsewhere for these services. Yes. We provide this service at our clinic. 9 8 Maybe. We could provide this service with more training. 9 No. We would need to refer PrEP patients elsewhere for this service. N= I don't know. Coconino Maricopa Pima Pinal Yavapai Yuma Many No Zip Code FIGURE 9. HIV RISK REDUCTION COUNSELING 7

Figure 9 depicts responses clinic s capacity to provide risk reduction counseling. In Coconino, Maricopa, Pima, Pinal, Yavapai, Yuma, and the provider working in many counties, (55%) answered yes, they can provide this service. Ten respondents (5%) in Maricopa, Pima, Pinal and Yavapai counties answered maybe and four respondents (0%) in Pima and Maricopa said they would need to refer patients elsewhere. Yes. We provide this service at our clinic. 0 Maybe. We could provide this service with more training. 5 No. We would need to refer PrEP patients elsewhere for this service. I don't know. N= Coconino Maricopa Pima Pinal Yavapai Yuma Many No Zip Code FIGURE 0. ENSURE HIV TESTING EVERY MONTHS Figure 0 shows respondents ability to provide HIV testing every three months for PrEP management. Twenty-four respondents (60%) in Maricopa, Pima, Pinal, Yavapai, and Yuma Counties said they have the ability to do so. Ten respondents (5%) in Maricopa, Pima and Pinal Counties answered maybe with more training, four respondents (0%) in Maricopa and Pima County said no, they would have to refer elsewhere and two (5%) were unsure. Yes. We provide this service at our clinic. 0 8 Maybe. We could provide this service with more training. 0 No. We would need to refer PrEP patients elsewhere for this service. I don't know. N= 0 5 0 5 0 5 Coconino Maricopa Pima Pinal Yavapai Yuma Many No Zip Code FIGURE. ENSURE CLINICAL FOLLOW-UP AND MONITORING REQUIREMENTS ARE MET Figure depicts provider s responses to whether their clinics can ensure PrEP clinical follow-up and monitoring. Twenty-six respondents (65%) responded yes, 8

respondents (0%) said maybe with more training. Two respondents (5%) in Maricopa County said they would need to refer patients elsewhere. Yes. We provide this service at our clinic. 6 Maybe. We could provide this service with more training. No. We would need to refer PrEP patients elsewhere for this service. 6 I don't know. N= 0 6 8 0 Coconino Maricopa Pima Pinal Yavapai Yuma Many No Zip Code FIGURE. BENEFITS COORDINATION TO ASSIST PREP PATIENTS WITH INSURANCE AND PATIENT ASSISTANCE PROGRAMS Figure represents provider s responses to clinics ability to provide benefits coordination to assist with insurance and patient assistance programs for PrEP patients. Twelve respondents (0%) in Coconino, Maricopa, Pima and Yuma said they are able to provide this service, 0 respondents (5%) in Maricopa, Pima, Pinal, Yavapai, and the provider that works in many counties said they maybe could with more training, eight respondents (0%) in Maricopa, Pima and Pinal said they would need to refer patients elsewhere and seven respondents (8%) in Maricopa, Pima and Pinal counties said they did not know. Provider Directory Respondents were asked if they would like to be included in the PrEP provider directory to be posted on HIVAZ.org. Out of the 5 respondents, 6 responded (6%) with their contact information from six counties. The respondents as shown in Figure, consisted of one from Yuma, one from Coconino, five from Maricopa, seven from Tucson, one from Yavapai, and the one provider that works in Mohave, Yavapai, Coconino, Apache, and Navajo Counties. Figure lists the 6 respondents that identified that they would like to be a part of the provider network. One provider, Patricia Ferrer from Clinicá Amistad, indicated that she would like to be included in the PrEP provider directory but has since requested that she not be included. Clinicá Amistad is a free clinic in Tucson where all medication visits and lab work are free to patients. Clinicá Amistad administrative staff determined that they could not provide PrEP care at this time because the lab work cost would be too expensive. 9

