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Acceptance of HIV pre-exposure prophylaxis (PrEP) referral among a sample of PrEP-eligible emergency department patients

a b s t r a c t

Objective: Pre-exposure prophylaxis (PreP) reduces the rate of HIV transmission in high-risk groups. Emergency departments (EDs) frequently encounter patients at risk for HIV acquisition who are eligible for PrEP. ED HIV screening programs have prioritized testing and linkage to care for patients who test positive, but fail to refer HIV-negative patients to PrEP clinicians. Our objective was to estimate referral acceptance to a PrEP clinician among a sample of at-risk ED patients.

Methods: This single-center cross-sectional study electronically queried a prospectively acquired dataset of sur- vey responses from a sample of patients presenting to an Urban academic ED from March 2019 to February 2020. Patients completed a risk assessment as part of the HIV screening program. PrEP eligibility was based off survey responses in accordance with 2017 CDC PrEP eligibility criteria. Identified PrEP-eligible patients completed a PrEP questionnaire. The primary outcome was the proportion of PrEP-eligible patients who acceptED referral to a PrEP clinician during their ED encounter. We secondarily report patient participant characteristics including the proportion of PrEP-eligible patients who were aware of and were knowledgeable about PrEP as a method to prevent transmission of HIV. Results: In total, 360 patients completed a PrEP questionnaire, of which 287 (80%) were not currently taking PrEP and eligible for PrEP referral. 57% were males, with 41% Black/African American. Of the 287 eligible for PrEP, 61 (21.3%, 95% CI: 16.8-26.5) indicated awareness of PrEP, of which, 49 (80.3%, 95% CI: 67.8-89.0) demonstrated accurate knowledge of PrEP. PrEP referral was offered to 238 (82.9%, 95% CI: 78.0-87.0) patients, of which, 76 (31.9%, 95% CI: 26.1-38.3) accepted.

Conclusions: Approximately one third of PrEP-eligible ED patients accepted PrEP referral during their ED encoun- ter, demonstrating an opportunity for increased PrEP education and intentional referral for eligible patients. Var- iability in PrEP acceptability by demographic and risk subgroup may be an important consideration in efforts to expand PrEP utilization.

(C) 2022

  1. Introduction

Pre-exposure prophylaxis (PrEP) is a method of biomedical HIV prevention where patients at risk for HIV acquisition take anti- retroviral medications to prevent transmission [1,2]. PrEP is highly effective at reducing HIV transmission due to sexual encounters and in- jection drug use (IDU) [1]. Despite national recommendation from the

* Corresponding author.

E-mail address: [email protected] (K.A. Faryar).

1 Present Address: university hospitals, Cleveland Medical Center, 11100 Euclid Avenue #B519B, Cleveland, OH 44106, USA.

US Preventive services Task Force and Centers for Disease Control and Prevention (CDC) for widespread PrEP use [1,2], there has been modest uptake in part due to barriers accessing at-risk patients who could benefit from PrEP, and lack of knowledge and interest in PrEP among el- igible patients [3-5].

Emergency departments (EDs) encounter patients at-risk for HIV acquisition who may not seek healthcare elsewhere [6]. ED HIV screen- ing programs have successfully linked HIV-positive patients to outpa- tient treatment for decades [7], but they do not consistently refer HIV-negative PrEP-eligible patients to PrEP clinicians. While prior stud- ies have demonstrated PrEP interest among at-risk patients in outpa- tient settings [8,9], there is limited evidence of PrEP knowledge and

https://doi.org/10.1016/j.ajem.2022.07.055

0735-6757/(C) 2022

interest among PrEP-eligible patients presenting to the ED [12,16,17]. Furthermore, it is unclear if PrEP awareness and knowledge affects acceptance of referral to a PrEP clinician during the ED encounter.

The objective of this study was to estimate acceptance of PrEP refer- ral among a sample of PrEP-eligible ED patients who presented to an urban academic ED, using a generalizable referral approach. The primary outcome was the proportion of PrEP-eligible patients who accepted referral to a PrEP clinician during their ED encounter. We sec- ondarily report patient characteristics including the proportion of PrEP- eligible patients who were aware of and knowledge about PrEP as a method to prevent transmission of HIV.

  1. Methods
    1. Study design and setting

This single-center, cross-sectional study electronically queried a pro- spectively acquired dataset of survey responses of PrEP eligible patients visiting our urban academic ED. This study was approved by the study site Institutional Review Board.

