Abstract
Pre-exposure prophylaxis (PrEP) is an effective method to prevent HIV acquisition in high-risk individuals. This cross-sectional survey study estimated the proportion of patients who were PrEP eligible among a targeted sample of emergency department (ED) patients with chief complaints indicative of HIV risk. Research assistants screened a convenience sample of adult patients who presented to two hospital EDs in Washington, DC, during a 6-month period with genitourinary, substance use, or intentional injury-related complaints. Patients with these complaints who reported being sexually active within the past 6 months and HIV negative completed a computer-assisted survey that included questions on sexual practices and partners, substance use, and attitudes and knowledge about PrEP. We used the Centers for Disease Control and Prevention (CDC) clinical guidelines to determine whether PrEP use was indicated. We report differences in PrEP eligibility by demographic characteristics, knowledge, and attitudes. Of the 410 participants, the majority were black (85%), and heterosexual females (72%). PrEP use was indicated in 20% (N = 84), most commonly because of condomless sex with a person of unknown HIV status (82%) and/or a sexually transmitted infection (STI) diagnosis (41%). One-third (34%) of participants had heard of PrEP. Overall, 36% of the sample (N = 148) wanted to learn more about PrEP while in the ED. The percentage who wanted to learn more about PrEP was higher among PrEP-eligible patients (52%) compared with PrEP-ineligible patients (32%). Using CDC criteria, targeted screening identified that a substantial proportion of ED patients are PrEP eligible based on their self-reported behaviors.
Keywords: pre-exposure prophylaxis, prevention, screening, HIV, emergency medicine
Introduction
Daily HIV antiretroviral pre-exposure prophylaxis (PrEP) with emtricitabine and tenofovir disoproxil fumarate has been shown to be a highly effective method to prevent HIV acquisition in high-risk individuals, reducing HIV incidence up to 95%.1 The US Centers for Disease Control and Prevention (CDC) currently estimates that 1.1 million adults in the United States are at risk of acquiring HIV,2 while an estimated 130,000 people in the United States are estimated to be on PrEP.3 Demonstrably, there is a large gap to be closed in PrEP uptake in the United States.
Washington, DC, has one of the highest rates of HIV infection in the United States, with a 1.8% prevalence rate in 2018.4 In 2018, DC had 360 new cases of HIV, with sexual contact being the leading mode of transmission. The DC Department of Health estimates that ∼3,400 residents started PrEP in 2018; this is ∼10% of residents who could benefit.5
Emergency departments (EDs) have played a critical role in the HIV epidemic, both by offering HIV screening to all patients and as one of the primary sources of post-exposure prophylaxis (PEP).6 EDs may also be an ideal location to screen for behaviors that lend themselves to biomedical prevention. A study conducted in South Carolina found that 66% of people with a new HIV diagnosis had at least one health care visit before diagnosis and 84% of those encounters were in an ED.7
Given the high HIV prevalence in DC and the low uptake of PrEP among at-risk populations, our main objective was to assess the proportion of adult patients presenting to the ED who were PrEP eligible as per the CDC criteria using targeted screening. Secondary objectives included understanding ED patients' awareness and attitudes toward PrEP.
Methods
Study design and setting
We conducted a cross-sectional study at two EDs in Washington, DC: (1) a tertiary academic hospital with an annual ED census of 75,000 visits (Site A); and (2) a public community hospital with an annual ED census of 55,000 visits (Site B). Approximately one-third of patients treated at Site A are insured by Medicaid in contrast to 60% at Site B. During study enrollment, neither ED conducted universal HIV screening. The study protocol was reviewed and approved by the Institutional Review Board of Site A for both EDs.
Selection of participants
Patients were eligible for the study if they were 18 years or older, English-speaking, had been sexually active (oral, anal, and/or vaginal) in the past 6 months, were HIV negative, and presented with a chief complaint related to a genitourinary (GU) problem (i.e., sexually transmitted infection screening, GU complaint, vaginal or penile problem), substance use, or intentional injury. These are an expanded group of chief complaints based upon previous work by Ridgway et al.8 Patients were excluded if they had been previously enrolled, were a prisoner or in police custody, or were unable to provide informed consent.
