Improving Emergency Access to Human Immunodeficiency Virus Prophylaxis for Patients Evaluated after Sexual Assault

Abstract

Background:

Patients evaluated after sexual assault may benefit from non-occupational post-exposure prophylaxis (nPEP) to prevent infection with human immunodeficiency virus (HIV), yet multiple barriers may prohibit nPEP delivery.

Purpose/Relevance:

The IN-STEP (Integrating nPEP after Sexual Trauma in Emergency Practice) project was designed to improve access to HIV screening and prevention for patients evaluated in the Emergency Department (ED) of our academic hospital after a sexual assault.

Methods:

The IN-STEP team identified and addressed four key areas for improvement: (1) training of ED providers to perform nPEP assessments; (2) access to HIV testing in the ED; (3) provision of nPEP medications, using a patient-centered approach; and (4) continuity of care between the ED and follow-up sites in the community. Improvements were implemented using parallel plan-do-study-act cycles corresponding to these four key areas.

Results:

IN-STEP resulted in significant systems improvements in HIV screening, prevention, and continuity of care. This program not only improved the care of patients affected by sexual assault, but also those evaluated for HIV due to other indications.

Conclusions/Implications:

Involvement of a multidisciplinary leadership team, clear delineation of a patient-centered project focus, and coordination across four parallel areas for improvement were useful for completing this complex effort.

INTRODUCTION

Human immunodeficiency virus (HIV) infection can be prevented following potential exposures to the virus, such as those resulting from an inadvertent needle stick, unprotected consensual sexual intercourse, or sexual assault (defined here as non-consensual intercourse).¹ Using a practice called “post-exposure prophylaxis” or PEP, oral antiretroviral medications are started within 72 hours of exposure and administered for an uninterrupted 1-month period following exposure.¹ PEP can be used for occupational exposures (oPEP; e.g., after a needlestick sustained by a healthcare worker) or non-occupational exposures (nPEP; e.g., after a sexual assault).

Effective nPEP requires prompt medical decision-making at the point of care following a potential exposure and, if nPEP is indicated, prompt initiation of antiretroviral medications. Notwithstanding the potential benefits of nPEP for patients who may have been exposed to HIV, initiation of nPEP can pose significant challenges.^2–5 In our experience, challenges to initiating nPEP include:

• Assessment: At the point of care, the expertise required to assess the potential risk of HIV exposure and determine whether nPEP is indicated may not be readily available. Even in centers with access to specialized HIV consultants, success may rely on the consistent and timely availability of these consultants.

• Testing: Baseline HIV testing is recommended prior to initiation of nPEP.¹ Patients who are HIV-negative may receive nPEP; patients who are HIV-positive should instead receive care for HIV infection. However, many centers use testing methods that require up to one day to obtain actionable results and, therefore, may delay nPEP decision-making.

• Medications: nPEP medications may not be readily available at many pharmacies and may be expensive⁵. Even if partial courses are dispensed at the point of care along with a prescription for the remainder of the recommended course, access to the full course cannot be ensured.

• Continuity: Follow-up care and testing over a month-long course of prophylaxis is important, yet this can be difficult to arrange⁵. Primary care providers and other community clinics are not always trained or equipped to manage nPEP care, patient counseling, and follow-up HIV testing.

Here, we describe a successful effort to address these challenges at our institution. Data collection efforts were evaluated by our Institutional Review Board (exemption #18–224 for survey data; determination #18–357 for clinical volume assessments not involving individual patient data).

METHODS

Multidisciplinary Stakeholder Engagement

As the only academic health system in our geographically large state, our hospital serves as a primary referral center and safety net hospital for the community and several surrounding states. Our Emergency Department (ED) provides front-line medical care for many patients evaluated after sexual assault. This care may constitute patients’ first—and possibly only—encounter with the healthcare system after an assault. Our health system also offers specialized outpatient HIV care for adult and pediatric patients.

