HIV Specialist - March 2021 - 33

providers is that they are not as familiar with
HIV treatment and prevention protocols as
providers who care for adults. With a paucity
of HIV-infected children in the U.S., there is
no HIV-focused primary care in pediatrics.
We wanted to make this training relevant
and timely through offering our providers
just-in-time training. Unlike with adult
patients, HIV testing is usually performed
in a risk-based fashion for adolescents and
young adults. Although it is worth noting that
the CDC recommend routine HIV screening
starting at age 13 and the American Academy
of Pediatrics at age 16. If a pediatric provider
orders an HIV test, it's generally because
the patient has demonstrated an increased
risk of HIV infection. This is largely because
most adolescents and young adults do not get
routine labs, in contrast with adult patients.
Therefore, we modified our HIV test order in
our electronic health record (EHR) to nudge
providers to consider PrEP in these patients.
Every HIV test contains a hard stop: " Would
this patient benefit from PrEP (a safe, daily
pill to reduce risk of HIV by ~99 percent)? " If
a provider indicates that the patient would
or he or she isn't sure, the provider is given
an option to select a standardized order set
to efficiently order the necessary labs and
access patient educational materials, a link to
provider educational materials (accessed at
the provider's convenience), and/or a referral
to our Virtual PrEP Program.

Outreach

Provider and youth outreach has been the
driver to reaching patients, whether within
or outside of the Stanford Children's Health
system. Our goal is to reach providers and
patients throughout the state of California.
To do this, we established several levels of
outreach and communications:
■ Webinars to teach pediatric providers and

pharmacists about PrEP
Presenting at local provider meetings and
grand rounds
■ A PrEP website where teens and their providers can learn about and sign up for the
program (prep.stanfordchildrens.org)
■ A social media campaign targeting young
people ages 13-25 in California, using
Facebook and Instagram
■ Search and display ads on Google
■ A media relations campaign targeting pediatric providers
■

Recommendations for scaling
PrEP for adolescents and young
adults

If providers are interested in starting a virtual PrEP program, we have a few suggestions
that are keys to success:
1. Target your messaging to the patient's
age: Your counseling will be very different
for a 15-year-old than for a 35-year-old.
2. Ensure that your infrastructure supports
easy access and confidentiality. There
should be as few barriers as possible for
youth to reach your services in ways that
feel safe to them. If you use volunteers to
reach out to PrEP enrollees, train them in
how to support these necessary aspects of
your program.
3. At every visit, make time to ask your patients if they have questions about subjects other than PrEP: " small talk before
big talk. " Also remember that adolescents
and young adults are starting their sexual
lives and will have many questions about
their sexual health and logistics.
4. Create more touch points with the
patients by expanding your care team to

include medical assistants, nurses, other
support staff and, potentially, medical/
physician assistant students as PrEP
navigators. Remember to let patients know
who will be on this team with you so they
are assured that you are honoring their
confidentiality.
5. To build adherence to PrEP, have a virtual
visit at least once a month until the
patient is managing well (then you can
space them out to every two or three
months). You're building a relationship
and developing trust, which can take time.
Our program will sometimes schedule a
follow-up visit between the patient's initial
labs and starting PrEP to answer any
additional medication questions. For many
patients, -this is likely the first time they
will be taking a medication on a daily basis
Readers may contact us with any questions
about the Stanford Medicine Virtual PrEP
Program for Adolescents and Young Adults:
PrEPadmin@stanfordchildrens.org. HIV
CARRIE CHAN, MSN, CPNP, serves
as a nurse practitioner at Stanford
Children's Health and an Assistant
Clinical Professor at the University of
California, San Francisco School of
Nursing.

GEOFFREY HART-COOPER, MD,
is the Medical Director of the Stanford
Medicine Virtual PrEP Program for
Adolescents and Young Adults and a
primary care pediatrician at Stanford
Children's Health.

MEGEN VO, MD, is a Clinical Assistant
Professor of Pediatrics in the Division of
Adolescent Medicine at Stanford.

REFERENCES
1. Centers for Disease Control and Prevention. HIV
Surveillance Report, 2018 (Updated); vol. 31. Published May
2020. Accessed Feb. 9, 2021, http://www.cdc.gov/hiv/library/
reports/hiv-surveillance.html.
2. California-AIDSVu. (n.d.). Accessed Feb. 9, 2021, https://
aidsvu.org/local-data/united-states/west/california/.

3. Hosek, S. G., et al. (2017). Safety and Feasibility of
Antiretroviral Preexposure Prophylaxis for Adolescent Men
Who Have Sex With Men Aged 15 to 17 Years in the United
States. JAMA Pediatrics. https://doi.org/10.1001/
jamapediatrics.2017.2007.

5. Kanny D, Jeffries WL IV, Chapin-Bardales J, et al. Racial/
Ethnic Disparities in HIV Preexposure Prophylaxis Among
Men Who Have Sex with Men-23 Urban Areas, 2017.
MMWR Morb Mortal Wkly Report 2019;68:801-806.

4. Hosek, S., & Pettifor, A. (2019). HIV Prevention
Interventions for Adolescents. Current HIV/AIDS Reports,
1-9. https://doi.org/10.1007/s11904-019-00431-y.

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http://prep.stanfordchildrens.org https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html https://doi.org/10.1001/jamapediatrics.2017.2007 https://doi.org/10.1001/jamapediatrics.2017.2007 https://aidsvu.org/local-data/united-states/west/california/ https://aidsvu.org/local-data/united-states/west/california/ https://doi.org/10.1007/s11904-019-00431-y http://WWW.AAHIVM.ORG

HIV Specialist - March 2021

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