Improving the HIV PrEP Cascade using an Intervention for Healthcare Providers

摘要/项目摘要： 艾滋病毒暴露前预防(PrEP)已被证明在#年对艾滋病毒预防非常有效 随机临床试验，但PrEP在美国的应用有限。PrEP的障碍之一 实施缺乏医疗保健提供者(HCP)的知识和开处方的意愿。作为以下结果： 报道了在真实世界环境和不同人群中的当前PrEP配方，并且新颖的PrEP 配方推出后，将继续需要支持和指导，以优化临床和 这一宝贵的艾滋病毒预防战略对公共卫生的影响。我们提出了一种PrEP优化干预 以HCP为目标，提高艾滋病毒感染风险人群的PrEP摄取率和持久性。这 干预措施包括：(1)基于Web的集成面板管理工具PrEP-Rx，它提供 结构化的艾滋病毒风险评估，自动提醒实验室检测和预约，以及报告 患者使用PrEP的历史；以及(2)由临床支持人员监督的集中PrEP协调 (称为PrEP协调员)，可以通过直接患者识别艾滋病毒高危人群 联系或通过审查性传播感染(STI)登记以及谁可以支持多个HCP。 我们提出以下目标： 主要目的：评价PrEP优化干预(PrEP协调器+PrEP-Rx)的疗效 在10家初级保健诊所之间通过阶梯式楔形设计增加PrEP处方。我们假设 当诊所使用PrEP时，平均开出的处方数量将显著增加 干预与不干预的对比。 次要目标： 1-根据患者的不同情况，探讨PrEP的启动、使用时间和停止原因的差异 年龄、种族/民族和性别/性别，以及研究诊所中的临床和HCP特征。 2-在阶梯式楔形阶段后的八个月随访期间，探索干预的可持续性。 3-调查实施PrEP的促进者和障碍以及拟议PrEP干预的经验 通过与研究诊所的HCP、PrEP协调员和诊所主任进行定性访谈。 PrEP协调员加上PrEP-Rx的组合有可能改进 通过识别感染艾滋病毒的高风险个人，为持续和加强整体护理做好准备， 标准化艾滋病毒风险评估，帮助启动PrEP，系统化随访或实验室 评估，并就新出现的PrEP数据对初级卫生保健方案进行教育。这些目标可能会有一个重要的公众 对健康的影响，并以对现有诊所资源的最小负担实现。我们正在使用创新的 提供PrEP的方法，这将导致对初级保健方案的培训，以增加有能力的初级保健方案的数量 提供PrEP。最终，拟议的研究有可能缩小PrEP级联中的差距。

Abstract/Project Summary: HIV pre-exposure prophylaxis (PrEP) has been shown to be highly effective for HIV prevention in randomized clinical trials but uptake of PrEP in the U.S. has been limited. One of the barriers to PrEP implementation is lack of healthcare provider (HCP) knowledge and willingness to prescribe it. As outcomes of current PrEP formulations in real-world settings and different populations are reported and novel PrEP formulations are introduced, HCPs will continue to require support and guidance to optimize the clinical and public health impact of this valuable HIV prevention strategy. We propose a PrEP optimization intervention targeted at HCPs to increase PrEP uptake and persistence among those at risk for HIV acquisition. This intervention includes: (1) an integrated web-based panel management tool called PrEP-Rx, which provides structured HIV risk assessment, automates reminders for laboratory testing and appointments, and reports patients' history of PrEP use; and (2) a centralized PrEP coordination overseen by a clinical support staff (referred to as the PrEP coordinator) who can identify individuals at high risk for HIV through direct patient contact or by reviewing registries for sexually transmitted infections (STIs) and who can support multiple HCPs. We propose the following aims: Primary Aim: Evaluate the efficacy of the PrEP optimization intervention (PrEP Coordinator + PrEP-Rx) to increase PrEP prescriptions through a stepped-wedge design among 10 primary care clinics. We hypothesize that the mean number of prescriptions issued will be significantly higher when the clinics use the PrEP intervention versus when they do not. Secondary Aims: 1- Explore differences in PrEP initiation, duration of use, and reasons for discontinuation based on patient's age, race/ethnicity, and sex/gender, and by clinic and HCP characteristics among study clinics. 2- Explore sustainability of the intervention during an eight-month follow-up after the stepped-wedge Phase. 3- Investigate facilitators and barriers of PrEP delivery and experiences with the proposed PrEP intervention through qualitative interviews with HCPs, PrEP Coordinators, and clinic directors of study clinics. The combination of the PrEP Coordinator plus PrEP-Rx has the potential to improve all steps of the PrEP continuum and enhance overall care by identifying individuals at high risk of HIV acquisition, standardizing HIV risk assessment, helping in PrEP initiation, systematizing follow-up visits or laboratory assessments, and educating HCPs about emerging PrEP data. These goals can have a significant public health impact and be attained with minimal burden on existing clinic resources. We are using innovative approaches for PrEP delivery which will result in training of HCPs to increase the number of HCPs capable of offering PrEP. Ultimately, the proposed research has the potential to reduce gaps in the PrEP cascade.