Health Care Facility Characteristics are Associated with Variation in Human Immunodeficiency Virus Pre-exposure Prophylaxis Initiation in Veteran's Health Administration

Implementation Science of Integrating Pre-Exposure Prophylaxis in Pharmacist-Led Services in the United States

BACKGROUND

Racial inequities in HIV in the United States (US) are pervasive. Pre-exposure prophylaxis (PrEP) is one of the most effective yet underutilized HIV prevention strategies, and stark inequities in PrEP uptake exist. Lack of access to PrEP clinics is a major barrier to access that could be overcome by integrating pharmacists into the provision of PrEP services including prescribing and dispensing.

METHODS

A number of reviews have shown promise in folding pharmacies into the expansion of PrEP services, but this review extends those by examining the implementation science evidence of pharmacist-led PrEP services in the US. We reviewed literature over the past five years of the implementation science of pharmacist PrEP services (2018-2023) and present seminal findings in this area.

RESULTS

Only two studies are anchored within an implementation science framework despite all studies assessing common implementation science constructs. Overwhelming evidence supports feasibility and adoption of PrEP services in pharmacies yet gaps in workflow integration, scalability and sustainability exist.

CONCLUSION

Continuing to build the implementation science evidence of pharmacy-based PrEP services is critical to standardize our measures across varying contexts and inform policy efforts that support pharmacy-based PrEP services.

Barriers and Facilitators to Long-Acting Injectable HIV Pre-Exposure Prophylaxis Implementation in Primary Care Since Its Approval in the United States

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is a highly effective method to mitigate the HIV epidemic, but uptake of PrEP has been slow and is associated with racial and gender disparities. Oral PrEP requires high levels of adherence to be effective, which may disadvantage certain high-risk groups. The first injectable HIV PrEP, a drug given every 2 months rather than as a daily pill, was approved by the US Food & Drug Administration in December 2021.

SETTING

A Family Medicine practice in a single health organization in the United States (November 2022 to February 2023).

METHODS

We conducted interviews with patients and key stakeholders to characterize factors affecting long-acting injectable (LAI) PrEP implementation. Data collection and analysis were guided by the Consolidated Framework for Implementation Research. Interviews were transcribed and analyzed using guided content analysis.

RESULTS

Twenty-five patients (n = 13) and practice stakeholders (n = 12) were interviewed. Overall, stakeholders described a very low uptake of LAI PrEP. Barriers to LAI PrEP included a lack of awareness, insurance and access issues, a lack of streamlined workflow, and a trust in pills over injectables. Facilitators to LAI PrEP implementation included the absence of a pill burden, a culture of shared decision making, and pharmacy support.

CONCLUSIONS

Although uptake has been slow, we have identified several promising strategies for improving rollout and implementation of LAI PrEP. Approaches that can bolster rollout of LAI PrEP include having an interdisciplinary care team that is supported by PrEP navigators and pharmacists and are informed by a patient-centered model of care to increase patient engagement and trust.

Implementing a collaborative practice agreement for HIV pre-exposure prophylaxis in the primary care setting

BACKGROUND

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) medications are highly effective at reducing HIV transmission despite their underutilization. Pharmacists can be involved in HIV PrEP management through collaborative practice agreements (CPAs).

OBJECTIVES

This study aimed to (1) describe the development of a CPA for a pharmacist-led HIV PrEP service within an outpatient primary care clinic and (2) describe the growth of the HIV PrEP CPA service after implementation.

PRACTICE DESCRIPTION

The service was developed and implemented within a network of 7 outpatient general internal medicine (GIM) clinics associated with a large academic medical center. Pharmacists are embedded in the clinics and provide care alongside an interprofessional team.

PRACTICE INNOVATION

An HIV PrEP CPA was developed and implemented by primary care pharmacists to increase access to HIV PrEP therapy through pharmacist-led visits. The pharmacist-led visits were piloted at one site before expanding to the other primary care clinics.

EVALUATION METHODS

Data were analyzed using an electronic health record-generated report that included all patients prescribed HIV PrEP medications by a GIM primary care provider (PCP) within the last year. The report was generated before the start of the intervention in October 2021 and again in May 2022. Retrospective chart review was then used to identify prescribing patterns and referrals to the pharmacy HIV PrEP CPA.

RESULTS

Seven months after the start of the HIV PrEP CPA, 122 patients were prescribed HIV PrEP by a GIM PCP. Thirty-four patients (27.9%) were newly started on HIV PrEP by a GIM PCP since the beginning of the initiative. A total of 53 patient referrals (43.4%) were placed to the pharmacy team. Five of the 7 GIM clinics have established pharmacist-led HIV PrEP services.

CONCLUSION

This report describes the successful development and implementation of a pharmacist-led HIV PrEP CPA in Ohio.

