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White DAE, Godoy A, Jewett M, Burns M, Pinto CM, Packel LJ, Garcia-Chinn M, Anderson ES, McCoy SI. Outcomes of an Emergency Department Program to Identify and Link Patients at Increased Risk for Acquiring HIV Infection to Outpatient HIV Prevention Services: The HIV PreventED Program. J Acquir Immune Defic Syndr 2024; 96:147-155. [PMID: 38771753 DOI: 10.1097/qai.0000000000003418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/01/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Emergency departments (EDs) provide care to patients at increased risk for acquiring HIV, and for many of them, the ED serves as their sole point of entry into the healthcare system. We implemented the HIV PreventED Program to increase access to HIV prevention services for ED patients. SETTING ED in Oakland, CA with an annual census of 57,000 visits. METHODS This cross-sectional study evaluated the first 9 months of the HIV PreventED Program. In this program, a navigator surveyed adult ED patients who tested HIV negative to determine their risk for acquiring HIV infection, incorporating HIV prevention counseling into their assessments. Patients at higher risk for acquiring HIV were referred to outpatient prevention services, if interested. The primary outcome measure was the number and proportion of ED patients at higher risk for acquiring HIV who followed up for outpatient prevention services. RESULTS In this study, 1233 patients who tested HIV negative were assessed by the navigator and received ED-based HIV prevention counseling. Of these, 193 (15.7%) were identified at higher risk and offered an outpatient referral for prevention services, of which 104 accepted (53.9%), 23 (11.9%) attended the referral, and 13 (6.7%) were prescribed preexposure prophylaxis (PrEP). The median time to linkage was 28 days (interquartile range 15-41 days). CONCLUSION A navigator focused on providing ED-based HIV prevention counseling and linkage to outpatient services is feasible. Strategies to more efficiently identify ED patients at higher risk for HIV acquisition, such as automated identification of risk data from the electronic health record, and policies to improve follow-up and the receipt of PrEP, such as same-day PrEP initiation, should be prospectively evaluated.
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Affiliation(s)
- Douglas A E White
- Department of Emergency Medicine, Alameda Health System-Highland Hospital, Oakland, CA; and
| | - Ashley Godoy
- Department of Emergency Medicine, Alameda Health System-Highland Hospital, Oakland, CA; and
| | - Montana Jewett
- Department of Emergency Medicine, Alameda Health System-Highland Hospital, Oakland, CA; and
| | - Molly Burns
- Department of Emergency Medicine, Alameda Health System-Highland Hospital, Oakland, CA; and
| | - Cinthya Mujica Pinto
- Department of Emergency Medicine, Alameda Health System-Highland Hospital, Oakland, CA; and
| | - Laura J Packel
- School of Public Health, Division of Epidemiology, University of California, Berkeley, Berkeley, CA
| | - Maria Garcia-Chinn
- School of Public Health, Division of Epidemiology, University of California, Berkeley, Berkeley, CA
| | - Erik S Anderson
- Department of Emergency Medicine, Alameda Health System-Highland Hospital, Oakland, CA; and
| | - Sandra I McCoy
- School of Public Health, Division of Epidemiology, University of California, Berkeley, Berkeley, CA
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Jackson KJ, Chitle P, McCoy SI, White DAE. A Systematic Review of HIV Pre-exposure Prophylaxis (PrEP) Implementation in U.S. Emergency Departments: Patient Screening, Prescribing, and Linkage to Care. J Community Health 2024; 49:499-513. [PMID: 38127296 PMCID: PMC10981603 DOI: 10.1007/s10900-023-01320-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patient's STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.
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Affiliation(s)
- Kristopher J Jackson
- Center for AIDS Prevention Studies, University of California, San Francisco, 550 16th Street - 3rd Floor, San Francisco, CA, 94158, USA.
| | - Pooja Chitle
- School of Public Health, University of California, Berkeley, CA, USA
| | - Sandra I McCoy
- School of Public Health, University of California, Berkeley, CA, USA
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3
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White DAE, Solnick RE. Communicable Disease Screening and Human Immunodeficiency Virus Prevention in the Emergency Department. Emerg Med Clin North Am 2024; 42:369-389. [PMID: 38641395 DOI: 10.1016/j.emc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Emergency departments (ED) provide care to populations with high rates of communicable diseases, like HIV, hepatitis C virus, and syphilis. For many patients, the ED is their sole entry point into the healthcare system and they do not routinely access screening and prevention services elsewhere. As such, the ED can serve an important public health role through communicable disease identification, treatment, and prevention. In this article, we examine national recommendations, peer-reviewed literature, and expert consensus to provide cutting edge strategies for implementing communicable infectious disease screening and prevention programs into routine ED care.
