Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1023 — Pathways to PrEP: What Medical Records Reveal About Access to HIV Pre-Exposure Prophylaxis in VA

Lead/Presenter: Avy Skolnik, COIN - Bedford/Boston
All Authors: Skolnik AA (Bedford/Boston CHOIR) Gifford AL (Bedford/Boston CHOIR) Bokhour BG (Bedford/Boston CHOIR) Wilson B (Louis Stokes Cleveland VAMC, GRECC) Van Epps P (Louis Stokes Cleveland VAMC, GRECC)

Objectives:
Daily antiviral HIV pre-exposure prophylaxis (PrEP) is efficacious and guideline-recommended, yet uptake has been slow. Some studies estimate that PrEP is utilized by 1% of individuals in need. We sought to understand quality indicators and potential access barriers by examining the "PrEP pathway" as seen in health record documentation and communication with Veterans receiving this important preventive service.

Methods:
In this mixed-methods study, Veterans were selected for detailed electronic health record (EHR) reviews from among the 825 Veterans prescribed PrEP nationally during 2012-2016. We conducted chart abstractions of encounter notes, consults, telephone notes, and secure messages. We (1) extracted descriptive information and PrEP quality indicators (e.g. presence or absence of sexual history documentation); (2) conducted qualitative content analysis of all PrEP-relevant free-text notes; and (3) constructed PrEP access pathways for each patient, including initiator of PrEP conversation, time interval between initial inquiry and index fill, reasons for delaying or denying PrEP, and patients' responses to delays or refusals.

Results:
Pathways observed in 131 PrEP cases revealed that Veterans (not providers) initiated 95% of PrEP conversations. Over 70% of cases evidenced barriers to access or missing quality indicators, with approximately 30% achieving both quality metrics and timely access. Time intervals from initial request-to-fill ranged from same-day to over one year. Qualitative themes associated with delays included provider knowledge gaps (e.g. about PrEP itself and PrEP policies), provider attitudes (e.g. about PrEP, about patients seeking PrEP), and organizational barriers (e.g. primary care expected to prescribe, but prescription privileges restricted to specialty). Knowledge gaps among various PACT team members further limited access, even prior to the clinical encounter.

Implications:
Though PrEP is widely recommended for individuals at risk for contracting HIV, many Veterans needing PrEP faced delays and barriers due to knowledge gaps, structural barriers, and stigma.

Impacts:
Current practices place substantial responsibility on Veterans to request and advocate for this service, in contrast to many other preventive services (e.g. colon cancer screening, tobacco cessation). Understanding prevalence, location, and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission among Veterans.