Research leverages emergency room visits to connect at risk populations to preventive services

With a disproportionate number of black cisgender women in the U.S. becoming HIV positive, researchers at The University of Texas Health Science Center at Houston (UTHealth) are sharing critical health information through an atypical venue: the emergency room.

The randomized controlled trial, which includes a risk assessment and a "warm handoff" to community clinics, is the brainchild of Mandy J. Hill, DrPH, MPH, director of the population health program and an associate professor in the Department of Emergency Medicine at McGovern Medical School at UTHealth.

"There is often a fair amount of waiting time for people who seek care in the emergency room for non-emergent illnesses," Hill said. "For many, the emergency room offers a public health safety net. This research leverages the emergency department visit as a vehicle to connect vulnerable populations to preventive services."

In 2017, black women accounted for 59% of new HIV diagnoses among women, according to the Centers for Disease Control and Prevention (CDC). Of all new cases in women, 86% acquired HIV through heterosexual contact and 14% through injection drug use.

"This research is important because black women are more likely to contract HIV than women of other races for social reasons that extend far beyond race," Hill said.

The CDC reported that black people, when compared to other racial groups, may experience more limits with access to high-quality health care and HIV prevention education. These limitations can make it harder to maintain an HIV-negative status.

A national expert on HIV-related challenges facing women and minorities, Adaora Adimora, MD, MPH, has reported that a "low ratio of men to women, economic oppression, racial discrimination, and high incarceration rates of black men" are key elements that fuel the HIV epidemic among the black people in the South. Women in relationships with one male partner may not be aware of their male partner's risk factors for HIV. In these cases, women may not feel they need to use condoms consistently or take preventive medication.

"Condoms can fail and, in some cases where male partners do not want to wear condoms, the priority of maintaining the relationship, such as for security or financial reasons, for the woman is above her own sexual health. So, it's very important that women who may be at risk for HIV become aware of HIV prevention services, which can include treatment as prevention, to protect their sexual health," Hill said.

The HIV prevention treatment that is currently available to cisgender women is called pre-exposure prophylaxis (PrEP), a combination of two HIV medicines, tenofovir, and emtricitabine, sold under the name Truvada.

"Sexually active people can now take a daily pill that is 92% effective at preventing HIV. But cisgender women represent less than 2% of the population who have filled a prescription for PrEP," Hill said.

To increase the use of PrEP, the study is enrolling 40 black women at Memorial Hermann-Texas Medical Center and Harris Health Lyndon B. Johnson Hospital who report risk factors for HIV that include sex without condoms and substance use. Participants will complete a pre-assessment baseline survey of their knowledge about HIV and prevention, and receive a "warm handoff" to clinical partners that include AIDS Foundation Houston and Legacy Community Health. The handoff includes a tablet-based map of Houston marked with the locations of partnering clinics in proximity to the emergency department with key facts about each clinic, taxi vouchers, and a referral card marked with a code to share with the clinic. The appointment is made in real time, or women are encouraged to make one within 72 hours.

Half of the participants will also receive a more in-depth survey tool that informs, educates, and improves knowledge. It incorporates brief, informational messages into a traditional survey.

Before the women leave the emergency room, both groups will complete a final assessment form to see if their knowledge about HIV and prevention has increased.

This unique study acknowledges and addresses the need for more studies that focus on black women concerning HIV preventive services given these startling statistics. Dr. Hill has the right idea to 'go to where the people are' to connect at-risk-for-HIV black cisgender women to services readily available in their community. I am proud to be a community physician partner in the greater Third Ward area through AIDS Foundation Houston."

Teriya M Richmond, MD, MPH, chief medical officer for AIDS Foundation Houston