Enrollment occurred over a 6-month period between January and July 2019 from 9 am to 10 pm on weekdays and from 9 am to 6 pm on the weekends at Site A, and from 9 am to 5 pm on weekdays at Site B. Trained research assistants (RAs) screened patients for study eligibility by reviewing information in the electronic ED tracking board (i.e., age, chief complaint). When a patient with an eligible chief complaint presented, the RA approached the patient, described the study, and reviewed eligibility criteria, which involved obtaining self-reported HIV and sexual activity status within the past 6 months. Because there are multiple studies conducted at both facilities, it was possible for an RA to miss an eligible patient while enrolling for another study, so our study is based on a convenience sample (Fig. 1).
FIG. 1.
Derivation of study sample.
All patients who met the eligibility criteria and agreed to participate signed a consent form stating that they were willing to complete a self-administered survey and allow the study team to abstract relevant information from their medical record. We collected and stored study data in REDCap (version 8.10.18: Nashville, TN).9 The survey included 46 questions with branching logic and took 10 min to complete. Participants received a $10 gift card after survey completion.
Measurements
The survey consisted of three sections: (1) sociodemographic information; (2) drug and sexual behaviors; and (3) self-perceived HIV risk and PrEP knowledge and attitudes (see Supplementary Appendix for copy of survey).
To determine whether the participants met CDC criteria for PrEP, we asked participants questions about injection drug use and sexual behaviors and if they had a diagnosis of syphilis, gonorrhea, or chlamydia in the past 6 months. The behavioral risk questions that we included (see questions 14–30) are standard questions in HIV research used by the National HIV Behavioral Surveillance System.10
The last section of the survey included questions about PrEP knowledge and attitudes and was modeled after questions used in previous HIV research.11–15 We asked whether participants had ever heard of PrEP, their PrEP knowledge,16 and a hypothetical question about whether they would use a condom while taking PrEP. We also asked participants whether they wanted to learn more about PrEP while in the ED that day. If they said yes, we asked whether they would be willing to take a daily medication to prevent HIV infection and if they were interested in receiving PrEP information. If they wanted information, we provided a brochure and a list of PrEP providers in Washington, DC.17
After ED discharge, three RAs extracted the following information from each chart: (1) chief complaint; (2) principal and secondary ICD-10 discharge diagnosis codes (up to three); (3) whether a sexually transmitted infection (STI) test(s) was ordered during the ED visit; (4) and if one was ordered, whether it was positive for syphilis, gonorrhea, chlamydia, bacterial vaginosis (BV) or trichomoniasis. A senior research coordinator abstracted a 10% random sample of the charts to test reliability of the abstractions for the STI test results. We found 94% inter-rater reliability.
Outcomes
The main outcome for this study was to determine the proportion of targeted ED patients who met the CDC criteria for PrEP based on self-report. We categorized heterosexual men and women as PrEP eligible if they reported any of the following events within the past 6 months: (1) having a seropositive sex partner (monogamous or not); (2) inconsistent condom use with a partner of unknown HIV status if not in a mutually monogamous sexual partnership; or (3) self-reported diagnosis of chlamydia, gonorrhea, or syphilis if not in a mutually monogamous sexual partnership. We used the same criteria for men who have sex with men (MSM) except that the second criterion was inconsistent condom use during anal sex if not in a mutually monogamous sexual partnership. We defined a nonmonogamous relationship as anyone who reported more than one partner during the past 6 months or reported one casual partner. Finally, we also categorized participants as PrEP eligible if they reported sharing drug injection equipment in the past 6 months.
We measured the following secondary outcomes: (1) the proportion of ED patients who had ever heard of PrEP; (2) the percentage of ED patients who wanted to learn more about PrEP while they were in the ED; and (3) the number of additional ED patients who would qualify for PrEP if we expanded the CDC criteria based on previous research suggesting that the CDC guidelines are too restrictive.18–21 We estimated the number of additional patients who would be PrEP eligible using the following criteria: (1) positive result from an STI test conducted during the index ED visit for chlamydia, gonorrhea, or syphilis and not in a mutually monogamous sexual partnership; (2) positive result from an STI test conducted during the index ED visit for chlamydia, gonorrhea, or syphilis, BV or trichomoniasis and not in a mutually monogamous sexual partnership; (3) self-reported STI in survey or positive result from an STI test conducted during the ED visit (for any of the five aforementioned STIs) regardless of monogamy; and (4) assuming that sexual partners of participants who stated that they did not know or refused to indicate the HIV status of their partner were HIV infected.
