Need for Further Education
The educational curriculum of the IMPACT initiative addressed gaps and disparities in HIV infection rates and prevention services, identified barriers to care, and outlined evidence-based strategies for prevention. While these teachings resulted in measurable improvements in participants’ knowledge, competence, and practice, there remains a need for further education as barriers to optimal practice persist.

In the aggregate analysis, 80% of learners acknowledged the need to make changes in their practice, but 6 months later 24% said they still didn’t have enough knowledge to make those changes. Approximately 34% said that patient adherence had proved to be a barrier; 28% cited a lack of time and resources to consider making changes; and 27% identified insurance, reimbursement, or legal issues as substantial challenges. 

On average, at the conclusion of the activities, half of the participants said they were “very comfortable” discussing sexual health issues with their patients. Some concerns about PrEP remain: the possible development of resistant HIV strains and less frequent use of condoms or other safer sexual practices in patients taking PrEP.

Next Steps for Improving HIV Prevention
Applying the learnings and eliminating disparities in access to HIV prevention services involves talking candidly and comfortably about HIV with patients, assessing the individual’s risk for infection, discussing available prevention methods, and prescribing or referring as appropriate.11 Assessing HIV risk requires conversations about sensitive topics (ie, sexuality, drug use) with patients who may be reticent to discuss such information. Clinicians can help by taking measures to eliminate stigma and facilitate relationships that can normalize discussions about sexual activity and its consequences. To begin, clinicians should ask their patients if they have had sex within the past 12 months. If so, follow-up questions can include how many partners they had sex with, the gender(s) of their partners, and in what type(s) of sexual behavior did they engage. The CDC has published a guide to taking a sexual history43 and a set of specific instructions for taking a sexual history from transgender people.44

Other questions may include the role of the influence of alcohol on recent sexual encounters, the use of drugs to get high before or during sex, condom use/nonuse, and whether patients had been in a detention center, jail, or prison for more than 24 hours during the last 12 months. Clinicians can delve further into questions about alcohol, tobacco, and other substance use in the recent past, whether use led to legal or financial trouble, whether a friend or relative expressed concern about substance use, and if patients have tried without success to curtail their substance use. Notably, no additional financial resources are required to make sure patients are asked about sex; drugs; and social, economic, cultural, and psychological issues that may affect HIV risk and access to HIV prevention and treatment services.

Targeting barriers related to the availability and access of HIV prevention and treatment services can help eliminate disparities. To do so, it is important to combat the stigma linked to societal and cultural factors associated with HIV and to increase cultural competence and patient literacy. For example, providers can learn basic medical Spanish to help improve clinician-patient relationships in Hispanic/Latino communities. Using tools for health literacy, providing outreach, and engaging in community-specific messaging to patients in various languages may also improve these relationships. Cultural competence has been associated with “higher quality of care, better patient self-management, and better health outcomes among minority patients.”30

A Pivotal Role for Primary Care
Primary care physicians write the majority of prescriptions for PrEP. This makes them ideally positioned to identify individuals at risk for HIV infection and to provide HIV prevention services for these individuals. The CDC’s guidelines for PrEP, first developed in 2014 and updated twice since then, emphasize that (1) many people at very high risk for HIV infection are not getting PrEP, and (2) any prescribing healthcare provider can provide PrEP care.31,32,45 (See box, CDC Guidelines on PrEP — and Other Helpful Resources.)

Thus, it is critical that healthcare providers receive education about HIV prevention strategies and interventions for overcoming barriers to the uptake of and adherence to services. A fairly significant proportion of IMPACT learners (4%) were emergency medicine clinicians, 4% were pediatricians, and an additional 4% were obstetrician-gynecologists. Therefore, future educational activities on HIV prevention could be extended to these audiences.

From this foundation, the optimization of HIV prevention and treatment will be expanded to move closer toward the goal of eliminating disparities in HIV care.

CDC Guidelines on PrEP–and Other Helpful Resources

The CDC published guidelines on the use of HIV pre-exposure prophylaxis (PrEP) in 2014, updated them in 2017, and published the revised document online in March 2018.

PrEP Clinician Helpline: 855-448-7737 or 855-HIV-PrEP

CDC. Complete Listing of Risk Reduction Evidence-based Behavioral Interventions.

CDC. HIV Risk Reduction Tool.

NASTAD. Pharmaceutical Company Patient Assistance Programs and Co-Payment Assistance Programs for Pre-exposure Prophylaxis

(PrEP) and Post-exposure Prophylaxis (PEP).

The Body. Assess Your Risk for HIV.

Richard A. Elion, MD, is associate clinical professor of internal medicine at George Washington University in Washington, DC, and medical director of CAPE. Mesfin Fransua, MD, is a professor of medicine in the Infectious Diseases Section of Morehouse School of Medicine in Atlanta, Georgia. H. Gene Stringer Jr, MD, is associate professor of medicine and chief of the Infectious Diseases Section of the Department of Medicine of Morehouse School of Medicine in Atlanta, Georgia.  Krista Sierra, MA, is director of grant and content development at Haymarket Medical Education in Paramus, New Jersey.

Acknowledgements: The educational activities for the IMPACT curriculum were supported by unrestricted grants from Gilead Sciences Inc. Writing assistance was provided by Jeremy Pagirsky of Haymarket Medical Education.

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