Pre-exposure Prophylaxis Prescription Research Articles

Clinical Decision Support System for Guidelines-Based Treatment of Gonococcal Infections, Screening for HIV, and Prescription of Pre-Exposure Prophylaxis: Design and Implementation Study.

The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support (CDS) system tool could fulfill this need and improve adherence to Centers for Disease Control and Prevention (CDC) treatment and screening guidelines for gonorrhea, HIV, and PrEP. The goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of HIV screening and prescribing PrEP that stem from a diagnosis of gonorrhea as an electronic health record-based CDS intervention. We also assessed whether this CDS solution worked in real-world clinic. We developed 4 tools for this CDS intervention: a form for capturing sexual history information (SmartForm), rule-based alerts (best practice advisory), an enhanced sexually transmitted infection (STI) order set (SmartSet), and a documentation template (SmartText). A mixed methods pre-post design was used to measure the feasibility, use, and usability of the CDS solution. The study period was 12 weeks with a baseline patient sample of 12 weeks immediately prior to the intervention period for comparison. While the entire clinic had access to the CDS solution, we focused on a subset of clinicians who frequently engage in the screening and treatment of STIs within the clinical site under the name "X-Clinic." We measured the use of the CDS solution within the population of patients who had either a confirmed gonococcal infection or an STI-related chief complaint. We conducted 4 midpoint surveys and 3 key informant interviews to quantify perception and impact of the CDS solution and solicit suggestions for potential future enhancements. The findings from qualitative data were determined using a combination of explorative and comparative analysis. Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods. Within the X-Clinic, the CDS alerted clinicians (as a best practice advisory) in one-tenth (348/3451, 10.08%) of clinical encounters. These 348 encounters represented 300 patients; SmartForms were opened for half of these patients (157/300, 52.33%) and was completed for most for them (147/300, 89.81%). STI test orders (SmartSet) were initiated by clinical providers in half of those patients (162/300, 54%). HIV screening was performed during about half of those patient encounters (191/348, 54.89%). We successfully built and implemented multiple CDC treatment and screening guidelines into a single cohesive CDS solution. The CDS solution was integrated into the clinical workflow and had a high rate of use.

Psychiatry and Family Medicine Residents' Likelihood of Prescribing HIV Pre-exposure Prophylaxis to Patients With Mental Illness and HIV Vulnerability.

People living with mental illness (PLMI) experience disproportionately high incidence of and vulnerability to HIV. Pre-exposure prophylaxis (PrEP) is an effective and safe HIV prevention method, but data regarding prescription to PLMI are lacking. Psychiatrists may serve as important points of access for PrEP prescription for PLMI. We conducted a vignette-based study of residents in psychiatry and family medicine (FM) to assess likelihood of prescribing PrEP and assumptions about the fictional patient. Participants were randomized to one of five vignettes in which the patients' psychiatric diagnosis was varied (schizophrenia on long-acting injectable or oral antipsychotic, bipolar disorder, major depression) or a control vignette without a psychiatric diagnosis. A total of 439 residents participated. We found that high percentages of psychiatry (96.8%) and FM (97.4%) residents were aware of PrEP. High percentages of psychiatry (92.0%-98.1%) and FM (80.8%-100%) residents reported that PrEP was indicated for all patient conditions. Family medicine residents were more likely to prescribe PrEP to all experimental conditions than psychiatry residents. There was no difference in likelihood of prescribing to the control condition without a psychiatric diagnosis. The belief that PrEP prescription was out of scope of practice was greater among psychiatry residents. A majority of psychiatry residents responded that PrEP was indicated for an array of patients with psychiatric diagnoses. However, psychiatry residents were broadly less likely to prescribe PrEP to patients with these diagnoses. The high percentage of psychiatry residents who reported that PrEP was indicated for all patients suggests that additional training is needed to facilitate PrEP prescription by psychiatrists.

Leveling Up PrEP: Implementation Strategies at System and Structural Levels to Expand PrEP Use in the United States.