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Affiliation(s)
- Douglas A E White
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Rachel E Solnick
- Icahn School of Medicine at Mount Sinai Hospital, 555 West 57th Street 5-25, New York, NY 10019, USA
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Devlin SA, Johnson AK, Stanford KA, Haider S, Ridgway JP. "There hasn't been a push to identify patients in the emergency department"-Staff perspectives on automated identification of candidates for pre-exposure prophylaxis (PrEP): A qualitative study. PLoS One 2024; 19:e0300540. [PMID: 38483939 PMCID: PMC10939190 DOI: 10.1371/journal.pone.0300540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
Automated algorithms for identifying potential pre-exposure prophylaxis (PrEP) candidates are effective among men, yet often fail to detect cisgender women (hereafter referred to as "women") who would most benefit from PrEP. The emergency department (ED) is an opportune setting for implementing automated identification of PrEP candidates, but there are logistical and practical challenges at the individual, provider, and system level. In this study, we aimed to understand existing processes for identifying PrEP candidates and to explore determinants for incorporating automated identification of PrEP candidates within the ED, with specific considerations for ciswomen, through a focus group and individual interviews with ED staff. From May to July 2021, we conducted semi-structured qualitative interviews with 4 physicians and a focus group with 4 patient advocates working in a high-volume ED in Chicago. Transcripts were coded using Dedoose software and analyzed for common themes. In our exploratory study, we found three major themes: 1) Limited PrEP knowledge among ED staff, particularly regarding its use in women; 2) The ED does not have a standardized process for assessing HIV risk; and 3) Perspectives on and barriers/facilitators to utilizing an automated algorithm for identifying ideal PrEP candidates. Overall, ED staff had minimal understanding of the need for PrEP among women. However, participants recognized the utility of an electronic medical record (EMR)-based automated algorithm to identify PrEP candidates in the ED. Facilitators to an automated algorithm included organizational support/staff buy-in, patient trust, and dedicated support staff for follow-up/referral to PrEP care. Barriers reported by participants included time constraints, hesitancy among providers to prescribe PrEP due to follow-up concerns, and potential biases or oversight resulting from missing or inaccurate information within the EMR. Further research is needed to determine the feasibility and acceptability of an EMR-based predictive HIV risk algorithm within the ED setting.
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Affiliation(s)
- Samantha A. Devlin
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, Illinois, United States of America
| | - Amy K. Johnson
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States of America
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Kimberly A. Stanford
- Department of Medicine, Section of Emergency Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Sadia Haider
- Department of Medicine, Section of Obstetrics and Gynecology, Rush University, Chicago, Illinois, United States of America
| | - Jessica P. Ridgway
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, Illinois, United States of America
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5
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Johnson AK, Devlin S, Haider S, Oehler C, Rivera J, Alvarez I, Ridgway J. Evaluation of multiple data sources for predicting increased need for HIV prevention among cisgender women: understanding missed opportunities for Pre-exposure Prophylaxis (PrEP). BMC Infect Dis 2023; 23:781. [PMID: 37946103 PMCID: PMC10636899 DOI: 10.1186/s12879-023-08719-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/17/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Ciswomen constitute a disproportionately low percentage of pre-exposure prophylaxis for HIV prevention (PrEP) users compared to men. Despite PrEP's effectiveness, women are 5.25 times less likely to take PrEP than men. Identifying women who have increased reasons for HIV prevention and educating and offering PrEP to these women is crucial to reducing HIV transmission and overall health equity. However, the best method of identifying women at highest risk of acquiring HIV remains unknown. This study aimed to identify common HIV risk factors and data sources for identifying these common factors (e.g., electronic medical record data, open source neighborhood data), as well as potential intervention points and missed opportunities for PrEP linkage. METHODS We conducted an evaluation of multiple data sources: semi-structured qualitative interviews, electronic medical record (EMR) chart abstraction, and open source data abstraction. We accessed EMRs for enrolled participants and all participants signed a standard release of medical information (ROI) form for all institutions at which they had received medical care for the five-year period preceding their HIV diagnosis. Data were abstracted using a standardized procedure. Both structured and unstructured fields (i.e., narrative text of free notes) within the EMR were examined and included for analysis. Finally, open data sources (e.g., STI cases, HIV prevalence) were examined by community area of Chicago. Open data sources were used to examine several factors contributing to the overall Economic Hardship Index (EHI) score. We used these calculated scores to assess the economic hardship within participants' neighborhoods. RESULTS A total of 18 cisgender women with HIV participated in our study. Participants were mostly Black/African American (55.6%) and young (median age of 34). Our analysis identified two main themes influencing HIV risk among participants: contextual factors and relationship factors. Further, potential pre-diagnosis intervention points and missed opportunities were identified during reproductive health/prenatal visits, behavioral/mental health visits, and routine STI testing. Our evaluation of multiple data sources included investigating the presence or absence of information in the EMR (STI history, HIV testing, substance use, etc.) as well as whether pertinent information could be gathered from open access sources. CONCLUSION Ciswomen recently diagnosed with HIV identified many shared experiences, including syndemic conditions like mental illness and substance abuse, sex with men who have sex with men, and frequent moving in areas with high HIV incidence prior to their diagnosis. It is imperative that providers ask patients about social history, information about partners, and other key variables, in addition to the standardized questions. Findings can be used to better recognize ciswomen most vulnerable to HIV and offer PrEP to them, reducing HIV transmission.
