HIV providers' perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study

Knowledge and Attitudes About HIV Pre-Exposure Prophylaxis Among Sexually Active Black and Latina Cisgender Women: Findings from the 2017 and 2018 New York City Sexual Health Survey

Pre-exposure prophylaxis (PrEP) is a highly effective tool to prevent HIV, yet it is underutilized among women. The current study aims to evaluate the awareness, attitudes, and perceptions of PrEP among a large survey sample of Black and Latina women in New York City (NYC). Interviewer-administered surveys were conducted in high HIV incidence neighborhoods in NYC among Black, Latina, and Afro-Latina women who reported recent sex with a man in 2017 (n = 398) and 2018 (n = 405). About 40% of participants were aware of PrEP, whereas 30.4% indicated interest in using it. The top reason for not utilizing it was low HIV risk perception. However, most participants supported the idea that using PrEP meant asserting control over their health (94.1%). Primary care providers and obstetricians/gynecologists were participants' preferred sources for PrEP (91.6%). Across survey cycles, compared to non-Black Latina participants, Black participants had significantly higher PrEP awareness (44.4% vs. 29.1%). PrEP awareness was also significantly higher among survey participants in 2018 (45.2%) than in 2017 (34.3%). Less than half of the participants were aware of PrEP, but those who were aware expressed largely positive attitudes toward the medication. Our findings may inform future PrEP implementation strategies to optimize awareness and access to PrEP among women disproportionately affected by HIV, like focusing on personal empowerment instead of risk-based messaging and training women's sexual health care providers in PrEP provision.

A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi

BACKGROUND

Mississippi (MS) experiences disproportionally high rates of new HIV infections and limited availability of pre-exposure prophylaxis (PrEP). Federally Qualified Health Centers (FQHCs) are poised to increase access to PrEP. However, little is known about the implementation strategies needed to successfully integrate PrEP services into FQHCs in MS.

PURPOSE

The study had two objectives: identify barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs.

METHODS

Semi-structured interviews were conducted with 19 staff and 17 PrEP-eligible patients in MS FQHCs between April 2021 and March 2022. The interview was guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework which covered PrEP facilitators and barriers. Interviews were coded according to the i-PARIHS domains of context, innovation, and recipients, followed by thematic analysis of these codes. Identified implementation strategies were presented to 9 FQHC staff for feedback.

RESULTS

Data suggested that PrEP use at FQHCs is influenced by patient and clinic staff knowledge with higher levels of knowledge reflecting more PrEP use. Perceived side effects are the most significant barrier to PrEP use for patients, but participants also identified several other barriers including low HIV risk perception and untrained providers. Despite these barriers, patients also expressed a strong motivation to protect themselves, their partners, and their communities from HIV. Implementation strategies included education and provider training which were perceived as acceptable and appropriate.

CONCLUSIONS

Though patients are motivated to increase protection against HIV, multiple barriers threaten uptake of PrEP within FQHCs in MS. Educating patients and providers, as well as training providers, are promising implementation strategies to overcome these barriers.

The Association between Social Support and Pre-Exposure Prophylaxis use among Sexual Minority Men in the United States: A Scoping Literature Review

Sexual minority men (SMM) are disproportionately affected by HIV. Although pre-exposure prophylaxis (PrEP) is an effective way of reducing HIV incidence, PrEP use has remained relatively low. Social support may be one effective factor in increasing PrEP use among SMM, but the association between social support and PrEP use/adherence is not well understood. The objective of this paper was to summarize the current literature on the association of social support and PrEP use among SMM in the United States. A systematic search was conducted using six different databases MEDLINE / PubMed, PsycINFO, Cochrane CENTRAL, Google Scholar, Embase, and Web of Science using terms established from keywords and medical subject headings (MeSH) terms before being adapted to each database. Data were extracted for key study factors (e.g., study population, geographic location, study design) and main findings. This search produced eleven articles: ten manuscripts and one conference abstract. Of these, two were randomized control trials, two were interventions, three were qualitative, and four were cross-sectional. The studies were widespread across the country, but most were in major metropolitan areas. From the articles included in this review, findings were inconsistent in the association between social support; some studies showed null findings, others that only certain sources of social support were significant, and others that there was a significant association between social support and PrEP use. This review highlights the complexity of the relationship between social support and PrEP use among SMM, indicating the need for further research to identify specific types and sources of support that effectively enhance PrEP uptake and adherence. Targeted interventions based on these insights could significantly reduce HIV incidence in the population.

Understanding adaptive responses in PrEP service delivery in Belgian HIV clinics: a multiple case study using an implementation science framework

INTRODUCTION

In Belgium, oral HIV pre-exposure prophylaxis (PrEP) is primarily provided in specialized clinical settings. Optimal implementation of PrEP services can help to substantially reduce HIV transmission. However, insights into implementation processes, and their complex interactions with local context, are limited. This study examined factors that influence providers' adaptive responses in the implementation of PrEP services in Belgian HIV clinics.

METHODS

We conducted a qualitative multiple case study on PrEP care implementation in eight HIV clinics. Thirty-six semi-structured interviews were conducted between January 2021 and May 2022 with a purposive sample of PrEP care providers (e.g. physicians, nurses, psychologists), supplemented by 50 hours of observations of healthcare settings and clinical interactions. Field notes from observations and verbatim interview transcripts were thematically analysed guided by a refined iteration of extended Normalisation Process Theory.

RESULTS

Implementing PrEP care in a centralized service delivery system required considerable adaptive capacity of providers to balance the increasing workload with an adequate response to PrEP users' individual care needs. As a result, clinic structures were re-organized to allow for more efficient PrEP care processes, compatible with other clinic-level priorities. Providers adapted clinical and policy norms on PrEP care (e.g. related to PrEP prescribing practices and which providers can deliver PrEP services), to flexibly tailor care to individual clients' situations. Interprofessional relationships were reconfigured in line with organizational and clinical adaptations; these included task-shifting from physicians to nurses, leading them to become increasingly trained and specialized in PrEP care. As nurse involvement grew, they adopted a crucial role in responding to PrEP users' non-medical needs (e.g. providing psychosocial support). Moreover, clinicians' growing collaboration with sexologists and psychologists, and interactions with PrEP users' family physician, became crucial in addressing complex psychosocial needs of PrEP clients, while also alleviating the burden of care on busy HIV clinics.

CONCLUSIONS

Our study in Belgian HIV clinics reveals that the implementation of PrEP care presents a complex-multifaceted-undertaking that requires substantial adaptive work to ensure seamless integration within existing health services. To optimize integration in different settings, policies and guidelines governing PrEP care implementation should allow for sufficient flexibility and tailoring according to respective local health systems.

"Something Like That": Awareness and Acceptability of HIV PrEP and PEP Among Kenyan Adolescents

BACKGROUND

Adolescents account for 15% of new HIV cases in Kenya. HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are highly effective prevention tools, but uptake is low among adolescents, particularly in resource-limited settings. We assessed awareness and acceptability of PrEP and PEP among Kenyan adolescents.

METHOD

Focus group discussions were conducted with 120 adolescent boys and girls ages 15 to 19 in Kisumu. Data were analyzed using the Framework Approach.

RESULTS

Adolescent participants often had not heard of or could not differentiate between PrEP and PEP. They also confused these HIV prevention tools with emergency contraceptives. Taking a daily pill to prevent HIV was perceived as analogous to taking a pill to treat HIV. Boys were aware of and willing to consider using PrEP and PEP due to their dislike for using condoms. Adolescents identified insufficient information, cost, and uncomfortableness speaking with healthcare workers about their HIV prevention needs due to sexuality stigma as barriers to using PrEP and PEP.

CONCLUSION

Low awareness and poor understanding of PrEP and PEP among adolescents reveal the need for increased education and sensitization about these HIV prevention options. Expanding access to sexual and reproductive health services that are tailored to the needs of adolescents and staffed with non-judgmental providers could help reduce sexuality stigma as a barrier to accessing care. New HIV prevention approaches such as long-acting injectables or implants, on-demand regimens, and multipurpose prevention technologies may encourage increased uptake of PrEP and PEP by adolescents.

Applying a Three-Tier Approach to Address Gaps in Oral Pre-Exposure Prophylaxis Uptake and Continuity in Uganda: A Mixed Methods Approach

BACKGROUND

We describe a 3-tier approach involving a gap analysis, root cause analysis, and pre-exposure prophylaxis (PrEP) collaborative to understand the gap and identify and address the main barriers to oral PrEP uptake and continuity in Uganda.

