Back on Track: Reversing the Impact of COVID on PREP

COVID-19 has altered the treatment landscape across multiple diseases, and HIV is no exception – but the impact is not limited to the treatment of people living with HIV.

With regular HIV/STI testing and in-person check-ups required to secure preventative HIV therapies such as PrEP (pre-exposure prophylaxis), what impact has the pandemic had on HIV prevention? And, more urgently, how can it be reversed?

Using data from Ipsos’ syndicated COVID-19 HIV Study in the U.S., together with findings from a 2020 U.S. study by Emory University, we highlight the potential impact of pandemic-induced restrictions on access to PrEP treatment across different patient groups. We also put forward recommendations for the healthcare industry on how to re-engage these groups and help get PrEP treatment back on track.

INTRODUCTION

Despite the promise of vaccines, we will undoubtedly experience the effects of COVID-19 for years to come – and this watershed moment in human history marks the beginning of a long journey ahead. Certainly for the healthcare industry, the impacts of COVID-19 have been significant and far-reaching. Not only has the pandemic changed HCPs’ ability to service patients, it has altered the treatment landscape across multiple diseases and reconfigured the administration of healthcare. One disease area in which these changes are manifest is HIV. Leaders in the HIV space continue to seek knowledge on COVID-19 and its future impact, and it will be imperative for them not only to right the ship when it comes to treating patients – both those starting a new treatment (dynamic) and those continuing ongoing treatment (maintenance) – but also in addressing the access and servicing of patients receiving HIV-preventative treatments such as PrEP (pre-exposure prophylaxis). We believe that learnings in the HIV antiviral drug space can be extrapolated to provide an understanding of the impact of COVID-19 on the HIV preventative PrEP landscape.

COVID-19, HIV AND ITS TREATMENT IMPACT

Ipsos’ HIV COVID-19 Impact Study is an ongoing online syndicated study in which a sample of HIV-treating physicians report quarterly on HIV patients seen in consultation (see ‘About the Research’ for full details). For the purposes of this article, we will focus on data provided by participating physicians in the US between March 2020 – December 2020. In early Spring of 2020, the beginning of the pandemic, sampled physicians in the US reported a decrease in their managed HIV patient caseloads by as much as 30% per week. Of the physicians that confirmed a change, 68% indicated that the decrease was due to COVID-19. This drop in caseload was coupled with a significant increase in the adoption of telemedicine; 82% of physicians stated that they were using telemedicine in May 2020 and significantly less, but still a substantial amount (69%), were using telemedicine by December 2020. This is versus just 15% employing telemedicine at their practices before the pandemic began. Also in Spring 2020, over a quarter of physicians (29%) reported the presence of fewer staff due to colleagues being quarantined after exposure to COVID-19. 57% stated that their workplaces advised to cancel all non-urgent/non-essential appointments for HIV patients. For patients maintaining treatment, this would have meant reduced access to consultations, in-person labs and examinations. Despite a softening of the impact of COVID-19 on HIV management in the later months of 2020, at the height of the surge in April through May 2020, around 65% of physicians agreed that patients were cancelling scheduled check-up appointments. Some 53% expected their patients’ access to medical care to change during the course of the pandemic. All of this serves as clear evidence of the impact that COVID-19 had, and will continue to have, on the servicing and administration of HIV treatment in the US. Not only has COVID-19 impacted the treatment of dynamic and maintenance patients in the HIV treatment space, it is also highly likely to have significantly changed the PrEP treatment landscape. We believe there is considerable value in linking considerations around impacts on the HIV treatment space with similar developments in the PrEP world.

WHAT IS PREP?

PrEP (pre-exposure prophylaxis) is medicine taken by people at risk of HIV to prevent contracting HIV from sex or injection drug use. For the purposes of this discussion, we will be focused primarily on men who have sex with men (MSMs), the primary target for PrEP as an HIV preventative treatment. PrEP is a once-daily pill. In the US, in order to secure a prescription for PrEP one has to submit to HIV/STI testing every three months and an in-person check-up with a clinician. It is safe to assume that COVID-19 social distancing guidelines would have had an immediate impact on access to these services, therefore making it difficult to obtain a prescription for PrEP.