A multidisciplinary group of stakeholders, including trainees, faculty, and staff representing expertise in infectious diseases, emergency medicine, sexual assault care, pharmacy, nursing, clinical laboratory science, and population health was convened. The group focused on identifying needs and opportunities for improvement of nPEP care and implementing systematic improvements to meet these needs.

Four Key Areas for Improvement

Over a series of focused discussions, group members identified four key areas needing simultaneous quality improvement. These areas correspond with the barriers outlined above, namely:

1. Expanded capacity for nPEP assessment by ED providers at the point of care.

2. Access to rapid HIV testing and patient counseling resources for positive or negative results.

3. Prompt and uninterrupted patient access to nPEP medications for the full course of prophylaxis, when indicated.

4. Continuity of follow-up care after ED discharge for patients who receive nPEP or who have HIV-positive screening results.

We sought further input about perceived barriers to nPEP assessment and nPEP-related care among our ED’s providers through in-person and email-based discussions with ED providers and through a deidentified provider survey administered in REDCap.⁶ The survey included items assessing providers’ understanding of nPEP and their preferences about future nPEP decision support tools. A follow-up survey requested input about key aspects of our initiative after implementation to facilitate ongoing improvements.

The IN-STEP Project

Our project, called IN-STEP (Integrating nPEP after Sexual Trauma in Emergency Practice), utilized a patient-centered approach to provide necessary care to a vulnerable population (i.e., patients evaluated after sexual assault) at risk of a stigmatized diagnosis (i.e., HIV infection). We sought to overcome the barriers identified above and provide nPEP through a consistent, compassionate mechanism originating at the ED point of care.

We recognized that one of the most substantial challenges to quality improvement (QI) across these key areas was the potential cost of nPEP medications. Although pricing for antiretroviral medications can vary, the lowest estimated cost for a 1-month course of nPEP at the time the project was conceived was over $5000. As a starting point for our effort, we successfully applied for local grant funding to cover the cost of a full course of nPEP medications for patients evaluated in the ED following a sexual assault. This funding allowed us to dispense nPEP at the time of the ED visit at no cost to the patient or insurer. The funding served as a catalyst to develop sustainable infrastructures for HIV screening, prevention, and care that could extend beyond the scope of the grant and that could benefit other patients at risk for HIV.

Parallel Plan-Do-Study-Act Cycles

The need for simultaneous improvements in each of four key areas to ensure effective organizational change strongly guided our group’s approach. We approached these four areas in parallel, with each requiring multiple, iterative steps to achieve a durable QI outcome. We conceived of each area as having its own plan-do-study-act (PDSA) cycle, with each cycle operating in parallel. Members of the core group focused on areas most closely aligned with their expertise. To facilitate communication across the cycles, we also developed iterative improvements in our team’s communication process.

RESULTS

Confirming the Key Areas of Focus

Figure 1 shows the percentage of ED providers (among n=42 respondents from a group of 114 eligible ED attendings, advanced practice providers, fellows, and residents; 36.8% response rate) who reported each of seven barriers to nPEP delivery before IN-STEP. Each of these barriers corresponded with one or more key areas identified by the IN-STEP team. To encourage input from a broad range of providers, including those who may have declined to participate in the survey-based format, providers were invited to provide input about IN-STEP via email or at meetings and presentations related to the project.

Figure 1.

Barriers to delivery of nPEP care identified by ED providers (n = 42) and localization of the four key areas addressed by IN-STEP across these barriers. Providers could select more than one barrier from the list shown or identify other barriers (n=1 endorsed other barriers, with no further details listed in the available free-text space for the survey item). Thus, percentages do not total 100%. nPEP: Non-occupational post-exposure prophylaxis. ED: Emergency Department. IN-STEP: Integrating nPEP after Sexual Trauma in Emergency Practice. HIV: Human Immunodeficiency Virus.

Key Area 1: nPEP Assessment

On average, respondents expressed awareness of nPEP’s use (90.5%, Table 1) yet only moderate confidence in performing nPEP assessments in the ED (median self-reported confidence of 3 on a 5-point Likert scale, Table 1). Providers also acknowledged uncertainty about where to locate nPEP decision support tools and indicated a preference that such tools, if developed, be short, uncomplicated, and easy to locate to afford prompt reference at the point of care (Table 1).

