The following is a summary of “Clinic-based interventions to increase preexposure prophylaxis awareness and uptake among United States patients attending an obstetrics and gynecology clinic in Baltimore, Maryland,” published in the October 2023 issue of Obstetrics and Gynecology by Wang, et al.
Cisgender women constitute a significant portion of new HIV diagnoses in the United States, with the majority (85%) attributed to heterosexual contact. Despite the effectiveness of HIV preexposure prophylaxis (PrEP) as a prevention strategy, awareness and prescriptions for PrEP among women remain low. For a study, researchers sought to enhance PrEP counseling and uptake among cisgender women attending obstetrics and gynecology clinics.
Conducted in a high HIV prevalence region, the study involved three phases within a single health system and three obstetrics and gynecology clinics. The phases included baseline (a 3-month period before the clinical trial, involving provider education and training of a registered nurse on PrEP), clinical trial (a 3-month period during which eligible patients were randomized to an active control or a PrEP registered nurse intervention), and maintenance (a 3-month period after the trial concluded). Electronic medical record clinical decision support tools, including best practice alerts, order sets, progress note templates, and educational materials, were available to both arms during the clinical trial. The intervention arm featured a PrEP nurse who contacted and counseled patients and had the capability to prescribe PrEP. The study evaluated these phases through the “reach, effectiveness, adoption, implementation, and maintenance” framework. The primary outcome was effectiveness, measured by the percentage of eligible patients with documented HIV prevention counseling in the electronic medical record or PrEP prescriptions. Secondary outcomes included reach (percentage of best practice alerts acted on or patients who spoke with the PrEP nurse), adoption (percentage of eligible patients with a triggered best practice alert or attempted contacts by the PrEP nurse), and maintenance (percentage of patients with documented HIV prevention counseling or PrEP prescriptions during the maintenance phase).
In the study involving 904 unique patients across all phases, with a mean age of 28.8±7.7 years, and 416 patients (46%) being pregnant, 436 patients were randomized in the clinical trial phase. In terms of reach and adoption, best practice alerts were triggered for 100% of eligible encounters, yet providers acted on only 52% of them. The preexposure prophylaxis nurse attempted to contact every patient and successfully spoke with 81.2% of them in the preexposure prophylaxis registered nurse arm. Regarding effectiveness, significantly more patients were counseled about preexposure prophylaxis in the preexposure prophylaxis registered nurse group compared to the active control group (66.5% vs 12.3%, respectively; P<.001), although preexposure prophylaxis prescriptions were equivalent (P=1.0). Among patients counseled about preexposure prophylaxis, 18.5% in the active control arm and 3.4% in the preexposure prophylaxis registered nurse arm were prescribed preexposure prophylaxis (P=.02). Regarding maintenance, clinical decision support tools alone resulted in preexposure prophylaxis counseling for 1.0% of patients during the maintenance phase, compared to 0.6% during the baseline phase and 11.2% during the clinical trial phase (P<.001). Preexposure prophylaxis prescriptions did not significantly differ among the three phases (P=.096).
In conclusion, while a preexposure prophylaxis nurse effectively increased HIV prevention discussions, it did not result in more preexposure prophylaxis prescriptions compared to the provider-utilized preexposure prophylaxis–focused clinical decision support tools. The decline in preexposure prophylaxis counseling post-trial phase suggested the need for sustained interventions to maintain effects.