The study site is an urban academic ED in an area with increasing HIV prevalence [10]. In 2019, the HIV prevalence rate in the surrounding county was 448.6 per 100,000 population, above the national average of 378 [11]. Annual ED volume is approximately 75,000 patients with al- most no pediatric patient encounters. This ED serves as the region’s primary source of episodic, unscheduled safety-net care and has oper- ated a publicly funded HIV screening program since 1998 [7].

    1. Selection of participants

We queried prospectively acquired records from the existing HIV screening program housed within this ED from March 2019 to February 2020. This program approaches patients who 1) are in demographic groups at higher risk for HIV acquisition, 2) have conditions associated with HIV risk in their medical record for that visit (e.g., chief complaint, problem list, diagnoses), or 3) are referred by clinical staff. Risk assess- ments are conducted by trained counselors according to a questionnaire-driven interview and entered into the program’s elec- tronic records system [7].

For this study, we added CDC PrEP eligibility criteria to the HIV risk assessment performed by counselors. Patients screened by program staff were identified as PrEP-eligible based on their responses to CDC PrEP eligibility criteria [1,12]. ED patients identified as eligible for PrEP were invited to complete a PrEP questionnaire by the same trained counselor in a consecutive manner, within the limits of the chaotic ED workflow. The screening program was operational for 16 h a day (0800-0000), 7 days a week. Patients who were currently taking PrEP were ineligible and excluded from analysis.

Questions regarding PrEP awareness, knowledge, and referral accep- tance were designed by the study team based on CDC criteria for PrEP use, expert opinion, and previously published evidence-based question- naires [15,17]. The PrEP questionnaire was designed with a pragmatic focus to mirror “real world” clinical encounters and was not rigorously designed or implemented.

Patient awareness of PrEP was assessed by answering affirmatively to the question “Have you heard of pre-exposure prophylaxis, or PrEP?” PrEP knowledge was assessed with the following question: “What is it used for medically?” Patient’s acceptance of PrEP referral was determined by whether the patient accepted written referral to a list of local PrEP clinicians.

    1. Measurements

Responses to the PrEP questionnaire were recorded in the screening program’s secure electronic database (REDCap) by trained counselors

[13]. Responses included “yes”, “no”, and “not answered”. Missing responses were recorded in the database as “not answered”.

    1. Outcomes

The primary outcome was the proportion of PrEP-eligible patients who accepted referral to a PrEP clinician during their ED encounter. We secondarily reported the proportion of PrEP-eligible patients who were aware of and were knowledgeable about PrEP as a method to pre- vent transmission of HIV. Acceptance of PrEP referral was also compared between race, ethnicity, gender, and risk factors for HIV acquisition.

    1. Analysis

Analysis was descriptive, reporting numbers and proportions with their respective 95% confidence intervals (CIs). We also calculated difference in proportions accepting and declining referral with their re- spective CIs by participant characteristics. CIs were not calculated if a numerator was 5 or less. All analyses were conducted in R (version 3.4.1.; R Foundation for Statistical Computing) [14].

  1. Results

Between March 2019 and February 2020, a total of 360 patients completed PrEP questionnaires, of which 287 (80%) were not currently taking PrEP and were eligible for PrEP referral. Demographics, risk factors for HIV acquisition, and awareness/knowledge of PrEP between patients who accepted the linkage referral and those who declined are shown in Table 1. Of the PrEP eligible patients, 57% were males (both birth and self-defined) and 41% were Black/African American. HIV risk factors include: 24 (8%) men who have sex with men (MSM), 134 (47%) heterosexual men and women (HMW), and 114 (40%) persons who inject drugs (PWID).

Of the 287 PrEP-eligible patients, 61 (21.3%, 95% CI: 16.8-26.5) indi- cated awareness of PrEP, of those, 49 (80.3%, 95% CI: 67.8-89.0) demon- strated correct knowledge of PrEP (i.e., used to “prevent HIV infection“). PrEP referral was offered to 238 (82.9%, 95% CI: 78.0-87.0) patients. PrEP referral was not offered to all patients due to program staffing limita- tions (e.g., staff busy with other patients) and ED operational barriers (e.g., patient left before program encounter complete). Of the 238 patients offered referral, 76 (31.9%, 95% CI: 26.1-38.3) accepted referral to a PrEP clinician. Reasons for not accepting PrEP referral included patient does not feel at risk (n = 91), inconvenience of PrEP (n = 17), side effects of PrEP (n = 7), cost of PrEP (n = 2), and patient feels PrEP is ineffective (n = 2).