Despite highly effective biomedical HIV pre-exposure prophylaxis (PrEP) options, suboptimal PrEP uptake impedes progress towards ending the epidemic in the United States of America (USA). Implementation science bridges what we know works in controlled clinical trial settings to the context and environment in which efficacious tools are intended to be deployed. In this review, we focus on strategies that target PrEP use barriers at the system or structural level, exploring the implications and opportunities in the context of the fragmented USA healthcare system. Task shifting could increase PrEP prescribers, but effectiveness evidence is scarce in the USA, and generally focused in urban settings. Integration of PrEP within existing healthcare infrastructure concentrates related resources, but demonstration projects rarely present the resource implications of redirecting staff. Changing the site of service via expanded telehealth could improve access to more rural populations, though internet connectivity, technology access, and challenges associated with determining biomedical eligibility remain logistical barriers for some of the highest burden communities in the USA. Finally, a tailored care navigation and coordination approach has emerged as a highly effective component of PrEP service provision, attempting to directly modify the system-level determinants of PrEP use experienced by the individual. We highlight recent advances and evidence surrounding task shifting, integration, service delivery, and tailoring. With the exception of tailored care navigation, evidence is mixed, and the downstream impact and sustainability of task shifting and care integration require further attention. To maximize PrEP outcomes, research will need to continue to examine the interplay between individuals, clinics, and the healthcare system and associated policies within which they operate.

Impact of national commissioning of pre-exposure prophylaxis (PrEP) on equity of access in England: a PrEP-to-need ratio investigation

ObjectivesHIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In England, NHS availability was limited to participants of the PrEP Impact Trial until late 2020. Some key populations...

A Behavioral Economic Examination of Sexual Behaviors in the Era of Pre-exposure Prophylaxis via Explanatory Sequential Mixed Methods.

Pre-exposure prophylaxis (PrEP) use may be associated with condom use decisions. The current investigation examined sexual decision-making in the context of PrEP among young adult men who have sex with men (MSM) between 18 and 30years old, using an explanatory sequential mixed methods design. For the quantitative aim, 99 MSM currently taking PrEP (i.e., PrEP-experienced) and 140 MSM not currently taking PrEP (i.e., PrEP-naive) completed an online survey, including the Sexual Delay Discounting Task (SDDT), which captures likelihood of condom use. For the qualitative aim, 15 people from each group were interviewed about their (1) conceptualizations of risky sex and (2) ways they manage their sexual risk. Participants were, on average, 25.69years old (SD = 3.07) and 64% White. Results from the quantitative aim revealed, controlling for covariates, PrEP-experienced participants exhibited significantly lower likelihood of (1) using an immediately available condom and (2) waiting for a delayed condom (i.e., sexual delay discounting) compared to PrEP-naive participants. Qualitative themes explaining what young adult MSM consider to be risky sex included: (1) any sex as risky sex, (2) risky sex as "sex without a conversation," and (3) risky sex as sex with risk for physical harm. Themes on ways young adult MSM manage sexual risk were classified as proactive, reactive, and passive. Results suggest that PrEP use is related to condom use decisions. Taken together, quantitative differences in sexual delay discounting, but qualitatively similar conceptualizations and management of risky sex, suggest that the SDDT may be a useful tool in sex research to capture processes (i.e., delay discounting) underlying sexual decision-making that may be missed by traditional self-reports. Implications of results, including potentially providing (good quality) condoms with every PrEP prescription, and future research topics are discussed.

Addressing Unmet PrEP Needs in Women: Impact of a Laboratory-Driven Protocol at an Urban, Essential Hospital.

HIV pre-exposure prophylaxis (PrEP) uptake in women remains low. We developed a laboratory result-driven protocol to link women with a positive bacterial sexually transmitted infection (STI) to HIV PrEP at an urban safety-net hospital. Electronic health records of women with positive chlamydia, gonorrhea, and/or syphilis tests were reviewed, and those eligible for PrEP were referred for direct or primary care provider-driven outreach. We assessed the proportion of women with STIs who received PrEP offers, acceptance, and prescriptions before (July 1, 2018-December 31, 2018) and after (January 1, 2019-June 30, 2020) implementation to evaluate changes in the delivery of key elements of the PrEP care cascade (ie, PrEP offers, acceptance, and prescribing) for women with STIs after protocol implementation. The proportion of women who received PrEP offers increased from 7.6% to 17.6% (P < .001). After multivariable adjustment, only the postintervention period was associated with PrEP offers (odds ratio [OR], 2.49; 95% CI, 1.68-3.68). In subgroup analyses, PrEP offers increased significantly among non-Hispanic Black (OR, 2.75; 95% CI, 1.65-4.58) and Hispanic (OR, 5.34; 95% CI, 1.77-16.11) women but not among non-Hispanic White women (OR, 1.49; 95% CI, 0.54-4.05). Significant changes in PrEP acceptance and prescriptions were not observed in the sample overall. A laboratory result-driven protocol was associated with a significant increase in PrEP offers to Black and Hispanic women with STI. These results provide concrete suggestions for health systems seeking to increase PrEP access and equity among women.

