Primary care is a setting that has great potential for screening and reducing the rate of HIV transmission

Brasch, Carl W

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Primary care is a setting that has great potential for screening and reducing the rate of HIV transmission.https://scholarworks.uvm.edu/fmclerk/1944/thumbnail.jp

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University of Vermont UVM ScholarWorks Family Medicine Clerkship Student Projects Family Medicine Community 2022 HIV Pre-Exposure Prophylaxis (PrEP): Increasing Awareness in Primary Care Carl W. Brasch University of Vermont Follow this and additional works at: https://scholarworks.uvm.edu/fmclerk  Part of the Medical Education Commons, and the Primary Care Commons Recommended Citation Brasch, Carl W., "HIV Pre-Exposure Prophylaxis (PrEP): Increasing Awareness in Primary Care" (2022). Family Medicine Clerkship Student Projects. 844. https://scholarworks.uvm.edu/fmclerk/844 This Book is brought to you for free and open access by the Family Medicine Community at UVM ScholarWorks. It has been accepted for inclusion in Family Medicine Clerkship Student Projects by an authorized administrator of UVM ScholarWorks. For more information, please contact schwrks@uvm.edu. HIV Pre-Exposure Prophylaxis (PrEP)Increasing Awareness in Primary CareCarl Brasch MS3Milton Family PracticeMilton, VTMay - June, 2022Preceptor: Gordon PowersProblem Background and Identification● Minority groups are disproportionately affected by HIV3● Taking a sexual history helps identify patients who are at risk and is a recommended part of routine primary care, yet it is often deferred5 ● Screening for high risk behaviors can help identify patients that may benefit from initiating treatment● Pre-Exposure Prophylaxis (PrEP) treatment is effective at reducing the chances of HIV transmission1New Diagnoses of HIV in 2019 per SubpopulationGOAL: Increase Awareness of PrEP Amongst Providers and High-Risk Patients in Primary Care Public Health Cost● As of 2019 an estimated 1,189,700 people in the US have HIV3● In 2019 an estimated 36,801 people in the US received a diagnosis of HIV3● From a patient perspective, the estimated lifetime cost of treatment is $326,500 for someone who becomes infected with HIV6● The estimated lifetime cost of treatment is $96,700 for patients who remain uninfected but fall into a high risk category6● According to Vermont Public Health Survey, 6% of Vermonters participate in high risk activities, the same percentage as the national average7● Since 2011 the proportion of adults in Vermont participating in high risk behaviors has increased7● Among Vermont Residents, LGBTQ+ individuals are six times more likely to participate in high risk behaviors7Community Perspectives and Barriers to CareGordon Powers, MDFamily Medicine Physician at Milton Family Practice“In one primary care visit there is so much ground to cover, we have to pick and choose our topics at each appointment.”“Amongst primary providers there is a lack of awareness of PrEP”“There is a misconception that it’s hard to prescribe PrEP due to the regular labs that have to be monitored while a patient is receiving treatment”“So many primary providers have packed schedules, it’s hard to fit in regular 3 month visits for lab monitoring.” Devika Singh, MDInfectious Disease Physician at UVM Health HIV/AIDS Clinic“A major gap in care is the ability to identify patients at risk with adequate sexual history taking.”“Outside of infectious disease clinics there is not enough knowledge about PrEP.”“There are a lot of training and logistical complications surrounding the injectable form of PrEP. A lot of clinics aren’t yet equipped to prescribe it.” Intervention and Methodology   ● Patient Perspective - Increase access to PrEP 101 CDC Handout○ Interviewed patients within Milton Family Practice○ Assessed their awareness of HIV transmission risks, and prophylactic treatment○ Increase ease of access to PrEP patient educational handout in the primary care setting● Provider Perspective - Increase access to PrEP CDC Guidelines○ Interviewed a provider from The University of Vermont Medical Center HIV/AIDS clinic, and a primary care provider at Milton Family Practice○ Explored their perspective on how primary care can play a larger role in preventing HIV transmission○ Streamlined primary provider access to updated guidelines which include:■ Guidelines of patients who are at risk and should consider PrEP treatment■ Labs required for routine monitoring for patients on PrEP ■ US Public Health Services Clinical Practice Guidelines for PrEP treatmentIntervention - CDC Handouts for Patients and Providers2 Results and Potential Solutions  Devika Singh, MD“We can learn so much by listening to patients that have HIV, hearing their story and appreciating their perspective on how providers can improve sexual history taking.”“Move away from talking about sexual risks, and instead use vocabulary surrounding sexual practices.”Gordon Powers, MD “Medicine has a lot to learn about providing adequate care for the LGBTQ+ population.”“Destigmatizing sexual history taking would go a long way towards providing adequate care for at risk populations” Surveyed Patients from Milton Family Practice● All patients interviewed were aware of behaviors that are associated with a high risk of HIV transmission● All patients reported having friends or family that fall into the high risk group● None of the Patients were aware of PrEP or the concept of HIV prophylaxis ● PrEP 101 handout was distributed to patients at Milton Family Practice to increase awareness among patientsEffectiveness and Limitations● Interviewed a small sample size of patients about their level of awareness○ Each patient interviewed was provided an educational handout for their own benefit and to distribute to acquaintances that fall into a high risk category  ● Only primary care providers in Milton Family Practice received the educational handout regarding updated guidelines for prescribing PrEP● Future evaluation of effectiveness would include monitoring for the percentage of adults who participate in high-risk behaviors that are being treated with PrEP, before and after distribution of information in the primary care settingFuture interventions● Facilitate widespread distribution of CDC 2021 PrEP guidelines to primary care clinics ● Increase patient education by expanding screening of primary provider’s panels for patients that fall into the high risk category and ensure that each of them receive the PrEP 101 handout ○ Encourage them to initiate a conversation with their primary provider about PrEP● Expand the sample size of patients interviewed to determine the percentage of high risk patients who are unaware of PrEP● Normalize sexual history taking among providers and medical students as a way of identifying patients that are classified as high risk○ Invite Infectious Disease Physicians and HIV patients to primary care clinics to offer their perspectivesReferences1. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf2. https://www.cdc.gov/hiv/risk/prep/index.html3. https://www.cdc.gov/hiv/basics/statistics.html4. https://www.cdc.gov/hiv/images/basics/statistics/infographics/cdc-hiv-statistics-diagnoses-subpopulations-1200x630.png5. Wimberly YH, Hogben M, Moore-Ruffin J, et al. Sexual history-taking among primary care physicians. J Natl Med Assoc. Dec 2006;98(12):1924-1929. 6. Schackman BR, Fleishman JA, Su AE, et al. The lifetime medical cost savings from preventing HIV in the United States. Med Care. 2015;53(4):293-301. doi:10.1097/MLR.00000000000003087. https://www.healthvermont.gov/sites/default/files/documents/pdf/HSVR_2018_BRFSSReport.pdf8. Krakower D, Mayer K H. Patient Evaluation and selection for HIV pre-exposure prophylaxis. In: UpToDate, Sax Paul E (Ed), UpToDate, Waltham, MA. (Accessed on June 10, 2022.)Interview Consent  1. Devika Singh, MD2. Gordon Powers, MD3. Michael S. Clark4. Brett Gennero5. Sean Ryan

HIV Pre-Exposure Prophylaxis (PrEP): Increasing Awareness in Primary Care

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HIV Pre-Exposure Prophylaxis (PrEP): Increasing Awareness in Primary Care

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