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Affiliation(s)
- Amy K Johnson
- Reasearch Associate Professor Center for Gender, Sexuality, and HIV Prevention, The Potocsnak Family Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Samantha Devlin
- Research Coordinator, University of Chicago, Chicago, IL, USA
| | - Sadia Haider
- Division of Family Planning, Rush University Medical Center (RUMC), Chicago, IL, USA
| | - Cassandra Oehler
- Clinical Assistant Professor Allegheny Health Network, Drexel University School of Medicine, Pennsylvania, USA
| | - Juan Rivera
- Social and Behavioral Research Manager, Howard Brown Health, Chicago, USA
| | - Isa Alvarez
- Clinical Research Coordinator, Division of Family Planning, Rush University Medical Center (RUMC), Chicago, IL, USA
| | - Jessica Ridgway
- Biological Sciences Division, University of Chicago, Chicago, IL, USA
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6
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Gormley MA, Nagy TR, Moschella P, Lu Z, Rodriguez J, Roth P. HIV Pre-Exposure Prophylaxis in the Emergency Department: A Systematic Review. Ann Emerg Med 2023; 81:468-481. [PMID: 36117011 DOI: 10.1016/j.annemergmed.2022.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/28/2022] [Accepted: 07/13/2022] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Many emergency departments (EDs) have identified the importance of HIV prevention and have implemented steps to screen and offer preexposure prophylaxis (PrEP). The objective of this study was to systematically review existing literature that identifies PrEP eligibility in the ED and summarize outcomes along the PrEP cascade of care (awareness, interest, linkage to treatment, initiation, and retention) for patients in ED. METHODS Four databases captured all PrEP-related studies in EDs from January 1, 2013 to January 27, 2022. Data were extracted on study characteristics and outcomes, and study quality was assessed using a modified quality assessment tool by the Effective Public Health Practice Project. RESULTS Of the 218 articles, 16 were subjected to full-text review, and 7 met inclusion criteria. Although most studies identified patients who were PrEP eligible using criteria adapted from the 2017 Centers for Disease Control and Prevention PrEP guidelines, the number and time frame for each criterion varied. Six studies reported outcomes on the PrEP cascade of care, showing a relatively high prevalence of awareness and interest but a very low prevalence of linkage and uptake. No studies documented retention in PrEP treatment. CONCLUSION Although up to a third of patients in ED assessed in the current study were PrEP eligible, less than half of PrEP-eligible participants had prior knowledge of PrEP, and very few who expressed interest in the ED were ultimately linked to PrEP treatment or initiated PrEP. Future research is necessary to identify strategies to increase PrEP education, interest, and linkage to care from the ED.
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Affiliation(s)
- Mirinda Ann Gormley
- Department of Emergency Medicine, Prisma Health Upstate, Greenville, SC; University of South Carolina School of Medicine Greenville, Greenville, SC; Clemson University School of Health Science Research, Greenville, SC.
