The PrEP resource: a mobile app for clinicians to facilitate screening, prescription and follow up of pre-exposure prophylaxis in the prevention of HIV

Introduction

Pre-exposure prophylaxis (PrEP) is a highly effective therapy used to prevent the transmission of HIV. Since its approval by the US Food and Drug Administration in 2012, PrEP has consistently excelled in reducing the spread of HIV in clinical trials and multiple real-world settings. Despite many studies reaffirming PrEP’s efficacy and proving up to 99% success in stopping HIV transmission, its use in clinical practice has been lower than expected.^1–3 The Centres for Disease Control and Prevention estimates that in the US, fewer than one in every four persons likely to benefit from PrEP were offered a prescription in 2020.⁴ Additionally, this same study highlighted that only 10% of eligible women received appropriate PrEP therapy.

Clinician discomfort due to insufficient knowledge and training is frequently cited as a barrier to PrEP uptake,^5–7 with some surveys reporting that just 22% of US primary care providers feel comfortable prescribing PrEP.⁸ Two interventions have been shown to increase comfortability: increased education and increased experience treating HIV patients.^5,9,10 These findings suggest that targeted educational interventions can increase a clinician’s knowledge, comfort and willingness to prescribe PrEP.

Clinical decision-making mobile applications (apps) may be one solution to this problem, as they offer real-time information and decision support based on published guidelines.¹¹ Physicians routinely use apps, with 65% regularly using them for clinical decision-making.¹² Apps provide quick, accessible information during patient care, and have demonstrated potential for widespread adoption.

Although two mobile apps are currently available to aid in screening and prescribing PrEP, the gap between prescriptions and the eligible population continues to be significant, suggesting a role for further innovation.^13,14 As HIV prevalence continues to be highest in low-middle resource settings in sub-Saharan Africa, Asia and the Pacific Islands, disparities in resources must be considered when developing interventions in HIV care.¹⁵ In studies evaluating the impact of mobile health technologies in low-resource settings, frustrations with lack of adaptability to specific clinical encounters, excessive complexity in navigation, frequent loss of connectivity and lack of effective feedback systems were frequently cited.¹⁶ To address these challenges and enhance PrEP awareness and knowledge, we developed ‘The PrEP Resource,’ a novel app for clinician use during patient encounters. This short report discusses the development process, and aims to introduce clinicians to a resource they can employ during clinical encounters.

Methods

We found two existing clinical-facing PrEP apps. They contain all the relevant information, but in long-form, textbook-style screenshots and outsourced links.^13,14 Although the information is comprehensive, the layouts do not mimic the flow of a clinic visit and may be challenging to use during patient encounters. We identified four design criteria to drive the development of The PrEP Resource app:

Following these criteria, we designed a basic wireframe using the online platform Figma (Fig. 1) to visualise the flow between essential design components. Colour schemes, fonts and logo design were then developed on top of the basic wireframe to meet the first two criteria. Individual workflows for screening, prescribing, follow-up visits and discontinuing PrEP were further streamlined using the US Public Health Service (USPHS) guidelines in consultation with an infectious disease specialist.¹⁷ The app was also designed to be fully functional offline.

Fig. 1.

Screenshots of The PrEP Resource working through an example of a cisgender, 19-year-old female patient who is sexually active with partners of unknown HIV status.

The Figma design file was then imported into FlutterFlow, an app development platform, where the app assets were finalised through alpha testing. Participants for beta testing were recruited via email. Two rounds of user experience surveys were distributed via SurveyMonkey to gather feedback and refine the app design.

The surveys queried user demographics, comfort with prescribing PrEP, and app-specific information evaluating the overall design, ease of use, functionality and completeness. Demographic information was only analysed from the first survey, as most participants completed both. One additional question on the second survey asked whether the respondent had participated in the first round of development.

