Presentation
“People Are Not Thinking About HIV Anymore:” Process Design for Pediatricians and Adolescents to Support Human Immunodeficiency Virus Testing and Preexposure Prophylaxis
DescriptionBACKGROUND AND SIGNIFICANCE:
Despite the disproportionate burden of Human Immunodeficiency Virus (HIV) in adolescents and young adults, uptake of HIV testing and pre-exposure prophylaxis (PrEP) remains suboptimal. The United States Preventative Services Task Force and Centers for Disease Control and Prevention guidelines endorse universal HIV testing and PrEP counseling. [1] However, only 9% of U.S. high school students have been HIV tested, and <1% of PrEP prescriptions are for minor adolescents.[2] HIV prevention service delivery also suffers from striking health inequities, with disparate rates of HIV testing and PrEP prescription by race, sex, and sexual orientation. [3,4]
Pediatric primary care visits are a window of opportunity for sexually transmitted infection (STI) and HIV screening, and based on results, delivery of effective interventions such as PrEP. Yet sexual health service delivery in pediatric primary care is hampered by limited time and a lack of pediatrician comfort with sexual health discussions. In these busy settings, high provider mental workload can also result in biased decision making. Developing strategies for pediatricians to follow existing guidelines, equitably and efficiently, for HIV prevention services could help address low screening rates and disparities in PrEP prescribing.
METHODS:
We are performing a sociotechnical analysis of pediatric primary care involving the diagnosis and treatment of STIs with a focus on HIV testing and PrEP counseling and prescribing. Data collection is being achieved via semi-structured interviews of up to forty primary care providers, forty adolescent patients, and other pediatric primary care clinicians and staff. Participant recruitment is from a network of 31 primary care practices focusing on practices with patient populations more likely to experience inequities. The provider interview script is based on the presentation and walkthrough of a realistic scenario of a patient presenting with a STI and the subsequent potential workflows and outcomes involving HIV testing, and PrEP counseling and prescribing. The interview guide was developed to capture information based on the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model to capture factors describing the work domain, processes, and outcomes. [5] Following the scenario discussion, provider interview participants are asked to evaluate the potential effectiveness of potential interventions including automated lab result messaging, text messaging to adolescent patients, and a dedicated PrEP Navigator who would manage PrEP counseling. Interviews are audio recorded and transcribed. The transcripts are analyzed using a rapid qualitative analysis method also known as the “sort and sift, think and shift” approach, to efficiently yield action-oriented findings.[6] Initial coding templates capture relevant data regarding barriers and facilitators at each stage of the workflow for the outcomes of HIV testing and PrEP. These data are then organized into a matrix, to allow for identification of key themes from within the SEIPS model, and additional novel themes.
RESULTS:
Provider interviews are in process, and adolescent interviews have just begun at the time of this submission, but with nine provider interviews complete, at least four broad themes are emerging. 1) Education: Providers are aware of PrEP and have positive attitudes toward it but are unfamiliar with guidelines on recommending and prescribing PrEP, would value provider education delivered through multiple channels to accommodate their availability, and to be given easy access to trustworthy information resources and tools. 2) Time and Workload: Providers repeatedly discussed time and workload constraints within an adolescent well or sick visit and the difficulties in arranging adolescent follow-up visits, in person, phone, or tele-visit, for HIV testing and PrEP. 3) Confidentiality: Participants discussed challenges, limitations, confusion, and concerns on how the electronic health record protects or fails to protect, adolescent privacy in multiple scenarios involving test results, documentation, and prescribing. 4) Resources. Providers interviewed to date represented 4 practices, 3 urban, 1 suburban, and even between the urban practices, presented a diverse range of practice personnel resources and processes that could be applied to PrEP counseling and prescribing.
Provider responses to the potential interventions were consistent. For automated messages, providers felt they could be useful, but alone were inadequate in addressing all the challenges in HIV testing and PrEP counseling and prescribing. In response to text messaging directed at adolescents, providers were optimistic but deferred to direct study of adolescents on this topic. Providers responded positively to a PrEP Navigator and felt that the most optimal solution would be to distribute tasks to a navigator-type role and the most appropriate and available clinicians and staff. Potential solutions involve a distributed workflow where the provider would make general decisions and recommendations on HIV testing and PrEP, but have additional tasks performed by a PrEP navigator, a nurse practitioner trained in PrEP, nursing, and/or patient service representatives. In these discussions, several potential workflow options were discussed including options for remote interaction with the patient for PrEP counseling, and the various communication and documentation channels required to support a distributed workflow. All participants spoke of the need to interview adolescents and discussed many challenges including their ability to attend follow-up visits, challenges in protecting confidentiality, specifically issues with the EHR, and finding ways to utilize adolescent preferences for communication and use of technology. Providers described a range of sociotechnical factors represented by differences between practices that included the availability of personal resources, processing of labs, and provider education and knowledge access.
