The HIV Pre-exposure Prophylaxis (PrEP) Toolkit developed by the Virginia Department of Health (VDH) is intended as a general resource for providers seeking more information about PrEP. In addition to the clinical information intended specifically for medical providers the toolkit contains all of the forms needed to assist a patient to enroll in the state’s PrEP program as well as forms that could be used by administrators at local health departments seeking to partner with VDH in providing PrEP.
For Clinical Staff
This is the Virginia Department of Health PrEP Clinic Reference Manual. The protocols outlined in this resource are meant to serve as a guide for project personnel and providers administering PrEP under the VDH-DDP PrEP Program. They are based on the CDC Guidance above along with NY City Health Department’s Guidance.
Tools for Program Staff
- PrEP Drug Assistance Program Application – This application needs to be filled out for every patient accessing PrEP through the Commonwealth’s stock of drugs dispensed through the Virginia Department of Health’s central pharmacy. Please read the instructions as you fill out the form, which is also available in Spanish. Once completed each form should be faxed to central office at 804-864-8050.
- PrEP Drug Assistance Program Application (Spanish) – This is the Spanish version of the DAP application.
- No Income Letter – PrEP is available to all Virginians regardless of income. If a patient has no income please provide this letter to the patient and have them return it when it is appropriately completed.
- Pharmacy Quick Reference Guide – This is just a quick guide to getting a prescription filled through the state’s PrEP DAP program.
- Sample PrEP Clinic Flow Model – This is an example of the clinic flow at the Richmond City Health Department’s PrEP clinic. This document can be used as a model for patient flow at an STD clinic.
- Medication Order Form – This form is filled out by the PrEP navigator to order a patient’s medication. The first time a prescription is submitted this document will accompany the prescription. To make subsequent requests for a patients medication, if the prescription is written for more than 30 days, only this form needs to be sent in. In addition, a patient signs this form when picking up medication so the pharmacy and central office can confirm that patients are getting their medication.
- Data Collection Tool – Each cell on this spreadsheet contains a drop-down menu related to the column heading. Please select the menu item that most closely reflects the patient’s choice. ALSO: please note – add any sexually transmitted infections found at the time of testing in the notes column. And, please be sure to update enrollment status as it changes by choosing a new item from the drop-down menu.
- PrEP Assessment Tool – This tool serves serves as the clinical screener for PrEP. If a patient answers yes to one or more of the questions on the sheet they should be referred to the PrEP navigator for PrEP education and a conversation about whether PrEP is an appropriate HIV prevention option for the patient.
- New Patient Checklist – A helpful checklist for the navigator to make sure they have completed all of the steps in the patient onboarding process.
- Agreement Form (OPTIONAL) – This form may be used as part of the patient education process with the patient checking each item as it’s reviewed and then placing it in the patient’s chart.
- Withdrawal Form – Please fill out this form when a patient formally withdraws from the PrEP program, drops out or is lost to care. Then submit it to the PrEP eligibility specialist so we can ensure that medication is stopped.
Tools for Administrative Staff
- Standard Budget Form – This is VDH’s standard budget form. Please fill in the appropriate line items and submit along with PrEP work plan.
- Budget Reallocation Request Form – This is the standard form used to submit a budget reallocation.
- PrEP Labs – Budget Justification Template – This template assists administrative staff in budgeting for PrEP by allowing the user to plug in the number of patients they expect and then estimate cost based on laboratory tests, estimated treatment STDs and vaccines based on percentages recommended by the Centers for Disease Control.
- Lab Calculator – This spreadsheet allows the use to calculate lab costs based on the VDH contracted price, valid until July 1, 2017. Simply enter the number of patients you anticipate for each test based on CDC guidelines and the spreadsheet will do the rest.
For more information on PrEP services and programming in Virginia, please contact Eric Mayes, PrEP Coordinator.