METHODS

We used a mixed methods design with retrospective, cross-sectional, and prospective components. The gap analysis involved descriptive analysis of PrEP uptake and continuity. The RCA identified the main barriers to initiation and continuity on PrEP among 1,334 clients who declined to start PrEP and 1,266 who missed their appointment but were at risk. The PrEP collaborative tested changes mapped onto specific barriers to optimize the PrEP clinical service delivery. A trend analysis of routinely collected data of the PrEP cascade determined significant shifts and trends in PrEP uptake and continuity.

RESULTS

Only 60% of the high-risk population eligible for PrEP were enrolled, while fewer than 30% of the cumulative number of PrEP users were refilled each quarter. Uncertainty and fear of side effects, perceptions about the harmfulness of the medication, perceived inability to adhere to PrEP, and stigma were the main reasons why clients rejected PrEP. Lack of access to the facility, side effects, pill burden, stigma, perceived low-risk exposure to HIV, and preference of staying at work as opposed to picking up refills affected continuity on PrEP. The collaborative registered statistically significant shifts in PrEP enrollment from 64% to 89% and continuity from 51% to 78% between July 21 and November 22 following the collaborative intervention.

CONCLUSIONS

We recommend using a 3-tier approach for other similar implementation contexts to strengthen PrEP programming, given the marked statistical shift in PrEP uptake and continuity. This begins with understanding the gap and barriers to use among clients, followed by mapping interventions to specific barriers through a quality improvement collaborative.

Barriers and Facilitators to Long-Acting Injectable HIV Pre-Exposure Prophylaxis Implementation in Primary Care Since Its Approval in the United States

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is a highly effective method to mitigate the HIV epidemic, but uptake of PrEP has been slow and is associated with racial and gender disparities. Oral PrEP requires high levels of adherence to be effective, which may disadvantage certain high-risk groups. The first injectable HIV PrEP, a drug given every 2 months rather than as a daily pill, was approved by the US Food & Drug Administration in December 2021.

SETTING

A Family Medicine practice in a single health organization in the United States (November 2022 to February 2023).

METHODS

We conducted interviews with patients and key stakeholders to characterize factors affecting long-acting injectable (LAI) PrEP implementation. Data collection and analysis were guided by the Consolidated Framework for Implementation Research. Interviews were transcribed and analyzed using guided content analysis.

RESULTS

Twenty-five patients (n = 13) and practice stakeholders (n = 12) were interviewed. Overall, stakeholders described a very low uptake of LAI PrEP. Barriers to LAI PrEP included a lack of awareness, insurance and access issues, a lack of streamlined workflow, and a trust in pills over injectables. Facilitators to LAI PrEP implementation included the absence of a pill burden, a culture of shared decision making, and pharmacy support.

CONCLUSIONS

Although uptake has been slow, we have identified several promising strategies for improving rollout and implementation of LAI PrEP. Approaches that can bolster rollout of LAI PrEP include having an interdisciplinary care team that is supported by PrEP navigators and pharmacists and are informed by a patient-centered model of care to increase patient engagement and trust.

Strategies to Eliminate Inequity in PrEP Services in the US South and Rural Communities

ABSTRACT

Inequity in preexposure prophylaxis (PrEP) care in the US South and rural communities is likely attributed to Social Determinants of Health and structural issues beyond individuals' control. We describe three approaches to modify PrEP care practice models to make access easier-"normalizing," "digitalizing," and "simplifying." "Normalizing" approaches are defined as practice models where medical providers who have access to PrEP candidates prescribe PrEP routinely (e.g., primary care providers, community pharmacists); these approaches are found to be highly applicable in real-world settings. Telehealth and other dHealth tools are examples of "digitalizing" PrEP, and their use has been increasing rapidly since the COVID-19 pandemic. "Simplifying" PrEP care (e.g., with HIV self-testing, on-demand PrEP) is highlighted in the most recent World Health Organization PrEP guideline. Identifying, implementing, and scaling up these new strategies can allow PrEP candidates to access it, potentially addressing inequities and promoting HIV risk reduction in the US South and rural communities.

Generalizable pipeline for constructing HIV risk prediction models across electronic health record systems

OBJECTIVE

The HIV epidemic remains a significant public health issue in the United States. HIV risk prediction models could be beneficial for reducing HIV transmission by helping clinicians identify patients at high risk for infection and refer them for testing. This would facilitate initiation on treatment for those unaware of their status and pre-exposure prophylaxis for those uninfected but at high risk. Existing HIV risk prediction algorithms rely on manual construction of features and are limited in their application across diverse electronic health record systems. Furthermore, the accuracy of these models in predicting HIV in females has thus far been limited.

MATERIALS AND METHODS

We devised a pipeline for automatic construction of prediction models based on automatic feature engineering to predict HIV risk and tested our pipeline on a local electronic health records system and a national claims data. We also compared the performance of general models to female-specific models.

RESULTS

Our models obtain similarly good performance on both health record datasets despite difference in represented populations and data availability (AUC = 0.87). Furthermore, our general models obtain good performance on females but are also improved by constructing female-specific models (AUC between 0.81 and 0.86 across datasets).

DISCUSSION AND CONCLUSIONS

We demonstrated that flexible construction of prediction models performs well on HIV risk prediction across diverse health records systems and perform as well in predicting HIV risk in females, making deployment of such models into existing health care systems tangible.

The provision of sexual and reproductive health information and services to travellers: an exploratory survey of Australian travel medicine clinicians

BACKGROUND

International travel can increase the risk of exposure to infectious diseases including sexually transmissible infections (STI). Pre-travel medical consultation provides an opportunity for travel-related health risk assessments and advice. This study explored how travel medicine clinicians integrate sexual and reproductive health (SRH) services into clinical practice.

METHODS

A convenience sample of travel medicine clinicians completed a cross-sectional survey online or via hard-copy disseminated at an annual national Australian travel medicine conference.

RESULTS

Of the 67 respondents, most (n , 51; 76.1%) had a postgraduate qualification relevant to travel medicine and 55.2% (n , 37) had worked in travel medicine for over 10years. Only 22.4% (n , 15) reported conducting a SRH history/STI risk assessment for all travel patients. STI testing pre-departure was conducted on patient request (48, 71.6%), if symptomatic (32, 47.8%) or based on risk history (28, 41.8%). SRH information pre-departure was most frequently provided if prompted by patient questions (n , 42; 62.7%), or based on the patient's history (n , 37; 55.2%). Over half the sample (n , 40; 59.7%) expressed interest in further training in SRH.

CONCLUSION

Providing and engaging with additional training may assist travel medicine clinicians to take a more proactive approach to SRH consultations and STI testing. Additional research is needed to explore models of care that will allow comprehensive SRH and STI services to be integrated into standard pre- and post-travel care.

Adapting Provider Training and Pre-Exposure Prophylaxis Advertising to Increase Pre-Exposure Prophylaxis Awareness and Uptake Among Black Cisgender Women

Black cisgender women (hereafter referred to as "women") have disproportionately high rates of HIV infection yet low rates of pre-exposure prophylaxis (PrEP) utilization. Barriers to PrEP uptake exist at the system, provider, and individual/client level. To learn how existing training and advertising can be adapted to address race- and sex-based gaps within PrEP service delivery, we conducted focus groups with providers and Black women. Participants were recruited at three health care organizations in the Midwest and South, screened for eligibility, and consented verbally. Focus groups occurred from August 2022 to February 2023. Women were asked about their knowledge and thoughts on PrEP. Providers were asked about factors influencing their decision-making about PrEP. A codebook was developed based on the Consolidated Framework for Implementation Research. Transcripts were coded using the Stanford Lightning Report Method. We completed four focus groups with 10 providers and 9 focus groups with 25 women. Three major themes emerged: (1) low comfort level and limited cultural sensitivity/competency among providers discussing HIV risk and PrEP with Black women, (2) women's concerns about PrEP's side effects and safety during pregnancy, and (3) lack of Black women representation in PrEP advertisement/educational materials. In addition, women in the South reported general medical mistrust and specific misconceptions about PrEP. PrEP trainings for providers need detailed information about the safety of PrEP for women and should include role-playing to enhance cultural competency. Likewise, PrEP advertisements/materials should incorporate information regarding side effects and images/experiences of Black women to increase PrEP awareness and uptake among this population. Clinical Trial Registration Number: NCT05626452.

Provider views of pre-exposure prophylaxis (PrEP) for cisgender women - where do women fit in HIV elimination in Australia?

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) in Australia has largely been targeted at gay, bisexual and other men who have sex with men. In the context of HIV elimination, the aim of this qualitative study was to explore PrEP prescribing for Australian cisgender women from the provider's perspective.

METHODS

Semi-structured interviews were held with Australian prescribers in 2022. Participants were recruited through relevant clinical services, newsletter distribution and snowball sampling. Interviews were audio-recorded, transcribed and analysed thematically.

