GME Patient Safety Quality and Innovation Symposium

Background: HIV remains a significant public health issue in the US, with over 30,000 new diagnoses annually. The Veterans Health Administration (VHA) is the leading provider of HIV care. HIV pre-exposure prophylaxis (PrEP) medication is over 99% effective in preventing HIV. Despite CDC recommendations, PrEP is underutilized, with 36% of high-risk patients prescribed PrEP nationally and only 20% in VA San Diego (VASD). Barriers to accessing PrEP at VASD were identified through Gemba walks and stakeholder interviews, including knowledge gaps of primary care providers (PCPs), lack of an efficient system to assess PrEP indications, low patient awareness, and required referral or e-consult to the Special Infectious Diseases (SPID) clinic for PrEP prescriptions. Inspired by a similar initiative at the Greater LA VA (GLAVA), interventions were developed to address barriers, including a PCP educational session, a note template to assess PrEP indications and handouts clarifying the SPID referral process, outreach letters to raise awareness of PrEP to high-risk patients on a local dashboard, and a new PrEP Champions Pathway allowing certain PCPs to prescribe PrEP directly. This project aims to increase the percentage of high-risk patients prescribed PrEP by 10%, increase new PrEP prescriptions by 20%, and improve PCP confidence and knowledge on PrEP by 20% in the 4N primary care and H-PACT clinic by 5/15/2025 in VASD.

Methods: The current PrEP initiation process was analyzed through Gemba walks and interdisciplinary interviews across the 4N primary care, H-PACT, and SPID clinics. Baseline data was collected, and interventions described above were implemented. Outcome measures included percentage of high-risk patients prescribed PrEP and number of new PrEP prescriptions. Structural measures assessed PCP confidence, comfort, and knowledge related to PrEP. Process measures tracked SPID referrals and e-consults. A balancing measure monitored SPID clinic waiting times. Data was analyzed using statistical analysis and statistical process control (SPC) charts.

Results: The percentage of high-risk patients prescribed PrEP remained stable post-intervention, although the total number of high-risk patients increased, resulting in a higher absolute number of patients receiving PrEP, although new PrEP initiations did not significantly increase. The educational sessions (n=48 pre-survey, n=37 post-survey) increased PCP confidence in PrEP indications from 52% to 91% and comfort with initiation from 31% to 70%, and knowledge-based responses showed over 20% improvement. There were no significant changes in SPID referrals, e-consults, or average SPID clinic wait times.

Conclusions: Although target increases in the percentage of high-risk patients prescribed PrEP and new PrEP prescriptions were not met, the project succeeded in increasing the absolute number of veterans on PrEP. Furthermore, the educational sessions were successful at increasing PCP confidence, comfort, and knowledge related to PrEP, aligning with similar efforts at the GLVA. More time may be needed to evaluate the impact of the interventions. Strengths include a multi-faceted approach and alignment with VHA HIV care priorities. Barriers include clinic time constraints and buy-in from providers and patients. Next steps include implementation of the PrEP Champions Pathway and continued monitoring of measures. This project is promising to expand PrEP access at VASD and reduce HIV infection among veterans.

Impact Statement: Within five months, implementation of interventions aimed at raising awareness of and improving access to HIV pre-exposure prophylaxis (PrEP) in a primary care clinic and H-PACT clinic serving patients with housing instability at VA San Diego improved provider confidence, comfort, and knowledge about PrEP by over 20%, and increased access by raising the absolute number of patients on PrEP.