| | - Tibor R Nagy
- Department of Emergency Medicine, Prisma Health Upstate, Greenville, SC
| | - Phillip Moschella
- Department of Emergency Medicine, Prisma Health Upstate, Greenville, SC; University of South Carolina School of Medicine Greenville, Greenville, SC; Clemson University School of Health Science Research, Greenville, SC
| | - Zhexi Lu
- Penn State University School of Medicine, Hershey, PA
| | - Julia Rodriguez
- University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Prerana Roth
- University of South Carolina School of Medicine Greenville, Greenville, SC; Clemson University School of Health Science Research, Greenville, SC; Department of Internal Medicine, Prisma Health Upstate, Greenville, SC
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7
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Aronson B, Kulie P, Castel AD, Powell NN, McCarthy M. Evaluating Patient Perceptions on PrEP Screening and Referral in the Acute Care Setting. AIDS Behav 2023; 27:1024-1029. [PMID: 36219272 DOI: 10.1007/s10461-022-03839-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/25/2022]
Abstract
Pre-exposure prophylaxis (PrEP) for HIV is highly effective, yet uptake has been limited. We measured PrEP knowledge, eligibility, and referral willingness among patients receiving emergency or acute care in Washington, DC. We surveyed HIV-negative patients with STI-related complaints on HIV risk behaviors, PrEP knowledge, eligibility, and willingness for PrEP referral. Among 174 participants, 70% were PrEP unaware and 33% were PrEP eligible. Most participants (81%) supported learning more, 64% would consider taking PrEP, and 28% agreed to immediate referral. Willingness to learn more about PrEP suggests referral from non-traditional settings may increase uptake. Further evaluation of this approach is warranted.
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Affiliation(s)
- Benjamin Aronson
- Department of Epidemiology, The George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave NW, Suite 500, 20052, Washington, D.C, USA
| | - Paige Kulie
- Department of Epidemiology, The George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave NW, Suite 500, 20052, Washington, D.C, USA
| | - Amanda D Castel
- Department of Epidemiology, The George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave NW, Suite 500, 20052, Washington, D.C, USA.
| | - Natasha N Powell
- Department of Emergency Medicine, The George Washington Medical Faculty Associates, Washington, DC, USA
- Department of Health Policy, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Melissa McCarthy
- Department of Health Policy, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
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8
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Hamdan S, Smyth E, Murphy ME, Grussing ED, Wei M, Guardado R, Wurcel A. Racial and Ethnic Disparities in HIV Testing in People Who Use Drugs Admitted to a Tertiary Care Hospital. AIDS Patient Care STDS 2022; 36:425-430. [PMID: 36301195 PMCID: PMC9700355 DOI: 10.1089/apc.2022.0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Ending the HIV epidemic requires increased testing, diagnosis, and linkage to care. In the past 10 years, rates of HIV have increased among people with substance use disorder (SUD). HIV testing is recommended during hospitalization. Despite rising rates of infections and recommendations, HIV testing remains suboptimal. This study sought to detect differences in HIV testing by race and ethnicity in people who use drugs (PWUD) admitted to Tufts Medical Center (TuftsMC). This study is a retrospective review of hospitalized PWUD admitted from January 1, 2017 to December 31, 2020. PWUD were identified through toxicology results, medication prescribed for SUD, and nursing intake questions. The primary outcome of interest was whether an HIV test was ordered during hospitalization. The indicator of interest was race and ethnicity. Of 13,486 PWUD admitted to TuftsMC, only 10% had an HIV test ordered. Compared with White patients, Black patients [adjusted odds ratio (AOR): 0.69, 95% confidence interval (CI) (0.59-0.83)] and Hispanic patients [AOR: 0.68, 95% CI (0.55-0.84)] had decreased odds of receiving an HIV test. Our report is the first to show racial and ethnic differences in HIV testing ordering for hospitalized PWUD. Without access to harm reduction tools and expanded systems-based testing strategies, the HIV epidemic will continue and disproportionately impact minoritized communities.
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Affiliation(s)
- Sami Hamdan
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Emma Smyth
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | | | - Mingrui Wei
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Rubeen Guardado
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Alysse Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
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Carlisle NA, Booth JS, Rodgers JB, Heath SL, Walter LA. Utilizing Laboratory Results to Identify Emergency Department Patients with Indications for HIV Pre-Exposure Prophylaxis. AIDS Patient Care STDS 2022; 36:285-290. [PMID: 35951447 DOI: 10.1089/apc.2022.0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
People newly diagnosed with HIV often have previous contact with health care professionals, often on multiple occasions, including within emergency departments (EDs). Although EDs have become vital partners in routine screening and linkage to care for persons with HIV, ED engagement in HIV prevention efforts, to include HIV risk assessment and pre-exposure prophylaxis (PrEP) referral, are rare. In this study, we electronically queried the hospital electronic health record (EHR) for ED encounters in 2019 and 2020 for patients who screened negative for HIV (N = 26,914) to identify objective evidence of HIV acquisition risk due to recent sexual behavior (sexually transmitted infection screen positive for chlamydia, syphilis, gonorrhea, or trichomoniasis) or recent injection drug practices (urine drug screen positive for heroin, amphetamines, cocaine, or other opiates). In the reviewed period, we identified 1324 patients (4.92%) at sufficient risk to warrant PrEP referral (i.e., PrEP indications), including 304 (22.96%) due to sexual behavior and 1032 (77.95%) due to potential injection drug use. Notably, among adults with PrEP indications regardless of transmission risk group, persons who inject drugs (PWID) represented a significantly larger proportion within our ED cohort as compared with Centers for Disease Control and Prevention (CDC) estimates for the US population (77.95% vs. 6.34%, p < 0.0001). Among adults with PrEP indications due to sexual behavior specifically, women represented a significantly larger proportion within our ED cohort as compared with estimates for the US population (62.17% vs. 16.48%, p < 0.0001). Our results demonstrate that utilizing laboratory results within the EHR may be a simple low-resource option for identifying and engaging PrEP candidates, especially women and PWID.
