Can Online Clinics Help Get PrEP to People Who Need It?

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Each year, tens of thousands of people in the U.S. are newly diagnosed with HIV. According to the Centers for Disease Control and Prevention (CDC), more than one million youths and adults are living with the virus, some unknowingly.

Over the last few years, pre-exposure prophylaxis (PrEP) has become an important -- and effective -- strategy in fighting HIV. But, the prevention tool isn't as widely used as it could be. More than 79,000 people started using PrEP between 2012 and the end of 2015, according to NAM Aidsmap, but not all communities are benefiting from it. Advocates say low usage rates could be attributable to social stigma, lack of education and limited access.

In an effort to bolster use, online urgent-care provider PlushCare has added an end-to-end PrEP therapy program as part of its suite of telehealth services. The option, which launched in July, is available in 18 states and offers users consistent online doctor visits, regular lab testing performed at local labs, and prescriptions filled at partner pharmacies -- services that are covered by most major insurance companies or Medicaid.

"It's a highly underutilized medicine," James Wantuck, M.D., PlushCare's co-founder and chief medical officer, told "[PrEP is] something that we can provide that doesn't necessitate you going into a clinic or into a doctor's office. It's the ideal thing that can be done virtually."

The Benefits of Offering PrEP Online

A thick body of research, including a 2015 Kaiser Permanente study, has found that PrEP is nearly 100% effective against HIV infection when taken consistently. However, a University of California report released last year suggested that the people most at risk of HIV infection are not the ones benefiting from PrEP.

According to the CDC, black and Latino men who have sex with men (MSM) experience relatively high rates of new HIV infections each year. Yet, the California study found that PrEP use was significantly lower among young MSM of color in the state than among white people.

That's where online clinics, such as PlushCare and NURX, come in. Advocates say these internet-based services may make PrEP more available to people who haven't accessed -- or are afraid to access -- preventative treatment.

"We may be able to easily reach a segment of the population that's not already engaged in care," said Shannon Weber, M.S.W., founder of Please PrEP Me, an online directory of over 230 clinics in California that provide PrEP.

Weber told that online health clinics could particularly serve people new to PrEP and those who've started the prevention therapy but don't want to visit their doctor. People who live in an area where there are no PrEP providers would also stand to benefit.

According to NURX co-founder Edvard Engesæth, M.D., some users have said that, if it weren't for NURX, they wouldn't have been able to start PrEP because it was hard to access the treatment -- either because of fear or not having access to a provider.

"They really appreciate how well they've been taken care of using the service," Engesæth told "Based on the experience with our service, there's a tremendous need for it."

An Innovative Service, but With Limitations

Although offering PrEP through an online clinic has its benefits, the innovative service is not without its limitations.

It is expensive to start PrEP, from the initial doctor visits and lab work to the daily medication one needs to take. Medicaid covers those costs. If a person with Medicaid lives in an area that doesn't have a provider who offers PrEP, then online clinics like PlushCare could be a vital tool.

However, one of the more glaring drawbacks of the service is that these clinics are often unable to accept Medicaid. PlushCare can only cover Medicaid enrollees in California, while NURX only accepts plans in California and New York state. That means millions of people on Medicaid can't use either service to access PrEP.

"We're working every day to get in network with more [insurers]," Wantuck told "Medicaid is tougher because it is so individual, state-by-state."

Another barrier is state availability. Both PlushCare and NURX plan to expand within the next few years, but right now, they're only available in a handful of areas. NURX is available in 12 states; PlushCare services 18. Nine of those states overlap: California, Florida, Illinois, Michigan, New York, Pennsylvania, Texas, Virginia and Washington.

Some of the covered states also decided against expanding Medicaid under the Affordable Care Act. According to Weber, increasing the number of PrEP providers has been sluggish, and the failure to expand Medicaid to all states has made the efforts more difficult. That, she reasoned, may also impact where PlushCare and NURX are available to Medicaid enrollees.

"That feels like such the challenge in PrEP access," Weber told "The states that we've been able to do a lot [in] are the states that have Medicaid access."

An online clinic must travel a long road before it can operate in a given state, said Engesæth. First, a company would need to identify a licensed PrEP prescriber, as well as a few pharmaceutical partners. Then the legal team would need to make sure that everything is compliant with state regulations, Engesæth said.

The process is lengthy, but well worth the effort if it means protecting people, Engesæth told "One of the top things on my list of priorities is to launch as quickly as possible in those [other states] so that we can get those people covered, as well," he said.