Prevention and Treatment of HIV in the Military Health System, Bureau of Prisons, Indian Health Service, and VA

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The following is a lightly edited transcript of a teleconference recorded in February 2019.



Preexposure Prophylaxis and Prevention

LTC Jason Blaylock, MD. Although emtricitabine/tenofovir disoproxil fumarate (Truvada, Gilead Sciences, Foster City, CA) for use as HIV preexposure prophylaxis (PrEP) was approved by the US Food and Drug Administration (FDA) in 2012, the military health care system (MHS) really didn’t start to use it until early 2014. Here at Walter Reed National Military Medical Center (WRNMMC), we started a PrEP clinic within the Infectious Disease clinic. This eventually served as a model for other military treatment facilities (MTFs), and our providers continue to advise others regarding initiating PrEP clinics throughout the MHS.

We also published data on the first PrEP population cohort within the US Department of Defense (DOD).1 We reviewed 769 active-duty service members who accessed PrEP care across the DOD. To date, we’ve evaluated about 1,000 patients for PrEP at WRNMMC since 2014, and we follow about 240 to 260 people a year on PrEP, accounting for drop-off and new initial starts.

Michael (Mike) Ohl, MD, MSPH. The US Department of Veterans Affairs (VA) is working hard to ensure that access to PrEP is uniformly high, regardless of facility or where in the country or what sort of experiences individual veterans are coming from. The challenges that we face with PrEP in VA are the same as challenges to scaling up PrEP in the US in general, including a need to increase awareness of PrEP and the benefits of PrEP among individuals and health care providers (HCPs). We see gaps in PrEP delivery in VA related to race, HIV risk factors, and geography.2,3 There is a need to increase awareness of PrEP outside of the highest HIV-prevalence urban areas where there has been more advertising and experience with PrEP.

There was very early adoption of PrEP at some VA facilities that were involved in PrEP research and that had large HIV care clinics, then a little slower adoption in facilities that were farther away from these centers. Even adjusting for the likely number of veterans who can benefit from PrEP, there is still variable uptake across facilities. There is also a widespread need to reduce racial gaps in PrEP use in VA.

A big challenge is retaining people on PrEP as long as the benefit persists. We see that there is high adherence to PrEP in the first 6 to 12 months after starting. But then adherence and persistence trail off, though some of that is due to individual veteran’s changing needs for PrEP over time and discussions between providers and individuals.

HIV infection among people who have started PrEP is very, very rare in VA, as we would expect. But unfortunately, we see some people who seroconvert with new HIV diagnoses who had previously been on PrEP and then stopped for some reason. A lot of work needs to be done to keep people engaged in PrEP, perhaps by applying strategies for retention learned from other settings to a population that may be less engaged in health care to start with. That is something the VA is thinking a lot about.


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Accessibility and Uptake of Pre-Exposure Prophylaxis for HIV Prevention in the VHA (FULL)

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