RESULTS

Seventeen prescribers participated, of whom 9 were sexual health physicians and 10 worked in New South Wales. All reported limited clinical experience prescribing PrEP for women. Potential enablers to PrEP prescribing to women included education for women and clinicians, easily identifiable risk factors, individualised risk assessment and expansion of existing services. Barriers were limited PrEP awareness among women and prescribers, difficulties with risk assessment and consult and service limitations. The type of service recommended for PrEP provision varied among participants.

CONCLUSIONS

Clinician experience of PrEP prescribing to Australian cisgender women is limited, with substantial barriers to access perceived by prescribers. Targeted education to PrEP prescribers, updated national PrEP guidelines to include women as a distinct group and further research regarding women's preferred model of PrEP access are required. Clarity of clinical ownership over PrEP implementation for women and, more broadly, women's sexual health, is essential in order to achieve HIV elimination in Australia.

Improving Pre-exposure Prophylaxis Counseling at a Military Women's Health Care Clinic to Champion CDC and Defense Health Agency Recommendations

INTRODUCTION

The CDC updated their guidelines in 2021 to recommend all doctors speak about pre-exposure prophylaxis (PrEP) against human immunodeficiency virus infection with all sexually active patients. In addition, there is a demonstrated need for physicians to counsel patients on PrEP to achieve military readiness. Results from the 2018 Health Related Behaviors Survey indicate 21.8% of U.S. service members were at high risk for human immunodeficiency virus. This improvement project aimed to assess deficiencies in providers' knowledge before and after an educational intervention and describe policies clinics can adopt to adhere to CDC recommendations.

MATERIALS AND METHODS

A pre-intervention survey was distributed to providers at the Walter Reed National Military Medical Center Gynecologic Surgery and Obstetrics clinic. Based on results, an educational lecture and standardized intake form were developed. Following the intervention, a post-survey was distributed to providers. A chart review was performed to determine whether PrEP counseling increased following the intervention.

RESULTS

Forty-seven gynecologic providers were sent a pre- and post-intervention survey. Thirty-seven individuals completed the pre-intervention survey (response rate 78.72%), whereas 18 people completed the post-intervention survey (response rate 38.30%). Descriptive analysis suggested comfort counseling on PrEP, comfort with Defense Health Agency guidance on PrEP, and knowledge of PrEP all increased. In terms of the chart review, 81 charts were reviewed pre- and post-intervention. Although we failed to meet our target counseling rate of 70%, the number of patients who were counseled on or prescribed PrEP following our intervention was statistically significant (P = .013).

CONCLUSIONS

This improvement project increased provider knowledge and comfort with PrEP, but only marginally affected behavior changes among providers. This failure may be related to the specific clinic in which the study was implemented. Further research is needed to facilitate routine counseling of PrEP among military women's health care providers.

Knowledge and attitudes of HIV pre-exposure prophylaxis among nurses in South Africa

BACKGROUND

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) has shown efficacy and effectiveness in populations who practise high-risk sexual activity. Nurses' knowledge and positive attitudes enhance PrEP implementation.

AIM

This study aimed to investigate the knowledge of and attitudes towards PrEP among nurses in primary health care facilities.

SETTING

The study was conducted in 10 health facilities that offer comprehensive services in Tshwane, South Africa.

METHODS

A cross-sectional survey assessed the knowledge of and attitudes towards PrEP among 114 nurses. Univariate, bivariate and logistic regressions were performed to estimate odds ratios and to determine whether age, sex and education had an association with the knowledge and attitudes.

RESULTS

Majority of the study sample consisted of female nurses (92.1%), and most respondents (68%) had moderate PrEP knowledge. Logistic regression showed that age and education were not associated with high level of knowledge. Pre-exposure prophylaxis was viewed negatively by 84.5% of the respondents. The odds of positive attitudes towards PrEP were 1.92 times higher among males than females (95% CI 0.54-6.83) and 1.24 times higher among nurses who had bachelor's degree than diploma holders (95% CI 0.51-3.01).

CONCLUSION

This study found that there is a need to strengthen the dissemination of information about PrEP, and nurses in South Africa require training to improve their knowledge of and attitudes towards PrEP.Contribution: The findings of the study add to the current knowledge base regarding PrEP access in the public healthcare system and it highlights gaps in the training of healthcare providers.

HIV pre-exposure prophylaxis and incidence of sexually transmitted infections in Brazil, 2018 to 2022: An ecological study of PrEP administration, syphilis, and socioeconomic indicators

BACKGROUND

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is one of the pillars of a combination prevention strategy for reducing the risk of new infections caused by HIV. The daily use of antiretroviral drugs by individuals who are not infected with HIV is required to prevent infection. Although its efficacy has been well established in the literature, in recent years, the decreased supply of antiretroviral drugs has been associated with an increase in the incidence of sexually transmitted infections (STI) and changes in the social determinants of health. An ecological study was conducted covering a five-year period (2018-2022), starting from the year of initiation of PrEP administration in Brazilian state capitals.

PRINCIPAL FINDINGS

Descriptive analysis was performed, and the spatial distribution of study data was taken into account. Correlation analysis was used to assess the association between PrEP administration, the incidence and detection rate of STI, and socioeconomic data. The southern region showed the highest incidence rates of STI, but the northern and northeastern regions demonstrated the worst socioeconomic indicators, especially those related to illiteracy and basic sanitation. PrEP administration was significantly correlated with illiteracy (ρ = -0.658), per capita income (ρ = 0.622), public garbage collection (ρ = 0.612), syphilis (ρ = 0.628) and viral hepatitis (ρ = 0.419) incidences. Further, all STI were significantly associated with illiteracy and per capita income.

SIGNIFICANCE

Our findings highlight the need to continue exploring PrEP use and rising syphilis rates. In terms of policy, PrEP administration appears to be inversely associated with regions of greater social vulnerability. Further efforts should focus on the social determinants and health needs of this population to improve access to PrEP and reduce social disparities.

State-level clustering in PrEP implementation factors among family planning clinics in the Southern United States

Background

Availability of PrEP-providing clinics is low in the Southern U.S., a region at the center of the U.S. HIV epidemic with significant HIV disparities among minoritized populations, but little is known about state-level differences in PrEP implementation in the region. We explored state-level clustering of organizational constructs relevant to PrEP implementation in family planning (FP) clinics in the Southern U.S.

Methods

We surveyed providers and administrators of FP clinics not providing PrEP in 18 Southern states (Feb-Jun 2018, N = 414 respondents from 224 clinics) on these constructs: readiness to implement PrEP, PrEP knowledge/attitudes, implementation climate, leadership engagement, and available resources. We analyzed each construct using linear mixed models. A principal component analysis identified six principal components, which were inputted into a K-means clustering analysis to examine state-level clustering.

Results

Three clusters (C1-3) were identified with five, three, and four states, respectively. Canonical variable 1 separated C1 and C2 from C3 and was primarily driven by PrEP readiness, HIV-specific implementation climate, PrEP-specific leadership engagement, PrEP attitudes, PrEP knowledge, and general resource availability. Canonical variable 2 distinguished C2 from C1 and was primarily driven by PrEP-specific resource availability, PrEP attitudes, and general implementation climate. All C3 states had expanded Medicaid, compared to 1 C1 state (none in C2).

Conclusion

Constructs relevant for PrEP implementation exhibited state-level clustering, suggesting that tailored strategies could be used by clustered states to improve PrEP provision in FP clinics. Medicaid expansion was a common feature of states within C3, which could explain the similarity of their implementation constructs. The role of Medicaid expansion and state-level policies on PrEP implementation warrants further exploration.

Successful Integration of HIV PrEP in Primary Care and Women's Health Clinical Practice: A Model for Implementation

Ending the HIV Epidemic is contingent upon the increased utilization of pre-exposure prophylaxis (PrEP). The majority of PrEP in the United States is prescribed in specialty care settings; however, to achieve national implementation goals, it is necessary to expand PrEP services in primary care and women's health clinics. To this end, a prospective cohort study was conducted of health care providers participating in one of three rounds of a virtual program aimed at increasing the number of PrEP prescribers in primary care and women's health clinics within the NYC Health and Hospitals network, the public healthcare system of New York City. Provider prescribing behavior was compared at pre-intervention (August 2018-September 2019) and post-intervention (October 2019-February 2021). Among 104 providers, the number prescribing PrEP increased from 12 (11.5%) to 51 (49%) and the number of individual patients on PrEP increased from 19 to 128. The program utilized clinical integration models centering on existing STI management workflows and was associated with increased numbers of PrEP prescribers and volume of prescriptions in primary care and women's health clinics. The dissemination of similar programs could support national scale-up of PrEP.