Table 1.

Responses from surveyed ED providers for an initial survey (n = 42 respondents, including 50.0% attending physicians, 33.3% post-graduate physician trainees, and 16.7% advanced practice providers) and a follow-up survey (n=28 respondents, including n=16 who responded to both the initial and follow-up surveys) administered 3–4 months after IN-STEP implementation.

	N(%)
Initial Survey: Before IN-STEP Implementation
Aware of nPEP Use to Prevent HIV (n=42)   Have Previously Evaluated Patient for nPEP (n=38)	38 (90.5%) 23 (60.5%)
Confidence for Performing nPEP Assessment (n=35)   1: Not Confident   2   3   4   5: Completely Confident	0 (0.0%) 7 (20.0%) 17 (48.6%) 11 (31.4%) 0 (0.0%)
Confidence for Referring to nPEP Follow-Up (n=29)   1: Not Confident   2   3   4   5: Completely Confident	0 (0.0%) 8 (27.6%) 12 (41.4%) 9 (31.0%) 0 (0.0%)
nPEP Guidelines or Resources Used Before IN-STEP (n=42)*   Centers for Disease Control and Prevention   Emergency Department Colleagues   Pharmacy Colleagues   Infectious Diseases Colleagues	20 (47.6%) 6 (14.3%) 6 (14.3%) 7 (16.7%)
Preferred Qualities for nPEP Decision Support Tool (n=42)*   Short/Uncomplicated   Easy to Locate   Illustrative Scenarios	40 (95.2%) 35 (83.3%) 17 (40.5%)
Follow-Up Survey: After IN-STEP Implementation
Have Used the nPEP Decision Support Tool (Tool was displayed in the survey for reference. n=26)   Yes: Used Tool   No: Prefer Not to Use Tool   No: Not Aware of Tool	15 (57.7%) 0 (0.0%) 11 (42.3%)
Perspectives of nPEP Decision Support Tool (n=25)*   Conveniently Located/Easy to Find   Clearly Written/Easy to Interpret   Increases My Knowledge About nPEP   Supports My Clinical Decisions About nPEP   Supports Discussions About nPEP with My Patients   Decreases My Need to Consult Other Providers About nPEP   Clarifies Follow-Up Plans for Patients Who Need nPEP	7 (28.0%) 17 (68.0%) 21 (84.0%) 21 (84.0%) 20 (80.0%) 19 (76.0%) 19 (76.0%)
Suggested Improvements for nPEP Decision Support Tool (n=21)*   Shorter/Less Complicated Algorithm   Longer/More Expanded Algorithm   More Information Regarding Specific Clinical Scenarios   Easier to Locate on Multiple Platforms	1 (4.8%) 0 (0.0%) 7 (33.3%) 15 (71.4%)
Have Recommended nPEP Take-Home Medication Packs for Patient(s) Evaluated After Sexual Assault (n=27)   Yes: Recommended for One or More Patient   No: No Patients for Whom nPEP Was Indicated   No: Take-Home Packs Unavailable   No: Not Aware of Take-Home Packs	6 (22.2%) 16 (59.3%) 1 (3.7%) 4 (14.8%)
Recommend Ongoing Availability of nPEP Take-Home Packs for ED Patients (n=26)   Yes: Continue Program for Patients Evaluated After Sexual Assault   Yes: Continue Program for Patients Evaluated After Sexual Assault   and Offer After Non-Occupational Needle Sticks   No: Do Not Continue Program	13 (50.0%) 13 (50.0%) 0 (0.0%)

^*Respondents could choose more than one option, and percentages may not total 100%.

