Implementation of an Opt-Out Outpatient HIV Screening Program.

BACKGROUND: Screening rates for Human Immunodeficiency Virus (HIV) remain low despite guidelines by both the CDC and USPSTF recommending that all adolescents and adults be screened at least once. The aim of this quality improvement study was to increase HIV screening among eligible patients. METHODS: This quality improvement study assessed the impact of interventions to increase HIV screening in an outpatient population at a large urban safety-net hospital. Outcomes were compared from the preintervention (December 2020 to November 2021) to postintervention years (December 2021 to November 2022). Stepwise electronic alerts to prompt HIV screening paired with provider financial incentives were implemented. The proportion of eligible individuals screened for HIV were compared after intervention implementation. RESULTS: Average monthly HIV screening increased from 506 ± 97 to 2484 ± 663 between the pre- and postintervention periods, correlating to a 5.1-fold increase in screening (7.8% to 39.8%, P < .01). Increases were seen across all ages, and those aged 55 to 64 and 65+ had the highest relative increase in screening at 7.5 and 9.3-fold, respectively (P < .01). Screening rates increased for Hispanics (7.9% preintervention vs 43.6% postintervention, P < .01). In the pre- and postintervention periods, 41 patients with new HIV diagnoses were identified (13 preintervention and 28 postintervention) and 85.4% were linked to care within 30 days. CONCLUSIONS: Stepwise interventions targeted at primary care clinicians are an effective way to increase HIV screening rates, particularly in older demographics. Earlier HIV diagnosis coupled with linkage to care is an important strategy in ending the HIV epidemic.

Missed Opportunities for HIV Prevention in a Large County Safety Net Health System.

INTRODUCTION: HIV pre-exposure prophylaxis (PrEP) is effective at reducing HIV transmission. However, PrEP uptake is low for racial and ethnic minorities and women, especially in the Southern US Health care clinicians should be prepared to identify all patients eligible for PrEP, provide counseling, and prescribe PrEP. METHODS: Retrospective analysis of persons newly diagnosed with HIV was conducted at a large public health system from January 2015 to June 2021. Interactions with the health system in the 5 years preceding HIV diagnosis were analyzed, and missed opportunities for HIV prevention interventions, including PrEP and condom use counseling, were identified. RESULTS: We identified 454 patients with a new HIV diagnosis with previous health system interactions. 166(36.6%) had at least 1 identifiable indication for PrEP: 42(9.3%) bacterial STI, 63(13.9%) inconsistent condom use, or 82(18%) injection drug use before HIV diagnosis. Only 7(1.5%) of patients were counseled on PrEP. Most patients (308; 67.8%) had no documented condom use history in the EHR before diagnosis, a surrogate marker for obtaining a sexual history. Patients who exclusively interacted with the emergency care setting did not receive PrEP education and were less likely to receive condom use counseling. CONCLUSION: Missed opportunities to offer HIV prevention before diagnosis were common among patients newly diagnosed with HIV. Most patients did not have sexual history documented in the chart before their HIV diagnosis. Educational interventions are needed to ensure that clinicians are prepared to identify those eligible and discuss the benefits of PrEP.

Implementation of Sexual Health Curriculum Series: Educational Initiative to Increase STI Screening and Treatment in Dallas, Texas.

OBJECTIVE: A new monthly virtual education curriculum on sexual healthcare was launched in 2021. This is an analysis of the pilot education series designed to increase primary care providers' knowledge of sexual health best practices including taking thorough sexual histories, STI screening and treatment, and PrEP prescribing. METHODS: A Sexual Health Curriculum Series was developed as part of a quality improvement initiative at a large urban safety-net hospital in Dallas County, Texas. Didactic sessions were administered to primary care providers and staff via a virtual meeting platform once a month from May 2021 to April 2022. RESULTS: A total of 52 participants completed the pre-series survey, and 21 participants filled out the final post-series survey. 70% of respondents who completed the post-series survey reported that they learned new information that was incorporated into their practice. The average percentage correct on individual pre-session surveys was 60% compared to 63% on individual post-session surveys (p = 0.03). CONCLUSION: Sexual health education is an important tool to help primary care providers adhere to sexual health best practices. There is a need for ongoing implementation of innovative strategies to improve knowledge and adherence to sexual health best practices. A sexual health curriculum may be effective in helping primary providers recognize patients at increased risk and apply evidence-based guidelines to their practices.

