Clinic-based interventions to increase preexposure prophylaxis awareness and uptake among United States patients attending an obstetrics and gynecology clinic in Baltimore, Maryland

Abstract

Cisgender women account for one of every five new U.S. HIV diagnoses, with the majority (86%) attributed to heterosexual contact. HIV pre-exposure prophylaxis (PrEP) is an effective prevention strategy; however, PrEP awareness and prescriptions among women are low. Our objective was to increase PrEP counseling and uptake among cisgender women attending obstetrics/gynecology (OB/GYN) clinics. The study included three OB/GYN clinics within a single health system in a high HIV prevalence region. There were three phases: baseline (three-month period before the clinical trial that included provider education and training of a registered nurse about PrEP [PrEP-RN]), clinical trial (three-month period during which eligible patients were randomized to an active control or PrEP-RN intervention), and maintenance (three-month period after the trial ended). Electronic medical record (EMR) clinical decision support tools (CSTs) were available to both arms during the clinical trial, which included best practice alerts (BPAs), order sets, progress note templates, and written and video PrEP educational materials for patients. In the intervention arm, a PrEP-nurse contacted and counseled patients, and was equipped to prescribe PrEP. We evaluated the phases through the RE-AIM framework (Reach-Effectiveness-Adoption-Implementation-Maintenance). The primary outcome of the study was effectiveness (e.g., percentage of eligible patients with documented HIV prevention counseling in the EMR or PrEP prescriptions). Secondary outcomes included reach (e.g., percentage of BPAs that providers acted upon or the percentage of eligible patients who spoke with the PrEP-RN), adoption (e.g., percentage of eligible patients with a BPA that triggered or the percentage of eligible patients the PrEP-RN attempted to contact), and maintenance (e.g., percentage of patients with documented HIV prevention counseling or PrEP prescriptions during the maintenance phase). There were 904 unique patients in all phases with a mean age of 28.8+/-7.7 years, and 46% were pregnant; 436 patients were randomized in the clinical trial phase. Reach/Adoption: BPAs were triggered for 100% of eligible encounters; however, providers acted on 52% of them. The PrEP nurse attempted to contact every patient and successfully spoke with 81.2% of them in the PrEP-RN arm. Compared to the active control, there were significantly more patients counseled about PrEP in the PrEP-RN group (66.5% vs. 12.3%, p<0.001), while PrEP prescriptions were equivalent (p=1.0). Among the subgroup of patients who were counseled about PrEP, 18.5% of patients in the active control and 3.4% in the PrEP-RN arm were prescribed PrEP (p=0.02). Maintenance: CSTs alone resulted in PrEP counseling of 1.0% of patients during the maintenance phase versus 0.6% during baseline and 11.2% during the clinical trial (p<0.001). PrEP prescriptions were not statistically different between the three phases (p=0.096). A PrEP nurse effectively increased HIV prevention discussions but did not lead to more PrEP prescriptions than the PrEP-focused CSTs used by providers. The decrease in PrEP counseling following the trial phase suggests that persistent interventions are needed to maintain effects.