Notes: The initial and follow-up surveys were open to all ED providers, and respondents could participate in one or both surveys. A total of 28 respondents completed at least part of the follow-up survey, but total responses for each item did not exceed 26. The REDCap software linked initial and follow-up surveys by respondent, but output data were de-identified for the research team. Among the subset of persons who completed both surveys (n=16), the follow-up survey results were comparable to those shown for the full group (n=28), so the full group’s data were reported. [For instance, 60.0% of those who responded to both surveys had used the tool (of total n=16), 35.7% reported the tool was conveniently located/easy to find (total n=14), 71.4% reported the tool was clearly written/easy to interpret (total n=14), 6.3% indicated that the algorithm should be shorter/less complicated (total n=16), and 68.8% thought the tool should be easier to locate on multiple platforms (total n=16). Similarly, most or all of the respondents endorsed each of the other items listed under “Perspectives of nPEP Decision Support Tool.”] IN-STEP: Integrating nPEP after Sexual Trauma in Emergency Practice. ED: Emergency Department. nPEP: Non-occupational post-exposure prophylaxis. HIV: Human Immunodeficiency Virus.

To guide educational efforts pertaining to nPEP, the survey included a series of hypothetical patient care scenarios regarding nPEP use and questions about nPEP safety in specific cases (e.g., pregnancy, breastfeeding, adolescence). We tailored IN-STEP educational materials to focus on areas where providers expressed more uncertainty (for instance, the nPEP safety profile in patients who are pregnant or breastfeeding) or where survey-reported nPEP decisions were not closely aligned with current guidelines (for instance, the importance of initiating nPEP within 72 hours of a potential HIV exposure).

Figure 2 (Cycle 1) provides an overview of the PDSA approach to improving the process of nPEP assessment in the ED. This included the development of a nPEP decision support tool for use when patients are evaluated after a sexual assault; a series of short, 10–30-minute educational sessions; and an online repository of clinical support resources. Educational materials emphasized the use of the nPEP decision support tool and information about HIV testing (Key Area 2), nPEP prescribing (Key Area 3), and outpatient follow-up (Key Area 4).

Figure 2.

Visual demonstration of parallel PDSA cycles representing the four main key areas, connected by the overarching theme of effective communication bridging the four areas together. PDSA: Plan-Do-Study-Act. nPEP: Non-occupational post-exposure prophylaxis. CDC: Centers for Disease Control and Prevention. HIV: Human Immunodeficiency Virus. POC: Point-of-care.

Key Area 2: HIV Testing

The need to perform baseline HIV testing at the point of care was a key practical barrier to nPEP delivery. Although HIV testing was available in the ED prior to IN-STEP’s implementation, two practical barriers limited its use: (1) Test results were not immediately available to providers, and (2) the mechanisms for ensuring follow-up of HIV test results after ED discharge were not clearly developed.

We addressed these barriers by implementing a rapid HIV screening assay in the ED (Alere Determine™ HIV-1/2 Ag/Ab Combo—a fourth-generation, point-of-care, finger-stick assay). To ensure that all positive screens were confirmed and each patient connected to follow-up care, two additional steps were taken: (1) Positive results automatically reflexed to confirmatory HIV testing; and (2) our institution’s HIV specialty clinic implemented a 24/7 connect-to-care telephone line. This line allowed ED providers to directly hand off positive screening results to specialized nursing staff and provided telephone-based support, if needed, for counseling ED patients with a positive test. Importantly, the HIV screening and connection to care mechanisms developed for this purpose were made available to all ED patients at risk for HIV infection. Figure 2 (Cycle 2) summarizes the process we followed to implement HIV testing improvements in the ED. These improvements required extensive collaboration with many stakeholders, including ED providers and charge nurses; laboratory personnel; HIV clinic providers and nurses; health literacy and language translation personnel; information technology specialists; legal and compliance departments; and other administrative stakeholders.

Key Area 3: nPEP Delivery

Local grant funding supported the purchase of full-course nPEP medications for patients in whom nPEP was indicated, offered, and accepted after a sexual assault. Led by pharmacy colleagues on the team, we developed take-home medication packs that ED providers could order and dispense from the ED’s automated medication dispensing station.