Same-Sex Marriage Laws, Provider-Patient Communication, and PrEP Awareness and Use Among Gay, Bisexual, and Other Men Who have Sex with Men in the United States

State-level structural stigma and its consequences in healthcare settings shape access to pre-exposure prophylaxis (PrEP) for HIV prevention among gay, bisexual, and other men who have sex with men (GBMSM). Our objective was to assess the relationships between same-sex marriage laws, a measure of structural stigma at the state level, provider-patient communication about sex, and GBMSM awareness and use of PrEP. Using data from the Fenway Institute's MSM Internet Survey collected in 2013 (N = 3296), we conducted modified Poisson regression analyses to evaluate associations between same-sex marriage legality, measures of provider-patient communication, and PrEP awareness and use. Living in a state where same-sex marriage was legal was associated with PrEP awareness (aPR 1.27; 95% CI 1.14, 1.41), as were feeling comfortable discussing with primary care providers that they have had sex with a man (aPR 1.63; 95% CI 1.46, 1.82), discussing with their primary care provider having had condomless sex with a man (aPR 1.65; 95% CI 1.49, 1.82), and discussing with their primary care provider ways to prevent sexual transmission of HIV (aPR 1.39; 95% CI 1.26, 1.54). Each of these three measures of provider-patient communication were additionally associated with PrEP awareness and use. In sum, structural stigma was associated with reduced PrEP awareness and use. Policies that reduce stigma against GBMSM may help to promote PrEP and prevent HIV transmission.

Readiness to Provide Oral and Injectable PrEP for Sexual and Gender Minority Youth Among Healthcare Providers and Clinics in the U.S. Northeast

PURPOSE

To examine readiness to provide oral and injectable pre-exposure prophylaxis (PrEP) for sexual and gender minority youth (SGMY) and to explore decision-making for HIV prevention strategies (e.g., condom use, daily and event-driven oral PrEP, and injectable PrEP) among healthcare providers.

METHODS

Between February and April 2022, we recruited 31 prescribing providers (M.Ds, D.Os, P.As, and N.Ps) practicing in primary care and specialized clinics in the U.S. Northeast for focus groups or individual interviews. Focus groups and interview transcripts were analyzed using thematic analysis.

RESULTS

Most providers specialized in Pediatrics (42%) or Adolescent Medicine (23%) and 58% had previously prescribed PrEP. Main barriers to PrEP readiness were low PrEP knowledge, limited time for visits, and competing clinical priorities. Organizational factors such as routine HIV/STI testing, PrEP-specific electronic health records templates, and specialized staff (e.g., PrEP navigators) promoted PrEP readiness. Providers held positive attitudes toward injectable PrEP to promote adherence among SGMY, yet barriers to implementation of this modality were identified (e.g., patient anxiety about needles, additional staffing needs). Providers described event-driven oral PrEP as an option for SGMY with episodic HIV risk. Assurances of conditional confidentiality, including preventing disclosure of sensitive information through insurance forms, and shared decision-making facilitated conversations about HIV prevention with SGMY.

DISCUSSION

Future PrEP implementation efforts for SGMY should consider combined efforts targeting provider knowledge about PrEP modalities (e.g., decision aids) and clinic organizational factors (e.g., routine HIV/STI testing, resources to assist providers and patients in navigating the multiple steps between prescription and adherence to PrEP).

Understanding HIV Pre-Exposure Prophylaxis Questions of U.S. Health Care Providers: Unique Perspectives from the PrEPline Clinical Teleconsultation Service

Introduction: Fewer than a quarter of people considered to have factors associated with HIV acquisition are prescribed pre-exposure prophylaxis (PrEP) in the United States. Prior studies demonstrate disparities in provider comfort and knowledge regarding PrEP, suggesting a need for provider capacity building to support widespread PrEP availability. This study examined real-world PrEP clinical questions/cases from providers to a teleconsultation service to identify knowledge gaps and improve PrEP-related training materials and clinical guidelines. Methods: The National Clinician Consultation Center (NCCC) PrEPline provides educational teleconsultation services on clinical decision-making related to PrEP for U.S. health care providers. The NCCC PrEP consultation data collected between 2017 and 2020 were reviewed and systematically categorized by clinical topics, subtopics, and complexity levels (low, moderate, and high). Results: Within the study period, the PrEPline provided 1,754 teleconsultations. More than three quarters came from advanced practice nurses and physicians. The topics of questions commonly focused on medication-based HIV prevention strategies (22.7%), PrEP laboratory ordering/monitoring (17.4%), and side effects and contraindications (14.6%). The majority of teleconsultations (57.9%) involved sharing information that was directly available/addressed in the Centers for Disease Control and Prevention (CDC) 2017 PrEP Guidelines (i.e., low complexity). Discussion: The low frequency of consultations from nonphysician and non-nurse practitioner providers may suggest a need for increased training and collaborative opportunities for other types of providers. The high percentage of low-complexity inquiries may reveal a desire for capacity-building materials specifically designed for practicing providers (e.g., abridged versions of guidelines). This study may inform future research, best clinical practices, and aid in the development of training materials to increase providers' HIV prevention comfort and knowledge.

Empowering Tennessee Pharmacists to Initiate PrEP Using Collaborative Pharmacy Practice Agreements

BACKGROUND

The uptake of Pre-Exposure Prophylaxis (PrEP) has revolutionized the fight against the Human Immunodeficiency Virus (HIV) epidemic. Consistent obstacles remain that have influenced the slow uptake of PrEP in the United States of America (USA). In order to address these barriers, pharmacists must be included in the dispensing and management of PrEP through collaborative pharmacy practice agreements (CPPAs). Our aim for this study was to characterize pharmacists' perceptions of initiating PrEP through a CPPA in the state of Tennessee.

METHODS

This qualitative study was conducted in the USA in 2021 with pharmacists practicing in Tennessee. A framework and specific questions guided the thematic analysis. The words and phrases were coded inductively and later collapsed into categories and placed into emergent themes.

RESULTS

Two themes illustrate the voices of practicing pharmacists' integration in the dispensing and management of PrEP: (1) Learning from other states and previous successful CPPAs to advance and expand innovative models of patient care and (2) advocacy through public policy change to empower pharmacists to initiate PrEP.

CONCLUSION

This qualitative study focused on exploring pharmacists' perceptions on the opportunity of initiating PrEP through a CPPA in Tennessee. These findings highlight the preparedness of pharmacists to advocate for easier initiative of PrEP in pharmacies across Tennessee, whether through relaxing existing CPPA regulation or pursuing independent prescriptive authority for pharmacists.

Insufficient PrEParation: an assessment of primary care prescribing habits and use of pre-exposure prophylaxis in patients at risk of HIV acquisition at a single medical centre

OBJECTIVES

To assess HIV pre-exposure prophylaxis (PrEP) prescribing habits by primary care providers and the number of patients at risk of HIV acquisition at a single medical centre in the Northwestern USA from 1 July 2018 to 31 June 2020.

METHODS

An electronic cross-sectional survey was administered in April and May 2021 to providers in family medicine, internal medicine, adolescent and young adult health, student health and women's health clinics affiliated with the medical centre with questions pertaining to PrEP prescribing practices. Electronic medical record abstraction was used to quantify the number of eligible patients who sought care in primary care departments and the adherence to PrEP initiation guidelines from 1 July 2018 to 31 June 2020.

RESULTS

74% (61/82) of providers reported familiarity with national clinical practice guidelines for the prevention of HIV infection. 50% (41/82) of respondents were located in family medicine clinics. 57% (47/82) of providers counseled less than one-quarter of those who they identified as at risk of HIV infection. The major barriers to prescribing PrEP were insufficient time and lack of familiarity with guidelines. Of the 4330 eligible patients for PrEP, 8% (337/4330) received at least one PrEP prescription during the study period. For patients newly prescribed PrEP, only 23% (39/170) had appropriate counseling and labs at initiation. The top three qualifying indications for PrEP were identifying as transgender (36%, n=1562), high-risk sexual behaviour (32%, n=1405) and injection drug use (30%, n=1289).

CONCLUSIONS

This study highlights intervention points in the HIV prevention cascade warranting attention in order to achieve the 2025 Ending the HIV Epidemic in the U.S. target for PrEP coverage. These include increasing provider adherence to prescribing guidelines and reducing the logistical barriers to prescribing.

Effect of Participative Web-Based Educational Modules on HIV and Sexually Transmitted Infection Prevention Competency Among Medical Students: Single-Arm Interventional Study

BACKGROUND

The number of new HIV diagnoses in the United States continues to slowly decline; yet, transgender women and men who have sex with men remain disproportionately affected. Key to improving the quality of prevention services are providers who are comfortable broaching the subjects of sexual health and HIV prevention with people across the spectrum of gender identities and sexual orientations. Preservice training is a critical point to establish HIV prevention and sexual health education practices before providers' practice habits are established.