Discussion and Initiation of HIV Pre-exposure Prophylaxis Were Rare Following Diagnoses of Sexually Transmitted Infections Among Veterans

BACKGROUND

Healthcare encounters for the diagnosis and treatment of sexually transmitted infections (STIs) are common and represent an opportunity to discuss and initiate HIV pre-exposure prophylaxis (PrEP). Little is known about how frequently PrEP is discussed and initiated in association with encounters for STIs.

DESIGN

Retrospective cohort and nested case-control study, matched by STI date, in national Veterans Health Administration (VHA) facilities  from January 2013 to December 2018.

PARTICIPANTS

Veterans with a first STI diagnosis (i.e., early syphilis, gonorrhea, or chlamydia) based on ICD codes, excluding those with prior HIV diagnosis, prior PrEP use, or STI diagnosed on screening during a visit to initiate PrEP.

MAIN MEASURES

Frequency of PrEP initiation within 90 days of healthcare encounter for STIs. In the case-control study, we performed a structured chart review from the initial STI-related clinical encounter and quantified frequency of PrEP discussions among matched patients who did and did not initiate PrEP in the following 90 days.

KEY RESULTS

We identified 23,312 patients with a first STI, of whom 90 (0.4%) started PrEP within 90 days. PrEP initiation was associated with urban residence (OR = 5.0, 95% CI 1.8-13.5), White compared to Black race (OR = 1.7, 95% CI 1.0-2.7), and syphilis diagnosis (OR = 5.7, 95% CI 3.7-8.6). Chart review revealed that discussion of PrEP was rare among people with STIs who did not subsequently start PrEP (1.1%, 95% CI 0.1-4.0). PrEP initiation was associated with documentation of sexual history (80.0% of initiators vs. 51.0% of non-initiators, p < 0.01) and discussion of PrEP (52.2% vs. 1.1%, p < 0.01) during the initial STI diagnosis encounter.

CONCLUSIONS

Discussion and initiation of PrEP were rare following healthcare encounters for STIs. Interventions are needed to improve low rates of sexual history-taking and discussion of PrEP during healthcare encounters for STIs.

Pharmacy-Based Interventions to Increase Use of HIV Pre-exposure Prophylaxis in the United States: A Scoping Review

HIV pre-exposure prophylaxis (PrEP) remains underutilized in the U.S. Since greater than 85% of PrEP prescriptions are filled at commercial pharmacies, pharmacists are uniquely positioned to increase PrEP use. This scoping review explores pharmacy-based initiatives to increase PrEP use. We searched PubMed, PsycINFO, CINAHL, and Scopus for peer-reviewed studies on pharmacist-led interventions to increase PrEP use or pharmacy-based PrEP initiatives. Forty-nine articles were included in this review. Overall, studies demonstrated that patients expressed strong support for pharmacist prescription of PrEP. Three intervention designs compared changes in PrEP initiation or knowledge pre- and post-intervention. Commentary/review studies recommended PrEP training for pharmacists, policy changes to support pharmacist screening for HIV and PrEP prescription, and telemedicine to increase prescriptions. Pharmacists could play key roles in improving PrEP use in the U.S. Studies that assess improvements in PrEP use after interventions such as PrEP prescription, PrEP-specific training, and adherence monitoring by pharmacists are needed.

Testing practices and incidence of chlamydial and gonococcal infection in the Veterans Health Administration, 2009-2019

BACKGROUND

Chlamydia trachomatis and Neisseria gonorrhoeae cases reached a record high in the United States in 2018. Although active duty military servicemembers have high rates of chlamydia and gonorrhea infection, trends in chlamydia and gonorrhea in the Veterans Health Administration (VHA) system have not been previously described, including among patients with human immunodeficiency virus (HIV) and young women.

METHODS

We identified all Veterans in VHA care from 2009-2019. Tests and cases of chlamydia and gonorrhea were defined based on lab results in the electronic health record. Chlamydia and gonorrhea incidence rates were calculated each year by demographic group and HIV status.

RESULTS

In 2019, testing for chlamydia and gonorrhea occurred in 2.3% of patients, 22.6% of women ages 18-24, and 34.1% of persons with HIV. 2019 incidence of chlamydia and gonorrhea was 100.8 and 56.3 cases per 100,000 VHA users, an increase of 267% and 294%, respectively, since 2009. Veterans aged <34 years accounted for 9.5% of the VHA population but 66.9% of chlamydia and 42.9% of gonorrhea cases. Chlamydia and gonorrhea incidence rates in persons with HIV were 1,432 and 1,687 per 100,000, respectively.

CONCLUSIONS

The incidence of chlamydia and gonorrhea rose dramatically from 2009-2019. Among tested persons, those with HIV had a 15.2-fold higher unadjusted incidence of chlamydia and 34.9-fold higher unadjusted incidence of gonorrhea compared to those without HIV. VHA-wide adherence to chlamydia and gonorrhea testing in high-risk groups merits improvement.

