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Scott Webb: Pre-exposure prophylaxis better known as prep is a game-changing medication being used to prevent the transmission of HIV. Prep is highly effective in preventing HIV and can be prescribed by primary care physicians. And joining me today to tell us about prep and the virtual prep program at Stanford children's health is Dr.

Jeff Hart Cooper. He's a general pediatrician at Stanford, children's health and medical director, and co-founder of Stanford's virtual prep program for adolescents and young adults.

This is Peds Talks from Stanford Children's Health. I'm Scott Webb. And Dr. Hart-Cooper, thanks so much for your time today. This is an interesting topic. I've seen some commercials and did a bit of research, but you're an expert in this area. So as we get rolling here, what exactly is PrEP?

Dr. Hart-Cooper: PrEP stands for pre-exposure prophylaxis for HIV. And what it is, is it's a daily pill. And when you take it every day, there's a greater than 99% reduction in the risk of sexually acquiring HIV. It has a USPSTF grade A recommendation for HIV prevention. So it's very vetted, it's effective, it's very safe.

And we have two different options. One is tenofovir disoproxil. It goes by TDF for short and the brand name for that is Truvada. It's also available in the generic form. And this it was actually FDA approved for youth back in 2018. So it's a newer addition for our younger patients and it also has a generic form. The second option that you have is tenofovir alafenamide or what we'll call TAF or Descovy is the brand name. And this is FDA approved in 2019. So two really great options for PrEP.

Scott Webb: Yeah, they do sound like really great options. As you say, they are relatively new. So it's great to sort of get this information out there and educate people even other providers. So when you talk about it reducing the risk of getting HIV, how does it do that?

Dr. Hart-Cooper: We treat HIV typically with three different medications that limit the virus from replicating. And what PrEP is, is it's two of those medications. And when you have enough of those medications in the blood, it blocks HIV from taking hold to begin with.

Scott Webb: Interesting. And who's eligible for PrEP or who should be considering getting PrEP?

Dr. Hart-Cooper: It really comes down to connecting with the patient in front of you and just understanding what is this patient's likelihood of acquiring HIV in the near future? A few different ways that I think about that is whether they have a current or an anticipated risk. An anticipated risk would be a patient that, let's say, is an 18-year-old, maybe not sexually active yet, but they're going to college in six months and so they likely will be in the near future. That's somebody that you really want to talk to about PrEP before they're necessarily even sexually active. That way, they're prepared for their first sexual encounter.

And when we think about risks beyond that current anticipated framework, from more of a behavior standpoint, this is somebody who's not always using condoms, right? And so anytime that condoms are not used during sex, there is a potential for transmitting HIV if one of the partners is HIV positive. And so this is something that I think asking a really open-ended question for patients is helpful. I'll often ask, "How often do you use condoms? Is it about half the time?" Sometimes I'll start with adding kind of a low bar. And then I think it's helpful to get more of a realistic answer from patients that way.

And in addition to not using protection always, it comes down to how confident are they that their partners are HIV negative. And this is actually a really difficult thing to tease out, especially for more casual partners, because patients can ask their partners their HIV status, but it's really hard to get into the weeds about this. So you may not know when that partner's last HIV test was, what partners have they had since then, that kind of thing. And so I think that while you can be really good at asking about HIV status, it's never a complete picture. And so what PrEP does is it gives this blanket of additional protection that counteracts some of these, I guess, like deficiencies in communication or some of these things that are harder to really tease out in great detail when you're first meeting people.

The last thing I would say too is that we can get into the kind of details of exactly which patient needs it. But again the takeaway message is does this patient have a risk of acquiring HIV in the near future? And the piece that I would add to that is that if your patient is asking you about PrEP, they probably can benefit from it. I've never had a patient that comes to me asking for PrEP that I've said, "Oh, this patient doesn't qualify." And so I think that to keep in mind, patients are not always telling us every detail of their sexual history and so to really follow a patient's lead if they're asking you about it.

Scott Webb: Yeah. I see what you mean, like really listening. And as you say, if a patient asks about it, they're probably a good candidate. And so when we speak about patients and getting PrEP, I'm assuming a prescription is needed, but how exactly do people get their hands on PrEP?

Dr. Hart-Cooper: A primary care general provider is able to prescribe PrEP, right? It's a very safe and a very effective medication. What you'll find is that some providers are more comfortable providing PrEP compared to others. But this is definitely within the scope of practice for really any primary care provider. For pediatricians and adolescent providers who maybe didn't learn how to prescribe PrEP in residency or training and who don't regularly see a lot of HIV-positive patients, maybe less familiar with the medication, so there's a little bit of very brief kind of minor training that goes into that.

But one piece I wanted to add as well, is that because we know that a lot of primary care providers are not necessarily as experienced or comfortable providing PrEP, one service that we offer is our Virtual PrEP program. And we actually are able to see any patient 25 and younger within the state of California. So if you have a patient who might benefit from PrEP, but maybe you're not comfortable providing it, it's really easy to refer them to us. And patients can also find information about our program and then refer themselves and we're happy to meet them.

Scott Webb: Yeah, I see what you mean. You know, when you think about maybe just your average sort of family doctor, right? And perhaps their comfort or discomfort in describing something like this, so referring to folks like yourself, to Stanford Children's Health. And I wanted to ask you specifically about Stanford Children's Health and Stanford Medicine. How exactly and specifically are you helping people to get access to PrEP?

Dr. Hart-Cooper: When we founded this Virtual PrEP program, we really created this to improve access to quality PrEP care for adolescents and young adults initially within our Stanford network. But now we're expanding to really any patient within California, because we know that there's a lot of PrEP need out there and we see this over and over again with studies that have been done. And the challenge is how do we get an experienced PrEP provider to that patient?

