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Clinical Nurse SpecialistA Copyright (c) 2020
Wolters Kluwer Health, Inc. All rights reserved.
Nurse Entrepreneur
Column Editor: Susan A. Alexander, DNP, CRNP, ADM-BC
Opportunities Meeting Needs
Expanding HIV Prevention Beyond Current Clinical Practice
Yeow Chye Ng, PhD, CRNP, CPC, AAHIVE, FAANP n Jack J. Mayeux, DNP, APRN, NP-C n
Susan A. Alexander, DNP, CRNP, ADM-BC
D
espite advances in treatment that have improved
the quality and quantity of life for patients, HIV
and its associated disorders continue to represent
a significant health concern globally. Recent statistics from
the Centers for Disease Control and Prevention suggest that
incidence rates for HIV have remained stable in years
2010-2016; however, young adults (25-34 years), males, and
blacks/African Americans continue to demonstrate higher
rates of HIV infections.1 Geographical variations in rates
of HIV infection have also been demonstrated, with higher
numbers of diagnosed and undiagnosed patients residing
in the Northeast and Southern areas of the United States.1
While efforts to care for patients diagnosed with HIV can
be improved by greater knowledge about who and where
vulnerable subpopulations are, practices aimed at the pre
vention of HIV infection in those who are at greater risk
will also benefit.
Before HIV or HIV-related infection occur, patients must
be exposed to and acquire the virus. Although the Centers
for Disease Control and Prevention recommends that ev
eryone between ages 13 and 64 years be tested for HIV
at least once, there are groups who need more frequent
testing (Table). HIV can be diagnosed by serum nucleic
acid, antigen/antibody, or antigen tests, but the latency pe
riod between exposure and sero-positive diagnosis of HIV
varies according to the test selection, ranging from 10 to
90 days after exposure to the virus for detection. The
lengthy period between exposure and seropositive confir
mation needed for the diagnosis of HIV has created a unique
opportunity for clinicians to focus on HIV prevention in patients.
Author Affiliations: Associate Professor (Dr Ng), The University of Alabama
in Huntsville; Adjunct Clinical Instructor (Dr Mayeux), The University of
Louisiana, Lafayette, Louisiana; Associate Professor (Dr Alexander), The
University of Alabama, Huntsville, Alabama.
Correspondence: Yeow Chye Ng, PhD, CRNP, CPC, AAHIVE, FAANP,
University of Alabama, 301 Sparkman Drive, Huntsville, AL 35805
(YeowChye.Ng@uah.edu).
DOI: 10.1097/NUR.0000000000000514
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One method of HIV prevention that is gaining more support is
pre-exposure prophylaxis (PrEP) for patients who have not
been diagnosed with HIV but are at high risk of the infection.
Pre-exposure prophylaxis for HIV prophylaxis is a daily
treatment with a single pill combination of tenofovir and
emtricitabine and was approved for prevention of HIV in
fection by the US Food and Drug Administration in 20122
followed by a second drug containing emtricitabine and
tenofovir alafenamide in 2019.3 Although any clinician with
prescriptive authority can prescribe PrEP to a patient for
whom therapy is clinically indicated, it has been used most
commonly in settings associated with long-term patient
follow-up, such as traditional primary care practices and
infectious disease specialty settings.4 However, not all pa
tients utilize such facilities for medical care. Clarifying our
understanding of the disproportionate increases in HIV in
fection rates in disparate subgroups supports the need for
increased efforts to prevent HIV that target clinical settings
where they seek care.
PREVENTING HIV IN URGENT CARE SETTINGS
HIV prevention with PrEP in the urgent care setting is a
concept that has been slow to gain traction and varies ac
cording to geographical area of the practice. While there
are some urgent care locations in the United States offering
PrEP services, there are many missed opportunities to pro
vide and educate people about PrEP services in these care
settings. Currently, many providers in the urgent care
setting have a limited knowledge of PrEP and may elect
to refer to another healthcare provider for initiation or
continuation.5 Unfortunately, many patients face chal
lenges that limit their capacity to keep appointments with
clinicians to whom they are referred for subsequent care.
Clinical indications for the use of PrEP can aid clinicians
in screening efforts and initiation of therapy. Urgent care
settings are utilized for many acute and chronic conditions,
with diagnoses of sexually transmitted infections (STIs) in
creasing in frequency.6 In past years, centers have experienced
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Table. Who Should Be Tested for HIV More
Frequently?