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Affiliation(s)
- Nicholas A Carlisle
- Division of Infectious Disease, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James S Booth
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joel B Rodgers
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sonya L Heath
- Division of Infectious Disease, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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10
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Mahal J, Deccy S, Seu R. Linking emergency department patients at risk for human immunodeficiency virus to pre-exposure prophylaxis. Am J Emerg Med 2022; 54:87-90. [DOI: 10.1016/j.ajem.2022.01.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 01/06/2022] [Accepted: 01/15/2022] [Indexed: 11/24/2022] Open
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Conley C, Johnson R, Bond K, Brem S, Salas J, Randolph S. US Black cisgender women and pre-exposure prophylaxis for human immunodeficiency virus prevention: A scoping review. WOMEN'S HEALTH (LONDON, ENGLAND) 2022; 18:17455057221103098. [PMID: 35699104 PMCID: PMC9201306 DOI: 10.1177/17455057221103098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/28/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Black cisgender women in the United States experience a disproportionate burden of human immunodeficiency virus acquisition. Pre-exposure prophylaxis is an effective oral daily medication that reduces the risk of human immunodeficiency virus through sex by 99% when taken as prescribed. However, less than 2% of eligible Black cisgender women take pre-exposure prophylaxis. The purpose of this scoping review was to describe the types of research studies done in this area, gaps in knowledge, and potential areas of research needed to increase pre-exposure prophylaxis use among Black cisgender women in the United States. METHODS We conducted our search in MEDLINE (PubMed), Embase (Elsevier), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), and Scopus (Elsevier) using a combination of keywords and database-specific subject headings for the following concepts: pre-exposure prophylaxis, African American/Black or minority, and women. We used the Joanna Briggs Institute's Reviewers' Manual process for Scoping Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews to ensure comprehensive and standardized reporting of each part of the review. RESULTS Fifty-nine studies were included in the final review. Results of the study were classified according to the three phases of the Human Immunodeficiency Virus Prevention Cascade-demand side, supply side, and adherence and retention. The majority of studies (n = 24, 41%) were cross-sectional quantitative surveys and 43 (34%) focused on the demand-side phase of the Human Immunodeficiency Virus Prevention Cascade. Fifty-eight percent of studies either assessed women's pre-exposure prophylaxis knowledge, attitudes, and intentions to use, or assessed perceived barriers and facilitators. Seven studies (12%) tested pre-exposure prophylaxis uptake and adherence among Black cisgender women. CONCLUSION This review found multiple missed opportunities to increase women's demand for pre-exposure prophylaxis and health care provider screening and referral for pre-exposure prophylaxis. Additional studies are needed to effectively assess pre-exposure prophylaxis uptake and adherence among Black cisgender women.
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Affiliation(s)
| | | | - Keosha Bond
- City University of New York School of
Medicine, New York, NY, USA
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12
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Mclaughlin SE, Kapadia F, Greene RE, Pitts R. Capturing missed HIV pre-exposure prophylaxis opportunities-sexually transmitted infection diagnoses in the emergency department. Int J STD AIDS 2021; 33:242-246. [PMID: 34879782 DOI: 10.1177/09564624211048671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The United States Centers for Disease Control and Prevention (CDC) recommends HIV pre-exposure prophylaxis (PrEP) be considered for all patients diagnosed with a sexually transmitted infection (STI). Emergency departments (EDs) are an important site for diagnosis and treatment of STIs for under-served populations. Consequently, we identified 377 patients diagnosed with a bacterial sexually transmitted infection (gonorrhea, chlamydia, and/or syphilis) at a major New York City emergency department between 1/1/2014 and 7/30/2017 to examine associations between key sociodemographic characteristics and missed opportunities for PrEP provision. In this sample, 299 (79%) emergency department patients missed their medical follow-up 90 days after STI diagnosis, as recommended. Results from adjusted generalized estimating equation regression models indicate that patients >45 yo (aOR = 2.2, 95% CI 1.2-3.9) and those with a primary care provider in the hospital system (aOR = 6.8, 95% CI 3.8-12.0) were more likely to return for follow-up visits, whereas Black patients (aOR = 0.44, 95% CI 0.25-0.77) were less likely to return for follow-up visits. These findings indicate that lack of STI treatment follow-up visits are significantly missed opportunities for PrEP provision and comprehensive human immunodeficiency virus prevention care.
