In the Journals Plus

Two-thirds of patients with HIV had missed opportunities for PrEP

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May 31, 2018

Dawn Smith, MD, MS, MPH
Dawn K. Smith

New findings from a retrospective cohort study revealed that 66% of patients newly diagnosed with HIV in South Carolina visited a health care facility before their diagnosis. The health care visits occurred after the CDC had issued interim guidance recommending daily pre-exposure prophylaxis, or PrEP, for patients at risk for HIV and, therefore, likely represent missed opportunities for its use, according to researchers.

“The CDC estimates that 1.2 million persons in the United States have risk behaviors that constitute indications for PrEP use,” Dawn K. Smith, MD, MPH, of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, and colleagues wrote in Clinical Infectious Diseases. “PrEP prescriptions have been steadily increasing but are still less than 10% of those estimated to have indications for PrEP use, with marked disparities by race/ethnicity, age, transmission risk group and gender, when compared to rates of new HIV infections.”

For the study, Smith and colleagues examined HIV case surveillance data from the Department of Health and Environmental Control’s Bureau of Laboratory System, South Carolina’s Sexually Transmitted Disease Management Information System and the Revenue and Fiscal Affairs inpatient, outpatient and ED hospital discharge database. They identified 885 patients newly diagnosed with HIV in South Carolina between 2011 and 2016. Among them, 586 (66%) were treated by a health care professional before their diagnosis. Patients had, on average, 6.9 health care visits before contracting HIV, representing several missed PrEP opportunities, according to the researchers.

Of 4,029 health care visits, most (84%) were to EDs, followed by outpatient (7%) and inpatient (6%) facilities. Although primary care clinicians and infectious disease specialists are primarily targeted for PrEP education and training, most visits representing missed opportunities were conducted by emergency medicine providers (61%), according the Smith and colleagues. Only 10% of visits were performed by primary care physicians.

“All clinicians who identify patients with indications for PrEP are recommended to provide it,” Smith told Infectious Disease News. “Many underinsured or uninsured patients use ED services for a variety of health concerns — including STD symptoms — that would indicate a need for HIV testing and consideration of PrEP or postexposure prophylaxis. Depending on the resources for continuity care at specific institutions, ED clinicians may provide ongoing PrEP care in an associated outpatient clinic at their institution or may link patients taking PrEP to a provider in the community who will provide the follow-up care.”

Patients with HIV who had missed opportunities for PrEP initiation were more likely to be women vs. men (P < .0001); black vs. white (P < .0001); and aged younger than 30 years (P < .0003). Few Hispanic patients with new HIV infections had a prior health care visit, which Smith and colleagues said is “concerning” given that new infections are rising among young Hispanic men who have sex with men.

Results further showed that one-quarter of patients had an STD during their health care visit and before their HIV diagnosis, suggesting that physicians “may not be responding to the fact that gonorrhea and syphilis are strongly suggestive of risk for HIV acquisition,” the researchers wrote.

Moving forward, Smith said it will be important to maximize opportunities during routine, emergency and other health care visits to test patients for HIV in accordance with CDC guidelines and to identify people who may benefit from PrEP.

“Reducing the number of missed opportunities will help close gaps in the number of people who could potentially benefit from PrEP and how many have received it,” she said. “The closure of these gaps plays an important role in reducing the number of new HIV infections in populations with high rates of new HIV diagnoses, especially African American and Hispanic/Latino people in the South.”– by Stephanie Viguers

Disclosures: The authors report no relevant financial disclosures.

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