In collaboration with health literacy and language translation staff, we prepared nPEP-related and sexual assault-related discharge instructions and informational inserts for the nPEP take-home packs. The take-home packs included full-course nPEP medications, easy-to-read information about nPEP, and direct contact information for follow-up clinics in the community (Key Area 4). Pharmacy tracked the rate at which take-home packs were dispensed to guide plans for medication restocking.

Figure 2 (Cycle 3) demonstrates the process for improving the delivery of nPEP medications. Two noteworthy adaptations resulted early in this iterative process. First, although we originally planned to dispense two medications often prescribed for nPEP (tenofovir disoproxil fumarate/emtricitabine and dolutegravir), the Centers for Disease Control and Prevention released new guidance during our pre-implementation phase regarding potentially teratogenic effects of dolutegravir,⁷ prompting a switch to an alternative regimen (tenofovir disoproxil fumarate/emtricitabine and raltegravir). Second, a pharmacy cost analysis revealed that dispensing a 30-day supply (instead of the guideline-specific 28 days¹) would reduce pharmacy labor and significantly extend the shelf life of the medications, by dispensing unopened bottles (containing 30-day supplies) in the take-home packs.

Key Area 4: Continuity of Care

While the preceding key areas focused on initiating nPEP at the point of care, we recognized the need to achieve continuity of care after ED discharge as a critical component of our initiative. After nPEP is initiated, patients should receive follow-up laboratory tests (e.g., blood chemistries that may be affected by nPEP, follow-up HIV testing), emotional and psychological support, medication adherence counseling, and ongoing education about HIV risk reduction.^1–5

Figure 2 (Cycle 4) provides a summary of the steps taken to achieve this. The IN-STEP team identified a total of 10 outpatient clinic sites that were willing to provide nPEP follow-up after ED discharge. Clinics offering care to adult and pediatric patients, insured and uninsured patients, Veterans Affairs and Indian Health Services patients, university students, and homeless persons agreed to participate. In collaboration with IN-STEP, our state’s AIDS Education and Training Center offered specialized, on-site nPEP training to participating clinics.

Our HIV clinic offering the 24/7 connect-to-care line for new HIV diagnoses (Key Area 2) agreed to extend this line for nPEP follow-up. ED providers could directly call this number whenever nPEP was initiated in the ED and, if possible, could also contact any of the 10 clinic sites to arrange referral. Patients accepting nPEP initiation in the ED also received detailed contact information for the follow-up clinical sites in the discharge instructions.

Our team did not follow-up with individual patients for research purposes. We anticipated that research involving identification of and/or direct contact with patients who had been evaluated after a sexual assault for the purposes of tracking an initial clinical QI initiative would likely have posed more risks than benefits to individual patients (including some patients <18 years of age and some patients affected by domestic violence or sex trafficking). In lieu of direct patient follow-up, we did confirm that the 24/7 line and one or more community clinics had received and completed referrals attributed to the ED initiative.

Communication and Impacts Across Key Areas

As the project evolved, our team also sought to implement iterative improvements in team communication across the key areas. In addition to periodic meetings, phone calls, and email discussions, we implemented a project dashboard (Supplemental Digital Content 1) to communicate important updates to the entire team on a periodic basis. Using a visual infographics construction, the dashboard allowed members of the team who were focused on specific key areas to easily see how colleagues in other areas were progressing and permitted the team to identify tasks or opportunities in need of increased attention or resources.

IN-STEP resulted in significant improvements in the process of HIV prevention and screening in our ED (Table 1, Figure 3). Although our primary focus was offering nPEP, when indicated, for patients evaluated after sexual assault, we also saw this effort as an opportunity to produce durable infrastructural changes that could influence care for all ED patients at risk for HIV. The development of improved HIV screening efforts and stronger connections to care between the ED and community clinics (Figure 3) highlight these changes.

Figure 3.

