Michelle Miller from the UI’s PrEP (pre-exposure prophylaxis) Clinic joins Rasika for a great conversation about HIV prevention.

Rasika Mukkamala:

Hello everyone and welcome back to From the Front Row. Today we are delighted to have Michelle Miller on the show as part two of our LGBTQ+ clinic series. Michelle Miller, PharmD, is a clinical pharmacy specialist in Ambulatory Care at University of Iowa Health Care. Her current practice includes being a member of the healthcare team in the University of Iowa LGBTQ+ clinic, as well as the creator of the HIV Pre-Exposure Prophylaxis PrEP clinic. She’s also an adjunct faculty member in the University of Iowa College of Pharmacy.

I’m Rasika Mukkamala, and if it’s your first time with us, welcome. We’re a student run podcast that talks about major issues in public health and how they’re relevant to anyone, both in and outside the field of public health. Welcome to the show, Michelle. Today we are welcoming Michelle to the show. Thank you for joining us. To start off, can you give us a little bit of context to our listeners about the PrEP clinic?

Michelle Miller:

Absolutely. The PrEP clinic has been around here at the university since 2017, and the primary goal is to serve people interested in reducing their risk of HIV.

Rasika Mukkamala:

Awesome. Can you tell us a little bit about what PrEP is and where the clinic is located?

Michelle Miller:

Yeah. So PrEP, P-R-E-P stands for Pre-Exposure Prophylaxis specifically regarding HIV. It involves taking one of two approved oral medications as a daily pill, or patients can receive a long-acting injection every two months, which is given in the clinic setting. The two oral options are known under the brand names Truvada and Descovy, and the injection is known under the brand named Apretude and is our newest addition to our options for PrEP. Patients on PrEP are required to have HIV monitoring every two to three months depending on whether they’re on oral or injectable. That’s a minimum as far as the labs that we have to do. However, we do offer full STI screening at all follow-up appointments and actually as often as patients feel they need it in between their appointments as well.

Our university lab, we do offer patient self-collection of samples for chlamydia and gonorrhea, which is unique. The testing’s available at three sites, which would include an oral swab, a rectal swab, as well as a urine sample. And all potential sites of contact do need to be tested. So if a patient has oral contact and are a receptive anal sex partner, we need to swab both their oral cavity as well as their rectum. Otherwise, we could miss a positive and that’s not good, yeah.

Rasika Mukkamala:

Thank you for sharing.

Michelle Miller:

Yeah. And then as far as where the clinic is located, I work out of the Iowa River Landing building in Coralville and we do have another service, which is the TelePrEP service, which is also affiliated with the university. And that service is an exclusively remote service, so they don’t see patients face-to-face. I do a combo. I see patients face-to-face as well as patients virtually through MyChart video visits. So we have both of those options here at the university and both clinics are run by pharmacists and both clinics accept self-referral, which means people do not have to be referred to us from their primary care provider, another provider within the university system. They can just say, “I want PrEP,” and be enrolled.

Rasika Mukkamala:

That’s awesome. Can you talk a little bit about the target market for this clinic and then if any of our listeners or their family or friends want to make appointments, how can they make those appointments?

Michelle Miller:

Yeah. Absolutely. Target market is tricky. I guess our perspective is we will prescribe PrEP for anyone and everyone interested in taking the medication to reduce their risk for HIV. There’s no specific requirements a patient has to meet before we can prescribe. We do some kidney function monitoring, which will help us decide on the agent, but we always have an option regardless of other health conditions that somebody might have. And the only other true requirement being that we do need to monitor test for HIV before starting it and confirm that the person interested is negative for HIV. We would have to do a little more intensive treatment. The medications we use for PrEP are not effective by themselves to treat HIV, so the therapy would just need to be modified a little bit.

We do have criteria we can use to identify individuals at the highest risk of HIV acquisition. This is primarily from the provider’s perspective. We want providers to be able to identify patients who may not A, know that PrEP is an option or is out there and have those providers identify they’re high-risk patients who we should be offering PrEP. That’s really where we use some of that risk criteria. And that risk criteria would include an individual who has had either anal or vaginal sex in the past six months, and maybe they have a partner who’s HIV positive or they don’t consistently use condoms or they’ve been diagnosed with an STI in the past six months. All of those risk factors, even a single one of those, we should be offering PrEP to those individuals. When it comes to individuals who inject drugs, if they have a partner with HIV, if they share needles, syringes or any other injection equipment, we should also be offering PrEP to those individuals.

But I frequently have people come to me who may not “fit” into that high-risk category, but just want to protect themselves very understandably. And I think there are also benefits outside of preventing HIV, which is to help relieve some anxiety that some people might have around that risk and just wanting to protect themselves as much as possible and that that’s why we’re here. As far as scheduling appointments, it’s pretty straightforward. We have two different contact point. Okay. I’m going to start over. As far as making appointments, that’s pretty straightforward. For the Iowa River Landing Clinic, patients or people interested can call (319)-384-7444, and they just let the scheduling team know they’re interested in being seen for PrEP and they’ll know exactly which providers to schedule that individual with. For the TelePrEP service, the phone number is just a little different. It’s (319)-467-8777.

