It would have been unthinkable three decades ago, when San Francisco was in the grip of the AIDS epidemic and the city’s gay community was living in terror of the mysterious, deadly virus. But now, preventing HIV may be as simple as pushing a few buttons on a smartphone.
Well, it could be in this country but our NHS have just announced it has pulled the plug on its decision-making process on whether to offer PrEP on the NHS. This is a real shock and you can read NHS England’s press release here. (You may also want to read the National AIDS Trust’s Director of Strategy’s blog on PrEP, What went wrong and what should happen now).
That’s the goal of San Francisco startup Nurx. On Tuesday the company rolled out an online service that allows people to order a three-month supply of PrEP delivered to their door within 24 hours — no visit to a doctor’s office required.
Dr. Bradley Hare, director of HIV Care and Prevention at Kaiser Permanente San Francisco, said such a delivery service could increase patient access to the important medication.
“I think no one would try to argue in San Francisco that we’ve been able to get everyone on PrEP who should be on PrEP,” he said.
Taken daily, pre-exposure prophylaxis or PrEP, medication can reduce a patient’s chance of contracting HIV by more than 90 percent. PrEP use already is so common among gay men in San Francisco that some list it on their online dating profiles, but Nurx’s founders say many people who should be on the regimen still face obstacles when trying to get a prescription. Some primary care doctors don’t know about PrEP or view it with suspicion, said Nurx co-founder and CEO Hans Gangeskar, and local clinics that offer the regimen are overcrowded.
“The current health care system has failed to get PrEP to the people who need it,” Gangeskar said.
Nurx has been offering on-demand delivery of birth control pills in California since mid-December, and recently expanded to New York. The company also delivers emergency contraception.
Supporters say by eliminating time-consuming and potentially embarrassing face-to-face doctors visits for PrEP, Nurx may prompt more at-risk people to protect themselves from HIV. And as the rate of HIV diagnoses continues on a downward trend in San Francisco, Nurx could help bring the city one step closer to stopping new cases. But the service also raises the question of whether doctors can adequately treat patients they don’t see.
“It’s not a replacement for a visit,” said Dr. Wanda Filer, president of the American Academy of Family Physicians, and a practicing physician in Pennsylvania. Filer supports getting patients access to PrEP as soon as possible, but says a prescription should be followed up with an in-person doctor visit — which is not a requirement of Nurx.
“It’s important that they have someone that they feel they have a medical relationship with,” Filer said. She added an in-person visit lets the patient ask questions, and allows the doctor to provide information about vaccines, safe sex and healthy relationships.
PrEP also can have serious side effects, including kidney failure, and doctors recommend regularly monitoring users’ kidney function and testing for HIV and other STDs.
Nurx was founded by Gangeskar and A. Edvard Engesaeth, former high school classmates from Oslo, Norway. Gangeskar has a legal background and used to practice intellectual property law in Washington, D.C. Engesaeth trained as a doctor in Norway. The team secured $120,000 in seed funding from Mountain View incubator Y Combinator in November and also has some angel investors, Gangeskar said, but declined to disclose the total sum the company has raised.
To order PrEP, a user will log on to the app, answer a handful of questions about his or her sexual history and health, and visit a lab or community clinic for blood work to test for HIV, hepatitis and kidney problems. That information will be transmitted to a doctor, who may issue a prescription after evaluating the individual’s health history. A Postmates courier or UberRush driver then steps in to deliver the pills to the patient’s door.
For now, same-day service is available in San Francisco and the Peninsula, Gangeskar said, and only if users get their blood tests completed early in the day. In other parts of California, the pills will ship via the U.S. Postal Service. Nurx is hoping to further simplify the process by using mail-in blood test kits, or dispatching technicians to take blood samples at people’s homes.
The doctor also has the option to contact patients via phone, video call or secure text message to ask additional questions and provide counseling.
Nurx usually charges about $15 for same-day delivery, Gangeskar said, but the cost depends on the distance traveled. Birth control and emergency contraception are free under the Affordable Care Act, and PrEP generally is covered by insurance.
Truvada, the drug that makes up the PrEP regimen, was approved by the U.S. Food and Drug Administration in 2012. In September, Kaiser Permanente reported it found no new HIV infections among 657 San Francisco PrEP patients treated over two and a half years.
Steve Gibson, director of sexual health services for the San Francisco AIDS Foundation, said it’s not always easy to get a prescription.
“It was shocking to me to have people walk into the clinic here in the Castro and say, ‘my doctor in San Francisco didn’t know about it,’ ” Gibson said. “Or ‘my doctor in San Francisco said no because my boyfriend’s HIV negative. Or my doctor said no because he thinks I’m going to stop using condoms.’ “
So patients flock to Strut, the foundation’s sexual health clinic for gay, bisexual and transgender men. They come from the South and East Bay, as well as from all corners of San Francisco. It’s not unusual to see 20 or 30 people waiting outside before the clinic opens, Gibson said, and there’s a monthlong wait to book a PrEP appointment.
But not everyone wants front-door delivery.
PrEP user Phillip Babcock, a 50-year-old Castro resident, said he doesn’t feel the need to disrupt his prescription refill experience.
“I’m not part of the new economy as much,” he said, “so I’m not used to having everything delivered to my house.”
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