PrEP Provider Directory Survey

New PrEP Provider Capacity Survey

The Connecticut Department of Public Health maintains a state-wide voluntary directory of clinical providers currently prescribing Truvada® as pre-exposure prophylaxis (PrEP) for the prevention of HIV available online at: http://www.ct.gov/dph/lib/dph/aids_and_chronic/prevention/pdf/prep_services.pdf

The directory is intended to simplify consumer access to PrEP by listing providers who are knowledgeable in PrEP prescribing and monitoring protocols; experienced in providing care to populations disproportionately affected by HIV; and able to accept new PrEP patients in a reasonable time frame.

This survey is intended to assess your clinic's readiness to provide PrEP and identify needs for training or technical assistance.

It is also designed to collect information consumers have found useful in making new PrEP appointments. Please provide as much information as you can about weekend and evening hours, availability of staff who can provide insurance benefits navigation, and direct contact information for a staff member who is knowledgeable about PrEP and can schedule appointments. This information can always be updated if need be.

Thank you for taking the time to fill out this survey. We look forward to working with you.

1.Clinic Information

Clinic Name

Street Address

City

Zip Code

Phone Number

Website

2.Clinical Provider Information

Name and Degree

10-digit National Provider Identifier (NPI) #

Specialty/Area of Practice

3.Contact Person for New PrEP Patients

Name (& Degree if applicable)

Title

Phone

4.Do you currently prescribe daily tenofovir/emtricitabine (Truvada®) for pre-exposure prophylaxis (PrEP) against HIV infection?

Yes

No, but our clinic would like training and technical assistance to do so

5.How many patients have you prescribed PrEP to?

6.Which of the follow populations does your clinic currently serve?

Men who have sex with men (MSM)

Transgender individuals

Injection drug users

7.Could a new PrEP patient also be seen for primary care?

8.Does the PrEP provider speak Spanish, or have resources in place to treat patients who only speak Spanish?

Yes

9.Do you/would you offer evening or weekend hours for PrEP patients?

Yes

10.If yes, list weekend or evening hours

11.Can your site assist patients with insurance enrollment?

Yes

12.Does your site have a patient care coordinator, case manager, or other support staff available to assist PrEP patients between visits (such as with medication adherence)?

13.Conducting routine, comprehensive sexual histories with male, female, and gender nonconforming patients, including discussions about anal receptive intercourse, can facilitate identification of patients who may benefit from using PrEP.

How would you rate your need for training in this skill?

No need for training; I/we routinely do this with our patients

I/we do this with some patients but could benefit from additional training

I/we rarely do this and could benefit from additional training

14.Screening and testing for sexually transmitted infections at extragenital sites (i.e., pharyngeal and rectal) is recommended as part of care when prescribing PrEP to sexually active patients.

Please indicate your clinic's need for training or technical assistance in this area:

No training needed; we routinely perform extragenital STI screens on site for sexually active patients

Training needed; clinicians or support staff could use training in collecting or submitting samples from extragenital sites

15.Please use this space for any additional information you would like to provide us

16.Would you like to be listed on the PrEP provider directory?

Yes

Yes, at a later date

17.If yes:
I understand that participation in this public directory is voluntary. I understand that by sharing the information above I consent to public listing on private and public websites (with the exception of information you direct to be withheld). I understand that inclusion in this directory does not confer any endorsement by the Connecticut Department of Public Health, nor does it establish licensing, credentialing, or certification in a specialty.

I agree with the above statement