5 0 5 0 8 5 6 COCONINO MARICOPA PIMA PINAL YAVAPAI YUMA MANY NO ZIP CODE Yes No FIGURE. PREP PROVIDER DIRECTORY Respondents were asked, Would you like to be included in a PrEP provider directory that will be posted on the HIVAZ.org website? TABLE. PROVIDER NETWORK Name Organization City Karen Lutostanski, FNP-C Horizon Health & Wellness Apache Junction David Keckich, MD Verde Valley Medical Center Cottonwood Steve McCrosky, FNP, AAHIVS North Country Health Care Flagstaff Anne Benson, FNP, AAHIVS North Country Health Care Flagstaff Matthew Parker Adelante Healthcare Mesa Mario Islas, MD Native Health Clinics Phoenix Dustin Marshall (office manager) Spectrum Medical Group Phoenix Sarah Thomas, MD Banner - UMC Family Medicine Phoenix Jeffrey C Dann, MD Adelante Healthcare Surprise Shannon Fennie, FNP-C El Rio Community Health Center Tucson Shawn Siqueiros NP-C El Rio Community Health Center Tucson Jerry Koleski, MD UA South Campus Family Medicine Clinic Tucson Androuw Carrasco, MD Alvernon Family Medicine Clinic Tucson Joycelyn Connet, FNP, MSN CODAC Living Out Loud Wellness Center Tucson Mayar Al Mohajer, MD UA Infectious Disease / Petersen HIV Clinics Tucson Ching Wang, MD Sunset Community Health Center Yuma Discussion Gaps in PrEP Awareness A total of 5 providers responded to the survey with completing the entire survey. Forty respondents provided a zip code representing six counties and one indicated that they work in many counties. Counties represented were Coconino (n=), Maricopa (n=), Pima (n=9), Pinal (n=), Yavapai (n=) and Yuma (n=). The respondent who indicated they work in many counties listed the following counties: Mohave, Yavapai, Yuma and Coconino. Twenty-two respondents (9%), located in Maricopa, Pima, Pinal and Yuma Counties had not been asked about PrEP by patients, indicating a need for increased community awareness, particularly among men that have sex with men (MSM) and partners of HIV-positive individuals. Similarly, only about half, (9%) of respondents 0

indicated that they had initiated a discussion about PrEP with a patient. This indicates a need for provider education around PrEP which should include sexual history taking to increase provider comfort and skill in talking with patients about HIV risk factors. One-third of those surveyed indicated that they are already prescribing PrEP. Those that indicated they prescribe PrEP work in Coconino (n=), Maricopa (n=5), Pima (n=6), Yavapai (n=), Yuma (n=), and the provider working in many counties. Of the respondents represented in this survey, Pinal is the only county represented in the survey results where there is no one is prescribing PrEP. There was only one provider each who responded to the survey from Yavapai and Yuma counties. Coconino County had two providers respond to the survey- one provider who responded with a Coconino zip code and one provider that indicated many areas which included Coconino. Based on their responses to the question regarding provider knowledge and comfort with PrEP, it can be concluded that the providers from Coconino, Yavapai, Yuma and many were experienced PrEP providers who had high levels of knowledge and comfort assessing patients for PrEP and prescribing PrEP. There were no survey respondents from 8 Arizona counties: Navajo, Apache, La Paz, Gila, Graham, Greenlee, Cochise and Santa Cruz. Thirteen respondents indicated that they would prescribe PrEP with more education and training and four respondents indicated they would refer patients for PrEP with more education and training underscoring the need for provider training. None of the 5 respondents indicated that they would not prescribe PrEP. This may be an indication that those who were willing to take the survey may have more positive attitudes about PrEP. The survey highlighted several areas of gaps in provider knowledge about PrEP: % of respondents are not familiar with current PrEP research. 8% cannot determine which patients should be prescribed PrEP. % did not know the required labs for PrEP initiation. 7% felt uncomfortable prescribing PrEP to patients. 6% were unaware of resources available to help patients pay for PrEP. All respondents answered that they are comfortable discussing HIV risk factors with patients. The survey also revealed some potential gaps in support services for PrEP: 8% indicated their clinic could provide medication adherence counseling. 5% indicated their clinic could provide HIV risk reduction counseling. 60% indicated their clinic could ensure HIV testing every months. 5% indicated their clinic could ensure other clinical follow-up and monitoring requirements are met. 8% indicated that their clinic could assist PrEP patients with insurance and patient assistance programs.

