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Abstract

Objective:

To assess pre-exposure prophylaxis (PrEP) knowledge and prescribing confidence one year after implementation of an obstetrics and gynecology (OBGYN) resident curriculum and evaluate barriers to PrEP prescribing in an OBGYN resident clinic.

Materials and Methods:

This mixed methods study evaluated OBGYN residents who provide care in a high HIV prevalence city. Resident physicians, including those who did and did not participate in the original curriculum, completed a survey of knowledge and comfort prescribing PrEP; responses were compared with previously collected survey results from prior to and immediately after the curriculum. Second, we conducted focus groups and individual interviews (n = 12 participants) to assess perceived barriers and areas for improvement in PrEP delivery. Transcripts were coded via Dedoose software and organized according to themes using a constant comparative approach.

Results:

The average score for the knowledge evaluation was 62.6%, which was lower than the immediate postcurriculum scores from one year prior (78.9%, p < 0.05). A significantly lower proportion of residents reported that they were comfortable with prescribing PrEP compared with the prior year (26.1% vs. 71.9%, p < 0.05). Only 56% of residents reported counseling a patient in clinic about PrEP, and 34% had reported prescribing PrEP 1-year postcurriculum. Qualitative themes regarding barriers to PrEP provision included knowledge, institutional, operational, and perceived low-risk population. Potential solutions for each barrier included department-wide and recurring education for all training levels, introduction of a PrEP monitoring pathway, implementation of nursing questionnaires, task lists, pretemplated texts, and increasing awareness of PrEP.

Conclusion:

Beyond educational deficits, several other operational and institutional barriers prevent the full inclusion of PrEP provision in an academic OBGYN ambulatory setting.

Introduction

A significant proportion of women account for new HIV cases.¹ Pre-exposure prophylaxis (PrEP) is a once-daily pill taken to prevent individuals from acquiring HIV.² Despite heterosexual contact being the main point of HIV acquisition, <5% of women use PrEP and <10% receive a prescription.² ACOG 2014 guidelines recommend discussing PrEP with all sexually active patients.^2,3 More importantly, women with HIV acquisition during pregnancy have a fifteen times higher risk of perinatal transmission than women already living with HIV.^4,5

Greater emphasis has been placed on program implementation to better facilitate PrEP prescribing among women’s health providers and uptake among patients. Two years ago (2020–2021), we implemented an early evaluation of a curriculum on the use of PrEP in an obstetrics and gynecology (OBGYN) clinic in Chicago that is primarily led by trainees.⁶ The goal of the curriculum was to increase resident knowledge and comfort in PrEP prescribing for a high-risk population.⁶ As a particularly high-risk area, Chicago is an important target for eliminating the burden of HIV/AIDS on women.⁷

Within this curriculum, four virtual simulation sessions in a high-volume OBGYN residency were facilitated with interactive didactic lectures, standardized patient counseling sessions, and pre- and postsimulation surveys on PrEP knowledge and prescribing comfort.⁶ Prior to this curriculum, 66% of residents had never prescribed PrEP. Directly after this curriculum, PrEP knowledge assessment scores increased by 20%, and residents reported increased PrEP initiation in clinic and a sense of empowerment in PrEP prescribing.⁶

Despite clinical and public health interventions that aim to eliminate barriers to PrEP provision at the provider level, literature has identified that barriers still exist at the systemic, logistical, and patient levels. Structural, clinician-based barriers have yet to be explored to the same degree as patient-level barriers.^8,9 Thus, our main objective was to assess the long-term efficacy of this curriculum by assessing PrEP prescribing knowledge and confidence one year after implementation. Second, we aimed to identify barriers to PrEP prescribing in an OBGYN resident clinic. Our goal was to identify possible solutions and ultimately implement a larger quality initiative to improve PrEP prescribing.

Methods

In this mixed methods study, we enrolled resident physicians who are part of the current residency cohort at the McGaw Medical Center of the Northwestern University (NU) Feinberg School of Medicine. Prior to initiation, approval was obtained from the NU Office of Medical Education and the NU Institutional Review Board (# STU00218407). Residents were identified using a publicly available roster of OBGYN residents and contacted via their academic email for recruitment. The recruitment email included details of the study and a link to the consent form and the survey using online secure software known as Research Electronic Data Capture.^9,10 The maximum sample size consisted of 48 residents, with the expectation that half of the cohort would participate.