Rasika Mukkamala:

Perfect. Thank you. And that’s so interesting and it’s really good to hear that there really is a variety of patients that you see and that some people use it for preventative measure. That’s something I didn’t know. So thank you for sharing and for educating our listeners about what kinds of patients come into your clinic and also that they can come in and see you as well.

Michelle Miller:

Yeah. Absolutely.

Rasika Mukkamala:

Can you talk a little bit about your role in the clinic and how you found an interest to work at this clinic and help create it?

Michelle Miller:

I was the original creator of our PrEP clinic here at Iowa River Landing. Definitely was not the first pharmacist probably to do this. I know when we started, there was a clinic in Washington that was run by a pharmacist. But it was early that we started our clinic in 2017. I started it with Dr. Nicole Nisly, who has since retired from the university, but she was one of the two people who started our LGBTQ+ clinic here at UIHC. She was my medical director. Pharmacist at the University of Iowa have been participating in what is called collaborative practice protocols for decades. These protocols essentially allow pharmacists to function like a mid-level provider such as a nurse practitioner or a physician assistant. And during the first four years of our LGBTQ+ clinic, I was an educator essentially educating patients who were interested in starting hormone therapy, and I did a lot of education for people who were interested in PrEP as well.

The problem is, is that our wait list was so long and people were waiting six months or more to get into the clinic. This was understandable. It was a need that needed to be served, but we did not want people who were wanting to start PrEP to have to wait that long to initiate therapy. So that was really a big concern for us. I was already seeing patients under what I mentioned was a collaborative practice protocol for things like anticoagulation, people taking blood thinner medications or patients with type 2 diabetes. And it just made sense with the consistent follow-up that’s needed with PrEP to implement a service similar to those services that have already been around at the university for a long time. So that is where the whole idea came to start the clinic.

Rasika Mukkamala:

How many providers do you have now in the clinic?

Michelle Miller:

Good question. So it started out with myself and then over the years our population has grown and now I have three colleague pharmacists. We all work within internal medicine here at Iowa River Landing, and all four of us provide PrEP for patients. And then for the TelePrEP service, there is currently two pharmacists who provide services there as well.

Rasika Mukkamala:

Wow. That’s a lot of you. That’s really awesome that all of you can work together and that you’re able to support the need. What does your patient capacity look like? How many patients do you see in one day approximately?

Michelle Miller:

Good question. The way our schedule is set up, so for TelePrEP, they are primarily only seeing patients for PrEP. I am not sure what their scheduling looks like as far as how many patients they can see in a day, but for us here at Iowa River Landing, we see a variety of patients throughout the day, but for the most part, each of us can see up to 16 patients in a day, and there are multiple of us providing appointments each day of the week so typically if somebody calls in and wants to get an appointment and wants to start, it would be unusual to not be able to see a provider within a week.

Rasika Mukkamala:

Wow, that’s great.

Michelle Miller:

Yeah.

Rasika Mukkamala:

Can you talk about some of the challenges that have been associated when you first started this clinic and then any challenges that you’re facing currently?

Michelle Miller:

The clinic, like I mentioned earlier, we started the clinic in 2017 and I would say the biggest challenge when we started the clinic, I was used to developing the protocols and that process went pretty smoothly. But one of the biggest challenges for us was getting approval for patient self-collection for those chlamydia and gonorrhea swabs. That was not something that was available here historically. Those had been historically collected by either the provider or clinic staff, which again would require a patient to be at an appointment, and we didn’t want that. We did not want that to be a barrier. But during that time, and through my research, we found there were several studies that had looked at the validity of patient self-collection of samples, and it was very clear that that was a very appropriate mechanism for collecting those samples.

So the challenge was that we were required to obtain both a patient sample and then a provider collected sample same day for at least 20 patients so that the lab could run and confirm that we were seeing the same results. Doing that is harder than it sounds, especially trying to coordinate my schedule and my provider’s schedule and the patient’s schedule to make sure we’re all in one place at one time. That got to be a little bit tricky. But we did get there, and that was in the very early stages of clinic and has been available and now luckily has actually expanded to all of our outreach clinics throughout the university as well. People in Cedar Falls or the Quad Cities can go to our outreach clinics or labs there and be able to do the self-collection as well, which is really key because like I said, do a lot of virtual visits and people who I’m seeing might live one or multiple hours away, and we don’t want them to have to come all the way here to do that collection. That would just be a whole nother barrier.

Rasika Mukkamala:

Yeah. And I think it’s really great that you’re accommodating to what the needs of the patients are, but some of them may live far away, or especially in the winter, they might not want to come all the way to Iowa City or it’s not accessible. So I think, thinking outside the box about how to make sure to meet patients where they’re at and providing them with the care, I think the self-collection is a really unique way to do that and something I haven’t really thought about. So that’s great.