And so when you think about what Stanford Children's Health is doing through Virtual PrEP, we're bringing a trained adolescent PrEP provider, who is either a pediatrician or an adolescent provider within Stanford, and we're bringing it to the patient wherever they are in the state. And in addition to providing a trained provider, who is really comfortable working with adolescents and young adults, we're also bringing a really robust PrEP adherence program. And so we actually have a wonderful team of six medical students and physician assistants students that really connect with our patients, engage them in care and provide really robust adherence support, answering their questions and making it sure that they're able to stay on PrEP for as long as they want or need to.

Scott Webb: It's really interesting. I was just thinking about the model and how we all sort of understand medicine and healthcare that the patients usually go to the doctors, right? And bringing the doctors, bringing Virtual PrEP to the potential patients is really a paradigm shift, right?

Dr. Hart-Cooper: Yeah. What's so amazing with this kind of virtual and digital healthcare transformation is that we don't have to be siloed in these academic institutions, right? I have patients coming from Northern California, from the central valley, from Southern California, and it's just as easy for them to see me in my clinic day as it is for a patient just down the street.

And so this is really about meeting patients where they are. It's about responding to these healthcare disparities when we see these really significant, you know, disparities in terms of race, ethnicity, sexual orientation, and HIV risk. And so this is one step that we're taking to try to mitigate that and really improve patient access to our providers and to optimal HIV prevention for themselves.

Scott Webb: Yeah. And let's talk about that. So how do people get in touch with Virtual PrEP for themselves or for their patients?

Dr. Hart-Cooper: So the quickest and easiest way is just to go to our website, prep.stanfordchildrens.org. And there you'll be able to, if you're a provider, look up how to refer a patient to us, and our schedulers are happy to connect with them. We just ask that you include a confidential phone number and email for your patients, so that we make sure that we're preserving their confidentiality.

Patients can also directly connect with our program. And so if they go onto our website, they can just click Contact Us and submit their information and then we'll call them right away and get them scheduled usually within that same week.

Scott Webb: That's great. So I'm assuming you're doing video visits or phone conversations that your providers, your team can pretty much meet patients really wherever they are technologically speaking, right?

Dr. Hart-Cooper: Absolutely. So these are all done through secure video visits, along with every other visit that we do at Stanford Children's Health. We're using the exact same platform. And we can connect with patients wherever they are. And so this is another really wonderful feature that we have with our program, is that I've had patients who are in the middle of a shift at a fast food restaurant or they have six different roommates, and so they can only meet with me if they're on this, like beach in San Diego. And they're in their backyard because their car broke down. But like, no matter where our patients are, all they have to do is log on to that visit. Find a secure place to have that visit because it is, sensitive information we're talking about. But our goal is to work PrEP into their lives and make it easier for them instead of having to have them come into the office and kind of work around our schedules.

Scott Webb: That's really amazing. It's so encouraging really to hear just how things have changed, how, you know, the doctors are going to the patients and meeting them. As you say, wherever you are, if you're in the middle of a shift at work, step outside, make sure that you've got some privacy and let's do this. So cool. As we get close to wrapping up here, I wanted to ask you are there other ways besides PrEP to lower the risk of getting HIV?

Dr. Hart-Cooper: We've all heard this before, but certainly practicing safer sex is a great way to protect yourself from getting HIV as well as other sexually transmitted infections. And it goes without saying that PrEP does not protect against other sexually transmitted infections, pregnancy and whatnot. And the other part that I think is really important is just encouraging communication with partners about their HIV status, right? And so we always want people communicating in sexual encounters, making sure that communication is happening and everything is consensual and everyone's kind of feeling comfortable in that encounter, but also just making sure that you know what is your partner's HIV status, when were they last tested, and any partners they've had since then is nice to be able to understand what that partner's HIV status is. But again, it's hard to get all that information especially if you're meeting somebody for the first time. And so that's where PrEP can be a nice additional comfort for our patients, is that we know that there's always incomplete information in terms of how certain you are that your partner's HIV status is really up-to-date and PrEP helps to fill that gap.

Scott Webb: Yeah, it certainly seems like it does.. And you're so right that in the moment, certain encounters, it can be difficult to sort of pull out a questionnaire, right? And get some of these--

Dr. Hart-Cooper: Totally. Yeah.

Scott Webb: It sounds good, but in reality, we've all been there and it can be difficult to get the answers or to trust that you're getting truthful answers. So PrEP, it gives you that added layer of confidence, if you will. Great stuff. Doctor, as we wrap up here today, any final thoughts or takeaways for listeners about PrEP, Virtual PrEP and the work that your team is doing at Stanford Children's?

Dr. Hart-Cooper: I would just say that we're here as a resource. If you're a provider that wants to learn more about prescribing PrEP for your patients, we'd love to support you and you can definitely get in touch with us on our website. But we're here for patients, for providers, for really anybody throughout the state and more broadly if needed. And we just want to make PrEP as easy as possible for our patients to access so that we can really chip away at youth HIV within the state.

Scott Webb: Definitely. And it's great to know that patients can reach out. You've given them the information today about how to go to the website, how to contact you. And for other providers who may not be comfortable or may not be as knowledgeable about PrEP, that they can reach out as well. They can refer their patients. Great stuff today, doctor. Thanks so much for your time and you stay well.

Dr. Hart-Cooper: You too. Thanks for having me.

Scott Webb: That's Dr. Geof Hart-Cooper, general pediatrician at Stanford Children's Health and Medical Director and co-founder of Stanford's Virtual PrEP Program for adolescents and young adults. And for more information on PrEP, visit prep.stanfordchildrens.org.

This is Peds Talks from Stanford Children's Health. I'm Scott Webb. Stay well.