Same-day PrEP Engagement in the Emergency Department (SPEED PrEP) - PROJECT SUMMARY Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV, but only a fraction of the people who could benefit from PrEP in the United States are receiving it. The Emergency Department (ED) is a promising venue for engaging people at risk for HIV in PrEP care, as individuals who utilize the ED often have limited access to outpatient care, may be more likely to be socioeconomically disadvantaged, and may live in communities disproportionately affected by HIV. We have performed mixed methods preliminary work to investigate barriers and facilitators to initiating PrEP in the ED. In surveys with ED patients, most had never heard of PrEP, but many (21%) expressed interest in starting PrEP in the near future. Interviews with ED physicians found general support for starting PrEP in the ED, but limited knowledge of how to do so. Our team has piloted ED-based PrEP linkage programs, both through HIV risk assessment occurring in the ED and via STI screening programs in the ED, relying on subsequent referral of individuals vulnerable to HIV to a future PrEP appointment. However, the vast majority of those referred from the ED did not attend their first PrEP appointment, highlighting a key drop-off in the PrEP care continuum from identification of PrEP eligibility and confirmation of interest in PrEP, to actual PrEP uptake. A promising strategy to alleviate this attrition in PrEP uptake is same-day PrEP initiation. This strategy has been studied in non-ED settings and found to be associated with improved rates of PrEP uptake. However, same-day PrEP initiation has not yet been rigorously studied in the ED setting. The ED is a unique clinical environment with constraints on time and resources; more work is needed to understand how to most effectively implement same-day PrEP in this setting. This proposal fills this gap, building on our preliminary work and bringing together a team of experts in HIV prevention, Emergency Medicine, Implementation Science, Clinical Trials, and Clinical Informatics to study the implementation of same-day PrEP in the ED. Guided by the Exploration, Preparation, Implementation and Sustainment framework and the Consolidated Framework for Implementation Research 2.0, our aims are to 1) Adapt same-day PrEP initiation models and refine implementation strategies for the local context of ED settings in two Ending the HIV Epidemic (EHE) high priority jurisdictions; 2) Compare the effectiveness of two delivery methods for same-day PrEP initiation in the ED (bedside medication delivery of SPEED-PrEP starter pack vs. PrEP prescription provided during the ED visit) via a hybrid Type 2 effectiveness-implementation randomized controlled trial, and 3) Evaluate implementation outcomes including penetration, adoption, acceptability, sustainability, and preliminary costs of same-day PrEP initiation in an ED setting. Results will provide valuable knowledge regarding the implementation of same-day PrEP in the ED, with important implications for HIV prevention among individuals most vulnerable to HIV as we seek to End the HIV Epidemic in the U.S.