DISCUSSION:
Our results to date demonstrate that, from a provider perspective, developing EHR-based tools alone, including alerts and guideline-based clinical decision support interventions, are insufficient to contribute to improved outcomes in the delivery of PrEP counseling and prescriptions to adolescents given complexities related to provider educational needs, patient confidentiality, and the adolescent visit workflow. Instead, our results, derived though a sociotechnical approach, indicate a much more extensive and versatile process design that supports alternate workflows to accommodate differences in practice resources, provider knowledge, and confidentiality protections. This process design includes supporting providers with multi-modal education content, distributing and coordinating tasks between providers, nurses, staff, and developing a range of integrated EHR tools for documentation and communication tools to support an extensive multi-role workflow. Of course, it will be critical to map these potential processes to the preferences of adolescents, but early results indicate providers support a versatile, dynamic, and distributed process where workflow and tasks are coordinated between clinicians and staff.
REFERENCES:
1. Centers for Disease Control and Prevention. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States- 2021 Update. Department of Health and Human Services, Centers for Disease Prevention and Control. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf. Published 2021. Accessed 2022.
2. Magnuson DH, T.; Mera, R. Adolescent Use of Truvada (FTC/TDF) for HIV Pre-Exposure Prophylaxis (PrEP) in the United States: (2012-2017). 22nd International AIDS Conference; 2018; Amsterdam, Netherlands.
3. Petsis D, Min J, Huang YV, Akers AY, Wood S. HIV Testing Among Adolescents with Acute Sexually Transmitted Infections. Pediatrics. 2020;145(4).
4. Watson DL, Shaw PA, Petsis DT, et al. A retrospective study of HIV pre-exposure prophylaxis counselling among non-Hispanic Black youth diagnosed with bacterial sexually transmitted infections in the United States, 2014-2019. J Int AIDS Soc. 2022;25(2):e25867.
5. Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013;56(11). doi:10.1080/00140139.2013.838643
6. Maietta, R., Mihas, P., Swartout, K., Petruzzelli, J., & Hamilton, A. B. (2021). Sort and Sift, Think and Shift: Let the Data Be Your Guide An Applied Approach to Working With, Learning From, and Privileging Qualitative Data. Qualitative Report, 26(6).
Despite the disproportionate burden of Human Immunodeficiency Virus (HIV) in adolescents and young adults, uptake of HIV testing and pre-exposure prophylaxis (PrEP) remains suboptimal. The United States Preventative Services Task Force and Centers for Disease Control and Prevention guidelines endorse universal HIV testing and PrEP counseling. [1] However, only 9% of U.S. high school students have been HIV tested, and <1% of PrEP prescriptions are for minor adolescents.[2] HIV prevention service delivery also suffers from striking health inequities, with disparate rates of HIV testing and PrEP prescription by race, sex, and sexual orientation. [3,4]
Pediatric primary care visits are a window of opportunity for sexually transmitted infection (STI) and HIV screening, and based on results, delivery of effective interventions such as PrEP. Yet sexual health service delivery in pediatric primary care is hampered by limited time and a lack of pediatrician comfort with sexual health discussions. In these busy settings, high provider mental workload can also result in biased decision making. Developing strategies for pediatricians to follow existing guidelines, equitably and efficiently, for HIV prevention services could help address low screening rates and disparities in PrEP prescribing.
METHODS:
We are performing a sociotechnical analysis of pediatric primary care involving the diagnosis and treatment of STIs with a focus on HIV testing and PrEP counseling and prescribing. Data collection is being achieved via semi-structured interviews of up to forty primary care providers, forty adolescent patients, and other pediatric primary care clinicians and staff. Participant recruitment is from a network of 31 primary care practices focusing on practices with patient populations more likely to experience inequities. The provider interview script is based on the presentation and walkthrough of a realistic scenario of a patient presenting with a STI and the subsequent potential workflows and outcomes involving HIV testing, and PrEP counseling and prescribing. The interview guide was developed to capture information based on the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model to capture factors describing the work domain, processes, and outcomes. [5] Following the scenario discussion, provider interview participants are asked to evaluate the potential effectiveness of potential interventions including automated lab result messaging, text messaging to adolescent patients, and a dedicated PrEP Navigator who would manage PrEP counseling. Interviews are audio recorded and transcribed. The transcripts are analyzed using a rapid qualitative analysis method also known as the “sort and sift, think and shift” approach, to efficiently yield action-oriented findings.[6] Initial coding templates capture relevant data regarding barriers and facilitators at each stage of the workflow for the outcomes of HIV testing and PrEP. These data are then organized into a matrix, to allow for identification of key themes from within the SEIPS model, and additional novel themes.