Given the likelihood that providers who took the survey may be more interested / experienced with PrEP, the statistics from the survey reveal some major gaps in the provision of PrEP services. The greatest gap being assisting PrEP patients with insurance and patients assistance programs. This highlights the need to work with other community based organization, behavioral health providers, navigators, or other organizations to help provide support services to PrEP patients. Respondents seemed open to attending training with 7% willing to attend in-person training, 7% willing to participate in an online course and % willing to attend a webinar. Given the clear need for more education, providers should be given a variety of on-line and in-person options for PrEP training. Of the 5 respondents who indicated that they are currently prescribing PrEP, over half of their PrEP patients were referred to them from a county STD clinic and 8% indicated that patients contacted them on their own. Only % indicated that their PrEP patient(s) had been referred by a community-based organization (CBO) indicating the need for increased PrEP awareness among CBO providers as well as education on how and where to refer possible PrEP candidates to PrEP providers. Recommendations Below is a summary of recommendations to address gaps in provider knowledge and the provision of PrEP services. Provider education offered in-person and online. Trainings should include the following topics: Current PrEP research and efficacy PrEP indications Required lab work for PrEP initiation and management Information on resources available to assist with paying for PrEP Provision of PrEP support services. Identify resources outside the clinic that can assist with PrEP support services such as benefits coordination, prevention messaging, and adherence counseling. Consider working with CBOs, behavioral health providers or navigators to help provide the additional components of a PrEP program outside of the clinical management of PrEP patients. Outreach with community-based organizations. Results revealed that CBO s are not a major source of PrEP referral. CBO s could play a greater role in assessing patients for PrEP and linking them to PrEP care. Offer CBO training that includes basic PrEP information and guidance how to refer interested clients to PrEP providers. Outreach with STD clinics. The results identified County STD Clinics as a major asset being the main source of patient referrals. Since these clinics have access to high-

risk patients, additional training and resources like the PrEP provider network should be provided to them. On-going communication with PrEP provider network. Continue communication with the providers who indicated they would like to be included in the PrEP directory. Provide training opportunities to clinic staff including front office staff, medical assistants and nurses to ensure they understand what PrEP is and are aware their provider is engaged in PrEP patient management. Limitations The survey was sent to two distribution lists: ) providers who were on the Arizona AETC contact list and ) providers on the Alliance of Community Health Center contact list. These two lists only reach a portion of the entire health care provider population in Arizona. The survey sample only consisted of 5 providers from 6 Arizona counties. The survey sample was a convenience sample and therefore contains inherent bias. Additionally, providers that chose to participate in the PrEP survey may have an interest in PrEP or have more positive attitudes toward PrEP than provider who chose not to take the survey. Views expressed by the survey respondents should not be generalized to all providers in Arizona.

Appendix Appendix A. Introductory Email In an effort to increase patient access to HIV pre-exposure prophylaxis (PrEP), the Arizona Department of Health Services (ADHS) HIV Prevention Office and the Arizona AIDS Education and Training Center (AETC) have developed the following survey to assess provider interest and capacity to manage PrEP patients. The survey should take 5 7 minutes to complete and can be accessed here: https://uarizona.co.qualtrics.com/jfe/form/sv_0mkxhxvfecadaz ADHS Prevention Office and AETC are compiling a directory of respondents who are currently prescribing PrEP. If you would like to be included in the voluntary directory please complete the last survey question. The provider directory will be posted on HIVAZ.org. As you may know, there are local respondents already prescribing PrEP. PrEP is the use of anti-hiv medications as a form of HIV prevention. Studies have shown that PrEP is effective. Clinical trials have shown that when taken daily, PrEP reduced sexually acquired HIV infection up to 9%. In May 0, the US Public Health Service released comprehensive clinical practice guidelines for PrEP. These new federal guidelines recommend PrEPfor HIV-negative individuals that are at substantial risk for HIV infection. Criteria for determining a person s HIV risk and indications for PrEP are included in the guidelines. Many insurance plans cover PrEP, including AHCCCS plans (sometimes a prior authorization is required). The Patient Access Network Foundation (PANF) can assist with co-pays and deductibles and the Gilead patient assistance program is available for uninsured patients. i

Appendix B. Survey HIV Pre-Exposure Prophylaxis Provider Assessment Pre-Exposure Prophylaxis (PrEP) is an HIV prevention strategy based on a daily pill taken by HIV-negative individuals. PrEP contains two antiretroviral medications- tenofovir and emtricitabine. The brand name is Truvada. PrEP is meant to be used in combination with other HIV prevention methods such as condoms. The Centers for Disease Control and Prevention (CDC) recommends PrEP as an effective method of reducing the risk of HIV infection. PrEP should be considered for those at high risk for contracting HIV. These may include men that have sex with men (MSM), injection drug users and HIV negative individuals with HIV positive partners. Q Has a patient ever asked you about PrEP? Yes No Q Have you ever initiated a discussion about PrEP with a patient? Yes No Q Which of the following statements best applies to you? I have prescribed and/or currently prescribe PrEP for HIV prevention. I refer patients to other providers who prescribe PrEP. With more education and training, I would refer patients to other providers who prescribe PrEP. With more education and training, I would prescribe PrEP. I will not prescribe PrEP to my patients. Other Q Display This Question: If Which of the following statements best applies to you? I will not prescribe PrEP to my patients. IsSelected Edit ii