-  History of anal or vaginal sex with HIV-positive partner
-  Man who has had sex with another man
-  Intravenous drug use with sharing of injection equipment
-  Commercial sex work (exchange of sex for drugs and/or money)
-  Diagnosed with other sexually transmitted diseases
-  Diagnosed with hepatitis and/or tuberculosis
-  History of sex with someone whose sexual history is unknown
(or includes any of the factors previously listed)
Source: Centers for Disease Control and Prevention. HIV Basics: Testing. Updated
December 3, 2019. https://www.cdc.gov/hiv/basics/testing.html. Accessed
February 28, 2020.
a 2-fold increase in the number of visits for people treated
for Chlamydia trachomatis and Neisseria gonorrhoeae and a
3-fold increase in visits by people diagnosed with other
STIs.6 Frequent STI is one of the risk factors for HIV
and highlighted in the PrEP guidelines.7 The combina
tion of requests by patients for STI testing and the rising
incidence of individuals with an STI seeking treatment in
urgent care has led to an increased risk of HIV and sup
ports the need for improvements in counseling and pro
vision of PrEP services in these ambulatory settings.
ONE NURSE PRACTITIONER'S EXPERIENCE IN
PRESCRIBING PREP
Jack J. Mayeux, DNP, APRN, NP-C, has worked with pa
tients in the urgent care setting for 5 years. His experience
in treating patients corroborates current statistics on rising
numbers of patients requesting screening and being diag
nosed with STIs. While C trachomatis and N gonorrhoeae
are among the most common STIs Mayeux treats in his
practice, he finds that more and more patients are being
treated for syphilis. In addition to STIs diagnosed in pa
tients for the first time, Mayeux has treated many patients
on multiple visits for repeat STI diagnoses.
Mayeux sees firsthand the need to discuss use of PrEP
with patients who are at risk of HIV and finds that both
the initiation and continuation of PrEP therapy are feasible
in the urgent care setting. According to Mayeux, "Many pa
tients coming to the urgent care setting for STI screening
and treatment have a primary care provider, but are reluc
tant to visit for this reason due to perception and judgment.
While there are cures for STIs, there is no cure for HIV."
"We have lab services in our facility. We can run all the
required PrEP lab testing and receive the result in less
than 35 minutes" (J. Mayeux, personal communication,
January 3, 2020).
Rapid screening can make PrEP counseling and initia
tion practical within almost any urgent care facility that is
Clinical Nurse SpecialistA
equipped with in-house laboratory services, and patients
always have the option of returning to their personal pri
macy care provider for continuation of PrEP services. Pa
tients who lack primary care providers can be referred by
urgent care facilities to local primary care services for con
tinuation of therapy.
Advanced practice nurses, such as nurse practitioners,
are prepared for a leadership role in the patient identifica
tion, counseling, treatment, and linkage of patients to other
appropriate care settings that is needed to reduce HIV in
fection. The need to protect his patients motivated Mayeux
to develop a PrEP protocol for use in the urgent care
setting. Over a period of 24 months, his PrEP protocol
was adopted at six different urgent care facilities across
Louisiana. Since that time, the PrEP protocol has been
implemented as part of the standard treatment option
for patients diagnosed with STIs.
TRACKING CURRENT EFFORTS IN
PREVENTING HIV
Yeow Chye Ng, PhD, CRNP, CPC, FAANP, was the first
family nurse practitioner to provide PrEP services from
an urgent care facility in Huntsville, Alabama. Ng is well
known for his contributions and advocacy in HIV bio
medical prevention with PrEP in primary care and urgent
care settings for persons at high risk of HIV infection. Be
cause PrEP is effective in preventing HIV only if patients
are adherent to taking the medication once daily, adop
tion of the self-management behavior by patients is an
important consideration for clinicians. "One's behavior can
be predicted more accurately if we have enough baseline
repeat measurements from the same patient. It is important
to note that adherence is a learned behavior and may
change frequently if the behavior is not reinforced through
an outcome, which could be as simple as one's perceived
goals, or quantifiable health outcome," states Ng.
Understanding why patients at high risk of HIV do not
receive PrEP therapy goes beyond patient characteristics
and access to care. A lack of knowledge about current
guidelines for PrEP use and comfort in broaching the
subject with patients at high risk of HIV has been cited
as factors that reduced prescribing of PrEP by healthcare
providers across multiple care settings, including emer
gency departments, primary care, and specialty care.8,9
Statistics suggest that these factors may be a significant
barrier in getting patients necessary treatment to prevent
HIV infection.