Impacts of IN-STEP efforts across the process of care for patients evaluated for HIV infection or for HIV prevention using nPEP. Each area shown in the figure was impacted by IN-STEP. The project resulted in the implementation of a new point-of-care HIV test in the ED, improvements in HIV confirmatory testing protocols, nPEP assessment and prescribing, patient education about nPEP and HIV, and connection to follow-up care in the community. IN-STEP: Integrating nPEP after Sexual Trauma in Emergency Practice. HIV: Human Immunodeficiency Virus. nPEP: Non-occupational post-exposure prophylaxis. ED: Emergency Department. EMR: Electronic medical record.

Results from the follow-up survey (Table 1) within the first 3–4 months of the program demonstrated overall awareness and utilization of the program and satisfaction with the content of the decision support tool. Based on these survey results, our team has worked to further increase the visibility of the tool for providers. Likewise, since this project was implemented, members of our team have begun to extend point-of-care HIV screening to other clinical areas in our hospital.

LIMITATIONS

Approaches like those described here may be useful for similar efforts at other institutions, although we recognize that elements of our project’s success may not be as easy to replicate in some settings. These elements include the involvement of a consistent, multidisciplinary leadership team; support for the implementation of both a point-of-care HIV screening assay and a 24/7 connection-to-care line; and the availability of local grant funding to catalyze the team’s efforts. We cannot directly compare the outcomes of IN-STEP to a similar initiative in which grant-supported medications were not available, and we realize that similar funding may not be available at all other sites. Other mechanisms of cost support might be explored, including other grants, medication assistance programs, or public health-based funding. Furthermore, in settings where medication support is not possible, efforts to improve access to care through screening and connection to care might still be implemented.

We also acknowledge that improvements in HIV screening and prevention are ongoing at our institution. Although the improvements described here were successfully implemented, we cannot yet assess the sustained impact of these efforts over the years to come or estimate the net value of these improvements to patients, providers, or the institution. Similarly, although we secured grant funding for a specific nPEP indication, our efforts now turn to identifying ways to sustain and expand improved access to nPEP medications. Overall, the information and experience obtained from IN-STEP’s successful implementation have supported discussions about expanding the program.

DISCUSSION

Complex challenges to evidence-based healthcare delivery and clinical infrastructure development may best be addressed using a systematic, multidisciplinary approach. In the IN-STEP project, we successfully implemented improvements in HIV screening and prevention in our ED. Here, we highlight three aspects of our project that helped to promote our efforts and that may be useful for other, similar initiatives.

First, we assembled a core leadership team to design, implement, and evaluate the project over time. This included a diverse group of stakeholders, guided further by input from surveyed ED providers who might ultimately implement the changes proposed by the project. The consistent, dedicated leadership of the team helped to advocate for patient- and project-related needs and sustain the project’s momentum over time.

Second, we defined a main patient-focused objective—in our case, improving nPEP delivery for patients evaluated after sexual assault—around which we could focus our efforts. This allowed us to seek and obtain grant funding to help propel the project forward, build collaborations with other groups at our institution and in our community, and initiate infrastructural improvements that could influence broader aspects of HIV screening and prevention in the ED.

Third, we envisioned each of the complex needs of the project as corresponding to one of four parallel areas of focus, which in turn required iterative input and improvement by team members whose interest and expertise aligned with each area. As the project expanded, we sought to iteratively improve communication across these areas, using a project-specific dashboard depicting the project’s progress, next steps, and needs.

CONCLUSIONS

The IN-STEP project is a QI effort dedicated to improving HIV prevention for patients evaluated in an academic hospital ED after a sexual assault. We applied iterative QI methods to each of four key areas: nPEP assessment, HIV testing, nPEP delivery, and continuity of care. IN-STEP resulted in successful improvements in HIV screening and prevention for patients evaluated after sexual assault and other indications.

IMPLICATIONS

Consistent leadership and advocacy by a multidisciplinary team, augmented by a defined, patient-focused objective and a coordinated approach to simultaneous QI across multiple key areas, led to significant improvements in HIV screening and prevention at our institution. Similar approaches may be useful in other complex QI initiatives.