Sexual Identity Development and Social Ecological Facilitators and Barriers of PrEP Uptake and Adherence Among Latinx Men Who Have Sex with Men.

Latinx gay, bisexual, and other men who have sex with men (LMSM) report lower pre-exposure prophylaxis (PrEP) use than their white, non-Latinx counterparts. We hypothesize that this disparity is partially attributable to social ecological factors that can be addressed via prevention interventions. In this retrospective study, we first examined data from 253 LMSM to determine whether theorized associations existed between acquisition of a PrEP prescription (uptake) in relation to several social ecological factors based on a conceptual framework of determinants of access to and uptake of PrEP for LMSM. We also explored relations between frequency of PrEP use (adherence) and social ecological factors with a subsample of 33 LMSM who had initiated PrEP 12months prior to assessment. In this study, individual-level factors from this framework included age and socioeconomic status. Perceived access to medical care represented both individual- and community-level determinants of PrEP uptake and adherence. Interpersonal-level factors were social support and relationship status. Structural/cultural-level factors were sexual identity development status, the masculinity norm of heterosexual self-presentation, traditional Latinx masculine gender role beliefs of machismo and caballerismo, racial identity, and immigration status. Results indicated that older men and those who endorsed the synthesis/integration status of sexual identity development were more likely to acquire a PrEP prescription during their lifetime in comparison to peers. PrEP adherence was linked with being older, reporting higher socioeconomic status, reporting more appraisal social support, self-identifying as white-Latinx, being U.S.-born, and endorsing less sexual identity uncertainty and more heterosexual self-presentation. Results specify modifiable factors that may inform tailored, community-based prevention efforts to increase PrEP use and decrease existing HIV/AIDS disparities among LMSM.

Increasing providers' PrEP prescription for Black cisgender women: A qualitative study to improve provider knowledge and competency via PrEP training.

Awareness and uptake of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) remains low among Black/African American cisgender women, partly due to low self-reported PrEP knowledge and comfort among primary care providers. Ensuring providers are trained on PrEP is crucial, as increased PrEP knowledge is associated with higher rates of PrEP prescription. We aimed to develop a PrEP training for providers to improve their self-efficacy in discussing and prescribing PrEP for Black women, with the ultimate goal of increasing PrEP awareness and utilization among Black women. In this qualitative study, we conducted focus groups with medical providers at three federally qualified health centers in the Southern and Midwestern United States to identify themes informing the development of a provider PrEP training. Providers were asked for input on content/design of PrEP training. Transcripts underwent rapid qualitative analysis using the Stanford Lightning Report Method. Themes were identified and presented under the domains of the Consolidated Framework for Implementation Research. Ten providers completed four focus groups. Themes included the individual characteristics of providers (low comfort initiating PrEP discussions, particularly among White providers) and the outer setting of client attitudes (perceptions of potential provider bias/racism, varying levels of concern about HIV acquisition). Opportunities were identified to maximize the benefit of training design (e.g., developing case scenarios to enhance providers' cultural competency with Black women and PrEP knowledge). This comprehensive PrEP training features both didactic material and interactive role-plays to equip providers with the clinical knowledge for prescribing PrEP while building their competency discussing PrEP with Black women. This training is particularly important for providers who have racial or gender discordance with Black women and express lower comfort discussing PrEP with these clients. Provider training could lead to minimizing racial- and gender-based inequities in PrEP use.

Estimating The Impact Of Out-Of-Pocket Cost Changes On Abandonment Of HIV Pre-Exposure Prophylaxis.

