Guideline Adherence to HBV Screening, Vaccination in Patients Prescribed HIV PrEP
In this video, Melissa E. Badowski, PharmD, MPH, discusses guidelines for hepatitis B virus (HBV) screening and vaccination in patients prescribed human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and the evaluation of immunity of vaccination against hepatitis A, human papillomavirus, and meningococcal vaccination. Dr Badowski also discussed these topics during a presentation at IDWeek 2023 titled "Guideline adherence to HBV screening and vaccination in patients prescribed HIV PrEP."
Awad R, Michienzi S, Badowski M. Guideline adherence to hepatitis b virus (HBV) screening and vaccination in patients prescribed human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP). Talk presented at: IDWeek 2023. October 11-15, 2023. Accessed October 4, 2023. https://idweek.org/
For more IDWeek 2023 content, visit the Resource Center.
Dr Melissa Badowski: My name is Melissa Badowski. I am a clinical professor at the University of Illinois at Chicago College of Pharmacy. And there I manage individuals living with HIV as well as prevention efforts.
Consultant360: Please provide an overview of your presentation at IDWeek 2023 titled, "Guideline Adherence to Hepatitis B Virus Screening and Vaccination in Patients Prescribed HIV PrEP."
Dr Melissa Badowski: Great. Thank you again for inviting me here. A little bit about the study that I'm presenting is that we had noticed that prior studies, and these were based off of older literature, some studies from 2013 and 2017, found 60% of providers routinely screened for Hepatitis B, and this was prior to initiation of PrEP. And it was based on a survey and it was distributed to providers in the United States. And this was based off of 2011, this survey was done. So again, 60% of providers, not that much, were screening for Hepatitis B.
And the other study looked at commercial insurance claims' database between 2011 and 2015, and that found only about 38% of patients were being screened prior to initiation of PrEP. So we wanted to see where our numbers stood. And we did do a study around that time, and we'll talk about this in a little bit, where at our institution we evaluated guideline adherence to screening for Hepatitis B since oral medications for PreP also are used to treat HIV infection. And so we were hoping with the increased prescribing of PrEP and subsequent increased familiarity with PrEP around these times, we would see an improvement in adherence to guideline screening.
So based on all of that, the goal of our study was to assess appropriate screening for hepatitis B infection for the US Public Health Service Guidelines. And this is based off of serologic testing. We were also looking to assess appropriate vaccination against hepatitis B per CDC recommendations. And so within our study, the secondary objectives looked to evaluate the immunity of vaccination against hepatitis A, HPV, as well as meningococcal vaccination.
So within this study, we retrospectively evaluated adult patients receiving an initial prescription for oral pre-exposure prophylaxis at the University of Illinois Hospital and Health Sciences system in our outpatient clinics. As previously mentioned, we did have a historical group that we compared to, and so that we refer to as cohort 1, and that was between July 2014 and September 2018. And then this now most recent piece of evaluation, which we termed our second cohort, we evaluated between October 2018 and October 2022. Individuals were excluded if they tested positive for HIV when we were doing our screening for PrEP, receiving treatment for hepatitis C, were pregnant, or were in custody in a prison or jail during that time.
Consultant360: What were the findings from your study?
Dr Melissa Badowski: Right. So from the cohort two, we screened 230 individuals, and we excluded 85 for reasons such as PrEP wasn't initially prescribed by one of our UI health providers, individuals tested positive for HIV infection, or they were prescribed oral PrEP essentially for post-exposure prophylaxis. So they coupled it with another antiretroviral agent. So we ended up with another 145 patients in cohort two, and that matched the same in cohort one. And our average age between these cohorts were 28 and 30 years. And a majority of males were prescribed PrEP from our study.
So our major findings were between cohort one and cohort two. So cohort one was the 2014 to 2018. Cohort two was that 2018 to 2022. There was significantly more individuals in the first cohort, so 79%, who received screening for hepatitis B compared to cohort two, which was 68%. And this was based on serologic testing. Similarly, there were significantly more individuals again in that first cohort who received their first dose of hepatitis B vaccine by or at the first follow-up. So that was 38% in cohort one compared to only 22% in cohort two. Finally, there was no difference between the cohorts that we found for hepatitis A immunity or vaccination, or meningococcal vaccination, but we did find significantly more individuals in cohort two that did have access or had documented hepatitis B vaccination. So that was 45% in cohort two compared to only 19% in cohort one.
Consultant360: How do those findings contribute to existing literature about hepatitis B virus and HIV PrEP?
Dr Melissa Badowski: I think the take home message in all of this is that there's so much more work to do in the area of HIV prevention, as well as those that we're screening for hepatitis B. Because within our own statistics within the United States, there are millions of people who are living with hepatitis B that don't even know about it. And so while our rates of screening were higher than previously reported in the literature, we're nowhere near 100%. And in fact, we had a decrease in the number of individuals that were screened for hepatitis B.
And I think one of the things we think about within the cohorts that we studied, cohort one was in the area of infectious diseases and family medicine where we evaluated these individuals. Cohort two was basically anyone who had a receipt of an oral prescription. So I think just learning and tuning into additional educational endeavors is going to be essential, not only within our own institution, but I think nationally as well, just for the overall prevention.
And I don't think it's just a one-time educational effort. I think these have to be continuous messaging. I know within my institution, we are a large teaching hospital, so I think every year we get new prescribers, those who are new graduates from medical schools. I think we have to have continuous messaging and additional educational efforts for not only screening of Hepatitis B, but then also additional prevention efforts for HIV.
Consultant360: What is next for research on this topic?
Dr Melissa Badowski: I think in terms of research, there's a lot of different avenues that we can take. The CDC recently recommended universal screening for hepatitis B. And so looking at all patients or individuals, it's not just those who are at risk, but at least once in their lifetime. So I think this would pair nicely with prevention efforts that we're looking to roll out as well. Although we're moving slowly, I think there's definitely a marked increase in PrEP prescribing. So, I think we just need to make sure that we're taking the guidelines and adhering to the screening recommendations.
Additionally, I think we need to look beyond the interventions where they're needed. So I think where these missed screening opportunities, are they more common outside of the area of infectious diseases? Is it for those who are seeking primary care, family medicine or even internal medicine? We are used to these medications at baseline. We know what to be testing for. But I think additional educational endeavors and maybe evaluating a little bit more in comparing in those areas.
And then, I know from a clinical pharmacist perspective, we also have collaborative practice agreements. So maybe is there a difference between those areas that have collaborative practice agreements compared to those that don't? I think another area that we're looking to evaluate is implementing electronic order set that's available for screening. So it's just easier to make sure that everything's checked appropriately and just doing this electronic order set. So I think that's another area that we'd like to focus on in terms of research.
Consultant360: What were the overall take-home messages from your study?
Dr Melissa Badowski: I think we covered it, but I think the underlying thing is really the educational endeavors that are needed. It's not just this one-time message, it's continuous. And I know it's hard in everybody's busy schedule to have everything that's screened for, but again, I think just making this more of a conversation, more something that's out there instead of just who's at risk. Everybody just assume everyone is at risk, and I think that would help to identify additional individuals living with HIV, living with hepatitis B, and then at least we can start treatment a lot sooner than having increased rates of transmission.
Thank you again for the invitation to join. I appreciate it.