Biography

Tirajeh Saadatzadeh, MD recently completed her Internal Medicine Residency at the University of New Mexico (UNM) Health Sciences Center. She now serves as Inpatient Chief Resident at the Veterans Affairs hospital in Albuquerque, NM. Following her chief residency, Tirajeh’s goals include completing a fellowship in infectious diseases.

Natalie Salas, MBBCh is an Assistant Professor in the Division of Infectious Diseases in the Department of Internal Medicine at the UNM Health Sciences Center in Albuquerque, NM. She is also a HIV primary care provider at UNM, and she serves as the Associate Program Director for the UNM Infectious Diseases Fellowship.

Carla Walraven, MS, PharmD, BCPS-AQ ID is the Antimicrobial Stewardship Pharmacist at the UNM Hospital in Albuquerque, NM. She is responsible for the daily review of hospitalized adult patients receiving selected antimicrobial therapies, and she oversees the development of new clinical processes that improve antimicrobial prescribing behaviors throughout the hospital.

Preeyaporn Sarangarm, PharmD, BCPS, BCCCP is a pharmacist at the UNM Hospital in Albuquerque, NM. As the Pharmacy Supervisor for Emergency Medicine and Critical Care, she is responsible for the clinical pharmacy services provided to patients in those areas.

Cameron Crandall, MD is a Professor and Vice Chair for Research in the Department of Emergency Medicine at the UNM Health Sciences Center in Albuquerque, NM. His research and service interests include improving health services for patients affected by domestic violence, sexual assault, and other injuries. He also serves as the Director for LGBTQ Diversity, Equity, and Inclusion and is responsible for improving the experience of sexual and gender minorities.

Joy Crook, MD, MPH is an Associate Professor of Emergency Medicine and the Vice Chair of Clinical Affairs for the UNM Department of Emergency Medicine. She is dual-boarded in Emergency Medicine and Emergency Medical Services. She serves as the Medical Director for the UNM Adult Emergency Department and as the New Mexico State Emergency Medical Services Medical Director.

Dusadee Sarangarm, MD is an Associate Professor in the Department of Emergency Medicine at the UNM Health Sciences Center in Albuquerque, NM. She is dual-boarded in Emergency Medicine and Clinical Informatics. She serves as the Associate Chief Medical Information Officer for the Health System as well as the Assistant Program Director for the Emergency Medicine Residency.

Charles Yaple, CG(ASCP)^CM is the Technical Supervisor of Point of Care Testing at the UNM Hospital. He oversees the processes, standardization, and quality assurance for point-of-care testing, including point-of-care HIV testing, at the hospital.

Amanda Stafford, RN, BSN is the Nurse Manager of the UNM Truman Health Services Clinic at UNM in Albuquerque, NM. She has dedicated her work as a nurse to serving people living with HIV, preventing new HIV infections, providing care to underserved populations, and offering transgender health care. She is currently finishing her studies to receive a dual MPH/MSW degree from New Mexico State University.

Christopher Wilson, MD, is completing his third year in the Emergency Medicine Residency at the UNM Health Sciences Center in Albuquerque, NM. As an active emergency department provider, he is frequently involved in first-line encounters with patients evaluated after a sexual assault.

Kimberly Page, PhD, MPH, MS is a Professor in the Division of Epidemiology, Biostatistics, and Preventive Medicine in the Department of Internal Medicine at the UNM Health Sciences Center. She is an infectious disease epidemiologist with expertise in HIV and viral hepatitis; and she has significant experience conducting prospective cohort studies, clinical trials, and implementation science research.

Martha Carvour, MD, PhD is an Assistant Professor in the Division of Infectious Diseases in the Department of Internal Medicine at the University of Iowa in Iowa City, IA. She previously completed an infectious diseases fellowship at the UNM Health Sciences Center in Albuquerque, NM, when she developed and spearheaded the IN-STEP project. She is an infectious diseases physician and epidemiologist with expertise in observational research methods, health services research, and quality improvement.