Decision Support Tool to Integrate PrEP Into Emergency Departments

Overview

This project will explore the development of a personalized decision support tool to assist with pre-exposure prophylaxis (PrEP) initiation and persistence among patients identified in the emergency department (ED) and urgent care settings as PrEP eligible. First, the investigators will use a sequence of validated implementation science methodologies to develop and validate a decision support tool designed to optimize PrEP persistence by strengthening self-efficacy by addressing the multifaceted medical and social needs of the individual patient. The investigators will then test the preliminary effectiveness of this tool through a pilot stepped wedge implementation trial in two EDs and an urgent care in Baltimore, MD and Washington, DC among 120 PrEP eligible patients to determine PrEP initiation, linkage to care, persistence, and adherence rates.

Despite its promise, rates of pre-exposure prophylaxis (PrEP) uptake in the United States (US) have been modest. Innovative strategies are needed to improve access to PrEP in venues where patients with a high-risk of HIV acquisition may present for care, such as the Emergency Department (ED) or Urgent Care (UC). Recent pilot studies have tested rapid PrEP initiation at the George Washington University (GWU) ED in Washington, DC, and the Johns Hopkins Hospital (JHH) ED in Baltimore, MD, two priority jurisdictions in the US Ending the HIV Epidemic (EHE) initiative, that contribute to 50% of overall new diagnoses in the U.S. These studies found that a significant proportion of patients in the ED are PrEP eligible (96% at JHU - 60% at GWU), yet only 3% of patients who were eligible successfully initiated PrEP following community referral. Barriers to PrEP implementation were multi-faceted, including structural issues (e.g., limited ED provider time to discuss PrEP), patient issues (e.g., competing medical issues, lack of self-perceived HIV risk), and social determinants (e.g., finance, unstable housing, lack of primary care and transportation). PrEP prescribing in the ED/UC (ED-PrEP), while feasible, will also need to consider the higher vulnerabilities and complex competing needs of patients who present for care in these settings, and thus, PrEP prescriptions must be paired with individualized social support to ensure long-term adherence and persistence beyond the initial ED encounter. This R34 Clinical Trial Planning Grant aims to enhance PrEP uptake among eligible ED/UC patients by piloting a patient-centered Decision Support Tool (DST) for PrEP prescribing. The project seeks to address barriers such as low HIV risk perception and social needs (e.g., insurance, transportation, housing) using the WHO Social Determinants of Health Framework adapted for PrEP. A "Personalized PrEP Pathway" tool will be developed through barrier/facilitator analysis using the Consolidated Framework for Implementation Research (CFIR) and refined via participatory prototyping. The investigators will also identify implementation strategies to optimize ED-PrEP acceptability. Lastly, the investigators will conduct a pilot trial to measure the clinical effectiveness of the DST intervention and implementation outcomes across three clinically distinct venues: the GWU ED in DC, the JHH ED in Baltimore, and the GWU Cedar Hill Urgent Care (CHUC), a high-volume DC UC with limited HIV resources. The GWU and JHH EDs will build upon existing HIV services, whereas inclusion of CHUC will be critical to determining the scalability of the pilot intervention. The ED-PrEP intervention will have three components: 1) Routine screening for PrEP eligibility and HIV testing; 2) PrEP prescribing by ED/UC providers; and 3) Use of a DST to facilitate PrEP initiation and persistence. A multidisciplinary team of experienced HIV clinicians, emergency medicine and implementation science experts seeks to accomplish the following aims: Aim 1: Develop a patient-centered decision-support tool (DST) to support ED-based PrEP prescribing. The investigators will conduct in-depth interviews (IDI) using CFIR followed by participatory prototyping with PrEP users (n=30) and key stakeholders (n=20) from the two EDs and local communities. IDIs will identify barriers/facilitators to PrEP uptake at the patient and system levels and inform the development of a "Personalized PrEP Pathway" DST that addresses perceived HIV risk and social determinants. Two participatory prototyping workshops, utilizing the nominal group technique, will be conducted to refine the DST to enhance end-user acceptability. Aim 2: Determine how to optimize the acceptability of an ED-based PrEP intervention using the Normalization Process Theory (NPT) framework across 12 EDs/UCs in the DC-Baltimore region. Local ED providers and PrEP navigators (n=60) will be recruited to review an asynchronous onboarding package for ED- PrEP. They will then be surveyed using a validated NPT tool to seek feedback on how to optimize intervention acceptability and feasibility. The investigators will then refine the tool and develop implementation support resources. Aim 3: Determine the preliminary effectiveness of ED-PrEP vs ED-PrEP + DST in increasing ED-based PrEP initiation and persistence. The investigators will conduct a phased implementation trial across the three sites among 120 PrEP-eligible ED patients. Phase 1 participants will receive a standard of care PrEP prescription facilitated by a PrEP Champion. In Phase 2, the Champion will also administer the DST and provide the recommended individual and structural supports. The primary outcome will be PrEP persistence at 4 months post-enrollment; secondary outcomes include PrEP initiation, linkage to care, biological and self-reported adherence at 1- and 4-months. Implementation process outcomes will include the number of eligible patients approached and screened, delivery of onsite HIV testing, volume of PrEP prescribing, and DST completion including the number of resources provided and referrals completed.