Implementation of HIV Pre-exposure Prophylaxis Toolkit: A Quality Improvement Project

In 2012, the Food & Drug Administration (FDA) approved the use of pre- exposure prophylaxis (PrEP) to reduce human immunodeficiency virus (HIV) transmission among high-risk individuals. When used correctly, PrEP reduces HIV infection risk by about 99%. Despite its effectiveness, PrEP is underutilized in the United States. In 2022, 1.2 million high-risk adults were eligible for PrEP, but only 437,000 received prescriptions. This quality improvement (QI) project aimed to enhance primary care providers' (PCP) identification of patients at high risk for HIV and rates of/frequency of/other assessing PrEP needs for high-risk HIV adults by implementing a PrEP toolkit intervention. Local Problem: In 2021, 133 individuals in Utah received a new diagnosis of HIV, and 3,453 Utahns were living with HIV. An estimated 16% of Utahns aged 13 and above were unaware of their positive HIV status. However, only 4,006 out of 6,840 eligible PrEP candidates received this preventative therapy in Utah in 2021. Methods: In this QI project, a PrEP toolkit intervention was developed to increase rates of both provider identification of adult patients at high risk for HIV and provider PrEP prescribing practices. Surveys were administered pre- and post-implementation of the toolkit to assess providers' screening and prescribing habits. The Centers for Disease Control and Prevention (CDC) guidelines were used to develop a clinic-tailored PrEP toolkit intervention. The PrEP toolkit and the four implementation strategies found within were designed to identify patients at high risk for HIV infection, evaluate changes in provider rates of assessing PrEP needs, and PrEP prescriptions handed to patients. Additionally, satisfaction and usability were evaluated in the post-implementation survey. Descriptive statistics were used to analyze the surveys. Interventions: The HIV PrEP toolkit consisted of four strategies to increase PrEP identification and prescribing practices in adult patients at high risk for HIV infection. The toolkit consisted of (1) a PrEP-specific electronic health record (EHR) template, (2) CDC PrEP pamphlets, (3) CDC PrEP flyers, and (4) CDC PrEP guidelines. The four strategies in the toolkit were developed to prompt providers and empower patients to advocate for themselves and initiate a conversation. Results: Nine PCPs were invited to participate. Seven providers (n=7, 77%) completed the pre- implementation survey, and two providers (n=2, 28.6%) agreed to participate in the toolkit implementation. Additionally, the most common method of providers identifying patients at high risk for HIV infection was by the initiation of a conversation by the patients (n=7, 100%). Three providers (n=3, 42.9%) reported screening for HIV risk factors in routine patient visits. Conversely, only two providers (n=2, 28.6%) reported screening for HIV risk factors among family planning visits. The post-implementation survey showed that one provider used the toolkit 100% of the time, and the second provider used the toolkit less than 50% of the time. Conclusion: The PCPs involved in the QI project expressed satisfaction with the toolkit and plan to continue using it in their practices. However, future phases are necessary to ensure the long- term success and sustainability of the PrEP toolkit and enhance providers' ability to implement identification and screening practices effectively. While the applicability of the project to alternative clinical settings is uncertain, the baseline assessment conducted provided valuable insights into current practices related to patients at high risk for HIV infection and assessing the need for PrEP therapy. Moving forward, identifying champions to advocate for a system-wide QI initiative, utilizing educational resources, monitoring provider practices, and involving ancillary staff are vital steps to increase identification and PrEP therapy rates in clinics. An executive report has been presented to the clinic's sponsor to address the project's findings and recommendations for improvement.