Analysis
We completed descriptive analyses of the survey results. We compared participants' demographic characteristics, injection drug use patterns, sexual behaviors, PrEP knowledge, and attitudes by PrEP eligibility status. All analyses were completed using SAS Enterprise 7.12 (SAS Institute, Inc., Cary, NC, USA).
Results
During the 6-month enrollment period, RAs screened 646 patients at two EDs. Eighty-seven percent were eligible and 73% of those eligible agreed to participate. The most common reasons for ineligibility were sexual inactivity in the past 6 months (n = 22), HIV infected (N = 16), and non-English speaking (N = 10) (Fig. 1).
Patient characteristics
Among the 410 enrolled participants, the majority were female gender (74%), non-Hispanic black (85%), and young adults (median age = 27) (Table 1). Participants were most frequently insured by Medicaid (69%) and almost one-fifth (17%) stated that they usually received their health care at an ED/urgent care. Most participants had a GU chief complaint (72%).
Table 1.
Participant Characteristics by Pre-Exposure Prophylaxis Eligibility Status
| Variables | Total |
PrEP ineligible |
PrEP eligible |
|---|---|---|---|
| (N = 410) | (N = 326) | (N = 84) | |
| Recruitment site, n (%) | |||
| A (academic hospital) | 158 (39) | 127 (39) | 31 (37) |
| B (public community hospital) | 252 (61) | 199 (61) | 53 (63) |
| Age (median, IQR) | 29 (32, 23) | 29 (32, 24) | 28 (31, 21) |
| Gender, n (%) | |||
| Male | 103 (25) | 63 (19) | 40 (48) |
| Female | 303 (74) | 260 (80) | 43 (51) |
| Transgender woman or man | 4 (1) | 3 (1) | 1 (1) |
| Race/ethnicity, n (%) | |||
| Non-Hispanic black | 350 (85) | 277 (85) | 73 (87) |
| Non-Hispanic white | 15 (4) | 9 (3) | 6 (7) |
| Hispanic/other | 45 (11) | 40 (12) | 5 (6) |
| Education level, n (%) | |||
| Less than high school | 43 (11) | 30 (9) | 13 (16) |
| High school diploma/GED/vocational | 243 (59) | 196 (60) | 47 (55) |
| Some college/associate degree | 77 (19) | 66 (20) | 11 (13) |
| Bachelor degree/graduate degree | 47 (11) | 34 (11) | 13 (16) |
| Usual major activity, n (%) | |||
| Working full-time | 209 (51) | 175 (54) | 34 (41) |
| Working part-time | 66 (16) | 51 (16) | 15 (18) |
| Looking for work/going to school | 93 (23) | 70 (21) | 23 (27) |
| Disabled/homemaker/retired | 30 (7) | 20 (6) | 10 (12) |
| Declined to answer | 12 (3) | 10 (3) | 2 (2) |
| Chief complaint,an (%) | |||
| Digestive system | 94 (23) | 87 (27) | 7 (8) |
| Genitourinary system | 296 (72) | 222 (68) | 74 (88) |
| All other | 19 (5) | 16 (5) | 3 (4) |
| Location of primary source of health care, n (%) | |||
| Health care provider office | 172 (42) | 146 (45) | 26 (31) |
| ED/urgent care center | 71 (17) | 47 (14) | 24 (28) |
| Other clinic | 150 (37) | 119 (37) | 31 (37) |
| Declined to answer | 17 (4) | 14 (4) | 3 (4) |
| Insurance,an (%) | |||
| Medicaid | 282 (69) | 226 (70) | 56 (67) |
| Private | 47 (12) | 36 (11) | 11 (13) |
| Uninsured | 67 (16) | 52 (16) | 15 (18) |
| Other | 13 (3) | 11 (3) | 2 (2) |
Missing data (N = 1).
ED, emergency department; GED, general equivalency degree; IQR, interquartile range; PrEP, pre-exposure prophylaxis.