Oral HIV pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV. Several different developments in the US either threaten to increase or promise to decrease PrEP out-of-pocket costs and access in the coming years. In a sample of 58,529 people with a new insurer-approved PrEP prescription, we estimated risk-adjusted percentages of patients who abandoned (did not fill) their initial prescription across six out-of-pocket cost categories. We then simulated the percentage of patients who would abandon PrEP under hypothetical changes to out-of-pocket costs, ranging from $0 to more than $500. PrEP abandonment rates of 5.5percent at $0 rose to 42.6percent at more than $500; even a small increase from $0 to $10 doubled the rate of abandonment. Conversely, abandonment rates that were 48.0percent with out-of-pocket costs of more than $500 dropped to 7.3percent when those costs were cut to $0. HIV diagnoses were two to three times higher among patients who abandoned PrEP prescriptions than among those who filled them. These results imply that recent legal challenges to the provision of PrEP with no cost sharing could substantially increase PrEP abandonment and HIV rates, upending progress on the HIV/AIDS epidemic.

Barriers to Oral PrEP: A Qualitative Study of Female Sex Workers, PrEP Prescribers, Policymakers, and Community Advocates in Morocco.

In 2017, Morocco became the first Arab country to incorporate pre-exposure prophylaxis (PrEP) in its HIV-prevention program. Yet no research has been published on PrEP from Morocco. Although female sex workers are one of the target populations of PrEP in Morocco, their enrollment in PrEP is lower than men who have sex with men. In this study, we conducted 38 semi-structured interviews with female sex workers, physicians who prescribe PrEP, policymakers, and community advocates to identify problems associated with access to and use of PrEP. We also investigated preferences for daily oral, vaginal ring, and long-acting injectable PrEP. A reflexive thematic analysis revealed seven themes: PrEP stigma; stigmatization and criminalization of sex work; one size doesn't fit all; knowledge and misconceptions about PrEP; economic burden; inconvenience of PrEP pills; and preferred PrEP modalities. This paper discusses the implications of the findings for increasing access and use of PrEP in Morocco.

HIV Testing and Preexposure Prophylaxis Prescriptions Among U.S. Commercially Insured Transgender Men and Women, 2014 to 2021.

Transgender persons are disproportionately affected by HIV, but preexposure prophylaxis (PrEP) use has been low in this population. Clinical encounters for gender-affirming hormone therapy (GAHT) provide opportunities for HIV prevention. To estimate the number of commercially insured transgender women (TGW) and transgender men (TGM) in the United States and their use of HIV prevention services. Retrospective analysis of secondary data. Merative MarketScan commercial databases from 2014 to 2021. TGW and TGM, defined as those with transgender-related diagnoses and prescriptions for feminizing or masculinizing GAHT. HIV testing and PrEP use. A substantially increasing trend was observed in the prevalence of transgender-related diagnosis codes from 2014 to 2021 and in the proportion of persons who used GAHT. The increases were driven by persons aged 18 to 34 years. In 2021, among 10 613 TGW with a test for or a diagnosis of a sexually transmitted infection (STI) in the previous 12 months, 61.1% had an HIV test; among those, 20.2% were prescribed PrEP. Among 4184 TGM with STI risk, 48.3% had an HIV test; among those, 10.2% were prescribed PrEP. The prevalence of TGW and TGM who had a test for or a diagnosis of an STI, had an HIV test, and were prescribed PrEP increased substantially from 2014 to 2021. The findings represent only persons with commercial health insurance who sought health care services for GAHT. It is important to identify transgender persons to monitor their receipt of HIV prevention services. Encounters for GAHT provide opportunities to offer HIV prevention and other prevention services. Many HIV prevention opportunities were likely missed at clinical encounters for GAHT. None.

Point-of-care testing for sexually transmitted infections and HIV pre-exposure prophylaxis among pregnant women in South Africa, 2021–2022: randomised controlled trial

ObjectivePregnant and postpartum women (PPW) in Southern Africa are at increased risk of acquiring HIV and curable sexually transmitted infections (STIs). Oral pre-exposure prophylaxis (PrEP) is safe and effective to...

