Launching PrEP
12 months ago, we welcomed Dr Babak Ashrafi as our Clinical Lead for Service Expansion. It was a new role that hadn’t previously existed at ZAVA so we sat down with him to find out his reasons for joining ZAVA and his involvement in the launch of one of our newest services, PrEP.
“Before joining ZAVA I worked as both a salaried GP and as a GP partner. I also spent five years at Nuffield Health. I’d been chopping and changing roles ever since I started to burn out as a partner in my inner city practice, and I still wasn’t happy. So, when I was contacted by ZAVA on LinkedIn I was interested to find out more, especially with regard to how ZAVA is revolutionising Healthcare with technology.
I was given a lot of autonomy and scope to make the role my own and after an initial settling in period, I’ve definitely found my feet. I’m here to help with any improvements that can be made to existing services, and also to lead from a clinical perspective on any new services we want to offer. For the first time in a long time, I am happy at work and really enjoy my job.
One of the biggest projects I worked on last year was the launch of our PrEP service. Pre-exposure prophylaxis (PrEP) is a medication taken to avoid catching HIV and initial study data published a few years ago showed without a doubt that PrEP was highly effective at preventing HIV infection in high risk groups. However, access to the drug in England has been relatively limited with PrEP only available on the NHS for 26,000 people taking part in the NHS IMPACT trial.
There are also other concerns relating to access — if a patient wants or needs PrEP, they’re required to attend an STI clinic in person. The wider LGBTQI community may be historically comfortable with this on the whole, but data shows that other high risk communities who need access to PrEP (e.g. certain heterosexual Black African communities) simply do not engage in the same way. This is where our idea for PrEP came from — understanding the background to this dilemma, and seeing an opportunity which would serve a previously disadvantaged subset of the population. By offering PrEP online to eligible patients we’re able to provide them with medication when and where they need it, with no waiting times, and the ability to talk to our doctors whenever they need.
To kick off the project, I initially spoke with my colleague, Alex, who runs ZAVA’s Pharmacy Operations. We needed to assess whether we (as non-specialists) could prescribe the drug, and whether it was available for us to order. Once we’d gathered this information, we met with the head of markets for Zava UK and decided on a plan of action that would enable us to launch a safe service offering consultation, assessment, prescription and aftercare. At this point, Alex took control of day-to-day project management and when necessary brought the relevant teams and people together. There was a lot of cross company collaboration with Markets, Marketing (including Creative and Content), Pharmacy / Operations, Legal, Clinical, Engineering and UX all involved at some point.
From a Clinical perspective we needed to define the service, decide who we could safely prescribe to and agree inclusion and exclusion criteria. As a digital healthcare provider, our guidelines sometimes have to be more strict, or slightly different, compared with national guidelines but we used BASSH/BHIVA 2018, as well as the drug SPC in order to outline our service. I also took it upon myself to read available guidelines specifically for PrEP and decide on an appropriate patient flow.
Additionally, I was also guided by the content of an internal talk I had organised by an HIV consultant from Chelsea & Westminster Hospital. At this session, and a few afterwards, I formulated and discussed my ideas about the patient flow for Zava’s PrEP service; first to a handful of clinical colleagues, then to the rest of the project team. I used this feedback to write a document detailing the service proposal. Once the team and I were happy, I completed the clinical guidelines and outlined the questions that had to be incorporated into our asynchronous clinical questionnaire to ensure patient safety.
As an example, PrEP should only be taken by people who are HIV negative and at high risk of contracting HIV, either through not wearing a condom or sharing needles. This is because it’s possible to develop resistance to HIV medication if PrEP is taken by someone who is HIV positive. National and International guidelines for PrEP also highly recommend regular (3 monthly) STI testing as routine. It’s especially important to test for hepatitis B and C at the start since the drugs in PrEP are antivirals which may affect future treatment options for patients that are Hep B or C positive. Another vital check that needs to be completed before a patient starts PrEP medication is a kidney function test. The drugs that make up PrEP tablets are processed in the body and disposed of in urine by the kidneys. If a patient’s kidneys aren’t functioning correctly, the drugs can build up in the body to unsafe levels. This in turn can further damage the kidneys.
As a result, we request all patients get a mandatory HIV and kidney blood test up to four weeks before starting PrEP medication and also recommend a full STI screen. Our clinical team will not approve the order and prescribe the drug without making sure the tests will be done.
Here’s an outline of ZAVA’s recommended/necessary testing before and during PrEP therapy — all of which is outlined clearly to patients on our website and within the order process and questionnaire:
- Up to 4 weeks before starting PrEP: HIV test and kidney test (necessary), full STI screen (recommended)
- Every 3 months: HIV test (necessary), STI screen (recommended)
- Every 6 months: kidney test (if at high risk of kidney problems)
- Every 12 months: kidney test (if at low risk of kidney problems)
Once the structure of the service was agreed, the next step was to ensure our clinical and customer support teams were adequately trained so that they could safely support patients. The training for our doctors consisted of three core elements, an interactive face-to-face session with an HIV consultant, self-directed learning using the European AIDS Clinical Society online training modules / familiarisation with ZAVA’s approved PrEP guidelines and a review of applied cases”
ZAVA’s PrEP service launched in November 2019 and over the last 7 months we have supported a number of patients in accessing medication that has protected them from HIV infection. It’s a service we are proud to be able to offer to patients and one we know makes a positive and significant difference to their everyday lives.
For more information about our PrEP service please visit: https://www.zavamed.com/uk/prep.html
