| Description |
Background: Human Immunodeficiency Virus (HIV) pre-exposure prophylaxis (PrEP) is a highly effective preventative treatment therapy that is underutilized among women in the U.S. The Centers for Disease Control and Prevention (CDC) has a targeted goal of decreasing new HIV infections in the U.S. to 3,000 by 2030 through interventions such as HIV PrEP. The American College of Obstetricians and Gynecologists (ACOG), the governing body for obstetricians and gynecologists, further supports HIV PrEP utilization. The purpose of this Doctor of Nursing (DNP) evidence-based quality improvement initiative was to implement an HIV PrEP referral protocol in a women's health advanced practice registered nurse (APRN) practice, consisting of 23 total providers; specifically, Certified Nurse Midwives (CNMs), dual CNM/Women's Health Nurse Practitioner (WHNP), a WHNP, and a dual CNM/ Family Nurse Practitioner (FNP). Thus, this project aimed to increase rates of counseling and referrals placed for HIV PrEP therapy, aligning clinical practice with CDC and ACOG recommendations, and to assess the protocol's feasibility, usability, and overall provider satisfaction. Local Problem: Within a large urban academic healthcare system in Utah, there is a lack of standardized protocols for screening, counseling, and referring women for HIV PrEP therapy. Current efforts are fragmented, with HIV PrEP offered in select outpatient clinics, like the Student Health Center and Infectious Disease Clinic, but not universally within the identified healthcare system. Providers within the identified clinical setting are unfamiliar with HIV PrEP, thus revealing a healthcare gap in HIV preventative treatment opportunities. Methods: A pre-implementation survey was given to participants to establish baseline practices, comfort levels, and attitudes regarding HIV PrEP. The project lead oversaw the implementation of a standardized protocol for screening, counseling, and referring women for HIV PrEP therapy, and engaged in regular clinical site visits to collect data which informed necessary iterative changes to the QI project. A post-implementation survey evaluated for feasibility, useability, satisfaction, and acceptability of the referral protocol. Data collected via retrospective chart reviews pre- and post-implementation demonstrated missed opportunities prior to intervention and total referrals placed during the implementation period. Interventions: An educational presentation on the safety, efficacy, and use of HIV PrEP, along with CDC recommendations and guidelines was provided to participants. The referral protocol flowsheet, tailored for the specific practice, was then introduced. Repeated Plan-Do-Study-Act (PDSA) cycles during the implementation period reinforced adherence and participation to the protocol, as well as addressed barriers and unanticipated obstacles. Results: The majority of providers consistently agreed pre- (n=7, 78%) and post- (n=11, 85%) implementation that HIV PrEP counseling and referrals should be offered within the selected Women's Health APRN practice setting. Significant improvements in provider confidence in the indicated use, safety, and efficacy of HIV PrEP from pre- to post- implementation were observed. 100% (n=5) of providers who utilized the HIV PrEP referral protocol were "satisfied," and 80% (n=4) were "likely" or "very likely" to use it in the future. A notable practice change occurred, in which 89% (n=8) of providers pre-implementation "never" counseled patients on HIV PrEP, whereas post-implementation, 54% (n=7) had begun to counsel "a few" patients. A total of two potential referrals for HIV PrEP were placed during the implementation period. Conclusion: Integrating an HIV PrEP referral protocol into a Women's Health APRN practice is a viable solution in addressing healthcare gaps in HIV preventative treatment. Adequate provider training and reinforcement improve provider confidence and practices related to HIV PrEP therapy. Various strengths and barriers were identified, and ongoing provider education and continued efforts are necessary to sustain practice changes associated with the QI initiative. |