Twenty percent of participants met the CDC criteria. Of the 84 PrEP-eligible patients, 69 were heterosexual and 15 were MSM. Among heterosexual participants, the two-most frequent reasons for PrEP eligibility were inconsistent condom use with a partner of unknown HIV status (n = 55) and having an STI in the past 6 months (n = 34). Among MSM, having sex with an HIV-infected partner or condomless sex with a partner of unknown HIV status were the most frequent reasons for PrEP eligibility. Although five participants reported injection drug use, only one was PrEP eligible because of sharing equipment; the other four reported risky sexual behaviors.
There were meaningful differences in sociodemographic characteristics of the sample by PrEP eligibility status (Table 1). Male participants were more likely to be PrEP eligible (39%) compared with females (14%). Participants who reported their usual source of care was the ED/urgent care were more likely to be PrEP eligible (34%) compared with those who reported usual care at a provider's office (15%).
Sexual preferences and behaviors
Most participants stated in the past 6 months they had sex without a condom (86%); 23% reported condomless sex with a person of unknown HIV status (Table 2). Thirteen percent of the sample reported an STI in the past 6 months.
Table 2.
Injection Drug Use and Sexual Risk Behaviors During the Past 6 Months by Eligibility Status
| Variables | Total |
PrEP ineligible |
PrEP eligible |
|---|---|---|---|
| (N = 410) | (N = 326) | (N = 84) | |
| Injection drug use, n (%) | 9 (2) | 3 (1) | 6 (7) |
| Sexual preference, n (%) | |||
| Heterosexual female | 296 (72) | 253 (77) | 43 (51) |
| Heterosexual male | 84 (21) | 58 (18) | 26 (31) |
| MSM | 21 (5) | 6 (2) | 15 (18) |
| WSW | 9 (2) | 9 (3) | 0 (0) |
| Had condomless sex, n (%) | 352 (86) | 273 (84) | 79 (94) |
| Had condomless sex with partner of unknown HIV status, n (%) | 91 (23) | 24 (7) | 67 (80) |
| No. of male partners,an (%) | |||
| None | 10 (3) | 10 (4) | 0 (0) |
| One | 226 (71) | 214 (83) | 12 (21) |
| 2–4 | 67 (21) | 31 (12) | 36 (62) |
| ≥5 | 11 (4) | 1 (0) | 10 (17) |
| Declined to answer | 3 (1) | 3 (1) | 0 (0) |
| Had sex with male partner with HIV,an (%) | 4 (1) | 0 | 4 (6) |
| Receptive anal sex without condom among MSM, n (%) | 6 (29) | 1 (17) | 5 (33) |
| No. of female partners,bn (%) | |||
| One | 45 (48) | 42 (63) | 3 (12) |
| 2–4 | 41 (44) | 23 (34) | 18 (69) |
| ≥5 | 7 (8) | 2 (3) | 5 (19) |
| Had sex with female partner with HIV,bn (%) | 9 (3) | 3 (1) | 6 (10) |
| Sexually transmitted infection in past 6 months,cn (%) | 51 (13) | 16 (6) | 35 (42) |
Reported among heterosexual females and MSM (N = 317).
Reported among heterosexual males and WSW (N = 93).
Chlamydia, gonorrhea, or syphilis as specified by CDC guidelines.
CDC, Centers for Disease Control and Prevention; MSM, men who have sex with men; PrEP, pre-exposure prophylaxis; WSW, women who have sex with women.
PrEP eligibility status differed by sexual preference and behavior (Table 2). MSM and heterosexual men were more likely to meet PrEP eligibility criteria (33% and 29%, respectively) compared with heterosexual women (14%). Behaviors that were most common among the PrEP-eligible participants included reporting condomless sex and/or having an STI in the past 6 months.
PrEP knowledge and attitudes
One-fifth of PrEP-eligible participants considered themselves to be at medium to high risk of HIV acquisition (Table 3). Approximately one-third (34%) of study participants had heard of PrEP. Among 138 participants who had heard of PrEP, 63% knew PrEP needed to be taken daily and 83% stated they would use a condom while taking PrEP. Familiarity with PrEP did not vary significantly by PrEP eligibility (Table 3).
Table 3.