Our cohort included residents who had participated in the prior curriculum as well as those who had not been exposed to the prior curriculum (i.e., new residents). Of our cohort, the fourth- and third-year residents had been exposed to the curriculum, whereas the first- and second-year residents had not been directly exposed to the curriculum. We had an a priori plan to include first- and second-year residents in the assessment even though they had not participated in the previous curriculum (as it occurred prior to the start of their training), in support of the near-peer phenomenon in which senior residents teach junior residents and create an overall practice culture.^11–16 Peer learning has been described as an important part of medical education, and education programs have emphasized training for residents to be better educators given this widely accepted expectation, including the ACGME.^11–16 Graduated residents who had previously participated were not invited to participate as they no longer practiced in this setting after the curriculum. Given the nature of residency training and the available population, we anticipated approximately half of the available residents would participate in surveys.

The survey disseminated was the same survey used to assess knowledge and prescribing confidence after the initial curriculum implementation (Supplementary Appendix SA1). Excel software was used to perform descriptive analyses and Chi-square tests to compare immediate post and one year postknowledge test scores as an aggregate. Additionally, we performed a post hoc comparison of the knowledge and comfort scores at 1 year to the precurriculum scores. Individual pre- and post-test scores were not compared.

For the qualitative portion of our study, residents were recruited using the same communication as described above and consented using the same consent form. Focus groups were facilitated during resident work hours via Zoom. Two virtual focus group sessions via Zoom along with three individual interviews were conducted to discuss perceived barriers and challenges to PrEP prescribing for OBGYN residents. Individual interviews were conducted for residents who wanted to participate but were not otherwise available. Focus groups consisted of four to six residents. Focus groups were led by the first author using a facilitation guide developed by an expert team with questions centered on exploring perceived barriers, prescribing confidence, challenges to prescribing PrEP, and potential solutions (Supplementary Appendix SA2). Recordings were uploaded to a secure SharePoint and transcribed by the research team for analysis. Focus group and individual interview recordings were coded using a constant comparative approach using Dedoose software to determine major themes by members of the research team.¹⁷ Responses were also evaluated regarding potential solutions for a quality improvement initiative in our resident clinic for PrEP prescribing.

Results

A total of 23 residents participated in the survey assessment. The resident cohort included five first-year residents, seven second-year residents, eight third-year residents, and two fourth-year residents. One resident did not disclose identifiable information, and thus, we were unable to determine the year. The average score for the knowledge evaluation was 62.6%. Compared with scores from the postcurriculum assessment survey immediately after the implementation of the PrEP curriculum, scores were significantly lower one year later (78.9%, p < 0.05). The overall average score for the knowledge evaluation one year after curriculum implementation was higher than the precurriculum knowledge score (55%), although differences did not reach statistical significance (p = 0.12).

A significantly lower proportion of residents reported that they were comfortable with prescribing PrEP compared with the prior year (26.1% vs. 71.9%, p < 0.05). This finding included being significantly less comfortable with prescribing PrEP to obstetric and gynecologic patients in a variety of settings (Table 1). Additionally, 56% of residents reported counseling a patient in clinic about PrEP, and 34% had reported prescribing PrEP one year postcurriculum. Additionally, comfort scores one year postcurriculum were still significantly higher than prior to when the curriculum was implemented (4.8% vs. 26.1%, p ≤ 0.05). This included significantly less comfort in prescribing PrEP in similar environments compared with one year postcurriculum (Table 2).

Table 1.

Comfort Prescribing PrEP Immediately Post and One-Year Postcurriculum

Survey measure	Immediately postcurriculum (n = 32)	1-year postcurriculum (n = 23)	p
Overall comfort prescribing PrEP	23 (71.9)^a	6 (26.1)	<0.05
Comfort prescribing to
Gyn patient with recent STI diagnosis	26 (81.3)	13 (56.5)	0.03
Gyn patient without recent STI diagnosis	21 (65.6)	6 (26.1)	<0.05
Gyn patient with partner living with HIV	26 (81.3)	16 (69.6)	0.48
Pregnant patient with recent STI diagnosis	24 (75.0)	7 (30.4)	<0.05
Pregnant patient on PrEP before	28 (87.5)	11 (47.8)	<0.05
Pregnant patient with partner living with HIV	25 (78.1)	11 (47.8)	<0.05

Data are n (%).

p Value is comparing immediately post and current scores.

PrEP, pre-exposure prophylaxis; STI, sexually transmitted infection.

Table 2.