757. Bridging the Gap: An Educational Intervention to Increase HIV PrEP Access in Resident Primary Care Clinics

Abstract Background HIV Pre-Exposure Prophylaxis (PrEP) is a safe and effective way to prevent HIV acquisition. Yet, in 2020, only 25% of individuals in the US and Puerto Rico who had an indication for PrEP received a PrEP prescription. While PrEP is accessible to primary care clinicians, many do not feel comfortable prescribing PrEP. Clinician education has been identified as a key opportunity to increase access and comfort in prescribing PrEP. Methods An educational intervention was designed aiming to increase PrEP knowledge and prescribing among residents and preceptors in the primary care clinics at Brigham and Women’s Hospital (BWH). The intervention followed the six steps described in Kern’s model of curriculum development (Figure 1). After formal needs assessment, an in-person interactive teaching session was designed and presented. This was supplemented by an online reference guide and note template dot phrases accessible in the electronic medical record (EMR). The curriculum was evaluated with pre and post intervention surveys. Survey data were analyzed using descriptive statistics and one tailed T tests. Results Of the approximately 30 residents and preceptors who participated in the intervention, 19 completed the pre survey and 9 completed the post survey. Only 37% (7/19) of pre survey respondents reported having had PrEP education in the past. 21% (4/19) had prior teaching during medical school, 21% (4/19) during residency, and 16% (3/19) in continuing medical education courses. Participants indicated that their comfort with prescribing PrEP increased overall after the intervention with a statistically significant increase in reported confidence in their ability to prescribe PrEP (mean Likert scale value of 3.88 vs 2.95, p = 0.03) (table 1). Conclusion PrEP is an underutilized modality in preventing HIV transmission, but many primary care clinicians do not feel comfortable prescribing PrEP even though it is accessible in primary care settings. Systematic PrEP education is lacking in the UME, GME, and CME settings. Targeted, interactive, multimodal educational interventions can be effective in increasing comfort with PrEP prescribing. Support from leadership and learner buy-in is critical for effective training. Disclosures All Authors: No reported disclosures

HIV pre-exposure prophylaxis provision by U.S. health centers in 2021.

The aim of this study was to assess HIV preexposure prophylaxis (PrEP) provision in U.S. health centers. The U.S. Ending the HIV Epidemic (EHE) initiative designated health centers as the main healthcare system through which PrEP scale-up occurs. Health centers offer primary care to over 30 million disproportionately uninsured, racially or ethnically minoritized, and low-income patients. This study is the first to assess PrEP provision across health centers, including characteristics of clinics, patient populations, and policies associated with PrEP prescribing. The Health Resources and Services Administration's Uniform Data System contained aggregate data on PrEP prescriptions and patient sociodemographics at health centers from January 1 through December 31, 2021, in 50 U.S. states, the District of Columbia, and eight U.S. territories. We compared patient demographics and availability of Medicaid expansion and PrEP assistance programs at health centers that prescribed vs. those that did not prescribe PrEP. Across 1375 health centers serving 30 193 278 patients, 79 163 patients were prescribed PrEP. Health centers that prescribed any PrEP had higher proportions of sexual, gender, racial, and ethnic minority patient populations compared with health centers that prescribed no PrEP. Compared with health centers that prescribed no PrEP, a higher proportion of health centers that prescribed PrEP were located in designated high-priority jurisdictions of the EHE initiative or states with Medicaid expansion or public PrEP assistance programs. Health centers are critical for scaling up PrEP in minoritized populations disproportionately affected by HIV, facilitated through federal and state-level policies. These findings highlight service gaps and inform future interventions to optimize PrEP implementation and support EHE initiative goals.

Geographic variations of pre-exposure prophylaxis reversal and abandonment among United States counties.

In the United States, one in five newly insurer-approved pre-exposure prophylaxis (PrEP) prescriptions are reversed with over 70% of those reversed, being abandoned. Given the Ending the HIV Epidemic (EHE) initiative's goals, we assessed geographic variations of PrEP reversal and abandonment across EHE and non-EHE counties in the United States. This was a cross-sectional analysis of secondary data. Data were collected from Symphony Analytics for adults 18 years and older, with a newly prescribed PrEP claim. Using the proportion of PrEP prescriptions by county, hotspot analysis was conducted utilizing Getis Ord Gi∗ statistics stratified by EHE and non EHE counties. Multivariable logistic regression was used to identify factors associated with residing in hotspots of PrEP reversal or PrEP abandonments. Across 516 counties representing 36,204 patients, the overall PrEP reversal rate was 19.4%, whereas the PrEP abandonment rate was 13.7%. Reversals and abandonments were higher for non-EHE (22.7 and 17.1%) than EHE (15.6 and 10.5%) counties. In both EHE and non-EHE counties, younger age, less education, females, and an out-of-pocket cost of greater than $100, were significantly associated with greater likelihood of residing in hotspots of PrEP reversal or abandonment, while Hispanics, Medicaid recipients, and an out-of-pocket cost of $10 or less had lower likelihood of residing in hotspots of reversal and abandonment. Findings indicate the need for implementation of focused interventions to address disparities observed in PrEP reversal and abandonment. Moreover, to improve primary PrEP adherence, national PrEP access programs should streamline and improve PrEP accessibility across different geographic jurisdictions.