OBJECTIVE

The study aimed to develop participative web-based educational modules and test their impact on HIV prevention knowledge and awareness in future providers.

METHODS

Sexual health providers at an academic hospital, research clinicians, community engagement professionals, and New York City community members were consulted to develop 7 web-based educational modules, which were then piloted among medical students. We assessed knowledge of HIV and sexually transmitted infection prevention and comfort assessing the prevention needs of various patients via web-based questionnaires administered before and after our educational intervention. We conducted exploratory factor analysis of the items in the questionnaire.

RESULTS

Pre- and postmodule surveys were completed by 125 students and 89 students, respectively, from all 4 years of training. Before the intervention, the majority of students had heard of HIV pre-exposure prophylaxis (122/123, 99.2%) and postexposure prophylaxis (114/123, 92.7%). Before the training, 30.9% (38/123) of the students agreed that they could confidently identify a patient who is a candidate for pre-exposure prophylaxis or postexposure prophylaxis; this increased to 91% (81/89) after the intervention.

CONCLUSIONS

Our findings highlight a need for increased HIV and sexually transmitted infection prevention training in medical school curricula to enable future providers to identify and care for diverse at-risk populations. Participative web-based modules offer an effective way to teach these concepts.

Overcoming structural barriers to diffusion of HIV pre-exposure prophylaxis

HIV prevention with antiretroviral medication in the form of pre-exposure prophylaxis (PrEP) offers a critical tool to halt the HIV pandemic. Barriers to PrEP access across drug types, formulations, and delivery systems share remarkable commonalities and are likely to be generalizable to future novel PrEP strategies. Appreciation of these barriers allows for planning earlier in the drug-development pathway rather than waiting for the demonstration of efficacy. The purpose of this article is to propose a core set of considerations that should be included in the drug-development process for future PrEP interventions. A literature synthesis of key barriers to PrEP uptake in the United States was conducted to elucidate commonalities across PrEP agents and delivery methods. Based on the published literature, we divided challenges into three main categories of structural barriers: (1) provider and clinic characteristics; (2) cost considerations; and (3) disparities and social constructs, with potential solutions provided for each. Pragmatic strategies for examining and overcoming these barriers before future PrEP regulatory approval are recommended. If these strategies are considered well before the time of commercial availability, the potential for PrEP to interrupt the HIV pandemic will be greatly enhanced.

Barriers and Opportunities to Improve the Implementation of Patient Screening and Linkage to Pre-Exposure Prophylaxis in Primary Care

Although pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection, only around 25% of at-risk individuals in the United States have accessed a prescription. One way to increase PrEP uptake is through the sexual health screening of patients and linkage to PrEP in primary care settings. The objective of this analysis was to assess the barriers and implementation strategies during a screening and linkage to PrEP pilot intervention. Primary care patients were screened for PrEP indication during routine primary care visits. Of the 1,225 individuals screened, 1.8% (n=22) were eligible for PrEP and from those, 77.3% (n=17) attended the specialist appointment and were prescribed PrEP. Primary care patients (n=30) and providers (n=8) then participated in semi-structured interviews assessing their experience with the pilot intervention. Using an applied thematic analytic approach, patients and providers identified barriers and related improvement strategies that could be classified into four main categories: 1) Financial Barriers: Individual- vs. Clinic-level Considerations 2) The Role of Stigma, Discomfort, and Cultural Factors 3) Logistical Hurdles and Streamlining the Intervention, and 4) The Lack of PrEP Knowledge and the Need for Education. Findings support the accepatability and feasibility of screening for PrEP in primary care along with appropriate implementation strategies. This study suggests that because of the high volume of patients seen in primary care, sexual health screenings and linkage to PrEP interventions have the potential to reduce new incident HIV infections among diverse sexual minority men.

Human Immunodeficiency Virus Pre-Exposure Prophylaxis Knowledge, Attitudes, and Self-Efficacy Among Family Planning Providers in the Southern United States: Bridging the Gap in Provider Training

Background

Pre-exposure prophylaxis (PrEP) is an effective human immunodeficiency virus (HIV) prevention intervention, but its access and use are suboptimal, especially for women. Healthcare providers provision of PrEP is a key component of the Ending the HIV Epidemic initiative. Although training gaps are an identified barrier, evidence is lacking regarding how to tailor trainings for successful implementation. Title X family planning clinics deliver safety net care for women and are potential PrEP delivery sites. To inform provider training, we assessed PrEP knowledge, attitudes, and self-efficacy in the steps of PrEP care among Title X providers in the Southern United States.

Methods

We used data from providers in clinics that did not currently provide PrEP from a web-based survey administered to Title X clinic staff in 18 Southern states from February to June 2018. We developed generalized linear mixed models to evaluate associations between provider-, clinic-, and county-level variables with provider knowledge, attitudes, and self-efficacy in PrEP care, guided by the Consolidated Framework for Implementation Research.

Results

Among 351 providers from 193 clinics, 194 (55%) were nonprescribing and 157 (45%) were prescribing providers. Provider ability to prescribe medications was significantly associated PrEP knowledge, attitudes, and self-efficacy. Self-efficacy was lowest in the PrEP initiation step of PrEP care and was positively associated with PrEP attitudes, PrEP knowledge, and contraception self-efficacy.

Conclusions

Our findings suggest that PrEP training gaps for family planning providers may be bridged by addressing unfavorable PrEP attitudes, integrating PrEP and contraception training, tailoring training by prescribing ability, and focusing on the initiation steps of PrEP care.

The effect of an HIV preexposure prophylaxis panel management strategy to increase preexposure prophylaxis prescriptions

OBJECTIVE

The HIV preexposure prophylaxis optimization intervention (PrEP-OI) study evaluated the efficacy of a panel management intervention using PrEP coordinators and a web-based panel management tool to support healthcare providers in optimizing PrEP prescription and ongoing PrEP care.

DESIGN

The PrEP-OI study was a stepped-wedge randomized clinical trial conducted across 10 San Francisco Department of Public Health primary care sites between November 2018 and September 2019. Each month, clinics one-by-one initiated PrEP-OI in random order until all sites received the intervention by the study team.

METHODS

The primary outcome was the number of PrEP prescriptions per month. Secondary outcomes compared pre- and postintervention periods on whether PrEP was discussed and whether PrEP-related counseling (e.g., HIV risk assessment, risk reduction counseling, PrEP initiation/continuation assessment) was conducted. Prescription and clinical data were abstracted from the electronic health records. We calculated incidence rate ratios (IRR) and risk ratios (RR) to estimate the intervention effect on primary and secondary outcomes.

RESULTS

The number of PrEP prescriptions across clinics increased from 1.85/month (standard deviation [SD] = 2.55) preintervention to 2.44/month (SD = 3.44) postintervention (IRR = 1.34; 95% confidence interval [CI] = 1.05-1.73; P  = 0.021). PrEP-related discussions during clinic visits (RR = 1.13; 95% CI = 1.04-1.22; P  = 0.004), HIV risk assessment (RR = 1.40; 95% CI = 1.14-1.72; P  = 0.001), and risk reduction counseling (RR = 1.16; 95% CI = 1.03-1.30; P  = 0.011) increased from the pre- to the postintervention period. Assessment of PrEP initiation/continuation increased over time during the postintervention period (RR = 1.05; 95% CI = 0.99-1.11; P  = 0.100).

CONCLUSIONS

A panel management intervention using PrEP coordinators and a web-based panel management tool increased PrEP prescribing and improved PrEP-related counseling in safety-net primary care clinics.

AC-2020-12-1420.R1 - HIV care providers' familiarity, concerns, and attitudes about HIV PrEP in Colombia: insights from the PrEP-Col-Study

In 2019, Colombia approved the combination of tenofovir disoproxil fumarate/emtricitabine for HIV Pre-Exposure Prophylaxis (PrEP). Therefore, we conducted a situational analysis in HIV-care providers to identify barriers and facilitators for PrEP implementation. A survey was applied to a non-probabilistic sample of health care workers of HIV-specialized clinics. We examined PrEP awareness and familiarity, comfort with PrEP-related activities, perceived barriers for PrEP implementation, concerns, and attitudes. Poisson regressions assessed the relationship between these factors and the variable "having a plan to offer PrEP". The participation rate was 41% and included physicians (42.6%) and other health professionals (57.4%). Fifty-one percent of the participants reported more than five years of experience caring for people living with HIV. Forty-two percent of non-physician health care workers were nurses. Most reported high familiarity/comfort with PrEP-relevant activities. Concerns about PrEP were prevalent (> 50%) and included causing more harm than good, reducing condom use, medication non-adherence, drug resistance, and healthcare system barriers. Physicians had a plan to offer PrEP (72.2%) more often than other health professionals (52.6). Having a plan to offer PrEP was related to PrEP knowledge and comfort assessing sexual behavior and providing HIV counseling. Overall, about half of HIV-care providers seemed ready to offer PrEP and constitute an asset for PrEP implementation efforts in Colombia. PrEP awareness among non-physicians, PrEP concerns, and negative attitudes need to be addressed to enhance implementation.