Characteristics and Outcomes of Infectious Diseases Electronic COVID-19 Consultations at a Multisite Academic Health System.

Objective The need for clinicians to access Infectious Diseases (ID) consultants for clinical decision-making support increased during the Coronavirus Disease 2019 (COVID-19) pandemic. Traditional ID consultations with face-to-face (FTF) patient assessments are not always possible or practical during a pandemic and involve added exposure risk and personal protective equipment (PPE) use. Electronic consultations (e-consults) may provide an alternative and improve access to ID specialists during the pandemic. Methods We implemented ID e-consult platforms designed to answer clinical questions related to COVID-19 at three academic clinical institutions in Dallas, Texas. We conducted a retrospective review of all COVID-19 ID e-consults between March 16, 2020 and May 15, 2020 evaluating characteristics and outcomes of e-consults among the clinical sites. Results We completed 198 COVID-19 ID e-consults at participating institutions. The most common e-consult indications were for 63 (32%) repeat testing, 61 (31%) initial testing, 65 (33%) treatment options, and 61 (31%) Infection Prevention (IP). Based on the e-consult recommendation, 53 (27%) of patients were initially tested for COVID-19, 45 (23%) were re-tested, 44 (22%) of patients had PPE precautions initiated, and 37 (19%) had PPE precautions removed. The median time to consult completion was four hours and 8 (4%) consults were converted to standard FTF consults. Conclusion E-consult services can provide safe and timely access to ID specialists during the COVID-19 pandemic, minimizing the risk of infection to the patient and health care workers, while preserving PPE and testing supplies.

PrEP University: A Multi-Disciplinary University-Based HIV Prevention Education Program.

The introduction of emtricitabine/tenofovir diphosphate (FTC/TDF) as pre-exposure prophylaxis (PrEP) for HIV prevention has raised questions regarding which clinicians will serve as prescribers and how providers will be educated about this HIV prevention strategy. We piloted an HIV Prevention Education Program called PrEP University (PrEP U) to address knowledge gaps in HIV prevention among medical trainees. We examined PrEP awareness and assessed learning as a result of the program, measuring knowledge before and after the lectures with an anonymous 5-question multiple choice test. A total of 198 learners participated in PrEP University, which included 127 first year medical students, and post-graduate trainees in internal medicine (n = 23), family medicine (n = 16), OBGYN (n = 13) and pharmacy (n = 19). Prior to PrEP U, 27% of all participants were not aware of PrEP and an additional 8% were unsure if they had heard of it. Knowledge increased significantly after the education program among trainees in OBGYN (2.3 vs 3.8, p < 0.001), pharmacy (1.4 vs 2.5, p = 0.012) and school of medicine (3.3 vs 4.4, p < 0.001), with a trend seen in family medicine (2.7 vs. 3.7, p = 0.067) and internal medicine (2.7 vs 3.4, p = 0.068). Overall, an HIV Prevention Education Program was successfully administered to nearly 200 participants and resulted in improved knowledge of HIV prevention and PrEP across. Pharmacists and OBGYN physicians are two groups with an expanding role in the use of PrEP. Similar programs at other medical schools should be implemented to ensure that future physicians and pharmacists are comfortable with PrEP prescription.

Pre-exposure prophylaxis accessibility research and evaluation (PrEPARE Study).

Tenofovir-emtricitabine (TDF-FTC) has demonstrated effectiveness as HIV preexposure prophylaxis (PrEP), but it is not commonly prescribed. Our study was designed to determine the barriers preventing utilization of PrEP among men who have sex with men (MSM), the group at greatest risk for HIV infection in the United States. A population-based sample of MSM presenting for HIV testing at 'Early Test' HIV testing and counseling sites in San Diego, California were offered PrEP and education about potential efficacy. Eligible individuals reported having unprotected sex within the past 12 months and who tested negative for HIV were offered study participation. Despite offering procedures for evaluation and prescription for PrEP to 416 eligible subjects, less than 0.5 % of participants received the drug. Surveys collected from 54 of those who declined study participation revealed multiple barriers to PrEP among MSM including cost, low perceived risk of infection and concerns about taking a daily medication and potential long-term side effects. Efforts should be made to address these barriers, especially lowering the cost of TDF-FTC, education about PrEP side effects and awareness of HIV risks.