Despite advances in treatment that have improved the quality and quantity of life for patients, HIV and its associated disorders continue to represent a significant health concern globally. Recent statistics from the Centers for Disease Control and Prevention suggest that incidence rates for HIV have remained stable in years 2010-2016; however, young adults (25-34 years), males, and blacks/African Americans continue to demonstrate higher rates of HIV infections.1 Geographical variations in rates of HIV infection have also been demonstrated, with higher numbers of diagnosed and undiagnosed patients residing in the Northeast and Southern areas of the United States.1 While efforts to care for patients diagnosed with HIV can be improved by greater knowledge about who and where vulnerable subpopulations are, practices aimed at the prevention of HIV infection in those who are at greater risk will also benefit.
Before HIV or HIV-related infection occur, patients must be exposed to and acquire the virus. Although the Centers for Disease Control and Prevention recommends that everyone between ages 13 and 64 years be tested for HIV at least once, there are groups who need more frequent testing (Table). HIV can be diagnosed by serum nucleic acid, antigen/antibody, or antigen tests, but the latency period between exposure and sero-positive diagnosis of HIV varies according to the test selection, ranging from 10 to 90 days after exposure to the virus for detection. The lengthy period between exposure and seropositive confirmation needed for the diagnosis of HIV has created a unique opportunity for clinicians to focus on HIV prevention in patients. One method of HIV prevention that is gaining more support is pre-exposure prophylaxis (PrEP) for patients who have not been diagnosed with HIV but are at high risk of the infection.
Pre-exposure prophylaxis for HIV prophylaxis is a daily treatment with a single pill combination of tenofovir and emtricitabine and was approved for prevention of HIV infection by the US Food and Drug Administration in 20122 followed by a second drug containing emtricitabine and tenofovir alafenamide in 2019.3 Although any clinician with prescriptive authority can prescribe PrEP to a patient for whom therapy is clinically indicated, it has been used most commonly in settings associated with long-term patient follow-up, such as traditional primary care practices and infectious disease specialty settings.4 However, not all patients utilize such facilities for medical care. Clarifying our understanding of the disproportionate increases in HIV infection rates in disparate subgroups supports the need for increased efforts to prevent HIV that target clinical settings where they seek care.
PREVENTING HIV IN URGENT CARE SETTINGS
HIV prevention with PrEP in the urgent care setting is a concept that has been slow to gain traction and varies according to geographical area of the practice. While there are some urgent care locations in the United States offering PrEP services, there are many missed opportunities to provide and educate people about PrEP services in these care settings. Currently, many providers in the urgent care setting have a limited knowledge of PrEP and may elect to refer to another healthcare provider for initiation or continuation.5 Unfortunately, many patients face challenges that limit their capacity to keep appointments with clinicians to whom they are referred for subsequent care.
Clinical indications for the use of PrEP can aid clinicians in screening efforts and initiation of therapy. Urgent care settings are utilized for many acute and chronic conditions, with diagnoses of sexually transmitted infections (STIs) increasing in frequency.6 In past years, centers have experienced a 2-fold increase in the number of visits for people treated for Chlamydia trachomatis and Neisseria gonorrhoeae and a 3-fold increase in visits by people diagnosed with other STIs.6 Frequent STI is one of the risk factors for HIV and highlighted in the PrEP guidelines.7 The combination of requests by patients for STI testing and the rising incidence of individuals with an STI seeking treatment in urgent care has led to an increased risk of HIV and supports the need for improvements in counseling and provision of PrEP services in these ambulatory settings.
ONE NURSE PRACTITIONER'S EXPERIENCE IN PRESCRIBING PREP
Jack J. Mayeux, DNP, APRN, NP-C, has worked with patients in the urgent care setting for 5 years. His experience in treating patients corroborates current statistics on rising numbers of patients requesting screening and being diagnosed with STIs. While C trachomatis and N gonorrhoeae are among the most common STIs Mayeux treats in his practice, he finds that more and more patients are being treated for syphilis. In addition to STIs diagnosed in patients for the first time, Mayeux has treated many patients on multiple visits for repeat STI diagnoses.
Mayeux sees firsthand the need to discuss use of PrEP with patients who are at risk of HIV and finds that both the initiation and continuation of PrEP therapy are feasible in the urgent care setting. According to Mayeux, “Many patients coming to the urgent care setting for STI screening and treatment have a primary care provider, but are reluctant to visit for this reason due to perception and judgment. While there are cures for STIs, there is no cure for HIV.” “We have lab services in our facility. We can run all the required PrEP lab testing and receive the result in less than 35 minutes” (J. Mayeux, personal communication, January 3, 2020).
Rapid screening can make PrEP counseling and initiation practical within almost any urgent care facility that is equipped with in-house laboratory services, and patients always have the option of returning to their personal primacy care provider for continuation of PrEP services. Patients who lack primary care providers can be referred by urgent care facilities to local primary care services for continuation of therapy.
