Article

Do confidentiality concerns impact pre-exposure prophylaxis willingness in emergency department adolescents and young adults?

1206 Correspondence / American Journal of Emergency Medicine 37 (2019) 11911213

Rheuame P, Labbe R, Thibault E, Gagne J-P. A rational, Structured approach to pri- mary Aortoenteric fistula. Can J Surg 2008;51:E125-6.
  • Varghese M, Jorgensen GT, Aune C, Bergan R, Nordeval S, Moland J, et al. Primary
  • aortoduodenal fistula-a case report and a review of the literature. Ann Vasc Surg 2016;34:271.e1-4.

    Fielding JWL, Black J, Ashton F, Slaney G, Campbell DJ. Diagnosis and management of 528 Abdominal aortic aneurysms. BMJ 1981;283:355-9.
  • Forsdahl S, Singh K, Solberg S, Jacobsen BK. Risk factors for abdominal aortic aneu- rysm. A 7-year prospective study: the Tromso study 1994-2001. Circulation 2009; 119:2202-8.
  • Kent KC, Zwolak RM, Egorova NN, Riles TS, Manganaro A, Moskowitz AJ, et al. Anal- ysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg 2010;52:539-48.
  • Ho S, Liu B, Loya R, Koury I. Primary aortoenteric fistula: a rare case of massive gas- trointestinal bleed. Cureus 2016:e766. https://doi.org/10.7759/cureus.766.
  • Do confidentiality concerns impact pre- exposure prophylaxis willingness in emergency department adolescents and young adults?

    Daily oral Pre-exposure prophylaxis (PrEP) is recommended to reduce the risk of human immunodeficiency virus infection in ad- olescents and young adults (AYAs) [1]. National electronic pharmacy data suggest that emergency department (ED) providers provide approximately 12-21% of PrEP prescriptions to AYAs [2]. The ED may be a key access for PrEP given the risk profile of the population served [3,4]. Yet, there have been limited studies to examine what factors impact willingness to take PrEP in ED settings.

    Lack of confidentiality protections may decrease AYA’s willingness to seek sexual health services [5-7]. Confidentiality breaches may exist for AYAs on their parents’ health insurance plans. While the Health Insurance Portability and Accountability Act prevents release of information without written authorization, the insurer can provide the policy holder with information related to billing and payment in an Explanation of Benefits [EOB] which occurs more often in EDs where AYAs are more likely to seek care [3,6].

    We sought to explore the relationship between confidentiality concerns and willingness to take PrEP in AYAs seeking care in EDs. We hypothesized that AYA confidential needs may contribute to decreased willingness to take PrEP.

    Data were drawn from a web-based cross-sectional survey conducted in a mid-size urban emergency department. Patients 18 to 44 years old completed a 10-minute anonymous survey after registration and triage. This data focuses on 18 to 25-year-old HIV seronegative participants. The Johns Hopkins Medicine Institutional Review Board approved this study.

    The survey questions included: demographic, sexual/drug use history; insurance status/source; confidentiality; HIV risk perception; and willing- ness to take PrEP. Confidentiality questions were developed from vali- dated questions on contraceptive services [8]. Participants were asked whether they wanted their parents to know they were taking PrEP and likelihood of using PrEP if further discussions with parents were required. Responses were converted to a binary (likely/unlikely) due to aggregation. Simple logistic regression was used to examine associations between pa- rental insurance coverage, confidentiality factors, and willingness to take PrEP. Multivariable logistic regression was performed to examine associa- tions between parental insurance coverage, confidentiality factors, factors associated with PrEP use as determined by existing literature and willing-

    ness to take PrEP. Analyses were conducted using StataSE 14 software.

    Participants included 156 between the ages of 18 and 25 years. Sociodemographic characteristics are summarized in Table 1. Most partic- ipants were female, self-identified as African-American, heterosexual and reported having health insurance coverage. Nearly half were on parental insurance.

    In bivariate analysis, age and STI diagnosis were significantly associ- ated with parental insurance coverage. Older AYAs and AYAs with a prior STI diagnosis had a lower odds of being on a parent’s insurance compared to younger AYAs. Not wanting a parent to know about PrEP

    use and being unlikely to use PrEP if required to discuss side effects with parents were negatively associated with willingness to take PrEP, whereas prior HIV testing was positively associated with willingness (Table 2). Parental insurance coverage approached significance in bivar- iate analysis with AYAs on parent’s insurance having a lower odds of being willing to take PrEP.