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Affiliation(s)
| | - Farzana Kapadia
- Department of Epidemiology, School of Global Public Health, New York University, New York, NY, USA
| | - Richard E Greene
- Department of Medicine, New York University Langone, New York, NY, USA
| | - Robert Pitts
- Department of Medicine, New York University Langone, New York, NY, USA
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13
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Blumenthal J, Landovitz R, Jain S, He F, Kofron R, Ellorin E, Ntim GM, Stockman JK, Corado K, Rivet Amico K, Moore DJ, Morris S. Pre-Exposure Prophylaxis Perspectives, Sociodemographic Characteristics, and HIV Risk Profiles of Cisgender Women Seeking and Initiating PrEP in a US Demonstration Project. AIDS Patient Care STDS 2021; 35:481-487. [PMID: 34851726 PMCID: PMC8905235 DOI: 10.1089/apc.2021.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Little information is known about the cisgender women who seek and initiate pre-exposure prophylaxis (PrEP) for HIV prevention in the United States. Adherence Enhancement Guided by Individualized Texting and Drug Levels was a 48-week single-arm open-label demonstration study of daily oral tenofovir disoproxil fumaratel emtricitabine (TDF/FTC) in cisgender women ≥ 18 years old at risk for HIV. Participants were surveyed at screening and enrollment about sociodemographics, HIV risk perception and behaviors, and PrEP perspectives and aggregated into three risk groups according to HIV sexual risk behavior: being in a serodiscordant partnership (SD), engaging in sex work (SW), and having partners with unknown HIV status at risk for HIV (UP). One hundred sixty-seven women presented for screening with n = 31 screen failures. Of the 162 women completing enrollment, mean age was 40 (standard deviation 11), with 41% non-Hispanic Black, 22% non-Hispanic White, and 19% Latina. Compared with those who screened ineligible, enrolled participants were more likely to have heard of PrEP, had higher HIV risk perception, and reported higher perceived PrEP efficacy. Sixty-four women (47%) were categorized as SD, 21 (15%) as SW, and 51 (38%) as UP. The SW were more likely to report higher levels of drinking and drug use (p = 0.002) and history of intimate partner violence in the past year (p < 0.001) compared with SD and UP. Among cisgender women enrolled, there were significant differences between the three risk groups by demographics, HIV risk behavior, and PrEP perspectives, suggesting that interventions to successfully implement PrEP in US women may need to be tailored by HIV risk group. Clinical Trial Registration number: NCT02584140.
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Affiliation(s)
- Jill Blumenthal
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Raphael Landovitz
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, California, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
| | - Feng He
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
| | - Ryan Kofron
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, California, USA
| | - Eric Ellorin
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Gifty M. Ntim
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, California, USA
| | - Jamila K. Stockman
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Katya Corado
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - David J. Moore
- Department of Psychiatry, University of California San Diego, San Diego, California, USA
| | - Sheldon Morris
- Department of Medicine, University of California San Diego, San Diego, California, USA
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Haukoos JS, White DAE, Rowan SE, Lyle C, Gravitz S, Basham K, Godoy A, Kamis K, Hopkins E, Anderson E. Development of a 2-step algorithm to identify emergency department patients for HIV pre-exposure prophylaxis. Am J Emerg Med 2021; 51:6-12. [PMID: 34649008 DOI: 10.1016/j.ajem.2021.09.084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Expanded access to HIV PrEP is a central pillar of the "Ending the HIV Epidemic" initiative. Identification of PrEP eligible individuals in EDs remains understudied. Our goal was to estimate the accuracy of the Denver HIV Risk Score (DHRS), a quantitative HIV risk tool, for determining PrEP eligibility, and to incorporate it into a novel screening algorithm to optimize sensitivity and specificity. METHODS We performed a prospective cross-sectional study in two urban EDs. Patients were eligible if ≥18 years of age and without HIV. Research staff collected individual HIV risk, components of the DHRS, and PrEP eligibility per 2017 CDC guidelines. Accuracy estimates were calculated for the DHRS alone and the DHRS plus additional PrEP-specific questions. RESULTS 1002 patients were enrolled with a median age of 39 years; 54.8% were male, 29.5% Black/non-Hispanic, and 22.5% Hispanic. Overall, 119 (11.9%, 95% CI: 9.9%-14.0%) were PrEP eligible; 5% endorsed history of sex with a partner at higher risk for HIV or condomless sex with multiple partners, 4% an STI, and 2% sharing IDU equipment. A DHRS ≥25 had a sensitivity of 92.4% (95% CI: 86.1%-96.5%) and a specificity of 17.2% (95% CI: 14.8%-19.9%) for PrEP eligibility. A 2-step algorithm, "DHRS-PrEP", beginning with a DHRS ≥25, followed by a step with questions specific to IDU, STI, and sexual partners improved the specificity to 100% (95% CI: 99.6%-100%). CONCLUSIONS Among a heterogeneous ED sample, a substantial proportion was identified as PrEP eligible, and a 2-step algorithm had high sensitivity and specificity for identifying PrEP-eligible patients.