COVID-19 AND PREP

COVID-19 and its impacts may potentially force HCPs and even patients, who become more vocal in their treatment decision-making as they become more treatment-experienced, to re-evaluate their needs around treatment options and servicing. A cohort study conducted at Emory University in 2020 of PrEP-using MSMs in the Southern United States found that the COVID-19 pandemic has impacted access to and utilization of HIV health services, with around 25% of the sample reporting challenges while attempting to access PrEP, HIV testing, or STD testing – mostly due to institutionally imposed guidelines on social distancing.1 You will recall that as part of securing a prescription for PrEP, one must submit to HIV/STI lab testing and an in-person check-in with a clinician. Despite these guidelines, according to the Emory study, many participants had not received an STD test or HIV test within the 3-month period of May-July 2020, and around 20% of participants discontinued PrEP or changed how often they take PrEP because of COVID-19. We must caveat here that inconsistent compliance with guidelines for testing had occurred in the same cohort before the onset of the pandemic.2 Furthermore, despite the limited access to services, there were very minimal changes to the number of missed PrEP doses among those who remained on treatment across the period of the study. It is nevertheless still important to note that a fifth of the cohort reported discontinuing PrEP use altogether or using it on an on-demand basis.3 It will be interesting to continue to track how patients view the current, more widely understood daily administration versus the on-demand option and dosing procedures, and whether or not they prove to be too cumbersome to procure whilst the COVID-19 pandemic, and its after-effects, remain. Will there be a growing need for longer lasting treatment or loosening guidelines around needing examinations to secure a prescription? Focusing back on results from the Ipsos HIV COVID-19 Impact study, participating physicians treating PrEP patients also experienced changes in their practices. Between March 2020 – December 2020, an average decrease of about 33% in their PrEP patient caseload was reported by physicians at an overall level. When asked the reason for the decrease, approximately half attributed it to the effects of COVID-19. From April-December 2020, approximately 56% of sampled physicians reported that their PrEP patients had cancelled scheduled check-up appointments due to the threat of COVID-19 and 45% reported that their workplaces advised to cancel all non-urgent/non-essential appointments for PrEP patients. With institutionally and CDC-imposed guidelines around social distancing, patient behavior likely changed as patients grew concerned about the risks of COVID infection. The Emory study reported a change in the sexual habits of MSMs in their cohort, whether single or in non-committal/non-monogamous or ENM (ethically non-monogamous) relationships: 68% of participants cited a decrease in penetrative sex, whilst 82% reported decreases in sexual activity with casual partners. According to the Emory Study, the lowering in sexual activity then re-bounded in the summer months as restrictions loosened.4 The impact of rebounds in ‘risky’ sexual activity and the lack of access to services to obtain preventative treatments like PrEP for HIV could potentially have significant consequences. It is critical that the marketing of PrEP encompasses not only Caucasian MSMs but all potential candidates, and especially those disproportionately affected as a result of the pandemic. Brands must seek to understand not only how to re-engage existing PrEP users, but also to reach out to communities of color, specifically MSMs, transgender men and women, and heterosexual women of color who are disproportionately affected by the disruptions in healthcare servicing and access across the board. It will be incumbent upon the healthcare industry to anticipate and innovate to best service these communities.

RE-ENGAGING AND GETTING PATIENTS BACK ON TRACK

We’ve presented the ways in which COVID-19 has impacted the HIV treatment and preventative treatment landscape. More specifically, we’ve centered our discussion around PrEP use, institutional access and servicing. The picture we’ve painted serves only as a moment in time and it will be important for the healthcare industry to continue to track the changes in the landscape, presenting an opportunity to be forward looking in healthcare’s approach to addressing compounding needs and concerns for those directly affected and those requiring the awareness, knowledge and the tools to treat. It is our opinion that it is in the best interest of pharma companies who produce specific HIV treatments to re-engage with their patient communities and partner with researchers to:

• Longitudinally monitor PrEP use, its discontinuation and on-demand use
• Monitor utilization of services and testing, and changes in sexual behavior
• Utilize data to best inform not only how to re-engage existing PrEP users, but also to reach out to communities of color, specifically MSMs, transgender men and women and heterosexual women of color
• Examine specific barriers and facilitators to care
• Track and analyze physician and patient data revealing changes in brand use, perceptions, product interest, etc.

COVID-19 has illuminated opportunities for evolution in healthcare and we believe it is pivotal that we take the opportunity to further address the needs of all communities in this HIV prevention and treatment space.