    In the final multivariate model, AYAs who indicated they would not want their parents to know they were taking PrEP had a lower odds of being willing to take PrEP [Table 2, OR = 0.30 (95% CI: 0.11-0.85)]

    (Table 2).

    This is the first ED study to examine parental insurance, confidential- ity, and willingness to take PrEP. Parental insurance coverage was not a direct barrier to starting PrEP; however, parent-AYA confidentiality con- cerns were associated with lower willingness. HIV testing history was associated with greater willingness suggesting that ED PrEP programs will need to be paired with HIV testing services.

    ED providers will need to guide AYAs around confidentiality protections that come with parental insurance coverage. This may require insurance companies to further elucidate their policies re- garding protections around confidentiality and to establish protocols that prevent disclosure of sensitive information. HIPAA regulations allow for AYAs to request insurers send EOBs by alternative means, but prior studies suggest that insurance companies receive very few yearly requests likely because AYAs are unaware of this right [6,8]. A dialogue between AYAs, clinicians, and insurance companies may be needed to assure confidentiality [9].

    This study has potential limitations. Given the high prevalence of

    risky sexual behavior in ED-seeking AYAs [3], our findings may not gen- eralize to AYAs seeking care in Primary care settings. Participants may also have been unaware that they were on their parents’ insurance.

    This work suggests that AYAs in EDs are less likely to be willing to take PrEP if parents know about their use. In order to increase PrEP access for AYAs in EDs, further research is needed to understand how parental insurance and confidential protections impact access to PrEP. Such research is critical as PrEP for AYAs expands in settings, including EDs where AYAs are frequently seeking care.

    Table 1

    Demographics, N = 156.

    Characteristic Mean (SD) N (%)

    Age, in years 22.1 (2.2)

    Insurance status

    Insured 143 (91.7%)

    Under 26 on parent’s insurance 71 (45.5%) Race (N = 116)

    White 20 (17.2%)

    Undefined 14 (12.1%)

    Black/African-American 82 (70.7%)

    Gender identity

    Female 92 (59.0%)

    Male 63 (40.4%)

    Other 1 (0.64%)

    Sexual orientation

    Heterosexual 135 (86.5%)

    LGBTQa 21 (13.5%)

    Sexual behaviors

    Men who have sex with men 4 (2.6%)

    Unprotected receptive anal sex 20 (12.8%)

    Unprotected receptive vaginal sex 59 (37.8%) STD/HIV history

    History of STI 38 (24.4%)

    Have been tested for HIV 126 (80.8%)

    Perception of HIV likelihood 3 (1.9%)

    Drug use last 6 months

    Marijuana 84 (53.9%)

    Otherb 7 (4.5%)

    a Lesbian, Gay, Bisexual, Transgender, or Questioning.

    b Methamphetamines, cocaine, or intravenous drug use.

    Correspondence / American Journal of Emergency Medicine 37 (2019) 11911213 1207

    Table 2

    Bivariate and multivariate comparisons among parental insurance coverage and willingness to take PrEP stratified by participant characteristics. Characteristics Parental Insurance Coverage Willingness to Take PrEP

    Unadjusted OR

    95% CI

    Unadjusted OR

    95% CI

    Adjusted OR

    95% CI

    Parental insurance coverage

    0.52

    0.25-1.07

    0.43

    0.15-1.98

    Age

    – 18-20

    5.69??

    2.74-11.82

    1.11

    0.53-2.37

    – 21-25

    0.32??

    0.15-0.68

    0.93

    0.42-2.05

    0.94

    0.33-2.71

    Race

    – White

    1.14

    0.28-4.59

    0.53

    0.11-2.63

    – Undefined

    1.09

    0.28-4.32

    3.15

    0.61-16.29

    3.08

    0.54-17.61

    – Black

    0.58

    0.22-1.55

    2.34

    0.63-8.75

    1.36

    0.33-5.58

    Previous HIV test

    0.68

    0.30-1.51

    4.34??

    1.24-15.15

    4.65

    0.54-39.6

    History of STI

    0.46?

    0.21-1.00

    2.00

    0.92-4.34

    2.55

    0.94-6.92

    Do not want parents to know that they’re taking PrEP

    1.26

    0.65-2.45

    0.32??

    0.15-0.66

    0.30??

    0.11-0.85

    Unlikely to use PrEP if…

    – Needed to talk to parents about side effects of PrEP

    1.00

    0.46-2.17

    0.44??

    0.20-0.98

    0.62

    0.12-1.3.21

    – Needed to talk about the sex they’re having

    1.69

    0.67-4.25

    0.45

    0.18-1.11

    1.42

    0.25-8.01

    * Indicate variable significantly associated at p-value = 0.05.