"Let's take that [stop sign] down." Provider perspectives on barriers to and opportunities for PrEP prescription to African American girls and young women in Alabama

HIV disproportionately impacts many groups, including Black adolescent girls and young women (AGYW) aged 13-24 living in the Deep South. Current prevention efforts have the potential to further exacerbate disparities within this population as HIV pre-exposure prophylaxis (PrEP) remains underutilized by Black AGYW in the South. We conducted in-depth interviews (IDIs) grounded in Andersen's Model of Healthcare Utilization exploring providers' PrEP prescribing practices to Black AGYW in Alabama. Eleven providers completed IDIs exploring providers' PrEP prescription knowledge and experiences. Cross-cutting themes included: (1) Community and provider-level stigmas (including those propagated by legislation) relating to HIV and sexuality limit sexual health discussions with Black AGYW clients; (2) Low PrEP knowledge and comfort with guidelines limits PrEP conversations and reinforces low uptake and prescriptions; (3) Healthcare systems and structural barriers impede PrEP access for youth. Multi-level (structural, community, and provider) barriers to PrEP prescription demands high activation energy for providers to prescribe PrEP. We present recommendations in training in sexual health assessment, updates to PrEP guidelines to accommodate risk assessment appropriate for AGYW, and increased implementation science focused on PrEP prescription for Black AGYW in order to reduce HIV incidence for this population.

Health Care Providers' Views on Clinic Infrastructure and Practice Models That May Facilitate HIV Preexposure Prophylaxis (PrEP) Prescribing: A Qualitative Meta-Synthesis

HIV (human immunodeficiency virus) preexposure prophylaxis (PrEP) is an effective biomedical HIV prevention tool. Increasing PrEP use among populations disproportionately affected by HIV is one of the key efforts in the United States' Ending the HIV Epidemic (EHE) initiative and the HIV National Strategic Plan for the United States. Given that PrEP is available only through prescription, it is important to explore structural, organizational, or environmental factors that could facilitate or impede health care provider's PrEP prescribing behavior. The purpose of this systematic review (PROSPERO [CRD: 42019138889]) is to identify qualitative studies that addressed this topic and conduct meta-synthesis using the thematic synthesis method to identify major themes on the characteristics of clinic infrastructure or clinic models that providers consider as facilitators of PrEP prescribing in the United States. Eighteen citations representing 15 studies were included in this review. Five overarching themes were identified: (1) routinized HIV risk assessment; (2) interdisciplinary/coordinated PrEP teams or services; (3) clinic capacity to provide essential PrEP-related services; (4) low out-of-pocket patient costs; and (5) access to the priority populations. Some of these themes are consistent with the recommendations of CDC's PrEP clinical guidelines and the EHE initiative. More recent studies that include perspectives of diverse providers, timely analysis of these studies, and implementation research to assess strategies to address the current practice gaps are needed to further promote PrEP prescribing among providers in the United States.

A Demedicalized Model to Provide PrEP in a Sexual Health Clinic

BACKGROUND

Sexual health clinics (SHCs) serve large numbers of patients who might benefit from preexposure prophylaxis (PrEP). Integrating longitudinal PrEP care into SHCs can overburden clinics. We implemented an SHC PrEP program that task shifted most PrEP operations to nonmedical staff, disease intervention specialists (DIS).

METHODS

We conducted a retrospective cohort analysis of PrEP patients in an SHC in Seattle, WA, from 2014 to 2020 to assess the number of patients served and factors associated with PrEP discontinuation. Clinicians provide same-day PrEP prescriptions, whereas DIS coordinate the program, act as navigators, and provide most follow-up care.

RESULTS

Between 2014 and 2019, 1387 patients attended an initial PrEP visit, 93% of whom were men who have sex with men. The number of patients initiating PrEP per quarter year increased from 20 to 81. The number of PrEP starts doubled when the clinic shifted from PrEP initiation at scheduled visits to initiation integrated into routine walk-in visits. The percentage of visits performed by DIS increased from 3% in 2014 to 45% in 2019. Median duration on PrEP use was 11 months. PrEP discontinuation was associated with non-Hispanic black race/ethnicity [hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.02 to 1.76], age <20 years (HR 2.17, 95% CI: 1.26 to 3.75), age between 20 and 29 years (HR 1.55, 95% CI: 1.06 to 2.28), and methamphetamine use (HR 1.98, 95% CI: 1.57 to 2.49). The clinic had 750 patients on PrEP in the final quarter of 2019.

CONCLUSIONS

A demedicalized SHC PrEP model that task shifts most operations to DIS can provide PrEP at scale to high priority populations.

Using a Structural-Ecological Model to Facilitate Adoption of Preexposure Prophylaxis Among Latinx Sexual Minority Men: A Systematic Literature Review

Research has consistently shown that individual, interpersonal, community and structural factors influence the degree to which individuals' access and utilize health care services, and these factors may play a role in explaining racial and ethnic differences in health care outcomes. Differences in HIV prevalence and treatment between Latinx adults and white adults in the U.S. must be considered in the context of these factors. However, much of the existing research connecting these factors and HIV/AIDS outcomes in Latinxs remains disparate, limited in scope, and has yet not been applied to the use of biomedical HIV preventions. The following systematic literature review examined research related to PrEP in Latinx sexual minority men (SMM) to build a structural-ecological framework of the existing research, while identifying gaps in the literature and areas for future research. We searched two electronic databases using a systematic review protocol, screened 71 unique records, and identified 23 articles analyzing data from Latinx SMM and intended and/or actual PrEP-use in the United States. Based on the present review, disparities in PrEP uptake by Latinx SMM could be explained, in part, by examining how all levels of the structural-ecological framework uniquely contributes to how Latinx SMM engage with HIV prevention measures and come to understand PrEP. It is clear from the existing literature base that some of the most prominent barriers deterring Latinx SMM from seeking PrEP services are the lack of information surrounding PrEP and HIV/gay stigmas. However, higher order structural-level risks can facilitate or reduce access to PrEP. We propose a structural-ecological model to help visualize multi-level domains of unique stressors that limit the implementation of PrEP among Latinxs. At this stage, the available literature provides little guidance beyond suggesting that culturally adapted interventions can be effective in this population. The model developed here provides that needed specificity regarding targeted interventions that will fit the needs of this population.

Tennessee Pharmacists' Opinions on Barriers and Facilitators to Initiate PrEP: A Qualitative Study

Pre-exposure prophylaxis (PrEP) is recommended to prevent the transmission of the human immunodeficiency virus (HIV). Although an effective treatment, the uptake in the United States remains low. Pharmacists are well-positioned to initiate the conversation with patients about PrEP, but few studies exist exploring their unique roles. The objective of this study was to characterize Tennessee pharmacists’ perceptions about access to PrEP. A qualitative study was used to gather the data that consisted of virtual Focus Groups over four months in 2021 from practicing Tennessee pharmacists. Emails were sent to all Tennessee licensed pharmacists to recruit them to participate in the study. Recruitment continued until Thematic Saturation was obtained. The corpus of data was audio-recorded, transcribed, and analyzed by the research team. Thematic Analysis revealed two themes: (1) Barriers to accessing PrEP; (2) Potential solutions to address barriers identified. These findings highlighted barriers and identified solutions to improve access to PrEP in Tennessee; additional financial assistance programs and marketing programs targeting patients and providers are needed to enhance PrEP access.

Implementing PrEP Services in Diverse Health Care Settings

BACKGROUND

Uptake of pre-exposure prophylaxis (PrEP) in the US has been limited. Evidence for why and how PrEP has been successfully integrated into some clinical settings, but not in others is minimal. To address this gap, we conducted a qualitative study to identify contextual factors that facilitated and challenged the implementation of PrEP services.

SETTING

In partnership with the NYC Department of Health, we convened a planning committee with expertise with groups highly affected by the HIV epidemic employed in diverse health care settings, to guide the project. Representatives from programs within New York were targeted for participation initially and subsequently expanded nationally to enhance diversity in program type.

