Severe inequities in HIV pre-exposure prophylaxis (PrEP) access and use persist among Black and Latinx
communities most impacted by the HIV epidemic. The Bronx, NY, with over 90% of the population identifying
as Black or Latinx, is an Ending the HIV Epidemic (EHE) priority county with the fifth highest HIV diagnosis rate
in the U.S. and the lowest PrEP use in NY. Research on barriers to PrEP engagement indicate that the current
structure of PrEP access and management is not consonant with the lives, priorities, or needs of the hardest
hit communities, further exacerbating ongoing racial/ethnic and socioeconomic disparities in HIV incidence.
Many of the same barriers leading to poor PrEP uptake in Black/Latinx communities also drive members of
these communities to seek care for sexually transmitted infections (STIs), a known risk factor for HIV, in
Emergency Departments (EDs). However, there is a discordance between the type of care likely to preserve
the long-term health of those seeking STI care in EDs (longitudinal, behavioral, and prevention-oriented) and
the care the ED is optimized to provide (acute, high intensity, life-saving/stabilizing), meaning that both patients
and health systems stand to gain from a restructuring of how STI care is delivered in EDs. Innovative, efficient,
and sustainable strategies for identifying and engaging high priority populations for HIV prevention seeking
sexual healthcare in EDs are thus needed. We therefore propose ED2PrEP, a pragmatic Type III hybrid
effectiveness-implementation trial comparing two strategies for increasing PrEP uptake among patients at risk
for HIV accessing care in Bronx EDs. The two strategies are (1) Post-Visit Outreach (PVO) involving proactive
outreach to patients following a STI-related ED visit. PVO will be initiated by a Sexual Health Navigator who
will provide PrEP education, counseling, and linkage to existing sexual health/PrEP clinics. (2) Tele-PrEP (TP)
will involve a real-time telehealth visit with a Sexual Health Provider during STI-related ED visits. TP will also
include education, counseling, and linkage, in addition to the provider’s ability to prescribe PrEP at the time of
the visit. To test the effectiveness of PVO and TP for increasing PrEP uptake among patients accessing STI
care in the ED, we will perform a crossover trial in which the strategies are implemented in two different EDs
for 9 months and then switched for another 9 months (Aim 1). Next, guided by the RE-AIM framework, we will
assess implementation outcomes for the strategies to identify how each strategy’s effectiveness is impacted by
implementation considerations (Aim 2). Finally, to inform scale-out locally and nationally, we will perform an
economic analysis to determine each strategy’s cost per outcome and relative cost-effectiveness (Aim 3).
ED2PrEP will generate critical data that could transform how EDs initiate PrEP and engage populations at the
highest risk for HIV and accelerate EHE goals in one hardest hit jurisdictions in the U.S. Findings could also be
informative to other jurisdictions, having dramatic effects on how HIV prevention is delivered.
