HIV Risk and Pre-Exposure Prophylaxis Eligibility Among Emergency Department Patients

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

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.

A Systematic Review of HIV Pre-exposure Prophylaxis (PrEP) Implementation in U.S. Emergency Departments: Patient Screening, Prescribing, and Linkage to Care

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.

Communicable Disease Screening and Human Immunodeficiency Virus Prevention in the Emergency Department

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.

"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

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.

Same-Day Initiation of Oral Pre-Exposure Prophylaxis is High Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil

PURPOSE

This study analyzed the sociodemographic and behavioral characteristics of adolescent men who have sex with men (aMSM) and transgender women (aTGW) initiating oral pre-exposure prophylaxis (PrEP) in human immunodeficiency virus (HIV) prevention clinics.

METHODS

PrEP1519 is a prospective, multicenter, open-label PrEP demonstration cohort study of aMSM and aTGW aged 15-19 years living in three large Brazilian capital cities. For this analysis, we included adolescents who enrolled in PrEP1519 from February 2019 to August 2021. Adolescents who visited PrEP clinics were classified into four groups based on PrEP eligibility and on their decision to use PrEP: (1) ineligible for same-day PrEP initiation; (2) eligible for same-day PrEP initiation, initiated PrEP at first visit; (3) eligible for PrEP initiation, initiated PrEP after the first visit; and (4) eligible for same-day PrEP initiation but declined. The groups that were eligible for same-day PrEP initiation were compared using the Chi-square and Fisher's exact tests.

RESULTS

Of the 1,254 adolescents enrolled in the PrEP1519 study, 61 (4.9%) were considered ineligible for same-day PrEP initiation. Of the 1,193 eligible for same-day PrEP initiation, 1,113 (93.3%) initiated PrEP [1,054 initiated PrEP in the first visit (88.3%) and 59 in subsequent visits (4.9%)] and 80 (6.7%) did not. Despite 90% of the PrEP decliners reporting a low risk of HIV infection, most reported condomless anal sex in the past six months (70%).

DISCUSSION

Same-day PrEP initiation among aMSM and aTGW was high, highlighting that this strategy was important to promote PrEP initiation among adolescents with increased vulnerability to HIV in Brazil.

Comparison of US emergency departments by HIV priority jurisdiction designation: A case for geographically targeted screening in teaching hospitals

The Ending the HIV Epidemic (EHE) Initiative targets a subset of United States (US) priority jurisdictions hardest hit by HIV. It remains unclear which emergency departments (EDs) are the most appropriate targets for EHE-related efforts. To explore this, we used the 2001-2019 National Emergency Department Inventories (NEDI)-USA as a framework to characterize all US EDs, focusing on those in priority jurisdictions and those affiliated with a teaching hospital. We then incorporate multivariable regression to explore the association between ED characteristics and location in an HIV priority jurisdiction. Further, to provide context on the communities these EDs serve, demographic and socioeconomic information and sexually transmitted infection case rate data were included. This reflected 2019 US Census Bureau data on age, race, ethnicity, and proportion uninsured and living in poverty along with 2001-2019 Centers for Disease Control and Prevention case rate data on chlamydia, gonorrhea, and syphilis. We found that EDs in priority jurisdictions (compared to EDs not in priority jurisdictions) more often served populations emphasized in HIV-related efforts (i.e., Black or African American or Hispanic or Latino populations), communities with higher proportions uninsured and living in poverty, and counties with higher rates of chlamydia, gonorrhea, and syphilis. Further, of the groups studied, EDs with teaching hospital affiliations had the highest visit volumes and had steady visit volume growth. In regression, ED annual visit volume was associated with an increased odds of an ED being located in a priority jurisdiction. Our results suggest that geographically targeted screening for HIV in a subset of US priority jurisdiction EDs with a teaching hospital affiliation could be an efficient means to reach vulnerable populations and reduce the burden of undiagnosed HIV in the US.

HIV Pre-Exposure Prophylaxis in the Emergency Department: A Systematic Review

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.

Development of a Mobile App to Increase the Uptake of HIV Pre-exposure Prophylaxis Among Latino Sexual Minority Men: Qualitative Needs Assessment

BACKGROUND

HIV disproportionally impacts Latino sexual minority men (SMM). Uptake of pre-exposure prophylaxis (PrEP), an effective biomedical intervention to prevent HIV, is low in this group compared with White SMM. Mobile health technology represents an innovative strategy to increase PrEP uptake among Latino SMM.

OBJECTIVE

We aimed to describe the qualitative process leading to the development of SaludFindr, a comprehensive HIV prevention mobile app aiming to increase PrEP uptake, HIV testing, and condom use by Latino SMM.

METHODS

We conducted 13 in-depth interviews with Latino SMM living in the Atlanta area to explore their main barriers and facilitators to PrEP uptake and to analyze their opinions of potential SaludFindr app functionalities. To explore potential app functions, we used HealthMindr, an existing HIV prevention app, as a template and added new proposed features intended to address the specific community needs.