Knowledge and Attitudes Regarding Pre-Exposure Prophylaxis by Eligibility Status
| Total |
PrEP ineligible |
PrEP eligible |
|
|---|---|---|---|
| (N = 410) | (N = 326) | (N = 84) | |
| Self-perceived risk of HIV, n (%) | |||
| No/low risk | 390 (95) | 324 (99) | 66 (79) |
| Medium/high risk | 20 (5) | 2 (1) | 18 (21) |
| Heard of PrEP, n (%) | 138 (34) | 104 (32) | 34 (40) |
| Know someone who has taken PrEP,an (%) | 20 (14) | 11 (11) | 9 (26) |
| How frequently should PrEP be taken,a,bn (%) | |||
| At least one day before sex | 28 (20) | 26 (25) | 2 (6) |
| Immediately before sex | 5 (4) | 5 (5) | 0 (0) |
| Before and after sex | 18 (13) | 13 (13) | 5 (15) |
| Every day even if not having sex that day, n (%) | 86 (63) | 59 (57) | 27 (79) |
| PrEP side effects?,a,bn (%) | |||
| A lot | 32 (23) | 24 (23) | 8 (23) |
| A few | 80 (59) | 59 (57) | 21 (62) |
| None | 25 (18) | 20 (20) | 5 (15) |
| PrEP effectiveness,a,bn (%) | |||
| Not/minimally/somewhat effective | 87 (63) | 70 (68) | 17 (50) |
| Very/completely effective | 50 (37) | 33 (32) | 17 (50) |
| Would use a condom while taking PrEP,an (%) | 114 (83) | 91 (88) | 23 (68) |
| Wants to learn more about PrEP while in ED today, n (%) | 148 (36) | 104 (32) | 44 (52) |
| Would be willing to take PrEP daily,cn (%) | 106 (72) | 67 (65) | 39 (89) |
| Received a PrEP brochure,cn (%) | 103 (70) | 72 (69) | 31 (71) |
Among those who reported that they had heard of PrEP before (N = 138).
Missing data (N = 1).
Among those who stated they wanted to learn more about PrEP (N = 148).
ED, emergency department; PrEP, pre-exposure prophylaxis.
Roughly one-third (36%) of the sample (N = 148) indicated that they wanted to learn more about PrEP (Table 3). The most common reasons stated for not wanting to learn more included perceiving themselves to be at low risk for HIV (55%) and/or their doctor had not recommended it to them (16%) (data not shown). Of the 148 participants who stated they wanted to learn more about PrEP, 72% stated they would be willing to take a daily medication such as PrEP to prevent HIV infection. Participants who were interested in learning more about PrEP were more likely to be PrEP eligible.
Expanded PrEP criteria
When we expanded the CDC criteria for PrEP to include a positive STI result for chlamydia, gonorrhea, or syphilis with a nonmonogamous partner during the index ED visit (in addition to self-reported STIs), an additional four participants would be PrEP eligible. If STI results included BV or trichomoniasis, a conservative estimate is that an additional eight participants would be identified (based on a positive ED test result). If the criteria included any of the five STIs regardless of whether the relationship with the sexual partner was monogamous, an additional 64 participants would be PrEP eligible. Finally, if we assumed that the sexual partners of participants who did not know or refused to report the HIV status of their partner were HIV infected, there would be 24 additional PrEP-eligible participants. If all four of the above criteria are included, an additional 78 participants would be PrEP eligible.
Discussion
In this study, targeted screening identified a substantial proportion (20%) of adult ED patients who met the CDC criteria for PrEP. Using less restrictive criteria, the PrEP eligibility proportion doubled. Despite the relatively large proportion of ED patients at moderate to high risk of HIV acquisition, only one-third had heard of PrEP. More than half of the PrEP-eligible participants stated they were willing to learn more about PrEP. These results suggest that EDs serving communities with a high HIV prevalence rate may be able to play a role in HIV prevention.
To our knowledge, only one other investigator has conducted an HIV risk assessment in the ED. Ridgway et al. reported a higher PrEP eligibility rate (34%), but their criteria were less restrictive than CDC guidelines and more similar to the proportion we found with less restrictive criteria (40%).8 Based on their HIV risk screening, they used electronic medical record (EMR) data (i.e., age, sex, chief complaint, and positive STI test in the past 6 months) to develop a predictive tool to conduct targeted screening of high-risk ED patients who might benefit from HIV prevention counseling and PrEP initiation.