RESULTS:
Provider interviews are in process, and adolescent interviews have just begun at the time of this submission, but with nine provider interviews complete, at least four broad themes are emerging. 1) Education: Providers are aware of PrEP and have positive attitudes toward it but are unfamiliar with guidelines on recommending and prescribing PrEP, would value provider education delivered through multiple channels to accommodate their availability, and to be given easy access to trustworthy information resources and tools. 2) Time and Workload: Providers repeatedly discussed time and workload constraints within an adolescent well or sick visit and the difficulties in arranging adolescent follow-up visits, in person, phone, or tele-visit, for HIV testing and PrEP. 3) Confidentiality: Participants discussed challenges, limitations, confusion, and concerns on how the electronic health record protects or fails to protect, adolescent privacy in multiple scenarios involving test results, documentation, and prescribing. 4) Resources. Providers interviewed to date represented 4 practices, 3 urban, 1 suburban, and even between the urban practices, presented a diverse range of practice personnel resources and processes that could be applied to PrEP counseling and prescribing.
Provider responses to the potential interventions were consistent. For automated messages, providers felt they could be useful, but alone were inadequate in addressing all the challenges in HIV testing and PrEP counseling and prescribing. In response to text messaging directed at adolescents, providers were optimistic but deferred to direct study of adolescents on this topic. Providers responded positively to a PrEP Navigator and felt that the most optimal solution would be to distribute tasks to a navigator-type role and the most appropriate and available clinicians and staff. Potential solutions involve a distributed workflow where the provider would make general decisions and recommendations on HIV testing and PrEP, but have additional tasks performed by a PrEP navigator, a nurse practitioner trained in PrEP, nursing, and/or patient service representatives. In these discussions, several potential workflow options were discussed including options for remote interaction with the patient for PrEP counseling, and the various communication and documentation channels required to support a distributed workflow. All participants spoke of the need to interview adolescents and discussed many challenges including their ability to attend follow-up visits, challenges in protecting confidentiality, specifically issues with the EHR, and finding ways to utilize adolescent preferences for communication and use of technology. Providers described a range of sociotechnical factors represented by differences between practices that included the availability of personal resources, processing of labs, and provider education and knowledge access.
DISCUSSION:
Our results to date demonstrate that, from a provider perspective, developing EHR-based tools alone, including alerts and guideline-based clinical decision support interventions, are insufficient to contribute to improved outcomes in the delivery of PrEP counseling and prescriptions to adolescents given complexities related to provider educational needs, patient confidentiality, and the adolescent visit workflow. Instead, our results, derived though a sociotechnical approach, indicate a much more extensive and versatile process design that supports alternate workflows to accommodate differences in practice resources, provider knowledge, and confidentiality protections. This process design includes supporting providers with multi-modal education content, distributing and coordinating tasks between providers, nurses, staff, and developing a range of integrated EHR tools for documentation and communication tools to support an extensive multi-role workflow. Of course, it will be critical to map these potential processes to the preferences of adolescents, but early results indicate providers support a versatile, dynamic, and distributed process where workflow and tasks are coordinated between clinicians and staff.
REFERENCES:
1. Centers for Disease Control and Prevention. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States- 2021 Update. Department of Health and Human Services, Centers for Disease Prevention and Control. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf. Published 2021. Accessed 2022.
2. Magnuson DH, T.; Mera, R. Adolescent Use of Truvada (FTC/TDF) for HIV Pre-Exposure Prophylaxis (PrEP) in the United States: (2012-2017). 22nd International AIDS Conference; 2018; Amsterdam, Netherlands.
3. Petsis D, Min J, Huang YV, Akers AY, Wood S. HIV Testing Among Adolescents with Acute Sexually Transmitted Infections. Pediatrics. 2020;145(4).
4. Watson DL, Shaw PA, Petsis DT, et al. A retrospective study of HIV pre-exposure prophylaxis counselling among non-Hispanic Black youth diagnosed with bacterial sexually transmitted infections in the United States, 2014-2019. J Int AIDS Soc. 2022;25(2):e25867.
5. Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013;56(11). doi:10.1080/00140139.2013.838643
6. Maietta, R., Mihas, P., Swartout, K., Petruzzelli, J., & Hamilton, A. B. (2021). Sort and Sift, Think and Shift: Let the Data Be Your Guide An Applied Approach to Working With, Learning From, and Privileging Qualitative Data. Qualitative Report, 26(6).
Event Type
Oral Presentations
TimeMonday, March 2510:30am - 10:52am CDT
LocationSalon A-3
Patient Safety Research and Initiatives