Improving access to pre-exposure prophylaxis for HIV prescribing in a primary care setting

Abstract

Although emtricitabine-tenofovir was approved for HIV pre-exposure prophylaxis (PrEP) in 2012, use by persons at risk of acquiring HIV has been limited. Because many primary care providers lacked familiarity and comfort prescribing PrEP, at our institution PrEP prescribing was concentrated among the infectious disease specialists, effectively limiting access. This project sought to increase the number of patients receiving new prescriptions for PrEP. The interventions targeted primary care providers (including internal medicine and family medicine), and were designed to increase the number of unique providers offering PrEP to their patients. The overall strategy was to expand the clinical scope of practice for primary care providers through education and provision of detailed care templates in the electronic health record. These initiatives were implemented through a series of informal Plan-Do-Study-Act cycles, then generalised throughout the medical system. To evaluate the success of the project, we queried the electronic medical record for all new prescriptions for PrEP, with provider name and specialty, for all outpatients 18 years of age and older from 2012 through 2020. In 2015, prior to the intervention, only 78 patients received new prescriptions for PrEP at our institution, and only 38% (30 of 78) of these were from primary care clinicians. After the intervention, the number of patients receiving PrEP increased to 190 in 2019, with 85% (162 of 190) prescribed by primary care providers. In addition, the number of primary care providers making a new prescription for PrEP increased from 20 in 2015 to 73 in 2019. We conclude that targeted clinical education, combined with electronic health record templates, was associated with a significant increase in PrEP prescribing.

Keywords: Educational outreach, academic detailing; Infection control; Primary care.

Figure 1

Number of patients with new orders for PrEP over time. Fam, family medicine; IM, internal medicine; PrEP, pre-exposure prophylaxis.

Figure 2

Electronic health record template for pre-exposure prophylaxis primary care visit. CKD, chronic kidney disease; HAV, hepatitis A vaccine; HBsAg, hepatitis B serum antigen; HBs, hepatitis B serum; HBV, hepatitis B vaccine; HCG, human chorionic gonadotropin; HPI, history of present illness; PrEP, pre-exposure prophylaxis; TWINRX, combined hepatitis A and B vaccine.