Brief Report: Incidence of HIV in a Nationwide Cohort Receiving Pre-exposure Prophylaxis for HIV Prevention

BACKGROUND

Cases of HIV, while infrequent, have been reported during tenofovir disoproxil fumarate/emtricitabine use as pre-exposure prophylaxis (PrEP). We describe the incidence of HIV and patterns of PrEP use within the Veterans Health Administration (VHA).

METHODS

We conducted a retrospective cohort study among persons initiating PrEP in the VHA between July 2012 and April 2016 using national VHA data. We defined time on PrEP and time at risk of HIV exposure as the total time from the first PrEP fill to exhaustion of supply of the final PrEP prescription. We identified incident cases of HIV infection after PrEP initiation based on laboratory data. Medication adherence measures and days without pills were calculated using pharmacy fill data. We used a chart review to determine patient-reported PrEP use around the time of diagnosis.

RESULTS

We identified 825 unique patients initiating PrEP; they were 97% men and 67% white, with a mean age of 41 years. Six HIV infections were observed during the study period, yielding an HIV incidence of 0.8 (Poisson exact 95% confidence interval: 0.3 to 1.8) cases per 100 person-years. Two cases occurred during active PrEP use by self-report and perfect adherence based on fill data. Both were infected with viruses containing the M184V mutation. Four additional cases were diagnosed after self-reported discontinuation.

CONCLUSIONS

HIV infection was rare in a nationwide cohort of PrEP users. Although most of the infections occurred during inconsistent PrEP use, infections during periods of high measured adherence were also observed. These findings highlight the importance of PrEP persistence during periods of risk.

Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis

BACKGROUND

Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV; however, its uptake remains modest. Given that there are fewer cost barriers to receiving PrEP within VHA than via commercial insurance, VHA represents an ideal setting in which to study other barriers that may impact patients seeking PrEP.

OBJECTIVE

We sought to understand potential barriers to obtaining PrEP within the Veterans Health Administration (VHA) through examination of documentation in electronic medical records.

DESIGN

Retrospective structured chart review, including chart abstractions of notes, referrals, and communications; content analysis of charts from a subsample of patients receiving PrEP in VHA.

PARTICIPANTS

One hundred sixty-one patients prescribed PrEP at 90 sites varying in PrEP prescribing rates.

APPROACH

We extracted descriptive information and conducted a qualitative analysis of all PrEP-relevant free-text notes including who initiated the PrEP conversation (patient vs. provider), time interval between request and prescription, reasons for denying PrEP, and patient responses to barriers.

KEY RESULTS

Patients initiated 94% of PrEP conversations and 35% of patients experienced delays receiving PrEP ranging from six weeks to 16 months. Over 70% of cases evidenced barriers to access. Barriers included provider knowledge gaps about PrEP, provider knowledge gaps about VHA systems related to PrEP, confusion or disagreement over clinic purview for PrEP, and provider attitudes or stigma associated with patients seeking PrEP.

CONCLUSIONS

Although PrEP is recommended for HIV prevention in high-risk persons, many PrEP-eligible individuals faced barriers to obtaining a prescription. Current practices place substantial responsibility on patients to request and advocate for this service, in contrast to many other preventive services. Understanding the prevalence and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission.

Evolving Toward Shared HIV Care Using the Champlain BASE eConsult Service

Background. Electronic consultation (eConsultation) is a potential strategy to improve access to specialist expertise and facilitate collaborative care models. The Champlain BASE eConsult service allows for asynchronous communication between primary care providers (PCP) and specialists on a secure, web-based system. HIV experts accessible include HIV physician specialists, HIV pharmacists, and social workers with expertise in HIV. Objective. This study aims to describe the use, value, and utility of this eConsultation service in the care of people living with HIV and to characterize the common question types and clinical topics asked by PCPs. Methods. We analyzed the data from eConsults sent to the HIV specialty group in Ontario’s Champlain Local Health Integration Network between February 2015 and December 2017. Usage data and close-out survey responses were analyzed using descriptive statistics, eConsults were classified using a predefined list of validated taxonomy, and a thematic analysis was performed on the consultation logs to identify common clinical themes. Results. Among the 46 eConsults, the most common question type related to drug treatment (58.7%, n = 27) and management (19.6%, n = 9). The main clinical themes involved the care of significant complexities in people living with HIV, such as comorbidities and drug interactions, and suggestions of coordinated patient care. As well, eConsult was used for advice regarding pre-exposure prophylaxis for HIV-negative patients at risk of HIV infection. PCPs highly valued the eConsult service (average rating 4.8/5). Conclusion. Overall, this study demonstrates that eConsult provides an efficient and valuable service to PCPs caring for patients living with or at risk for HIV by improving access to HIV specialists and facilitating the delivery of team-based comprehensive care.