METHODS

Using an interview guide informed by the Consolidated Framework for Implementation Research, we conducted 20 interviews with participants who successfully implemented PrEP programs in different settings (eg, primary care, emergency department, sexual health clinics), using different delivery models. We used template and matrix analysis to identify and characterize contextual determinants and implementation strategies.

RESULTS

Participants frequently described determinants and strategies fluidly and conceptualized them in context-specific terms. Commonly discussed Consolidated Framework for Implementation Research constructs included implementation climate (tension for change, compatibility, relatively priority), stakeholders' knowledge (or lack thereof) and beliefs about PrEP, and costs associated with PrEP implementation.

CONCLUSION

Our work identifies patterns in PrEP program implementation, describing how organizations dealt with determinants in their own context. Our research points to the need to connect rigorous implementation research with how frontline implementers conceptualize their work to inform and improve PrEP implementation.

"Let's Be a Person to Person and Have a Genuine Conversation": Comparing Perspectives on PrEP and Sexual Health Communication Between Black Sexual Minority Men and Healthcare Providers

Patient-provider communication is a key factor affecting HIV pre-exposure prophylaxis (PrEP) awareness and access among Black sexual minority men (SMM). Optimizing patient-provider communication requires a deeper understanding of communication dynamics. In this study, we investigated the perspectives of both HIV-negative/status-unknown Black SMM and practicing community healthcare providers regarding patient-provider communication about PrEP and sexual health. We conducted eleven semi-structured qualitative focus groups (six with Black SMM; five with providers) in the Northeastern USA and thematically analyzed transcripts. A total of 36 Black SMM and 27 providers participated in the focus groups. Our analysis revealed points of alignment and divergence in the two groups' perspectives related to patient-provider communication. Points of alignment included: (1) the importance ascribed to maximizing patients' comfort and (2) belief in patients' right to non-discriminatory healthcare. Points of divergence included: (1) Black SMM's preference for sexual privacy versus providers' preference that patients share sexual information, (2) Black SMM's perception that providers have an ethical responsibility to initiate conversations about PrEP with patients versus providers' perception of such conversations as being optional, and (3) Black SMM's preference for personalized sexual health conversations versus providers' preference for standardized conversations. Findings underscore a need for providers to offer more patient-centered sexual healthcare to Black SMM, which should entail routinely presenting all prevention options available-including PrEP-and inviting open dialogue about sex, while also respecting patients' preferences for privacy about their sexuality. This approach could increase PrEP access and improve equity in the US healthcare system.

Metrics of HIV Pre-exposure Prophylaxis (PrEP) Implementation Before and After a Multidisciplinary Task Force at an Academic Institution

BACKGROUND AND OBJECTIVES

There is a paucity of guidance on HIV pre-exposure prophylaxis (PrEP) implementation in an academic medical center. The objectives of this study were to describe interventions by a multidisciplinary PrEP task force at an academic medical center and compare metrics of PrEP implementation pre- and post-creation of this entity.

METHODS

The interventions of the task force are described within the rubric of the PrEP care continuum. Participants were adults prescribed PrEP for greater than or equal to 30 days at 9 clinical sites across a university health system. Metrics of PrEP implementation were compared over 12-month intervals before and after the creation of the task force.

RESULTS

An increased proportion of participants had HIV testing within 7 days of new PrEP prescriptions (92% vs 63%, P < .001) and were prescribed PrEP in increments of 90 days or shorter (74% vs 56%, P < .001) after the creation of the task force. There were higher rates of testing for bacterial sexually transmitted infections in men who had sex with men and transgender women in the post-intervention compared with pre-intervention period.

CONCLUSIONS

A multidisciplinary team that focuses on optimizing PrEP delivery along each step of the care continuum may facilitate PrEP scale-up and best practices in an academic setting.

Sex-Positivity, Medical Mistrust, and PrEP Conspiracy Beliefs Among HIV-Negative Cisgender Black Sexual Minority Men in Atlanta, Georgia

Because the public health response to the disproportionate HIV burden faced by Black sexual minority men (BSMMM) has focused on sexual risk reduction and disease prevention, other vital components of sexual health (e.g., intimacy, pleasure, benefits of sex) have been often overlooked. Sex-positive describes a more open, holistic approach toward sex and sexuality that prioritizes these other components, though such an approach is rarely applied to BSMM's sexual health. For sex-positive BSMM, risk/preventive discourse may foster or exacerbate medical mistrust as a reaction to the dissonance between how these men view sexual health and how the medical establishment views it, which may discourage sexual healthcare-seeking. We assessed sex-positivity and its association with medical mistrust and PrEP conspiracy beliefs among 206 HIV-negative cisgender BSMM in Atlanta, Georgia. We performed exploratory factor analytic procedures on responses to a sex-positivity scale, followed by multivariable linear regressions to determine sex-positivity's associations with medical mistrust and PrEP conspiracy beliefs. We extracted two sex-positivity factors: sexual freedom (α = 0.90), reflecting openness toward casual sex and rejection of sexual mores, and essence of sex (α = 0.77), reflecting the intimate, relational, and pleasurable qualities of sex. Sexual freedom was independently associated with perceived provider deception (β = 0.19, CI = 0.04, 0.34). Essence of sex was independently associated with PrEP conspiracy beliefs (β = 0.16, CI = 0.02, 0.31) and marginally associated with perceived provider deception (β = 0.14, CI = - 0.00, 0.29). Healthcare providers and public health practitioners may cultivate greater trust with BSMM by incorporating a sex-positive approach into patient/participant interactions, clinical decision-making, and interventions. Improving access to sexual pleasure acknowledges BSMM's right to optimal, holistic sexual health.

An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers' PrEP-Related Clinical Judgments

Social biases may influence providers' judgments related to pre-exposure prophylaxis (PrEP) and patients' consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.

Awareness, knowledge, and attitudes related to HIV pre-exposure prophylaxis and other prevention strategies among physicians from Brazil and Mexico: cross-sectional web-based survey

BACKGROUND

In order to end the HIV epidemic by 2030, combination HIV prevention including pre-exposure prophylaxis (PrEP) should be widely available, especially for the most vulnerable populations. In Latin America and the Caribbean (LAC), only 14 out of 46 countries have access to PrEP. In Brazil and Mexico, PrEP has been provided at no cost through the Public Health System since 2017 and 2021, respectively. Thus, HIV physicians' perspectives about PrEP and other prevention strategies may differ. This study aimed to compare awareness, knowledge, and attitudes related to PrEP and other prevention strategies among HIV physicians from Brazil and Mexico.

METHODS

Cross-sectional, web-based survey targeting physicians who prescribe antiretrovirals from both countries. Participants answered questions on socio-demographic, medical experience, awareness, knowledge, and attitudes towards PrEP and other HIV prevention strategies. We stratified all variables per country and compared frequencies using Chi-square, Fisher exact, and Wilcoxon-Mann-Whitney tests, as appropriate.

RESULTS

From January-October 2020, 481 HIV physicians were included: 339(70.5%) from Brazil, 276(57.4%) male, and median age was 43 years (IQR = 36-53). Awareness of PrEP did not differ between Brazil and Mexico (84.6%), while awareness of other prevention strategies, including post-exposure prophylaxis and new PrEP technologies, was higher in Brazil. More Brazilians perceived U=U as completely accurate compared to Mexicans (74.0% vs. 62.0%, P < .001). Willingness to prescribe PrEP was 74.2%, higher among Brazilians (78.2%, P = .01). Overall, participants had concerns about consistent access to PrEP medication and the risk of antiretroviral resistance in case of acute HIV infection or seroconversion. The main barriers reported were assumptions that users could have low PrEP knowledge (62.0%) or limited capacity for adherence (59.0%). Compared to Brazilians, Mexicans reported more concerns and barriers to PrEP prescription (all; P ≤ .05), except for consistent access to PrEP medication and the lack of professionals to prescribe PrEP (both; P ≤ .01).

CONCLUSIONS

Although awareness of PrEP was similar in Brazil and Mexico, differences in knowledge and attitudes may reflect the availability and stage of PrEP implementation in these countries. Strengthening and increasing information on PrEP technologies and other HIV prevention strategies among HIV physicians could improve their comfort to prescribe these strategies and facilitate their scale-up in LAC.

How Do Family Physicians Perceive Their Role in Providing Pre-exposure Prophylaxis for HIV Prevention?-An Online Qualitative Study in Flanders, Belgium

Introduction:

In Belgium, the provision of pre-exposure prophylaxis (PrEP) for HIV prevention is centralized in specialized HIV clinics. Engaging family physicians in PrEP care could help scale-up its delivery and reach underserved populations. The objective of this study was to gain insight into family physicians' self-perceived roles in providing PrEP.

