Initiating PrEP Through the Emergency Department Has Pros, Cons to Improving Uptake

Considerations and solutions were offered in a qualitative study evaluating the feasibility of offering patients with a prescription for pre-exposure prophylaxis (PrEP) as well as a limited supply of the medication after a visit to the emergency department (ED). The study, published in the Western Journal of Emergency Medicine,¹ featured clinic staff from both HIV clinics and EDs.

PrEP is a form of treatment that is able to stem the spread of HIV across the world. However, despite its efficacy, the uptake of PrEP is not where it needs to be, with few individuals who need the medication getting a prescription and disparities in uptake existing worldwide even as overall usage increases globally.² Initiating PrEP through the ED, whether through same-day initiation that allows those visiting the ED to start the medication before lab results or through giving patients a 14-day supply of antiretroviral therapy (ART) after testing positive for HIV. This study aimed to evaluate the feasibility of these initiatives by interviewing staff in both an HIV clinic and an urban ED that provide PrEP services.

Interviews were conducted at a safety-net medical center in California between May 25 and July 12, 2023, or between July 15 and July 24, 2024. The clinic contained both an ED and HIV clinic on the same campus and serves publicly insured and uninsured patients. All participants served in a variety of clinical roles to highlight staffing efficiency and collaboration.

PrEP initiation programs in emergency departments require collaboration and effective planning | Image credit: alimyakubov - stock.adobe.com

All interviews were half an hour long and included questions on their role in the ED, their experience with HIV prevention interventions in the ED, anticipated barriers and solutions for PrEP initiation, and perceived need for HIV prevention interventions. Thematic analysis of interview transcripts were conducted after the interviews were completed.

There were 22 staff members interviewed: 8 attending physicians, 5 of whom were in the ED and 3 of whom were in the HIV clinic; 4 resident physicians, 3 of whom were in the ED; 1 nurse practitioner from the ED; 5 registered nurses, of which 3 were from the ED; 2 pharmacy staff who were split between the ED and HIV clinic; and 2 social workers from the ED. A total of 13 of the participants reported not having any experience with delivering PrEP.

The primary operational challenges reported were time, capacity, and resource constraints of the ED. Having conversations about preventive health that was outside of their visit could lengthen the amount of time spent in the ED and could spread the staff thin as they try to care for other patients. Participants stated that using electronic health records or electronically accessible workflows could help to identify those who need PrEP and can help in prescribing. Sharing the workload can also help to provide the patient with not only the medication but the information that they need. Participants also mentioned the potential biases associated with identifying those most at risk of HIV and training staff would be required to undergo such an intervention.

Participants noted that addressing the factors that affect the patient’s ability to start and keep taking PrEP need to be considered as well. Reliable connections to follow-up care is needed and asking for all forms of contact information can help to maintain contact with the patients. Patient navigators can act as a resource for these patients to facilitate their connection to their health care.

Participants agreed on 3 components of initiating PrEP that would have to be implemented to work: providing an initial supply of PrEP in the ED, partnerships between Eds and PrEP clinics to meet additional psychosocial needs, and providing patient education materials that were language-inclusive. Most participants anticipated that there would be a high need for PrEP initiation that started in the ED. Although they were worried that clinicians in the ED would resist the additional tasks needed, they also stated that it was an opportunity to reframe what emergency care could mean and would allow for staff to engage with patients.

There were some limitations to this study. The patient perspective was not considered when conducting this study. The study may not be generalizable to smaller hospitals, as the study was entirely conducted in a large, urban hospital.

The researchers concluded that there were methods of initiating PrEP for patients in the ED though there would be challenges. Developing an effective workflow requires collaboration with those who work in the field and can provide a framework to work off of as interventions are developed and employed. Collaborations between staff in the ED and preventive medicine programs can help to facilitate the development of proper interventions in the future.

References

1. Bisom-Rapp E, Patel K, Jaradeh K, Hayirli TC, Peabody CR. Feasibility of emergency department-initiated HIV pre-exposure prophylaxis. West J Emerg Med. 2024;25(6):985-992. doi:10.5811/westjem.33611
2. Pre-exposure prophylaxis use expands, but not fast enough. UNAIDS. January 17, 2022. Accessed December 4, 2024. https://www.unaids.org/en/resources/presscentre/featurestories/2022/january/20220117_preexposure-prophylaxis-use-expands