PrEP prescription in indiana 2017-2022: Implications for clinical practice.

The Ending the HIV Epidemic initiative is poised to eradicate HIV through increasing screening and linkage to care. Despite this, the rate of HIV testing remains inadequate, and effective preventive measures like pre-exposure prophylaxis (PrEP) are not adequately prescribed. A retrospective chart review was conducted to include 2017 through July 2022 from a large nonprofit health care system in the Midwest. Inclusion criteria included an HIV-negative diagnosis between 2017 and July 2022. Additional information includes gender, age, race/ethnicity, the primary payment method, the facility where screening occurred, history of PrEP prescription, and the provider who documented sexual health screening. Most patients were female (73%, n = 3366), followed by 27% (n = 1242) who identified as male. The majority identified as white (52.4%, n = 2415), and patients who identified as Black represented 45.3% (n = 2087) of the sample. Of the participants in the sample, n = 3030 (65.8%) did not have a documented sexual health assessment at the time of HIV screening. Black patients were 0.40 times less likely to report a PrEP prescription than their white counterparts. Patients screened by the provider and identified with infectious disease via a sexual mode of transmission demonstrated three times increased odds of being prescribed PrEP. This research highlights the importance of updating medical records systems to capture salient sexual health factors. Ongoing professional development should be made readily available so providers can conduct comprehensive sexual health assessments.

Identifying the Need for and Availability of Evidence-Based Care for Sexually Transmitted Infections in Rural Primary Care Clinics.

Increasing rates of bacterial sexually transmitted infections (STIs) may lead to increased HIV rates, as the STI and HIV epidemics are syndemic. Centers for Disease Control and Prevention guidelines recommend including extragenital (i.e., rectal and/or pharyngeal) STI screenings for certain populations at increased risk of STIs and concurrent infections with HIV. A descriptive study was conducted by interviewing staff members from 4 rural primary care clinics in areas of high need for STI and HIV services in South Carolina. Qualitative data about their clinical practices in 2021 were obtained. The primary outcome was to determine the awareness and availability of health care services associated with STI and HIV care in these locations. Clinics in target counties provided limited STI and HIV testing and treatment services, especially for populations at risk of infection, indicating the need for additional clinical training and professional development for all clinic staff. Specifically, only 1 of 4 clinics provided extragenital STI testing, and no clinics reported prescribing preexposure prophylaxis. Rural primary care clinics can fill important gaps in the availability of STI and HIV services with appropriate support and incentives. Findings from this study may aid in facilitating policy (state Medicaid agency) and program (state health department) decisions related to STI and HIV testing and treatment.

HIV Preexposure Prophylaxis Provision among Adolescents: 2018 to 2021.

HIV preexposure prophylaxis (PrEP) is safe, effective, and was approved for adolescents in 2018. Adolescents and young adults make up 20% of HIV diagnoses in the United States. Our objective was to describe trends in adolescents prescribed PrEP during 2018 through 2021 and characteristics of these adolescents and their PrEP providers. We identified adolescents aged 13 to 19 years with oral PrEP prescriptions during 2018 through 2021 in a national pharmacy database using a validated algorithm. We assessed trends by calculating the overall percentage change and estimated annual percentage change with 95% confidence intervals. We described characteristics of adolescents and their PrEP providers in 2021. We performed χ2 analyses to assess differences by sex and age group. The number of adolescents prescribed PrEP increased 76.2% from 2018 to 2021 (estimated annual percentage change: 18.0% [95% confidence interval: 16.6-19.5]), despite decreases in 2020. We observed increases among all sex and age groups, with larger increases among older adolescents aged 18 to 19 years. The majority of the 6444 adolescents prescribed PrEP in 2021 were male (82.6%) and aged 18 to 19 years (87.8%). Among 2455 physician PrEP providers, 29.6% were pediatricians, with varying specialty distributions by adolescent age group (P < .001). Among the 217 pediatricians who prescribed PrEP to adolescents aged 13 to 17 years, 67.7% were general pediatricians. PrEP provision for adolescents has increased, largely among older and male adolescents. The availability of PrEP provides an important opportunity for pediatric providers to take an active role in HIV prevention.