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Affiliation(s)
- Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States of America; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Epidemiology, Colorado School of Public Health, Aurora, CO, United States of America.
| | - Douglas A E White
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, United States of America
| | - Sarah E Rowan
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Aurora, CO, United States of America; Public Health Institute at Denver Health, Denver, CO, United States of America
| | - Carolynn Lyle
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States of America
| | - Stephanie Gravitz
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States of America
| | - Kellie Basham
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, United States of America
| | - Ashley Godoy
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, United States of America
| | - Kevin Kamis
- Public Health Institute at Denver Health, Denver, CO, United States of America
| | - Emily Hopkins
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States of America; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Erik Anderson
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, United States of America
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15
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Harmon J, Kelley MMG, Heath SL, Ross-Davis KL, Walter LA. Characteristics of HIV Seroconverters Identified in an Emergency Department HIV Screening Program. AIDS Patient Care STDS 2021; 35:255-262. [PMID: 34242089 DOI: 10.1089/apc.2021.0031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The emergency department (ED) may represent a missed opportunity to proactively intervene upon patients at "high risk" for HIV. We sought to describe characteristics of ED HIV seroconverters (individuals who screened positive in the ED for HIV who had either (1) a previous prior negative HIV test in the electronic health record (EHR) or who (2) self-reported a prior negative HIV test) to identify a "high-risk" phenotype for pre-infection engagement. A retrospective chart-review was performed of HIV seroconverters at an academic, urban ED. General demographics, mental health illness comorbidities, and Centers for Disease Control and Prevention (CDC)-identified "high risk" factors, including intravenous drug use (IVDU) and history of sexually transmitted infection (STI) were noted. One hundred thirty total patients were identified, 48 (36.9%) with prior HER-negative test and 82 (63.1%) with self-reported previous negative test. Of total seroconverters: 100 (76.9%) were male and 77 (59.2%) were between the ages of 13-34, comparable to national rates of new HIV diagnoses. Ninety-two patients (70.8%) were Black and 16 (12.3%) had a history of IVDU, significantly increased compared with regional and national new HIV rates (p < 0.05). Fifty-two patients (40%) had an STI within 1 year before HIV-positive screen, 67 (51.5%) had a history of mental health illness, and 77 (59.2%) were uninsured. This review revealed an HIV seroconversion population disproportionately affected by race, IVDU, mental health comorbidities, and additional social factors. The ED may represent a unique opportunity for at-risk, pre-HIV exposure intervention, particularly for vulnerable populations.