Please briefly indicate why you will not prescribe PrEP for HIV prevention. Q5 Display This Question: If Which of the following statements best applies to you? I have prescribed and/or currently prescribe PrEP for HIV prevention. Is Selected Edit To how many patients have you prescribed PrEP? -5 6-0 >0 Q6 Display This Question: If Which of the following statements best applies to you? I have prescribed and/or currently prescribe PrEP for HIV prevention. Is Selected Edit By whom was your PrEP patient(s) referred? (Check all that apply) Community Based Organization (CBO) If so, which one? Another health care provider County STD clinic Patient contacted me on their own Patient was already receiving primary care at my clinic I don't know Other Q7 Would you attend a PrEP clinical training (either online or in-person)? iii

Yes No Maybe Q8 What is your preferred training modality? (Check all that apply) In-person training Webinar Self-guided online course Clinical consultation with HIV experts Written materials Other Q9 To what extent do you agree or disagree with the following statements? Strongly Disagree Disagree No opinion or uncertain Agree Strongly Agree I am familiar with current research on PrEP safety and efficacy. I am comfortable discussing HIV risk factors with my patients. I can determine if PrEP is indicated for my patients. I know the required labs for PrEP initiation and management. I am comfortable prescribing PrEP for my patients. I know the resources available to help patients pay for PrEP. Q0 iv

Please rank your clinic s ability to provide the following PrEP support services: Yes. We provide this service at our clinic. Maybe. We could provide this service with more training. No. We would need to refer PrEP patients elsewhere for this service. I don't know. Medication adherence counseling HIV risk reduction counseling Ensure HIV testing every months Ensure other clinical follow-up and monitoring requirements are met Benefits coordination to assist PrEP patients with insurance and patient assistance programs Q What is the zip code where you work? Q Would you like to be included in a PrEP provider directory that will be posted on the HIVAZ.org website? Yes No Q Display This Question: If Would you like to be included in a PrEP provider directory that will be posted on the HIVAZ.org w... Yes IsSelected Edit v

Please include any relevant contact information for the PrEP directory: Contact name: Contact phone number: Other information: vi

Appendix C. Compiled Survey Data. Has a patient ever asked you about PrEP? # Answer Response % Yes 5% No 9% Total 5 00% # Answer Response % Yes 5% No 9% Total 5 00% Statistic Value Min Value Max Value Mean.9 Variance 0.6 Standard Deviation 0.5 Total Responses 5 vii

. Have you ever initiated a discussion about PrEP with a patient? # Answer Response % Yes 5% No 9% Total 5 00% Statistic Value Min Value Max Value Mean.9 Variance 0.6 Standard Deviation 0.5 Total Responses 5 viii

. Which of the following statements best applies to you? ix

# Answer Response % I have prescribed and/or currently prescribe PrEP for HIV prevention. 5 % 5 I refer patients to other respondents who prescribe PrEP. With more education and training, I would refer patients to other respondents who prescribe PrEP. With more education and training, I would prescribe PrEP. I will not prescribe PrEP to my patients. 7 6% 9% 9% 0 0% 6 Other 6 % Total 5 00% Other I am a pharmacist with no prescriptive authority to prescribe PrEP. The physician that I work with prescribes PrEP. With more education and training I would consider prescribing PrEP; I would certainly refer pts. I will prescribe PreEP to patients, but I have not had the opportunity since I received the education and training. Previously I referred the patient to another provider. I would prescribe PrEP if the right patient presented, but that has not happened yet. CODAC works with other community respondents including SAAF and county health department to encourage and support at-risk individuals I have not had any patients in my clinic that would qualify for PrEP, but would prescribe it if it came up. x

Statistic Value Min Value Max Value 6 Mean.87 Variance.0 Standard Deviation.7 Total Responses 5. Please briefly indicate why you will not prescribe PrEP for HIV prevention. Text Response Statistic Value Total Responses 0 5. To how many patients have you prescribed PrEP? # Answer Response % -5 8 57% 6-0 % >0 9% Total 00% xi