Advanced practice nurses, such as nurse practitioners, are prepared for a leadership role in the patient identification, counseling, treatment, and linkage of patients to other appropriate care settings that is needed to reduce HIV infection. The need to protect his patients motivated Mayeux to develop a PrEP protocol for use in the urgent care setting. Over a period of 24 months, his PrEP protocol was adopted at six different urgent care facilities across Louisiana. Since that time, the PrEP protocol has been implemented as part of the standard treatment option for patients diagnosed with STIs.
TRACKING CURRENT EFFORTS IN PREVENTING HIV
Yeow Chye Ng, PhD, CRNP, CPC, FAANP, was the first family nurse practitioner to provide PrEP services from an urgent care facility in Huntsville, Alabama. Ng is well known for his contributions and advocacy in HIV biomedical prevention with PrEP in primary care and urgent care settings for persons at high risk of HIV infection. Because PrEP is effective in preventing HIV only if patients are adherent to taking the medication once daily, adoption of the self-management behavior by patients is an important consideration for clinicians. “One’s behavior can be predicted more accurately if we have enough baseline repeat measurements from the same patient. It is important to note that adherence is a learned behavior and may change frequently if the behavior is not reinforced through an outcome, which could be as simple as one's perceived goals, or quantifiable health outcome,” states Ng.
Understanding why patients at high risk of HIV do not receive PrEP therapy goes beyond patient characteristics and access to care. A lack of knowledge about current guidelines for PrEP use and comfort in broaching the subject with patients at high risk of HIV has been cited as factors that reduced prescribing of PrEP by healthcare providers across multiple care settings, including emergency departments, primary care, and specialty care.8,9 Statistics suggest that these factors may be a significant barrier in getting patients necessary treatment to prevent HIV infection.
Despite approval of PrEP therapy, the incidence of HIV infection has remained stable over years 2013-2017.1 A better appreciation of the association between STIs and subsequent HIV infection may help focus prevention efforts. According to Ng, improving our knowledge about localized increases in incidences of STI cases can help to focus resources for HIV risk reduction campaigns that can address both patient- and healthcare provider–related factors. Such a task requires large volumes of data and the computational resources needed to gain meaningful insights from its processing.
Its common use of standardized disease and procedural coding makes administrative health data an excellent source for identifying vulnerable patients who have been treated for STIs. Ng seeks to understand the incidence of STIs in older adults, a subpopulation not commonly associated with risk of HIV, and to better characterize their risk of acquiring HIV infection. His initial work will involve the acquisition of multiple years of national data from sources such as Medical Expenditure Panel Survey and the CMS Data Warehouse to identify geographic areas of increased STI infections. Although data sets containing protected health information can be costly and difficulty to acquire, Ng believes data sets without protected health information will be valuable for his work. “Publicly available data sets can contain attributes that will help us to appreciate the geographical clusters of patients who are treated for STIs. Once we know where to go, we can begin our efforts at working with clinicians in urgent care settings to improve screening and initiation of PrEP in high-risk patient groups across all ages,” states Ng.
Acquiring data is the first step in Ng's work, which will be followed by the quantitative analysis and geomapping needed to find areas of greatest HIV risk. Partnering with data scientists and other clinicians, Ng will use a commercial cloud-based vendor to store and analyze the large data sets needed for his work in targeted HIV risk reduction. While focused outreach to healthcare providers may not be a new concept in patient care, access to data and other resources that facilitate widespread system change by small clinician groups may be a game-changer in treatment and prevention efforts. Implementation of PrEP in the urgent care setting can be a chance for patients to receive lifesaving care that might otherwise have been missed.
1. Centers for Disease Control and Prevention. HIV Surveillance Supplemental Reports 2019: estimated HIV incidence and prevalence in the United States, 2010-2016. 2019; https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-24-1.pdf
. Accessed February 28, 2020.
2. US Food and Drug Administration. FDA Approves First Drug for Reducing the Risk of Sexually Acquired HIV Infection
. US Food and Drug Administration: Silver Spring, MD; 2012.
3. US Food and Drug Administration. FDA Approves Second Drug to Prevent HIV Infection as Part of Ongoing Efforts to End the HIV Epidemic
. US Food and Drug Administration: Silver Spring, MD; 2019.
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6. Pearson WS, Tao G, Kroeger K, Peterman TA. Increase in urgent care center visits for sexually transmitted infections, United States, 2010-2014. Emerg Infect Dis
7. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States 2017 update: clinical practice guideline 2017. https://www.cdc.gov/hiv/pdf/guidelines/cdc-hiv-prep-guidelines-2017.pdf
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8. Mimiaga MJ, White JM, Krakower DS, Biello KB, Mayer KH. Suboptimal awareness and comprehension of published preexposure prophylaxis efficacy results among physicians in Massachusetts. AIDS Care
9. Tellalian D, Maznavi K, Bredeek UF, Hardy WD. Pre-exposure prophylaxis (PrEP) for HIV infection: results of a survey of HIV healthcare providers evaluating their knowledge, attitudes, and prescribing practices. AIDS Patient Care STDS