Comfort Prescribing PrEP Prior to Curriculum and One-Year Postcurriculum

Survey measure	Precurriculum (n = 32)	1-year postcurriculum (n = 23)	p
Overall comfort prescribing PrEP	2 (6.3)^a	6 (26.1)	<0.05
Comfort prescribing
Gyn patient with recent STI diagnosis	8 (25.0)	13 (56.5)	<0.05
Gyn patient without recent STI diagnosis	4 (12.5)	6 (26.1)	0.11
Gyn patient with partner living with HIV	8 (25.0)	16 (69.6)	<0.05
Pregnant patient with recent STI diagnosis	5 (15.6)	7 (30.4)	0.15
Pregnant patient on PrEP before	6 (18.8)	11 (47.8)	<0.05
Pregnant patient with partner living with HIV	5 (15.6)	11 (47.8)	<0.05

Data are n (%).

p Value is comparing immediately post and current scores.

A total of 14 residents participated in the qualitative portion of the study. This resident cohort included two fourth-year residents, five third-year residents, three second-year residents, and four first-year residents. Themes regarding barriers to PrEP counseling and prescribing coalesced around four major concepts: knowledge barriers, institutional barriers, operational barriers, and perceived low-risk populations.

Knowledge barriers encompassed a lack of understanding of eligibility for PrEP, prescribing guidelines for PrEP, and follow-up for patients on PrEP (Table 2). One participant stated, “As a first year [I] only see OB patients. I don’t know that I’ve ever screened someone to know that they might need PrEP. I don’t know if you prescribe PrEP for pregnant patients… .” This barrier included knowledge gaps for the whole department. Residents felt that because there was minimal experience and/or knowledge from attendings and other clinicians, they felt less supported in counseling or prescribing PrEP. Solutions proposed included department-wide training that is longitudinal and recurrent to keep staff updated on prescribing guidelines. Participants felt that encouraging faculty to partake in these educational sessions would support improved resident knowledge about prescribing PrEP (Table 3).

Table 3.

Barriers to PrEP Counseling and Prescribing and Proposed Solutions

Themes	Quotes	Potential solutions
Knowledge barriers	“I think there is a lack of knowledge and understanding about the medications, and then lack of education about identifying proper patients that would be good candidates for it”	- Department-wide education - Training that is recurring and longitudinal - Encouraging faculty involvement and support
Institutional barriers	“It’s a little hard in our model of care because we don’t have a true continuity clinic. Someone will get started on PrEP but won’t continue it because the interval screening is hard, the refills are hard, patients change their mind on taking PrEP, because of stigma”	- PrEP monitoring pathway to give opportunities for allied health professionals to do short visits regarding PrEP counseling
Operational barriers	“I don’t think it’s really in my workflow. Like whether that’s a lack of dot phrases, but I don’t think about it reflexively for every single person”	- Incorporating previsit nursing questionnaires - Creation of dot phrases - PrEP monitoring pathway with separate visits for PrEP prescribing and counseling - Incorporating PrEP prescribing into problem task lists for both obstetric and gynecology visits - Including information in check out instructions
Perceived low-risk population	“Unfortunately, heterosexual women are not thought about the population for HIV acquisition even though it is something that actually happens”	- Increasing awareness of PrEP as an option for our patient population - Promotion of updated ACOG guidelines

OB/GYN, obstetrics and gynecology.

Institutional barriers centered on a lack of continuity that exists within a resident clinic, inciting concerns about loss of follow-up, lack of trust, and increased stigma (Table 2). One participant stated, “There were some places where I felt more comfortable talking with patients about PrEP or understanding their follow up… . But that is such a small fraction of all the people that should be offered PrEP.” Initiating a “PrEP monitoring pathway” in which allied health professionals perform short telehealth visits for routine follow-up, including lab tests and counseling for those on PrEP, was a proposed mechanism for providing more continuity that is discrete and accessible for patients (Table 3).

Many residents felt that incorporating PrEP counseling into their workflow was difficult. Some commented on the numerous tasks and topics required out of a fifteen-minute visit, and adding PrEP counseling seemed burdensome. Other operational barriers such as not having reminders, educational materials, or pretemplated texts to use in the electronic medical record made incorporating PrEP counseling more challenging (Table 3). A junior resident stated, “There isn’t time for more of an adjunct screening for risk factors for needing PrEP. It falls to the side if your primary issue is like x.” Proposed solutions to operational barriers included incorporating a preclinic visit questionnaire for patients prior to being seen by a physician. Easy and accessible methods of communication and documentation such as pretemplated texts, problem list tasks, or pretemplated after-visit summaries made residents feel more encouraged to incorporate PrEP counseling into their workflow. Many of these initiatives were proposed as mechanisms by which a PrEP monitoring pathway would be helpful in streamlining these resources (Table 3).