This study was determined not to require Institutional Review Board review by the Uniformed Service University Human Protections Program. Participants being recruited were given detailed descriptions of how user data would be collected and stored. Participant privacy was protected using anonymous surveys that did not record identifying information, and data collected via TestFlight was logged within 24 h of user submission with user information deleted at that time.

Results

Survey results

Eleven clinicians completed the first survey (six family medicine, five obstetrician and gynaecologists), and eight completed the second (four family medicine, three obstetrician and gynaecologists and one infectious disease physician). Six participants completed both surveys, so we could assess whether the app improved from its first iteration to the second.

Demographic information demonstrated that 82% of respondents ‘rarely’ or ‘never’ prescribed PrEP. When asked about comfort level when prescribing PrEP, 36% of participants were ‘comfortable’ or ‘very comfortable,’ 36% were ‘neutral’ and 27% were ‘uncomfortable.’ No participants chose ‘very uncomfortable.’ The most common reason for discomfort prescribing PrEP answered by six of the participants was ‘not prescribing it enough,’ selected by 100% (6/6); this was followed equally by ‘lack of training,’ ‘unfamiliar with guidelines’ and ‘unfamiliar with options,’ each at 50% (3/6). No participants selected ‘outside my scope of practice.’

Thematic analysis of user feedback demonstrated that participants liked the app’s simplicity, ease of use, flow and navigation best. Constructive criticism focused on visuals, including attention to font size, blurry graphics and colour scheme. Feedback about functionality showed that participants desired more efficiency and clarity in the clinical sections, namely screening for sexually transmitted infections and follow-up recommendations. After updates were made, participants found the app appealing, easy to use and succinct, with centrally consolidated guidance. Fig. 2 demonstrates improvement in feedback scores between the first and second surveys.

Fig. 2.

Comparison of performance per survey domain.

Discussion

Our first survey provided valuable information regarding PrEP prescribing patterns and comfort levels of respondents. Our findings align with the background literature, reaffirming that the reasons for hesitance in prescribing PrEP are inexperience, unfamiliarity with guidelines and lack of training.^5–7The PrEP Resource app may meet these needs, and serve as a tool to increase clinician comfort and education on this topic. After two rounds of feedback, users found the app easy to learn, navigate, utilise and, most notably, comprehensive enough to initiate PrEP therapy for eligible patients.

We included family medicine physicians and obstetrician and gynaecologists, because these groups are best poised to prescribe PrEP to women who are markedly underprescribed.⁴

We acknowledge that several participants lacked comfort in prescribing PrEP, which may limit their ability to evaluate the guidelines. However, we developed the app in direct consultation with an infectious disease specialist, and strict adherence to the USPHS and World Health Organization guidelines. We also recognise that a limitation of our study was the small sample size of 11 participants from only two clinical specialties; however, we felt this was enough to give us useful feedback prior to moving forward with a larger sample size.

Healthcare equity and accessibility to PrEP were significant considerations throughout the development process. Our app was designed specifically for compatibility with low-resource, time-constrained and low-bandwidth settings typically encountered in lower-middle-income countries where HIV prevalence is the highest. All app functions, including prescribing information and calculators, can be accessed offline, allowing the clinical encounter to be entirely self-contained within the software. To maximise exposure, the app’s final version is available for free on the App Store for iOS devices and Google Play Store for Android devices.

Healthcare professionals must balance quick and accurate decision-making with personalised patient care. This challenge becomes even more poignant when clinicians lack comfort and familiarity, leading to high cognitive load, increased risk of errors and burnout.¹⁹ Developing clinical decision-making aids that reduce mental effort is crucial for improving patient outcomes. The PrEP Resource has the potential to meet clinical needs by offering healthcare professionals an accessible, user-friendly and accurate tool for prescribing PrEP therapy.

To maximise exposure, the app’s final version is available for free on the App Store (https://apps.apple.com/us/app/the-prep-resource/id1672652294) for iOS devices and Google Play Store (https://play.google.com/store/apps/details?id=com.completemedicine.prepresourceV3) for Android devices.