When we relaxed the CDC guidelines, PrEP eligibility increased to 40 of our sample. CDC guidelines for PrEP eligibility do not include BV or trichomoniasis. BV is the most common vaginal infection in women of reproductive age.18 A meta-analysis by Atashili et al. estimated that BV was associated with a 60% higher incidence of HIV infection among women. Although trichomoniasis is less prevalent in the United States compared with other STIs, it is associated with increased HIV transmission and HIV acquisition in women.18,20 STIs disproportionately affect people of color and the highest proportion of new HIV cases and people living with HIV are black or African American.22 Moreover, there are large disparities in PrEP uptake by race. Expanding the PrEP eligibility criteria to include all STIs associated with increased risk of HIV acquisition could potentially increase PrEP eligibility, access, and use among at-risk subgroups that have not been adequately reached.
Current CDC guidelines require knowledge of a partner's HIV status, whether the partner engages in risky behaviors, and whether the relationship is monogamous. In a cohort of 679 heterosexual women, knowledge about the partner resulted in few women meeting the CDC criteria for PrEP.19 When we expanded the CDC criteria in our cohort and assumed that those who did not know their partner's HIV status were HIV infected and we disregarded whether the relationship was monogamous, the additional participants we identified were more likely to be heterosexual women compared with heterosexual men. Women account for 19% of all new HIV diagnoses, yet less than 5% are PrEP users.19,23 Given that the majority of our participants were heterosexual women who sought care in the ED for sexual health issues, the ED may be an opportune setting to reach this population.
Like other studies that have measured PrEP knowledge in high HIV prevalence areas, the majority of participants had not heard of PrEP, demonstrating a lack of education in HIV prevention.2,22,24,25 Over half of participants who had heard of PrEP indicated they were interested in learning more and would be willing to take it if it was offered to them. This high willingness to take PrEP is consistent with previous research conducted in heterosexual men and women.26–29 A next step is to determine the proportion of PrEP-eligible ED patients who would be willing to be linked to a community PrEP provider and/or start PrEP in the ED.
EDs have played an important role in HIV, including HIV screening, linking patients to treatment, and offering PEP after a high-risk sexual encounter.6 While conducting universal HIV risk assessment is beyond the capacity of busy EDs, using targeted screening may be feasible and appropriate for EDs serving communities with high HIV prevalence. EDs already use targeted screening strategies for other public health issues, including screening for elder and child abuse in patients with suspicious injuries and substance use screening for patients suspected of misuse.
The results of this study must be interpreted in the context of the following limitations. Screening was only conducted at two EDs in a city with a high HIV prevalence. Due to limited resources, survey results are based on a convenience sample. Although we were unable to screen all eligible patients, we believe PrEP eligibility is representative of the target population because patients were missed randomly by RAs.
Second, the results are based on self-report. We likely underestimated PrEP eligibility among participants if they were reluctant to report high-risk behaviors. We did not identify many additional eligible participants when we included positive results of chlamydia, gonorrhea, or syphilis from the index ED visit. However, if we had queried the EMRs of the two study sites for positive STI tests in the past 6 months, we may have identified significantly more additional eligible participants. In contrast, among those willing to learn about PrEP, it is likely that if we had actually offered participants PrEP or linkage to a PrEP provider, a lower percentage would accept.8
Targeted PrEP screening in two EDs in a city with a high HIV prevalence resulted in the identification of a substantial proportion of patients at risk of HIV infection. The majority of adults in our sample were unaware of PrEP. The potential for the ED to reach at-risk subgroups that have largely not benefited from PrEP to date coupled with the willingness of many patients wanting to learn more suggests it is worth further investigation to determine whether the ED is an appropriate setting for HIV prevention.
Supplementary Material
Author Contributions
P.K., A.D.C., N.N.P., and M.L.M. conceived the study, designed the trial, and obtained research funding. P.K., N.N.P., and M.L.M. supervised the conduct of the trial and data collection. P.K., M.L.M., and Z.Z. provided statistical advice on study design and analyzed the data. P.K. and M.L.M. drafted the article, and all authors contributed substantially to its revision. P.K. takes responsibility for the article as a whole.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This project was supported by CTSI grant UL1TR001876-04.
Supplementary Material
References
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