Michelle Miller:

Absolutely. And I think the next step is we would really hope to be able to even mail out kits. That’s becoming more common as well with a lot of home testing. And for me at least, that would be a goal for the future is to even be able to mail out because there isn’t still always an accessible place for people to go, and again, we just want to expand the availability of those tests.

Rasika Mukkamala:

Yeah. That’s great. So a lot of our listeners on this podcast are public health students. So I was wondering if you could go into detail about some of the public health issues that this clinic is helping to address, like equity of care or health disparities or anything else that you’re thinking of.

Michelle Miller:

Yeah. The primary goal of PrEP really is to reduce the number of patients newly diagnosed with HIV every year. Nationally, PrEP has definitely been increasing year after year as far as the utilization of PrEP for individuals, but we’re still far below where we could be for the number of people who would qualify or should be offered PrEP. Many medical providers might have low awareness of PrEP or experience providing it and might be hesitant to do that. Many patients that may benefit from PrEP, they just might not even know that it’s an opportunity for them. The healthcare system is also super complicated, and many patients have limited access and limited knowledge on how to just navigate the complex system. I mean, myself, I’m trying to help my parents navigate choosing Medicare plans, and I deal with this every day, and it’s still so complicated. The cost of the medications, the cost of doing the labs, that can also be a limiting factor or an issue for individuals.

Luckily, Truvada did go generic in 2020, and that decreased the cost substantially. Now there’s much better coverage through many insurance plans and is much more affordable. We have other strategies we can use to help patients pay for the medication as well. One great thing that happened in 2019 was that the US Government announced an initiative called Ending the HIV Epidemic in the US, or you might hear it referred to as EHE. The initiative is essentially coordinated by the US Department of Health and Human Services, and the primary goal is that they want to reduce new HIV infection in the United States by 75% by 2025, so coming up in just another year or so and by 90% by 2030. Really important and helpful part of this initiative is that they implemented something called Ready, Set, PrEP. And Ready, Set, PrEP has been a tremendous resource for us. So people who don’t have insurance to cover PrEP medications or who his insurance covers, but not very well, we can help get medication for patients at no cost. That has been huge to combat this and really target bringing those rates of positive HIV testing down.

Rasika Mukkamala:

Wow. That’s awesome. And I think, like you mentioned, it takes a village to all work together to help with prevention efforts. So like you mentioned, there’s a lot of initiatives from local, state, federal governments, and it takes healthcare providers and patients, and it takes support systems like friends and family sometimes to help educate patients on where to go and help to seek care. So I think it’s great that you and the clinic are helping patients get the care that they need.

Michelle Miller:

Absolutely. And I commend many of my patients because they have been an amazing resource for people that they know. I’ve had a lot of people come to me who didn’t necessarily know this was a thing and this was out there. But I have a lot of patients who have advocated for their friends or family and said,” Hey, this is a thing, and this could help you and keep you safe, and you should really consider it,” and have helped guide them. So yeah, I think like you mentioned, every person can make a difference for sure.

Rasika Mukkamala:

Yeah. So the last question that I have for you is something that we asked all of our guests and your response can be healthcare or not. What is one thing that you thought you knew but were later wrong about?

Michelle Miller:

This is a tricky one. I’m not very good at questions like this. I don’t know if I’m just in my brain, not a very good historian. But I truly staying on theme. I think when I was a resident, I worked with Dr. Nisly and she really opened my eyes to health disparities in general, but at the time, I totally thought I knew what my future career looked like. I would continue to work with my internal medicine colleagues in primary care providing services for patients with diabetes or high blood pressure, or people on blood thinning medications. I could have never imagined the bulk of my job and my day to day being working with the LGBTQ+ community, but I’m actually in this scenario, very happy to say that my prediction, I guess for my future was wrong. I am so tremendously grateful that I was given the opportunity to work in the LGBTQ+ clinic. Starting the PrEP clinic has been so tremendously gratifying and has brought me so much joy and been so rewarding.

It taught me to be open to new opportunities, even if I don’t feel qualified, which I definitely, when I was asked by Dr. Nisly to participate, I knew I knew about the medication side of things, but I didn’t know a lot of other things. But I think that’s one of the key things we learn as learners is just we learn how to learn and that was super helpful and truly was totally life-changing for my career and has brought me so much joy. So I guess my advice is just always keep an open mind. You never know what opportunities will be there for you.

Rasika Mukkamala:

Well, thank you so much, Michelle, for joining us on the show. If you like what you heard, please leave a like, comment or repost on Spotify or Apple Music wherever you listen to your podcast. Stay safe, stay healthy, and we’ll see you next week. Thank you.

Lauren Lavin:

Thank you everyone for tuning into our episode this week, and thank you to Michelle Miller for joining us today. This episode was hosted and written by Rasika Mukkamala and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple podcasts and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team. You can reach us at cph-gradambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.