Improving Primary Care Providers' PrEP Recommendations to High-Risk Populations

Purpose: Pre-exposure prophylaxis (PrEP) is a highly effective intervention for preventing HIV transmission, yet uptake remains below national targets. Despite Centers for Disease Control and Prevention recommendations for routine PrEP assessment in primary care, multilevel barriers limit implementation, particularly in the U.S. South. This quality improvement project aimed to implement and evaluate a PrEP program within a county health department in Chatham County, North Carolina to address a critical gap in HIV prevention services. Methods: Guided by the Institute for Healthcare Improvement Model for Improvement, a 12-week pilot PrEP program was implemented in the Chatham County Public Health Department Sexually Transmitted Infections (STI) Clinic. Implementation activities included staff training, workflow redesign, integration of PrEP screening tools into the electronic health record, rapid HIV testing, and patient education materials. Iterative Plan-Do-Study-Act (PDSA) cycles were used to refine processes, improve documentation, and address barriers. Results: Fifty STI clinic visits among 46 unique patients occurred during the project period. Thirty-six percent met high-risk criteria for PrEP; however, only one patient initiated therapy. Nurse-led PrEP screening achieved 100% documentation, while provider documentation improved from 0% to 80.5% following EHR modifications. Patient-level misconceptions were identified, particularly among heterosexual women who perceived PrEP as relevant only for men who have sex with men. Operational challenges included an average 17.7-minute increase in visit duration due to PrEP screening and counseling. Conclusions: This project demonstrated the feasibility of integrating PrEP services into a county health department and identified key barriers related to workflow, documentation, and patient education. Although initiation rates were low, findings highlight critical opportunities to improve uptake. Notably, two individuals who later sought PrEP were newly diagnosed with HIV, underscoring the urgency of expanding prevention services. These results support broader implementation of PrEP programs to reduce HIV disparities in North Carolina and similar high-risk regions.