This document summarizes Massachusetts' efforts to make pre-exposure prophylaxis (PrEP) available to prevent HIV transmission. It discusses the state's comparable demographics and challenges to other states. It outlines strategies used, including procuring prevention agencies, distributing guidance on PrEP, defining service packages, and Medicaid demonstration project planning. Next steps include surveying provider demand, linking prevention providers to prescribers, and implementing data collection to support PrEP implementation.

1. Getting Past the Barriers:
A State Works to Make PrEP Available
SYNChronicity
Connecting to Change To Advance Community Health
April 20-21, 2012
Arlington, VA
Kevin Cranston, MDiv
Director
Bureau of Infectious Disease
Massachusetts Department of Public Health

2. Is MA Comparable to Other States?
• Relatively affluent
(3rd highest per capita income in U.S.)
• Densely populated
(3rd densest in U.S.)
• Decreasing HIV incidence
(down 52% since 2000)
• Generous Medicaid program
(first Medicaid HIV waiver; coverage at 200% of FPL)
• First statewide health reform legislation
(98% coverage)
• Significant state investment in HIV services
($31M; highest per person living with HIV/AIDS in U.S.)

3. But our challenges are the same
• MSM is the predominant HIV exposure mode
• Ongoing racial/ethnic health disparities
• Hit hard by the global economic crisis
• ASOs challenged to survive
• Operate under the same limitations of CDC
and HRSA/Ryan White HIV funding

4. Problems to addressed
to implement PrEP
• Payment source(s)
• Limits of current off-label use of Truvada
• Challenges of building interest among MSM and their
health care providers
• Challenge of engaging those at highest risk
• How to support needed range of medical monitoring
services to surround PrEP
• Concerns about reinforcing health disparities
• Other ethical considerations

5. Strategies to PrEPare
• Reprocurement of prevention and screening
contracts to create readiness for targeted
implementation of PrEP; seven agencies qualified:
AGENCY Region
Western/
Berkshire Medical Center
Pittsfield
Boston Medical Center Boston
Southeast/
Cape Cod Hospital/IDCS
Cape Cod
Central -
Edward M. Kennedy CHC
Worcester
Fenway Health Boston
Greater Lawrence Family Northeast/
Health Center Lawrence
Greater New Bedford Southeast/
Community Health Center New Bedford

6. Strategies to PrEPare
• Distributed MDPH position statement and CDC and
HRSA guidances to MA providers
• Formed a PrEP Clinical Advisory Group
• Defined an intensive prevention services package:
– repeat HIV testing, STI screening and treatment, HIV and
STI Partner Services, condom availability, ongoing
behavioral risk assessment, prevention counseling)
• Drafted supplementary data collection forms:
– Initial PrEP interest form
– Initial client data collection form
– Follow-up client data collection form
– PrEP discontinuation form

7. Strategies to PrEPare
• Participated in calls with CDC and other
interested jurisdictions:
– New York State
– San Francisco
– Los Angeles
– Washington, DC

8. Strategies to PrEPare
• Medicaid demonstration project planning:
– developing a PrEP demonstration project
– test the adequacy of reimbursement under
Medicaid
– feasibility of administering PrEP (inclusive of
clinician time, medications, lab services, and
prevention counseling) to low income patients in a
Medicaid coverage environment

9. Strategies to PrEPare
• Review of Medicaid coverage of Truvada
monotherapy
– 30-80 scrips and unique utilizers per month
– Indicative of nPEP and/or PrEP use of drug?
– 800-1,200 combination therapy claims
– Limitations of billing information
– Establishes pattern of coverage

10. Next Steps
• Survey clinical providers regarding current
and anticipated PrEP demand and use
• Link funded prevention and screening
providers to likely PrEP prescribers
• Planned meeting with state Office of
Medicaid, selected members of PrEP Clinical
Advisory Group, and funded P&S providers
• Implement data collection forms

11. Thank you
kevin.cranston@state.ma.us