Initiating PrEP in Primary Care: Addressing the Adolescent and Young Adult High Risk Populations
Problem: Adolescents and young adults (AYA) ages 13 to 24 comprise a quarter of the new HIV diagnoses in the United States. Lack of access to HIV-preventive therapies such as pre-exposure prophylaxis (PrEP) reduces opportunities to prevent HIV infection in this population. Initiating PrEP in AYA significantly reduces the negative health outcomes of HIV, but it is evident that many clinicians are still reluctant to initiate PrEP in AYA patients based on perceived threats and barriers.
Context: Primary care clinics, including school-based clinics, have an opportunity to offer HIV prevention services including PrEP. This project, the Adolescent and Young Adult Comprehensive PrEP Education Project (AYA ComPrEP) is an HIV-prevention quality improvement project that is directed towards providing AYA high-risk populations with access to PrEP in the primary care setting. The project was supposed to be completed at the Balboa Teen Clinic of Balboa High School, a clinic serviced by the Community Health Programs for Youth (CHPY) of the San Francisco Department of Public Health (SFDPH). Due to the COVID-19 pandemic shelter-in-place policy, the training for clinicians and staff, and roll out of PrEP service for adolescent clients of Balboa Teen Clinic was deferred to an unknown date. An online training and simulation for the University of San Francisco clinicians (nurse practitioner students) was conducted instead.
Interventions: A site feasibility analysis was conducted, which include consultations with CHPY leadership and management, site assessment, conduct of face-to-face in-depth interviews among staff of Balboa Teen Clinic, and review of literature and best practices to develop recommendations for a pilot PrEP program for AYA. Some interventions were modified to focus on increasing the confidence of providers, nurse practitioners students of the University of San Francisco (USF) to prescribe PrEP to AYA. The focus of this DNP project was shifted to designing modules, conducting and evaluating of an online simulation, a PrEP training workshop for providers. The simulation include didactic, role play, case studies covering information, best practice recommendations on HIV and AIDS, HIV counseling, reproductive health, sexual orientation and gender identity initiative, and PrEP for AYA.
Measures: A pre-assessment and post-simulation evaluation was utilized to determine the change in providers’ knowledge, enabling attitudes, confidence, and readiness to offer HIV prevention services, and prescribe PrEP in preparation for their integration in clinics that they will be working. Case studies in the form of simulated patients to measure how they would apply the knowledge and confidence gained towards real life practice scenarios.
Results: Nineteen clinicians attended the online PrEP simulation training-workshop. The data analysis revealed a 17.11% increase in HIV/AIDS & PrEP knowledge mean score (average scores: 76% for pre-simulation versus 89% for post-simulation) among participants. Likewise, HIV and PrEP enabling or non-stigmatizing attitude scores has increased by 18.3% (average scores: 71% for pre-simulation versus 84% for post-simulation). All the 19 clinicians revealed that their knowledge and confidence to prescribe PrEP to adolescents and young adults in their practice has increased as a result of attending the simulation (13 strongly agreed; 6 agreed) as compared to 2 clinicians prior to the simulation.
Conclusions: PrEP targeted for at-risk AYA is necessary to reduce HIV rates. This is possible by breaking barriers to PrEP prescription through education and training of clinicians. PrEP should be included in the training and preparation of clinicians to address the adolescent and young adult populations. Online simulation training workshop for PrEP is an effective alternative means if face-to-face training is not possible.