  1. Discussion

Understanding ED patients’ acceptance of PrEP referral is necessary in order to improve ED-based HIV Prevention efforts and increase PrEP initiation nationwide. Among a population of PrEP-eligible ED patients, we found that almost a third of patients accepted outpatient referral to a PrEP clinician. reasons for declining PrEP referral mirrored those cited in the literature including lack of perceived risk, side effects, cost, inconvenience, and stigma [5,15]. While prior studies have assessed ED patients’ theoretical interest in [16,17] or willingness to start PrEP [18], we measured PrEP referral acceptance by providing real-time PrEP referral to patients during their ED visit. The fact that PrEP referral was accepted by nearly one third of PrEP-eligible patients highlights the opportunity for large-scale PrEP referral from the ED.

In our study, approximately one in five patients indicated awareness of PrEP. Of the patients who demonstrated PrEP awareness, the majority were knowledgeable about its medical use. EDs encounter a large group of patients who are at risk for HIV acquisition and eligible for PrEP [12,16,19]. Despite FDA approval of PrEP medications over a decade ago and increased national attention to HIV prevention efforts, PrEP

Table 1

Demographic characteristics and acceptance of PrEP referral among PrEP-Eligible ED patients.

Total PrEP eligible

Not offered referrala

Accepted PrEP referral

Declined PrEP referralb

Difference (accepted – declined)

N = 287 N = 49 N = 76 N = 162 N = 238

n

%

n

%

n

%

n

%

% Diff

95% CI LLc

95% CI ULd

Sex (birth)

Male

164

57.1%

27

55.1%

37

48.7%

100

61.7%

-13.0%

-27.5

1.4

Female

123

42.9%

22

44.9%

39

51.3%

62

38.3%

13.0%

-1.4

27.5

Gender (self-defined) Male

164

57.1%

27

55.1%

37

48.7%

100

61.7%

-13.0%

-27.5

1.4

Female

120

41.8%

20

40.8%

39

51.3%

61

37.7%

13.7%

-0.8

28.1

Transgender/Nonbinary

2

0.7%

2

4.1%

0

0.0%

0

0.0%

0.0%

Not answered

1

0.3%

0

0.0%

0

0.0%

1

0.6%

-0.6%

Race

Black/African American

119

41.5%

24

49.0%

33

43.4%

62

38.3%

5.1%

-9.2

19.5

Biracial/Multiracial

8

2.8%

1

2.0%

5

6.6%

2

1.2%

5.3%

White

156

54.4%

24

49.0%

35

46.1%

97

59.9%

-13.8%

-28.3

0.7

Other/Unknown

4

1.4%

0

0.0%

3

3.9%

1

0.6%

3.3%

Ethnicity

Hispanic/Latinx

6

2.1%

0

0.0%

4

5.3%

2

1.2%

4.0%

Not Hispanic/Latinx

280

97.6%

48

98.0%

72

94.7%

160

98.8%

-4.0%

-10.3

2.2

Not answered

1

0.3%

1

2.0%

0

0.0%

0

0.0%

0.0%

PrEP Eligibility Criteriae,f

Men who have sex with men (MSM)

24

8.4%

2

4.1%

10

13.2%

12

7.4%

5.8%

-3.8

15.3

Heterosexual men & women (HMW)

134

46.7%

25

51.0%

38

50.0%

71

43.8%

6.2%

-8.4

20.7

Persons who inject drugs (PWID)

114

39.7%

15

30.6%

29

38.2%

70

43.2%

-5.1%

-19.3

9.2

>3 sexual partners within past 12 months

122

42.5%

18

36.7%

32

42.1%

72

44.4%

-2.3%

-16.8

12.1

sexually transmitted infection within past 12 months

28

9.8%

4

8.2%

7

9.2%

17

10.5%

-1.3%

-10.3

7.7

Awareness of PrEP Yes

61

21.3%

8

16.3%

23

30.3%

30

18.5%

11.7%

-1.2

24.6

No

224

78.0%

41

83.7%

53

69.7%

130

80.2%

-10.5%

-23.5

2.5

Not answered

2

0.7%

0

0.0%

0

0.0%

2

1.2%

-1.2%

Knowledge of PrEP

Yes

49

17.1%

7

14.3%

15

19.7%

27

16.7%

3.1%

-8.5

14.7

No

11

3.8%

1

2.0%

7

9.2%

3

1.9%

7.4%

Not answered

1

0.3%

0

0.0%

1

1.3%

0

0.0%

1.3%

a Includes ED patients eligible for PrEP (not taking PrEP) but not offered referral due to staff limitations or operational barriers (i.e. program staff busy with other patients, patient left ED before program encounter is complete).

