PrEP referral process may require improvement
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Only about half of patients who were seen at a sexual health center and subsequently referred to HIV PrEP attended an initial visit, indicating the need to fine-tune the PrEP referral process, researchers reported at IDWeek.
“Sexual health clinics are ideal sites for identification and referral of clients to PrEP services. We’re at the front line of STI care, with easy access to walk-in appointments and clients at risk for HIV. Yet, there are gaps in our knowledge about how well our referral process works,” Rebecca A. Lillis, MD, associate professor at Louisiana State University Health Sciences Center in New Orleans, said during a virtual presentation of the data.
To learn more, Lillis and colleagues reviewed an initial report generated from the electronic health record to determine the number of individual clients seen at their sexual health center in 2019 and manually reviewed the charts to determine whether a PrEP or clinic referral was made.
Referrals were made in one of three ways. First, the handoff method involved a navigator meeting the client face to face at the sexual health center and scheduling the PrEP appointment. Second, the navigator sent a message in the EHR and then called the client at a time convenient for the navigator to schedule the client’s PrEP appointment. Third, the client was provided with the navigator’s business card so the client could contact the navigator themselves at a time that was convenient for the client.
From January through December 2019, 3,570 unique patients were seen at the sexual health center and 230 were referred to the PrEP clinic. For referred patients, the median age was 29.9 years, 40.4% were Black, 10% were Hispanic, 83% were cisgender male, 13.5% were cisgender female and 3.5% were transgender female.
Overall, only 43% of those referred for PrEP attended an initial appointment and only one-quarter attended a subsequent appointment, representing a “worrisome drop-off” along the PrEP cascade, Lillis said.
When analyzed according to referral method, 79% of clients referred by the handoff method, 38% of those referred via EHR message and 26% of those who scheduled their own appointment attended their initial PrEP visit. Notably, those referred by handoff were more likely to attend an initial PrEP appointment (P < .0001), Lillis reported.
Results showed that men who have sex with men were more likely to attend an initial PrEP appointment than those with other reasons for referral (52.3%; P = .0251). The proportion of clients who attended an initial PrEP visit was also high among people who inject drugs, those with HIV-positive partners and transgender clients — ranging from 58.3% to 66.7% — but there were only three to 12 clients in each group, so the numbers did not reach statistical significance. Heterosexual individuals were least likely to attend a PrEP appointment, with only 10% of heterosexual men and only 27% of heterosexual women attending an appointment.
Additionally, Lillis noted that clients who identified as MSM made up 65% of the group referred for PrEP and 73% of those who attended their appointments, but only slightly more than half of MSM who were referred actually attended a PrEP appointment.
The researchers found that neither the diagnosis of STI on the day of referral nor presenting to the sexual health center as a contact to STI was associated with attending an initial PrEP appointment. Data also showed that clients with gonorrhea were more likely to attend an initial PrEP visit (P = .022). This finding did not hold true for any other STI.
Lillis also reported that two of the three clinic providers saw 86% of clients in 2019 but were responsible for 95% of PrEP referrals.
“Despite co-location of these two clinics, there were significant drop-offs along the PrEP care continuum, with only half of clients referred attending an initial PrEP appointment and about 25% referred attending a subsequent appointment,” Lillis said. “Discrepancies among providers and the number of clients referred to PrEP may present an opportunity to standardize our referral pathway through staff education and training. Further efforts are needed to understand barriers to referral and attendance of an initial PrEP appointment.”
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Lillis RA, et al. Abstract 104. Presented at: IDWeek; Oct. 21-25, 2020 (virtual meeting).
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