Using Your EHR to Identify Patients Who May Benefit from PrEP at Your Health Center

PrEP, also known as pre-exposure prophylaxis, is one of the many tools available to help end the HIV epidemic in the United States. Electronic health records (EHRs) can help highlight disparities in PrEP uptake for populations at increased risk for acquiring HIV who could benefit from PrEP. HITEQ has identified strategies to help you leverage your health center’s EHR to identify and engage clients and close the PrEP access gap.

How Do You Know Who Is a Good Candidate for PrEP?
Identifying candidates for PrEP can be challenging but not impossible. The first step to finding the right candidates involves understanding the criteria for PrEP. Not everyone is a great candidate for PrEP or can adhere to the frequent testing and monitoring required of PrEP patients. Some patients are comfortable using condoms and other HIV prevention methods, and providers should respect and affirm their decision. 

People at risk who should be assessed for PrEP include: 

• Sexually active gay and bisexual men without HIV
• Sexually active heterosexual men and women without HIV
• Sexually active transgender persons without HIV
• Persons without HIV who inject drugs
• Persons who have been prescribed non-occupational post-exposure prophylaxis (PEP) and report continued risk behavior, or who have used multiple courses of PEP

The chart below further helps distinguish patients who are indicated for PrEP.

Source: https://www.cdc.gov/hiv/clinicians/prevention/prep.html

Health center providers should also discuss PrEP with the following HIV-negative individuals (in addition to those mentioned above):

• Individuals attempting to conceive with an HIV-positive partner. 
• Pregnant individuals at ongoing risk of acquisition of HIV during pregnancy. Ongoing risk for serodifferent couples during pregnancy includes inconsistent use of condoms and other barrier methods, incomplete viral suppression in the partner with HIV infection, or both.
• Those who:
• Have, or whose partners may have, multiple or anonymous sex partners
• Engage, or whose partners may engage, in sexual activity at sex parties or other high-risk venues
• Are involved, or whose partners may be involved, in transactional sex, such as sex for money, drugs, or housing
• Report recreational use of mood-altering substances during sex, such as alcohol, methamphetamine, cocaine, and ecstasy
• Report injecting substances or have partners who inject substances, including illicit drugs and hormones
• Are receiving nonoccupational post-exposure prophylaxis for HIV (nPEP) and demonstrate continued high-risk behavior, or have used multiple courses of nPEP

Implement a Detailed Sexual History Template
Health centers can use standardized templates in the EHR to take a detailed sexual history that can help identify patients who fit any of the criteria above or who may be a good fit for PrEP. Using standardized templates and EHR functions like the clinical rules engine and order sets can even allow health centers to automate processes for PrEP based on responses. Consider the 5 Ps of sexual health---partners, practices, protection from STIs (sexually transmitted infections), past history of STIs (including HIV), and pregnancy as part of a sexual history template.

Source: https://www1.nyc.gov/assets/doh/downloads/pdf/csi/csi-prep-pep-sex-history.pdf
 
Use Predictive Modeling
We cannot tell the future, but we can make educated guesses about what could be with predictive modeling. Predictive modeling uses statistics to predict outcomes for one or more variables. Some health centers use predictive modeling to determine which patients in their health centers would be good candidates for PrEP by developing algorithms based on incident HIV infection variables. For example, syphilis infection increases the risk of HIV acquisition. Algorithms that can identify a patient with a recent syphilis diagnosis can be a catalyst for a conversation between the patient and provider about PrEP. Examples of incident HIV variables include:

• Registration data
• Race/Ethnicity
• Biological sex/sex at birth (e.g., male, female)
• Gender identity (e.g., transgender, gender non-conforming)
• Sexual orientation (e.g., gay, bisexual, heterosexual)
• English as a primary language
• Diagnosis codes
• Syphilis of any site or stage except late latent 
• HIV counseling
• Contact with or exposure to venereal disease 
• High-risk sexual behavior
• Exposure to HIV
• Laboratory tests
•  Positive urine test for methadone
•  Positive urine test for cocaine
•  Number of HIV testing episodes
•  Number of HIV antibody or RNA tests
•  Number of tests for rectal gonorrhea or chlamydia
•  Number of positive tests for rectal gonorrhea or chlamydia
•  Number of positive tests for urethral chlamydia
•  Number of positive tests for urethral gonorrhea
•  Number of RPR or treponemal tests for syphilis
• Prescriptions 
• Intramuscular penicillin G benzathine 
• Buprenorphine and naloxone

Health centers can use this information to develop an HIV risk scoring system for potential PrEP candidates. If a patient scores high, the health center can take action (e.g., provider alerts) to get the patient on PrEP. 

Care Plans for PrEP
Care plans are not just for people with HIV; health centers can use care plan templates in their EHR to engage prospective PrEP candidates. PrEP Coordinators at health centers make care plans that include using condoms and other safer sex methods and follow up every 3 or 6 months to ensure that the patient is adhering to the plan. An HIV prevention care plan or PrEP care plan can include reminders for regular refills and follow up testing. For health centers using Z codes, determine if your EHR can populate a PrEP care plan upon entering a Z code linked to a diagnosis such as high-risk sexual behavior or exposure to HIV. Consider building a PrEP-specific care plan based on CDC guidelines and document each conversation about PrEP in the patient’s chart. Set up a 30-day action alert to re-engage identified patients who may be ambivalent about starting PrEP. The chart below can serve as a framework for a care plan template for patients identified who are ready to begin taking and adhering to PrEP.

Source: https://www.cdc.gov/hiv/clinicians/prevention/prep.html

No matter which strategy you decide, identifying PrEP candidates should be a priority for your health center. With the right tools, your health center can increase PrEP uptake and help end the HIV epidemic in your area. 

References

• Denver HIV Risk Score Tool: Increase HIV Screening Efficiency. www.denverptc.org/resource.php?id=33. Accessed 11 Dec. 2020.
• Krakower, Douglas S, et al. “Development and Validation of an Automated HIV Prediction Algorithm to Identify Candidates for Pre-Exposure Prophylaxis: A Modelling Study.” The Lancet HIV, vol. 6, no. 10, Oct. 2019, pp. e696–e704, 10.1016/s2352-3018(19)30139-0. Accessed 11 Dec. 2020.
• Marcus, Julia L, et al. “Use of Electronic Health Record Data and Machine Learning to Identify Candidates for HIV Pre-Exposure Prophylaxis: A Modelling Study.” The Lancet HIV, vol. 6, no. 10, Oct. 2019, pp. e688–e695, 10.1016/s2352-3018(19)30137-7. Accessed 11 Dec. 2020.
• “Pre-Exposure Prophylaxis.” HIV.Gov, 10 Jan. 2019, www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis.
• Take a Sexual History from All Patients. New York City Health Department.