Finally, the barrier of perceived low-risk population referenced resident perception of low-risk population within their patient population, resulting in low investment to know how to counsel and/or prescribe PrEP (Table 2). A participant stated, “I can’t say I’ve ever had an attending say did you ask about PrEP. I feel like for OBGYN, the specialty, PrEP is kinda new for us, so we all need to be better about it.” Addressing many of the educational barriers and reviewing the prescribing guidelines was a proposed solution by many residents. Overall, increasing awareness of cisgender heterosexual women as a high-risk group was encouraged and motivating for residents to perform PrEP counseling and prescribing (Table 3).

Discussion

We performed a one year evaluation of PrEP prescribing knowledge and confidence of OBGYN trainees in a high-risk community following a PrEP educational curriculum. Residents reported a significantly low frequency of PrEP prescribing in addition to lower knowledge scores compared with immediately after the curriculum. Knowledge and comfort scores one year postcurriculum were higher than scores prior to implementation of the curriculum, but only comfort scores were significantly different. This may reflect the retention of some knowledge and comfort from the curriculum in those who participated. Recognizing that individual barriers such as knowledge are only a segment of the challenges, we assessed systemic barriers to PrEP prescribing. Residents expressed concern over the lack of continuity within the clinic and that there were few mechanisms in place to support the prescribing of PrEP. Overlapping these system challenges was the perceived low-risk population, with which several residents felt the patient population in this clinic was not appropriate candidates for PrEP.

Potential solutions were elicited to address these barriers to help guide future quality initiatives in improving PrEP prescribing. Suggestions included initiating a “PrEP monitoring” pathway with the incorporation of allied health professionals and telehealth visits to ensure continuity. Facilitating departmental education on a routine basis was considered essential, along with providing easy mechanisms via the electronic medical record to help disseminate information. Many models of a “PrEP monitoring” pathway and recurring departmental education have been implemented at other institutions.^18–23

The strengths of this study include the mixed methods modality to help inform future solutions to address barriers to PrEP prescribing at multiple levels. Limitations include our sample size. Unfortunately, not every resident was able to participate in this study. However, our qualitative analysis met saturation overall and across classes, as the feedback provided was consistent across classes. Similarly, we were not able to survey every resident who had previously participated in this curriculum, as some had graduated from the program. Likewise, we included residents who had not previously participated in the curriculum, specifically first- and second-year residents, considering the widely accepted near-peer phenomenon.^11–16

Large gaps remain in prescribing PrEP for women, despite heterosexual contact being a large contributor to HIV acquisition. Lack of HIV prevention in this population can have devastating consequences, making it imperative we address barriers for future providers in women’s health. Efforts aimed at increasing prescribing of PrEP should be prioritized in high-risk patient populations, such as those seen in an OBGYN resident clinic in Chicago. Careful attention must be paid to ensuring longstanding education for all providers, including faculty, and implementing a sustainable workflow for follow-up and safety. We are hopeful these data will help inform a larger quality initiative, in which we plan to implement some of the solutions proposed and attempt to reduce the transmission of HIV to our patients.

Footnotes

Acknowledgments

The authors would like to acknowledge the current and past residents of Northwestern Obstetrics and Gynecology for their willingness to participate in this research study and share their thoughtful ideas.

Authors’ Contributions

A.M.P.Y.: Conceptualization, methodology, formal analysis, investigation, data curation, and writing. S.B.: Conceptualization, methodology, and writing. H.P.: Data curation, formal analysis, and writing. L.P.: Data curation, formal analysis, and writing. L.Y.: Conceptualization, methodology, formal analysis, writing, and supervision.

Authors Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

The authors did not receive funding for the work performed in this study.

Supplementary Material

Abbreviations Used

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Supplementary Material

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Assessing Barriers in Obstetrics and Gynecology Trainee Knowledge and Prescribing of HIV Pre-Exposure Prophylaxis in a High-Risk Community

Abstract

Objective:

Materials and Methods:

Results:

Conclusion:

Introduction

Methods

Results

Discussion

Footnotes

Acknowledgments

Authors’ Contributions

Authors Disclosure Statement

Funding Information

Supplementary Material

Abbreviations Used

References

Supplementary Material