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Affiliation(s)
- John Harmon
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | | | - Sonya L. Heath
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Lauren A. Walter
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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16
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Haukoos JS, White DA, Rowan SE, Lyle C, Gravitz S, Basham K, Godoy A, Kamis K, Hopkins E, Anderson E. HIV Risk and Pre-Exposure Prophylaxis Eligibility Among Emergency Department Patients. AIDS Patient Care STDS 2021; 35:211-219. [PMID: 34097464 DOI: 10.1089/apc.2021.0012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Our objective was to estimate the prevalence of pre-exposure prophylaxis (PrEP) eligibility, characterize self-perceived and quantified human immunodeficiency virus (HIV) risk, and assess PrEP knowledge and receptiveness of initiating PrEP among emergency department (ED) patients. We performed an IRB-approved cross-sectional study from two urban EDs. Patients were eligible if ≥18 years of age and not known to have HIV. Research staff obtained verbal consent and used a structured 29-item instrument to assess HIV risk, PrEP eligibility based on 2017 Centers for Disease Control and Prevention (CDC) guidelines, and general PrEP knowledge among unselected and enriched patient samples, the latter informed by the Denver HIV Risk Score (DHRS). We enrolled 1002 patients with a median age of 39 years; 54.8% were male, 30.9% White/non-Hispanic, 29.5% Black/non-Hispanic, and 22.5% Hispanic. In the full cohort, 119 [11.9%, 95% confidence interval (CI): 9.9-14.0%] were PrEP eligible, and among the unselected cohort, 36 (7.1%, 95% CI: 5.1-9.8%) were PrEP eligible. Using the DHRS, 100 patients were considered "high risk" with 32 (32.0%) reporting zero perceived risk. Correlation between the DHRS and self-perceived HIV risk was low (r = 0.13). Of the full cohort, 203 (20.3%) had heard of PrEP, and of these, 33 (16.3%) were PrEP eligible with 25 (75.8%) willing to start PrEP immediately. Yet, of the 119 patients who were PrEP eligible, only 34 (28.6%) had heard of PrEP. In summary, among a heterogeneous ED population, there was discordance in self-perceived and quantified HIV risk. HIV PrEP eligibility was ∼7% with the highest eligibility among those identified as DHRS "high risk." A significant opportunity exists to identify and initiate PrEP among ED patients.
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Affiliation(s)
- Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Douglas A.E. White
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California, USA
| | - Sarah E. Rowan
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
- Denver Public Health, Denver Health, Denver, Colorado, USA
| | - Carolynn Lyle
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Stephanie Gravitz
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Kellie Basham
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California, USA
| | - Ashley Godoy
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California, USA
| | - Kevin Kamis
- Denver Public Health, Denver Health, Denver, Colorado, USA
| | - Emily Hopkins
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erik Anderson
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California, USA
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17
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Zucker J, Carnevale C, Theodore D, Castor D, Meyers K, Gold J, Winetsky D, Scherer M, Cohall A, Gordon P, Sobieszczyk M, Olender S. Attitudes and Perceived Barriers to Routine HIV Screening and Provision and Linkage of Postexposure Prophylaxis and Pre-Exposure Prophylaxis Among Graduate Medical Trainees. AIDS Patient Care STDS 2021; 35:180-187. [PMID: 33901410 PMCID: PMC8106251 DOI: 10.1089/apc.2021.0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
New York City is the metropolitan area in the United States with the highest number of new HIV diagnoses nationwide. The End-The-Epidemic (EtE) initiative calls for identifying persons with HIV who remain undiagnosed, linking and retaining persons living with HIV to maximize viral suppression, and facilitate access to pre-exposure prophylaxis (PrEP) for patients at increased risk of HIV. HIV screening represents the first step to both the primary and secondary HIV prevention cascades. We conducted an online, anonymous, cross-sectional survey of residents at all stages of training within four residency programs at one institution in Northern Manhattan between August 2017 and August 2018. All internal medicine, emergency medicine, obstetrics and gynecology trainees, and pediatrics were invited to complete the survey via email. Of 298 eligible trainees, 142 (48%) completed the survey. Most trainees were aware of the HIV testing law and agreed that HIV testing was their responsibility, but few successfully screened most of their patients. Most trainees were not knowledgeable about non-occupational post-exposure prophylaxis (nPEP) or PrEP, but felt that it was important to provide these services across settings. Barriers to HIV, nPEP, and PrEP varied across specialties. Ending the HIV epidemic will require efforts across clinical specialties. In this survey from an EtE jurisdiction, most trainees felt that it is important to provide HIV prevention services in most settings; however, their knowledge and comfort with HIV prevention services other than testing were low. Barriers varied across specialties, and developing specialty-specific materials for trainees may be beneficial.
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Affiliation(s)
- Jason Zucker
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Caroline Carnevale
- New York-Presbyterian Hospital HIV Prevention Program, New York, New York, USA
| | - Deborah Theodore
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Delivette Castor
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Kathrine Meyers
- Aaron Diamond AIDS Research Center at Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Jeremy Gold
- Department of Internal Medicine and Columbia University Irving Medical Center, New York, USA
| | - Daniel Winetsky
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew Scherer
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Alwyn Cohall
- Department of Pediatrics, Columbia University Irving Medical Center, New York, USA
| | - Peter Gordon
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Magdalena Sobieszczyk
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Susan Olender
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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