RESULTS

We identified general PrEP uptake barriers that, although common among non-Latino groups, had added complexities such as the influence of religion and family on stigma. Low perceived PrEP eligibility, intersectional stigma, lack of insurance, cost concerns, and misconceptions about PrEP side effects were described as general barriers. We also identified Latino-specific barriers that predominantly hinder access to existing services, including a scarcity of PrEP clinics that are prepared to provide culturally concordant services, limited availability of Spanish language information related to PrEP access, distrust of peers as credible sources of information, perceived ineligibility for low-cost services owing to undocumented status, fear of immigration authorities, and competing work obligations that prevent PrEP clinic attendance. Health care providers represented a trusted source of information, and 3 provider characteristics were identified as PrEP facilitators: familiarity with prescribing PrEP; being Latino; and being part of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) group or ally. The proposed app was very well accepted, with a particularly high interest in features that facilitate PrEP access, including a tailored list of clinics that meet the community needs and a private platform to seek PrEP information. Spanish language availability and free or low-cost PrEP care represented the 2 main clinic criteria that would facilitate PrEP uptake. Latino representation in clinic staff and providers; clinic perception as a safe space for undocumented patients; and LGBTQIA+ representation was listed as additional criteria. Only 8 of 47 clinics listed on the Centers for Diseases Control and Prevention PrEP locator website for the Atlanta area fulfilled at least 2 main criteria.

CONCLUSIONS

This study provides further evidence of the substantial PrEP uptake barriers that Latino SMM face; exposes the urgent need to increase the number of accessible PrEP-providing clinics for Latino SMM; and proposes an innovative, community-driven, and mobile technology-based tool as a future intervention to overcome some of these barriers.

Utilizing Laboratory Results to Identify Emergency Department Patients with Indications for HIV Pre-Exposure Prophylaxis

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.

Perceptions on HIV Pre-Exposure Prophylaxis Among Urgent Care Clinicians in the Southern United States

Background:

Underutilization of HIV pre-exposure prophylaxis (PrEP) in the Southern United States (US) is well-documented. Urgent care (UC) centers are positioned as community-facing access points to PrEP, but the feasibility of integrating PrEP services into this setting is unclear. We conducted a survey of UC clinicians in the Southern US to better understand their perceptions of the feasibility of providing PrEP in their practice setting.

Objective:

The study aims to determine the feasibility and acceptability of providing PrEP services in the UC setting through a cross-sectional survey of UC clinicians.

Methods:

We conducted a 48-item cross-sectional survey of UC clinicians in the Southern US, between July and September 2020. The survey was distributed through the Urgent Care Association (UCA) and American Academy of Urgent Care Medicine (AAUCM) professional listservs as well as directly to publicly listed e-mail addresses.

Results:

Eighty-two clinicians responded to the survey. Most clinicians had familiarity with PrEP (97%). All respondents rated PrEP as an effective way to prevent HIV. However, less than half felt UC facilities were an appropriate place to prescribe PrEP. Few respondents (8%) expressed doubts that expansion of PrEP access would decrease the incidence of HIV in their community.

Conclusion:

These findings show UC clinicians are familiar with PrEP, and many believe it would benefit their patients; however, provider opinions on the appropriateness of providing PrEP in the UC setting differ. Further studies on PrEP implementation in UC centers are needed.

What will it take to meet UNAIDS targets for preexposure prophylaxis users?

PURPOSE OF REVIEW

Preexposure prophylaxis (PrEP) is a critical strategy to curb new HIV infections globally. National and global targets have been set for people starting PrEP. However, global PrEP initiations fell short of UNAIDS 2020 targets, and reflection is needed on how we set and meet targets for PrEP use.

RECENT FINDINGS

Recent literature documents challenges to meeting ambitious goals for PrEP coverage in multiple phases of PrEP: PrEP initiations are limited by gaps in the identification of those who might benefit from PrEP. Conversely, getting PrEP to those who need it most is threatened by inaccurate risk perception and HIV and PrEP stigma. Once people are on PrEP, a substantial number discontinue PrEP in the first year (the 'PrEP Cliff'), a finding that is robust across groups of PrEP users (e.g., women, men who have sex with men, transwomen) and across global prevention settings. Further, PrEP inequities - by which we refer to utilization of PrEP in a specific group that is not commensurate with their epidemic risk - threaten the overall population benefit of PrEP because those at highest risk of acquiring HIV are not adequately protected.

SUMMARY

To realize global goals for PrEP utilization and impact, we must address multiple points of PrEP delivery programs that address not just PrEP starts, but also retention in PrEP and measurement and accountability to PrEP equity. We call for new approaches to better identify PrEP candidates, suggest additional research to address the known and consistent reasons for PrEP discontinuations, and advocate for metrics to measure and be accountable to PrEP equity.