Despite approval of PrEP therapy, the incidence of HIV
infection has remained stable over years 2013-2017.1 A bet
ter appreciation of the association between STIs and sub
sequent HIV infection may help focus prevention efforts.
According to Ng, improving our knowledge about localized
increases in incidences of STI cases can help to focus re
sources for HIV risk reduction campaigns that can address
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Nurse Entrepreneur
both patient- and healthcare provider-related factors. Such
a task requires large volumes of data and the computa
tional resources needed to gain meaningful insights from
its processing.
Its common use of standardized disease and procedural
coding makes administrative health data an excellent source
for identifying vulnerable patients who have been treated
for STIs. Ng seeks to understand the incidence of STIs
in older adults, a subpopulation not commonly associ
ated with risk of HIV, and to better characterize their risk
of acquiring HIV infection. His initial work will involve
the acquisition of multiple years of national data from sources
such as Medical Expenditure Panel Survey and the CMS
Data Warehouse to identify geographic areas of increased
STI infections. Although data sets containing protected
health information can be costly and difficulty to acquire,
Ng believes data sets without protected health information
will be valuable for his work. "Publicly available data sets
can contain attributes that will help us to appreciate the
geographical clusters of patients who are treated for STIs.
Once we know where to go, we can begin our efforts at
working with clinicians in urgent care settings to improve
screening and initiation of PrEP in high-risk patient groups
across all ages," states Ng.
Acquiring data is the first step in Ng's work, which will
be followed by the quantitative analysis and geomapping
needed to find areas of greatest HIV risk. Partnering with
data scientists and other clinicians, Ng will use a commer
cial cloud-based vendor to store and analyze the large data
sets needed for his work in targeted HIV risk reduction.
While focused outreach to healthcare providers may not
be a new concept in patient care, access to data and other
resources that facilitate widespread system change by small
clinician groups may be a game-changer in treatment and
prevention efforts. Implementation of PrEP in the urgent
care setting can be a chance for patients to receive lifesav
ing care that might otherwise have been missed.
References
1. Centers for Disease Control and Prevention. HIV Surveillance
Supplemental Reports 2019: estimated HIV incidence and preva
lence in the United States, 2010-2016. 2019; https://www.cdc.
gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance
supplemental-report-vol-24-1.pdf. Accessed February 28, 2020.
2. US Food and Drug Administration. FDA Approves First Drug for
Reducing the Risk of Sexually Acquired HIV Infection. US Food
and Drug Administration: Silver Spring, MD; 2012.
3. US Food and Drug Administration. FDA Approves Second Drug to
Prevent HIV Infection as Part of Ongoing Efforts to End the HIV
Epidemic. US Food and Drug Administration: Silver Spring, MD; 2019.
4. Weinstein M, Yang OO, Cohen AC. Were we prepared for PrEP?
Five years of implementation. AIDS. 2017;31(16):2303-2305.
5. Mayeux JJ, Ng YC. Pre-exposure prophylaxis in the urgent care
setting: a systematic review. J Nurse Pract. 2019;15(8):595-599.
6. Pearson WS, Tao G, Kroeger K, Peterman TA. Increase in urgent
care center visits for sexually transmitted infections, United States,
2010-2014. Emerg Infect Dis. 2017;23(2):367-369.
7. Centers for Disease Control and Prevention. Preexposure prophy
laxis for the prevention of HIV infection in the United States 2017
update: clinical practice guideline 2017. https://www.cdc.gov/
hiv/pdf/guidelines/cdc-hiv-prep-guidelines-2017.pdf. Accessed
February 28, 2020.
8. Mimiaga MJ, White JM, Krakower DS, Biello KB, Mayer KH. Sub
optimal awareness and comprehension of published preexposure
prophylaxis efficacy results among physicians in Massachusetts.
AIDS Care. 2014;26(6):684-693.
9. Tellalian D, Maznavi K, Bredeek UF, Hardy WD. Pre-exposure pro
phylaxis (PrEP) for HIV infection: results of a survey of HIV healthcare
providers evaluating their knowledge, attitudes, and prescribing
practices. AIDS Patient Care STDS. 2013;27(10):553-559.
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