Abstract
Introduction. Although pre-exposure prophylaxis (PrEP) is recommended by the Centers for Disease Control and Prevention, there is a practice gap in treatment at Planned Parenthood of Illinois. This project evaluated a clinical practice alert and evidence-based patient education script to determine if the intervention increased the number of appointments to discuss or initiate PrEP in patients at risk for acquiring HIV. Method. From October to December 2018, a clinical practice alert and evidence-based patient education script were implemented at one Planned Parenthood of Illinois health center. Aggregate data collected included the number of times the clinical alert was generated, the number of times staff read the script, the number of scheduled appointments to discuss PrEP, and the number of times PrEP was prescribed. Qualitative data were collected from clinic staff to further evaluate the intervention. Results. Eleven patients triggered the alert and staff read the education script nine times during the 8-week implementation period. One patient scheduled an appointment to discuss PrEP; no new prescriptions were initiated. One identified patient scheduled an appointment with a provider to initiate PrEP on a date after the implementation period ended. Staff found the alert and script helpful to initiate conversations with patients. Conclusions. This intervention established a system for clinic staff to identify patients at risk for acquiring HIV in order to discuss accurate, evidence-based PrEP information. Findings are limited to this particular setting due to a small sample size, which eliminated the possibility for statistical analysis.
Keywords
Assessment of Need
Pre-exposure prophylaxis (PrEP) is a Food and Drug Administration–approved antiviral medication that can reduce the transmission of human immunodeficiency virus (HIV) in populations at high risk for acquiring HIV. PrEP, when taken daily and used in combination with condoms, can decrease the risk of acquiring HIV from sex by 99% (Centers for Disease Control and Prevention [CDC], 2019).
Risk assessment of behavior factors, such as inconsistent condom use or multiple unprotected and anonymous sex partners, is an important step to determine PrEP eligibility. Additionally, nonjudgmental and comprehensive educational messages are shown to support PrEP utilization (Scholl, 2016). Planned Parenthood of Illinois (PPIL) offers PrEP as routine preventative health care per CDC guidelines; however, new prescription uptake remains low. This project aimed to increase PrEP education and uptake at a PPIL health center located in Peoria, Illinois, and was determined to be exempt from review or oversight by the Chamberlain University Institutional Review Board.
Description of Innovation
Reproductive health assistants—clinic staff responsible for patient intake and assisting clinicians—were trained to read an evidence-based education script to any patient who, when presenting for any type of appointment at the Peoria health center, triggered a clinical practice alert built into the electronic medical record.
The “PrEP discussion indicated” alert identified priority population patients—those at the highest risk of acquiring HIV based on sexual health history—in the following cases:
Females Assigned at Birth answered “yes” to either “Sexual partners have a penis and/or partners’ other partners have a penis” or “Do any of your current partner(s) have an STD [sexually transmitted disease] or HIV?”
Males Assigned at Birth answered “yes” to “Sexual partners have a penis” or “Have you or your partner(s) exchanged sex for drugs or money” or “Have you or your partner(s) shared needles?”
The script included concise statements regarding HIV risk and infection rates in the United States (CDC, 2019), the safety and effectiveness of PrEP to decrease risk (CDC, 2019; World Health Organization, 2016), why and when someone might start PrEP, expected side effects, and affordability.
The script ended with offering the patient the option to further discuss PrEP with a clinician at their current or future appointment. Assessment and recommendations were based upon CDC (2018) clinical practice guidelines.
Method
We collected data on the number of patients seen during the intervention duration, the number of patients triggering the clinical practice alert, and the number of patients read the education script. Comparison data included the number of patients (n = 16) prescribed PrEP at the Peoria health center in the 3 years prior to the intervention. The primary outcome was the number of patients who desired to discuss PrEP further or schedule an appointment to discuss PrEP. A secondary outcome was the number of patients initiating PrEP at that time. We also collected qualitative data from clinic staff to further evaluate the impact and acceptability of the intervention.
Results
During the 8-week implementation period, 11 of 686 patients triggered the alert. Staff read the script nine times. One patient scheduled an appointment to discuss PrEP; no PrEP prescriptions were initiated. Seven of the identified patients declined to discuss PrEP at their current or a future appointment; one patient scheduled an appointment to initiate PrEP on a date after the intervention ended.
Of the two alerts that did not result in reading the script, one alert was missed by staff and one patient was already taking PrEP.
Qualitative data from staff show increasing comfort reading the script over time, but they perceived patient discomfort with the script length and content as a barrier to discussing or initiating PrEP. Staff also thought the alert missed some patients at risk for acquiring HIV.
Discussion
As a result of this practice change, PPIL established, and continues to use, a system to identify patients at risk for acquiring HIV. The education script helps clinic staff initiate conversations with patients about HIV and prevention strategies, including PrEP.
A strength of this intervention was the early buy-in and ongoing collaboration with key stakeholders, including the Information Technology and the Business Operations and Intelligence teams at PPIL, who designed the alert and integrated electronic medical record changes in a timely manner, as well as the clinical education team, who determined the sexual health history criteria to identify the priority population.
Limitations include the convenience sample size and the inability to quantitatively analyze results. Because this intervention was designed to fulfill a higher degree requirement to address a practice gap at PPIL, the study period occurred over 8 weeks, which was not substantial time to accurately assess the impact of the intervention.
Next Steps
Including community and patient voices is essential when considering future strategies to increase PrEP prescription uptake at PPIL. Alternative educational methods could increase PrEP uptake at PPIL; the script may not motivate PrEP initiation. Strategies are also needed to ensure that every time an alert is triggered, education is provided and documented. Future interventions in similar settings should assess barriers identified within this project’s scope, such as when serving populations routinely lost to the follow-up necessary to consistently adhere to PrEP. Importantly, asking more inclusive questions when taking sexual health histories could identify patients with other risk factors, for example, female patients who report sharing needles or sexual partners who do not identify as men who have sex with men. Although the intervention did not intentionally exclude nonbinary or transgender patients, the inclusion criteria for the alert may have missed ideal PrEP candidates.
Implications for Practice
Provider-initiated discussions of HIV prevention is a highly recommended risk reduction strategy, and integrating prevention services into reproductive health settings can normalize these discussions (Garfinkel et al., 2017). Implementing a clinical alert to prompt PrEP education with patients identified as at risk for acquiring HIV can increase opportunities to prescribe or refer these patients for this service. Ensuring that accurate, evidence-based information is available to patients is essential. This practice change can be replicated and expanded to broadened populations served by other health care organizations and provide relevant data to decrease the disparities and stigma associated with HIV and sexual health.
