How EHR Data Revealed Disparities in the Fight Against HIV

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Prescriptions of pre-exposure prophylaxis (PrEP), an antiretroviral medication that significantly lowers the chances of HIV infection, ballooned by 976% in 2 years in New York City. But despite the uptick in volume of prescriptions, men of color, women, and patients outside the city center were less likely to be prescribed the drug, a New York City Department of Health and Mental Hygiene analysis of electronic health records has found.

Researchers found that PrEP prescriptions were more common among younger, white, male patients and at Manhattan-based practices, community health centers, and practices with on-site infectious diseases specialists.

The analysis was made possible by the Hub Population Health System (or “The Hub”), which enabled health department researchers to securely and quickly collect anonymous data covering 2014 to 2016 from electronic health records from 602 New York City medical health practices. “We were able to leverage that system to query aggregate patient counts from the EHRs of a sample of 602 ambulatory care practices, applying clinical logic to develop queries that identify PrEP prescriptions among these practices’ patient populations,” Salcuni said.

Public health departments historically have gathered information concerning infectious disease outbreaks through in-depth interviews of afflicted patients—methods that are “costly and resource intensive and require years of planning and execution to carry out,” according to a Journal of the American Medical Informatics Association article. The Hub, on the other hand, allows researchers to gather data quickly and enables healthcare professionals to respond faster to evolving public health priorities.

The increase in prescriptions followed the publication of PrEP guidelines by the Center for Disease Control and Prevention (CDC) and as clinical trials proved the efficacy of the drug, which when taken daily can reduce the chances of HIV infection by 90%.

During the 2-year period, the NYC health department launched several campaigns targeting individuals at high risk of infection. The “Be Sure, Play Sure, Stay Sure” sexual health media campaign promotes PrEP awareness, and in 2016 the health department launched the PlaySure Network, a network of clinical and nonclinical providers that collaborate to ensure patient access to HIV testing, HIV treatment, and PrEP. Members of the PlaySure network especially targeted individuals without insurance, who may not have regular contact with healthcare providers.

Campaigners from the health department have to date made one-on-one education visits to more than 2,500 providers at more than 1,300 clinical sites across the city. “In order to have the greatest impact, we visited providers at sites which had recently diagnosed HIV in men of color who have sex with men, who are disproportionately affected by HIV in New York City,” Salcuni said. “We prioritize practices located in high-poverty neighborhoods, independent practices, and primary care providers, who have been shown in other studies to be less comfortable prescribing PrEP compared to infectious disease specialists, despite their unique position to identify potential patients.”

Although emergency medicine physicians are generally aware of PrEP, many are uncomfortable discussing the drug, and may lack familiarity of the CDC guidelines, according to a study at Washington University in St. Louis.

“A contributing factor is that a lot of our PrEP presentation campaigns have been largely targeted at physicians in primary care. So emergency medicine physicians have largely been ignored or overlooked,” said Brett Tortelli, BA, lead author of the study. Although emergency medicine physicians are unlikely to prescribe PrEP or provide continued care, they are uniquely placed to identify individuals at high risk of infection who are uninsured, Tortelli said.

The study surveyed 67 emergency room physicians and found that 79% were aware of PrEP, but only 24% knew about the guidelines. And 57%were uncomfortable discussing PrEP with patients, 54% had concerns about whether it was effective, 90% worried about side effects, and 70% feared it would promote HIV resistance.

“All of these concerns have been addressed in clinical studies already, so I think the big problem here is that emergency room physicians are largely unaware of the specifics,” Tortelli said. “Targeting educational campaigns towards those individuals may improve that. And specifically educating them on the research could dispel some of the misunderstandings.”

Another study on PrEP knowledge suggests this problem has deep roots. The survey of 1,588 medical students at 18 medical schools found that 28% were unaware of PrEP, 18% of students in their last year of medical school were never taught about the drug, 57% believed behavioral intervention should be tried before prescribing PrEP, 45% believed patients would not adhere to it, and 22% didn't think it was effective.

The NYC health department analysis suggests the rate of increase in prescriptions in NYC doesn’t show signs of slowing, according to Salcuni, who said that the health department is planning another series of campaigns to address the disparities in prescribing by gender that focus on women’s health providers.