Statistic Value Min Value Max Value Mean.7 Variance 0.8 Standard Deviation 0.9 Total Responses 6. By whom was your PrEP patient(s) referred? (Check all that apply) xii

# Answer Response % Community Based Organization (CBO) If so, which one? 7% County STD clinic Patient contacted me on their own Patient was already receiving primary care at my clinic 7% 86% 9% 5 I don't know 7% 6 Other % 8 Another health care provider % Community Based Organization (CBO) If so, which one? Other patients partner of my patient Statistic Value Min Value Max Value 8 Total Responses xiii

7. Would you attend a PrEP clinical training (either online or in-person)? # Answer Response % Yes 59% No 6 5% Maybe 7% Total 00% Statistic Value Min Value Max Value Mean.68 Variance 0.77 Standard Deviation 0.88 Total Responses xiv

8. What is your preferred training modality? (Check all that apply) # Answer Response % In-person training 6 6% Webinar 8 0% 5 Self-guided online course Clinical consultation with HIV experts Written materials 9 6% 8 0% 8 0% 6 Other % Other I have already been doing PrEP training to others. We are a Ryan WHite clinic and so have NOT been able to see HIV-negatives. Statistic Value Min Value Max Value 6 Total Responses xv

9. To what extent do you agree or disagree with the following statements? xvi

# Question I am familiar with current research on PrEP safety and efficacy. Strongly Disagree Disagree No opinion or uncertain Agree Strongly Agree Total Responses Mean 8 8 9.6 5 6 7 I am comfortable discussing HIV risk factors with my patients. I can determine if PrEP is indicated for my patients. I know the required labs for PrEP initiation and management. I am comfortable prescribing PrEP for my patients. I know the resources available to help patients pay for PrEP. 0 0 0 8.56 7 9 0.7 7 5.0 8. 7 7 5 9.90 xvii

Statistic I am familiar with current research on PrEP safety and efficacy. I am comfortable discussing HIV risk factors with my patients. I can determine if PrEP is indicated for my patients. I know the required labs for PrEP initiation and management. I am comfortable prescribing PrEP for my patients. I know the resources available to help patients pay for PrEP. Min Value Max Value 5 5 5 5 5 5 Mean.6.56.7.0..90 Variance.6 0.5...08.0 Standard Deviation Total Responses.8 0.50.9.5.. 0. Please rank your clinic s ability to provide the following PrEP support services: xviii

# Question Medication adherence counseling Yes. We provide this service at our clinic. Maybe. We could provide this service with more training. No. We would need to refer PrEP patients elsewhere for this service. I don't know. Total Responses Mean 0 5.78 5 HIV risk reduction counseling Ensure HIV testing every months Ensure other clinical followup and monitoring requirements are met Benefits coordination to assist PrEP patients with insurance and patient assistance programs 0.5 7 9.5 0.5 0 7.9 xix

# Question Medication adherence counseling Yes. We provide this service at our clinic. Maybe. We could provide this service with more training. No. We would need to refer PrEP patients elsewhere for this service. I don't know. Total Responses Mean 0 5.78 5 HIV risk reduction counseling Ensure HIV testing every months Ensure other clinical followup and monitoring requirements are met Benefits coordination to assist PrEP patients with insurance and patient assistance programs 0.5 7 9.5 0.5 0 7.9 xx

Statistic Medication adherence counseling HIV risk reduction counseling Ensure HIV testing every months Ensure other clinical followup and monitoring requirements are met Benefits coordination to assist PrEP patients with insurance and patient assistance programs Min Value Max Value Mean.78.5.5.5.9 Variance 0.88 0.6 0.7 0.5. Standard Deviation Total Responses 0.9 0.68 0.8 0.67.0. What is the zip code where you work? Statistic Value Total Responses 0 xxi

Text Response many 856 857 8506 850 8506 850 857 850 850 850 857 857 8575 857 8576 857 850 8570 8570 8570 8579 8500 8579 858 8600 866 8506 850 8579 xxii

855 857 850 857 857 857 8579 857 8500 857 Statistic Value Total Responses 0. Would you like to be included in a PrEP provider directory that will be posted on the HIVAZ.org website? # Answer Response % Yes 7 % No 59% Total 00% xxiii

Statistic Value Min Value Max Value Mean.59 Variance 0.5 Standard Deviation 0.50 Total Responses. Please include any relevant contact information for the PrEP directory: Statistic Value Total Responses 6 xxiv