    ?? Indicate variable significantly associated at p-value b 0.05.

    Declarations of interest

    None.

    Acknowledgments

    Thank you to the participants in this study and the staff in Johns Hop- kins Hospital Emergency Department Staff and HIV testing program.

    Funding

    This work was supported by the Adolescent and Young Adult Scientific Working Group (AYA SWG) Microgrant of the Johns Hopkins Center for AIDS Research (CFAR) Adolescent (PI: Dell).

    Kelvin L. Moore Jr. Brown University, 69 Brown Street, Box 2490, Providence, RI 02912, USA Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, 200 North Wolfe Street, Room 2063,

    Baltimore, MD 21287, USA E-mail address: [email protected].

    Shanna Dell, MPH, RN

    Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St,

    Baltimore, MD 21205, USA

    Miles K. Oliva, BA Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, 200 North Wolfe Street, Room 2063,

    Baltimore, MD 21287, USA E-mail address: [email protected].

    Renata Arrington-Sanders, MD, MPH, ScM*

    Yu-Hsiang Hsieh, PhD, MSc Richard E. Rothman, MD, PhD

    Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, 200 North Wolfe Street, Room 2063,

    Baltimore, MD 21287, USA

    *Corresponding author. E-mail addresses: [email protected] (Y-H Hsieh), [email protected] (R.E. Rothman).

    E-mail address: [email protected].

    References

    1. US Public Health Service. Pre-exposure prophylaxis for the prevention of HIV infection in the United States — 2014: a clinical practice guideline. Available from: http://www.cdc. gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf, Accessed date: 14 January 2018.
    2. Magnuson D, Hawkins T, Mera R. Adolescent use of Truvada (FTC/TDF) for HIV Pre-Exposure Prophylaxis (PrEP) in the United States: (2012-2017). AIDS Meeting, July 23-27, 2018; 2018.
    3. Callahan ST, Cooper WO. Changes in ambulatory Health care use during the transition to young adulthood. J Adolesc Health 2010 May;46(5):407-13. https://doi.org/10. 1016/j.jadohealth.2009.09.010.
    4. Stanley K, Lora M, Meriavy S, et al. HIV prevention and treatment: the evolving role of the emergency department. Am Emerg Med 2017;70(4):562-72.
    5. Arrington-Sanders R. Human immunodeficiency virus pre-exposure prophylaxis for adolescent men how do we ensure health equity for at-risk young men? JAMA Pediatr 2017;171(11):1041-2. https://doi.org/10.1001/jamapediatrics.2017.2397.
    6. Tebb KP, Sedlander E, Pica G, et al. Protecting adolescent confidentiality under health care reform: the special case regarding explanations of benefits (EOBs). San Francisco: Philip R. Lee Institute of Health Policy and Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco; 2014.
    7. Knopf AS, Ott MA, Liu N, et al. Minors’ and young adults’ experiences of the research consent process in a phase II safety study of pre-exposure prophylaxis for HIV. J Adolesc Health 2017 Dec;61(6):747-54. https://doi.org/10.1016/j.jadohealth.2017.06.013.
    8. Pasternak RH, Geller G, Parrish C, et al. Adolescent and parent perceptions on youth participation in risk behavior research. Arch Pediatr Adolesc Med 2006 Nov;160 (11):1159-66. https://doi.org/10.1001/archpedi.160.11.1159.
    9. Sedlander E, Brindis CD, Bausch SH, et al. Options for assuring access to confidential care for adolescents and young adults in an explanation of benefits environment. J Adolesc Health 2015 Jan;56(1):7-9. https://doi.org/10.1016/j.jadohealth.2014.10.262.

      Comments on Shenfu injection for improving cellular immunity and clinical outcome in patients with sepsis or septic shock

      To the Editor,

      We read with interest the article by Ning Zhang et al. [1]. The author conducted a prospective, random, controlled trials (RCTs) to compare the clinical effects and safety of Shenfu injection (SFI) in patients with sepsis or septic shock, which found that SFI should improve cellular im- munity but not clinical outcome. We congratulate the authors for this successful article, however, some issues should be discussed to avoid misinterpretations.

      The authors claimed their Sepsis and Septic Shock diagnostic criteria in this RCTs based on the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) [2], however, the international

      https://doi.org/10.1016/j.ajem.2018.11.015

      29 October 2018

      Abbreviations: SFI, Shenfu injection; RCTs, random, controlled trials.

    Leave a Reply

    Your email address will not be published. Required fields are marked *