Pre-Exposure Prophylaxis (PrEP) Protocol for the Urgent Care Setting

Purpose: The purpose of this presentation is to provide the audience with our proposed pre-exposure prophylaxis (PrEP) protocol for use within urgent care settings. With a focus on human immunodeficiency virus (HIV) prevention, the presentation also aims to discuss potential problems and solutions often encountered when initiating PrEP in urgent care settings. Since approval in 2012, Pre-exposure Prophylaxis (PrEP) has found various levels of success within a multitude of healthcare settings (US Food and Drug Administration, 2012). PrEP is a once daily medication taken to reduce the risk of HIV infection by those who participate in high-risk behavior (Centers for Disease Control and Prevention [CDC], 2017). This high-risk behavior can constitute multiple sexual partners, bisexual or gay men who have anal sex without a condom or who have been diagnosed with a sexual transmitted disease within the past 6 months, intravenous drug use, or having a partner who is HIV positive (CDC, 2017). While the primary care and specialty care practices have embraced PrEP, urgent care offices have been reluctant to adopt this preventative method due to a lack of standard protocol specific to the urgent care environment (Ayers, 2017). Current guidelines are only intended for primary care or specialty care clinics , leaving the approximately 7,400 urgent care (UC) centers and providers throughout the United States with limited guidance (CDC, 2017; Urgent Care Association of America, 2017). In addition, due to the laboratory requirements for the initiation of PrEP, many urgent care providers refrain from using this critical preventive method.

Methods: A review of current CDC 2017 guidelines for the initiation and continuation of PrEP services were discussed and reviewed. Additionally, a review of literatures focusing on the successful methods of PrEP management were also studied and reviewed. Suggestions and the methodology of PrEP initiation were reviewed and adopted into our current proposed urgent care PrEP protocol.

Results: The most recent clinical guidelines published by the CDC (2017) consists of information focused on primary care and specialty care clinics. While these guidelines are informative and give ample information to help guide practice, they comprise 77 pages of data. Due to the size of this document, using it as a quick reference can be troublesome when attempting to assess which labs and required follow up are needed. The large volume of information can cause the busy urgent care clinician to feel overwhelmed when seeing an average of 4.5 patients per hour (American Academy of Urgent Care Medicine, 2015). This overwhelming feeling would be compounded within seasonal peak times, such as flu season, due to a larger patient volume needing to be seen by the urgent care provider (Japsen, 2018). During peak times, the increase in demand for urgent care services can worsen stress and reduce the time needed to reference current guidelines effectively. Additionally, there is a lack of provider comfort and numerous perceived barriers held by urgent care clinicians toward the initiation of PrEP (Krakower, Ware, Mitty, Maloney, & Mayer, 2014). This lack of comfort primarily stems from an absence of specific training, guidelines, and protocol for initiating PrEP in the urgent care setting. Lack of clinician comfort with PrEP is easy to identify when combining the patient volume, knowledge in HIV antiviral prescribing, and guidelines only targeted for primary care and specialty clinicians.

Due to the lack of guidance and provider comfort level, a strong initiative to develop a specific protocol for the urgent care setting and the introduction of PrEP services was completed. The purpose of this protocol is to assist in providing the urgent care clinician and medical staff with guidance to create effective and efficient methods to initiate or continue PrEP. This protocol could be used as a quick reference and has been tailored and developed from the CDC 2017 guidelines. Use of the protocol can help with identifying patients who may benefit from PrEP use, identify required laboratory tests, assist with the scheduling of follow up appointments, and address the needs for information related to future referrals. Specific barriers encountered with the initiation of PrEP are addressed by this protocol. For those individuals presenting with signs and symptoms of acute HIV infection, recommendations are to perform HIV Ag/Ab testing before progressing with initiation (CDC, 2017). Another complication of initiating PrEP are positive laboratory results which are often encountered. Some of these results may be treated without referral, such as a positive result for Gonorrhea that may be treated during the medical encounter. Likewise, some positive lab results, such as Hepatitis B, should be referred to other providers and PrEP initiation deferred to a specialist. With the use of the developed protocol, guidance and knowledge can be shared with all urgent care providers allowing them to implement PrEP and significantly reduce the spread of HIV.

Conclusion: While the role of the urgent care clinician and the introduction and continuation of PrEP is currently under-utilized, the developed protocol has the ability to dramatically change this concept. With the guidance provided by the developed protocol, provider comfort and use of PrEP within the UC setting can increase which will benefit all patients seeking this valuable HIV prevention tool. Overall, due to the large number of urgent care centers located across the United States and the massive volume of patients seen for various conditions, increasing PrEP utilization based on new established guidelines in place, developed protocol could potentially provide a significant impact on HIV prevention.