Background: Despite multiple studies supporting the safety and efficacy of pre-exposure prophylaxis (PrEP) for the prevention of HIV infection, many patients who are at high risk of HIV transmission are not treated with PrEP. HIV risk counseling and the initiation of PrEP have historically been limited to outpatient settings. Inpatient providers frequently encounter patients with active HIV risk factors who are not regularly connected to outpatient care and therefore may be less likely to have access to PrEP. Inpatient admissions represent an underutilized opportunity to counsel patients about HIV risk factors and initiate PrEP.
Purpose: The goal of this quality improvement initiative was to increase HIV PrEP prescribing and referrals to our outpatient PrEP clinic among hospitalized patients with active HIV risk factors. As a part of this initiative, we developed workflows for inpatient PrEP screening, counseling, and initiation at an urban safety-net hospital in San Francisco, California.
Description: Inpatient providers screened patients for PrEP eligibility based on risk factors, medical contraindications, and patient interest. Interested patients were referred to an interdisciplinary HIV team for counseling, patient engagement, and care navigation. Patients who wanted to start PrEP were initiated inpatient or were linked to PrEP clinic or a primary care clinic for outpatient follow-up. Multiple PDSA efforts, including a formal survey assessing providers’ knowledge, comfort, and perceived barriers to inpatient PrEP prescribing allowed for the tailoring of these efforts to achieve better implementation.Prior to initiating this study, zero patients were referred to our hospital’s outpatient PrEP clinic from inpatient providers. Over the first 9 months of the intervention, 39 inpatients were referred to the PrEP clinic and either received in-depth counseling from the HIV team prior to discharge or initiated PrEP before discharge. This initiative reached particularly vulnerable populations at risk for HIV: 79% were experiencing homelessness, 62% were people who inject drugs, and 57% identified as Black or Latinx.
Conclusions: PrEP counseling and initiation can be successfully incorporated into standard inpatient care. Utilizing inpatient admissions to engage at-risk patients in HIV prevention efforts may reduce disparities in HIV outcomes. More research is needed to evaluate patient-level barriers to inpatient PrEP initiation as well as the longitudinal impact of initiating PrEP during a hospitalization compared to outpatient initiation.