Predictors of Preexposure Prophylaxis Eligibility among Pregnant People with Opioid Use Disorder.

We seek to evaluate risk factors for eligibility for preexposure prophylaxis (PrEP) among pregnant people with opioid use disorder (OUD). This is a single-site retrospective cohort study of pregnant people admitted for management of OUD at an urban, tertiary care center from 2013 to 2022. PrEP eligibility was defined based on (1) modified American College of Obstetricians and Gynecologists' (ACOG) 2014 criteria: diagnosis of a sexually transmitted infection (STI), engagement in transactional sex work, intravenous drug use (IVDU), or incarceration and (2) modified 2021 Centers for Disease Control (CDC) criteria: diagnosis of bacterial STI (e.g., gonorrhea or syphilis) or transactional sex work. Risk factors associated with PrEP eligibility were evaluated using chi- square or Fischer's exact tests for categorical variables and t-tests or Wilcoxon rank-sum tests for continuous variables. Multivariable regression was used to control for confounding covariates, defined as p < 0.10 on bivariate analysis. p < 0.05 was used to indicate statistical significance. A total of 132 individuals met inclusion criteria, of whom 101 (76.5%) were deemed eligible for PrEP by meeting one or more modified 2014 ACOG criteria: 42 (31.8%) were incarcerated or had one or more STIs, while 30 (22.7%) endorsed engaging in transactional sex work and 68 (58.6%) endorsed IVDU. Using modified 2021 CDC criteria, 37 (28%) met PrEP eligibility, with 12 (9.1%) diagnosed specifically with a bacterial STI and 30 (22.7%) engaging in transactional sex work. Only comorbid psychiatric illness was associated with an increased risk for PrEP eligibility based on 2014 criteria, which persisted after controlling for maternal race/ethnicity (aRR 1.52, 95% confidence interval [CI] 1.24-1.86), and 2021 criteria, which persisted after controlling for nulliparity (aRR 2.12, 95% CI 1.30-3.57). A significant number of pregnant people with OUD meet one or more criteria for PrEP, with comorbid psychiatric conditions increasing the risk of meeting criteria. · Comorbid psychiatric illness is significantly associated with high risk of PrEP eligibility.. · A large proportion of pregnant individuals with active OUD meet criteria for PrEP prescribing.. · Risk-based screening algorithms for PrEP eligibility have limitations..

Implementing an Automated Prediction Model to Improve Prescribing of HIV Preexposure Prophylaxis

Summary Antiretroviral preexposure prophylaxis (PrEP) is nearly 100% effective at decreasing HIV acquisition but is underused in priority populations. Primary care clinicians need tools to help them identify persons likely to benefit from PrEP use and prescribe it when appropriate. The researchers developed and validated an automated decision support tool with interactive alerts in the electronic health record to increase PrEP discussions and prescribing in primary care. They piloted the tool at three federally qualified health centers and assessed feasibility, acceptance by clinicians, and preliminary impact on PrEP care. Of 33,803 patients who visited the pilot clinics from July 2022 through January 2023, providers received PrEP alerts at the point of care for 2.2% of patients, demonstrating feasibility. Although numbers of PrEP prescriptions remained low, the proportion of all patients with new PrEP prescriptions was 4.5 times higher at pilot clinics compared with matched control clinics (0.09% vs. 0.02%). Implementation of the decision support tool was associated with a statistically nonsignificant 5.5% increase in HIV tests per 100 patients. In qualitative interviews, providers said the tool facilitated PrEP discussions with patients, particularly for those patients who would not have initiated discussions because of stigma. The researchers found that acceptance, use, and impact of machine-learning models for PrEP depends on collaborating with and building trust among providers, including blending a data-driven approach to identifying patients at increased risk for HIV acquisition with providers’ traditional decision-making framework. These approaches could be useful for health care organizations seeking to implement automated prediction models across all areas of medicine.