b Reasons for not accepting PrEP referral included patient does not feel at risk (n = 91), inconvenience of PrEP (n = 17), side effects of PrEP (n = 7), cost of PrEP (n = 2), patient feels PrEP is ineffective (n = 2), other (n = 18), and not answered (n = 2). Reasons were not mutually exclusive.

c 95% Confidence Interval Lower Limit.

d 95% Confidence Interval Upper Limit.

e Eligibility defined by CDC Preexposure prophylaxis for the prevention of HIV infection in the United States – 2017 Update: a clinical practice guideline1.

f Criteria not mutually exclusive.

awareness and knowledge among ED patients is consistently low rang- ing from 20 to 34% in the literature [16-18]. These numbers are grossly below national estimates of PrEP need [20,21], demonstrating an oppor- tunity for initial education with the potential for passive or active referral to a PrEP clinician for eligible HIV-negative ED patients.

This is one of the first studies to identify PrEP acceptance by risk group [17]. Although this study was underpowered to report statisti- cally significant comparisons between patients who accepted PrEP link- age referral and those who declined, we found greater PrEP acceptance for females, MSM, and heterosexual men and women (HMW) than for males and PWID. Females represent 19% of new HIV diagnoses [22] and two thirds of PrEP-eligible HMW [20] but they are disproportion- ately less likely to be on PrEP medication due to lack of awareness and knowledge, as well as missing eligibility criteria ( such as such as HIV status of sexual partner) [23,24]. Increased PrEP acceptance by females would be an important contributor to closing the PrEP gender gap. Sim- ilarly, lower acceptance among PWID is problematic given their high risk of HIV transmission [25].

PrEP referral in this study mirrored other specialty outpatient refer- ral mechanisms (e.g., traditional verbal or written referral) in an effort to mimic emergency medicine standard of care. Our PrEP referral was consistent with those offered by other EDs who are screening for PrEP eligibility among their ED populations [16,19]. Additional linkage to care services were intentionally not performed in order to assess base- line referral acceptance using standard referral practices common to

both community and academic EDs. More resource-intensive and sus- tained linkage to care services, such as those that are performed in ED HIV Screening programs for HIV-positive patients [7], could be highly important to facilitate PrEP initiation.

This study is subject to the inherent limitations of a single-center cross-sectional study and therefore not generalizable to all EDs. PrEP referral mechanisms were designed to mirror standard emergency medicine referral practices in order to improve operational acceptability in both academic and community EDs with limited referral resources. The PrEP questionnaire was not rigorously designed or tested, but rather it was designed to be user-friendly for trained counselors in the busy ED setting. Because a sample of PrEP-eligible patients was invited to complete the PrEP questionnaire, results may be biased towards pa- tients who are interested in knowing more about PrEP or being referred to PrEP.

In summary, approximately one third of PrEP-eligible ED patients accepted PrEP referral during their ED encounter demonstrating an opportunity for increased PrEP education and intentional referral for el- igible patients. Variability in PrEP acceptability by demographic and risk subgroup may be an important consideration in efforts to expand PrEP utilization.

Presentations

This work has not been presented at any meetings.

Support/Funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Author contributions

KAF conceived the study. KAF and MSL supervised the conduct of the study and data collection. RB and RMA provided data curation and formal analysis. KAF drafted the original draft. All authors provided sub- stantial review and editing. KAF takes responsibility for the paper as a whole.

CRediT authorship contribution statement Kiran A. Faryar: Writing – review & editing, Writing – original draft,

Supervision, Methodology, Investigation, Conceptualization. Robert

Braun: Writing – review & editing, Methodology, Formal analysis, Data curation. Rachel M. Ancona: Writing – review & editing, Method- ology, Formal analysis, Data curation. Caroline Freiermuth: Writing – review & editing. Michael S. Lyons: Writing – review & editing, Supervision, Conceptualization.

Declaration of Competing Interest

KAF, RB, RMA, and MSL received investigator-initiated health ser- vices award support paid to the institution from Gilead Sciences, Inc.

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