In California, Startup Delivers PrEP to Your Door

California residents can now get PrEP delivered to their door via Nurx, a web-based app that also provides birth control. Clients can get a prescription for Truvada after undergoing laboratory tests to ensure that they are not already HIV-positive and have normal kidney function.

"By making PrEP more accessible to high-risk users, the Nurx app has the potential to be a game-changer in the fight to end the epidemic," said company co-founder and CEO Hans Gangeskar.

A San Francisco PrEP researcher talked about the benefits of the delivery app.

"The Nurx service is designed to make PrEP, contraception, and sexually transmitted infection testing more available to diverse clients," Dr. Robert Grant of UCSF, a leading PrEP researcher who is advising the company, told the Bay Area Reporter . "It will be especially helpful for people who live outside of major cities and have more difficultly finding a PrEP provider."

Even in San Francisco, Grant noted, PrEP clinics are stretched to capacity by increasing demand.

But others are skeptical about a service that provides medication without in-person visits with a doctor.

"While the goal to improve access to effective HIV prevention tools is admirable, removing any or all direct contact with a physician or medical provider is not," said Michael Weinstein of the Los Angeles-based AIDS Healthcare Foundation, who has been critical of PrEP. "At a time when [STI] rates are skyrocketing, particularly among young people using hookup apps like Grindr and Tinder, we challenge the wisdom and ethics of an app that allows people to order a drug to prevent HIV as readily as ordering pizza."

Closing the Gap

The U.S. Food and Drug Administration approved Gilead Sciences' Truvada (tenofovir/emtricitabine) for pre-exposure prophylaxis in July 2012. Studies of gay and bisexual men and transgender women have shown that Truvada reduces the risk of HIV infection by more than 90 percent if used consistently.

Yet despite its proven effectiveness, only a small proportion of people who could benefit from PrEP are currently using it. Barriers include lack of awareness, stigma, and a shortage of doctors who are willing to provide it.

According to a recent report from the Centers for Disease Control and Prevention, a quarter of gay and bisexual men and a fifth of people who inject drugs in the U.S. may be eligible for PrEP; adding at-risk heterosexual men and women brings the total to over 1.2 million.

It is difficult to estimate how many people have used PrEP, since this information is not centrally collected. But experts estimate that perhaps 40,000 people in the U.S. are taking it. Locally, both the San Francisco AIDS Foundation's Strut clinic and Kaiser Permanente San Francisco have prescribed PrEP for more than 600 people - mostly gay men - with no new HIV infections among those who use it regularly.

Nurx aims to help close the gap, enabling more people to easily access PrEP.

The San Francisco-based company - dubbed the "Uber for birth control" - is backed by the startup incubator Y Combinator and angel investors. It launched its app to provide birth control and emergency contraception last December and began offering Truvada in California at the end of March, with plans to expand to other states.

"We hope to make PrEP more accessible to those that need and want it," said Edvard Engesaeth, a medical doctor trained in Norway who co-founded Nurx with Gangeskar.

Interested users complete a health profile on the Nurx website and answer questions about their risk factors and sexual history; a mobile phone app is also being developed. Nurx partner physicians review the information to determine if clients are eligible, and doctors and clients can communicate throughout the process via text messages, email, or phone.

Eligible users must then complete lab tests for HIV, hepatitis B and C, kidney function, and pregnancy if applicable. Nurx also "strongly suggests" testing for chlamydia, gonorrhea, and syphilis, Gangeskar said.

People who are already HIV-positive need combination treatment, and using Truvada alone can lead to drug resistance. Since tenofovir can cause kidney problems, people with pre-existing kidney impairment should not take Truvada. CDC guidelines call for PrEP users to receive an HIV test every three months, and STI screening and kidney function monitoring at least every six months.

Nurx blood and urine tests can be done at any LabCorp location nationwide. To simplify testing further, the company is looking at dispatching phlebotomists to clients' homes to draw blood or using mail-in blood test kits.

If the physician decides a client is eligible for PrEP, a three-month supply of Truvada is prescribed and delivered to the user's address. People in the Bay Area can receive PrEP by courier within 24 hours; elsewhere in the state, pills are shipped via the postal service.

Nurx changes around $15 for delivery on top of the cost of PrEP. Truvada retails for about $1,500 per month and is covered by Medicaid and many insurance companies, though copay and deductible policies vary widely. Gilead provides payment assistance for eligible people.

"Billing insurance is done directly by the pharmacies and labs that we work with, rather than by Nurx," Gangeskar told the B.A.R. "We walk our users through the billing process for PrEP, as it can definitely be tricky."

Mixed Opinions

The Nurx founders believe eliminating the need for face-to-face interaction with doctors could improve access to PrEP.

"Using the Nurx app allows a patient to speak about their sexual history in a much more open way and it gives them the freedom to be completely honest without the possibility to feel judgment from another person in the room," Gangeskar said. "It also allows them to ask a wide variety of questions before and after their prescription has been approved instead of being rushed through a traditional office visit."

But some advocates feel a regular relationship with a health provider offers important benefits.

"I do see this app as a potentially powerful tool for people in rural areas, or for folks who live in places where PrEP access is especially challenging," Jim Pickett from the AIDS Foundation of Chicago told the B.A.R. "However, I am not convinced this tool will help the populations that are actually most vulnerable to HIV and are not accessing PrEP in large numbers yet, namely young gay black men and transgender women of color.

"PrEP is more than a pill, it's a program," Picket continued. "The ongoing HIV and STI testing, sexual health and adherence counseling, medical monitoring, and the ability for an individual to regularly interact in person with health care providers to address holistic health and wellness issues beyond HIV prevention are all very important facets of PrEP provision. How will this app support and enhance this connection rather than disrupt it?"

Ken Almanza from AIDS Project Los Angeles Health and Wellness had similar misgivings.

"Working mostly with people of color, I find that frequent human interaction is a necessary component for my clients," he said. "You would be surprised how many patients end up accessing mental health, dental care, and other necessary services while in our clinics. PrEP is an amazing bridge for clients to learn about other services available to them."

Nurx is attempting to address these concerns by partnering with community organizations, medical providers, and other resources to reach the populations that should be taking PrEP.

"Nurx was pretty enthusiastic about connecting to discuss designing a system that will reach and improve the lives of people struggling to access safe, competent health care," said Brandyn Gallagher of Outshine NW, a Seattle-based organization that promotes LGBT health and equity. "Nurx has the potential to revolutionize health care in a way that actually centers personal empowerment rather than centering traditional provider-patient power dynamics."

Grant said that Nurx will help those who can't always get to a doctor.

"I think the service will be particularly helpful for people who have difficultly scheduling or keeping medical appointments, including young people, single mothers, and busy professionals," he said. "It will also be attractive to people who are afraid of doctors because of negative judgments they have experienced in the past. Success in freeing ourselves from HIV transmission can occur if life-preserving sexual health services become easy to access for diverse and active people, which is Nurx's goal. I hope staying free of HIV and AIDS becomes as easy as ordering a pizza."