Methods

We conducted 16 online group discussions with a total of 105 Flemish family physicians, between November 2020 and February 2021. A brief online questionnaire assessed their socio-demographics and experience with sexual health. We analyzed verbatim transcribed data using a grounded theory approach.

Results

Despite limited awareness and experience, participants reported a high willingness to be more actively involved in PrEP care. Four potential roles for the family physician in PrEP care were identified: acting as low-threshold entry point for advice; opportunistic case finding of PrEP candidates; initiating appropriate care for PrEP-eligible clients; and ensuring high-quality follow-up care for PrEP users. Participants framed each of these roles within their current activities and responsibilities as primary care providers. Yet, participants differed in their views on the concrete operationalization of these roles, and in the extent of their involvement in PrEP. Particular challenges were a lack of experience with antiretrovirals, perceived limited exposure to clients at high HIV risk, and a lack of expertise and resources to conduct time-intensive risk assessments and counseling related to PrEP.

Conclusion

Belgian family physicians demonstrated a keen willingness to be involved in PrEP care, but had differing views on the practical implementation into their practices. Providing tailored training on sexual health and PrEP, and investing in collaboration between primary and secondary care, could optimize the integration of PrEP in the primary care practice.

Association between having a regular healthcare provider and pre-exposure prophylaxis use among men who have sex with men: a cross-sectional survey

Healthcare providers whom people see regularly (e.g., primary care providers [PCPs]) are likely to interact with individuals at risk of human immunodeficiency virus (HIV). However, most PCPs report never prescribing pre-exposure prophylaxis (PrEP), a medication that prevents HIV infection. This study examined the association between having a regular healthcare provider and PrEP use among men who have sex with men (MSM). We analyzed health survey data from Black (n = 151) and White (n = 113) MSM in Atlanta, GA using log binomial regressions. Among Black MSM, the proportion who used PrEP was nearly three times higher for those with a regular provider compared to those without one (aPR 2.58; 95% CI: 0.96, 6.93). Conversely, the proportion of White MSM who used PrEP was slightly lower among those with a regular provider (aPR 0.67; 95% CI: 0.36, 1.27). Findings suggest having a regular provider may be more strongly associated with PrEP among Black MSM.

Health Care Worker Perspectives of HIV Pre-exposure Prophylaxis Service Delivery in Central Uganda

Background

Scale-up of HIV pre-exposure prophylaxis (PrEP) services in Uganda is ongoing. However, health care workers (HCWs) may not be aware of PrEP nor what offering this service entails. We explored the impact of standardized HCW training on the knowledge and perspectives of PrEP service delivery in Uganda.

Methods

We recruited HCWs from facilities that offered HIV-related services in Central Uganda. Using the Uganda Ministry of Health curriculum, we trained HCWs on PrEP services. We collected data about PrEP knowledge, preparedness, and willingness to deliver PrEP to multiple key populations before the training, immediately after the training, and >6 months later (exit). We additionally conducted 15 qualitative interviews after the exit survey. Quantitative data were analyzed by Fisher exact test, while qualitative interview data were analyzed inductively.

Results

We recruited 80 HCWs from 35 facilities in urban (N = 24, 30%), peri-urban (N = 30, 37%), and rural (N = 26, 33%) areas. Most HCWs were nurse counselors (N = 52, 65%) or medical/clinical officers (N = 15, 18%). Surveys indicated that awareness of PrEP increased after the training and remained high. Knowledge of PrEP (i.e., as an effective, short-term antiretroviral medication to use before HIV exposure for people at high risk) generally increased with training, but significant gaps remained, and knowledge decreased with time. Most HCWs recommended PrEP for female sex workers and HIV serodifferent couples, as well as other key populations. We observed increases in the number of HCW who felt their facility was prepared to cater for HIV prevention and provide PrEP, but this view was not universal. HCWs believed in PrEP effectiveness and embraced it as an additional HIV prevention method. Concerns included patient adherence and behavioral risk compensation. HCWs noted challenges in PrEP delivery in terms of inadequate clinic preparedness, infrastructure, staff capacity, and poor attitudes toward key populations by untrained health workers. They felt further training was needed to ensure a smooth scale-up of services without stigmatization.

Conclusions

Standardized training improved knowledge, willingness, and preparedness to offer PrEP services among most HCWs in Central Uganda. Ongoing training will be needed to optimize PrEP delivery services and expand delivery to levels needed for population-level impact.

HIV PrEP Clinician Communication Preferences Among Black Sexual Minority Men

Black sexual minority men (BSMM) are substantially less likely than White SMM to accept a clinician's recommendation to initiate HIV pre-exposure prophylaxis (PrEP). The purpose of this study is to identify PrEP messaging preferences among BSMM. Data were obtained from 12 focus groups and one in-depth interview among BSMM in Baltimore, MD (N = 39). Focus groups were stratified (18-24, 25-34, and 35 and older), and facilitators probed on ways clinicians could discuss PrEP with BSMM. An adapted pile sorting approach was used to identify themes. Most identified as homosexual, gay, or same-gender-loving (68%), were employed (69%), and single (66%). Thematic analysis revealed that BSMM wanted clinicians to explain PrEP efficacy and side effects, tailor messaging, provide prevention messaging with care, and disclose PrEP use. Clinicians could increase uptake and adherence among BSMM by implementing PrEP communication preferences. Discussing PrEP efficacy and safety is also necessary. When possible, clinicians should disclose PrEP use history to build trust.

Implementation strategies for integrating pre-exposure prophylaxis for HIV prevention and family planning services for adolescent girls and young women in Kenya: a qualitative study

INTRODUCTION

Across sub-Saharan Africa, ministries of health have proposed integrating pre-exposure prophylaxis (PrEP) for HIV prevention into family planning (FP) services to reach adolescent girls and young women (AGYW); however, evidence on effective implementation strategies is still limited. We conducted a qualitative study of integrated PrEP-FP service implementation at two FP clinics in Kisumu, Kenya.

METHODS

From June 2017 to May 2020, the Prevention Options for Women Evaluation Research (POWER) study enrolled 1000 sexually active, HIV-negative AGYW age 16 to 25. Actions taken to implement PrEP were captured prospectively in 214 monitoring and evaluation documents and 15 interviews with PrEP implementers. We analysed data using conventional and directed content analysis, with the latter informed by the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC) compilation.

RESULTS

POWER deployed a variety of implementation strategies to train and educate stakeholders (e.g., having new providers shadow PrEP providers); develop stakeholder interrelationships (e.g., organizing support teams with protected time to reflect on implementation progress and make refinements); provide technical assistance; and change physical infrastructure and workflow. Although these strategies reportedly influenced contextual factors across four of the five CFIR domains, they primarily interacted with contextual factors relevant to inner setting, especially implementation climate and readiness for implementation. Overall, implementing PrEP proved easier and less labor-intensive at a private, youth-friendly clinic than a public FP clinic, largely because the baseline structural characteristics (e.g., space, workflow) and organizational mission of the former were more conducive to offering AGYW-centered care. Nevertheless, adoption of PrEP delivery among non-study staff at both sites was low, likely due to the widespread perception that PrEP was not within their scope of work.

CONCLUSIONS

Some FP clinics may be "lower-hanging fruit" than others for PrEP implementation. Approaching PrEP implementation as a behavioral intervention for FP providers may help ensure that providers have the requisite capability, opportunity, and motivation to adopt the clinical innovation. In particular, PrEP implementers should assess the need for implementation strategies that support providers' clinical decision-making, establish worker expectations and accountability, and address workload constraints.

TRIAL REGISTRATION

Clinical Trial Number: NCT03490058 .

Applying implementation science frameworks to identify factors that influence the intention of healthcare providers to offer PrEP care and advocate for PrEP in HIV clinics in Colombia: a cross-sectional study

Background

Few studies have used implementation science frameworks to identify determinants of PrEP prescription by healthcare providers. In this work, we developed and psychometrically examined a questionnaire using the theoretical domains framework (TDF) and the consolidated framework for implementation research (CFIR). We used this questionnaire to investigate what factors influence the intention of healthcare providers to offer PrEP care and advocate for PrEP.

Methods

We conducted a cross-sectional study in 16 HIV healthcare organizations in Colombia. A 98-item questionnaire was administered online to 129 healthcare professionals. One hundred had complete data for this analysis. We used exploratory factor analysis to assess the psychometric properties of both frameworks, and multinomial regression analysis to evaluate the associations of the frameworks’ domains with two outcomes: (1) intention to offer PrEP care and (2) intention to advocate for PrEP impmentation.

Results

We found support for nine indices with good internal consistency, reflecting PrEP characteristics, attitudes towards population needs, concerns about the use of PrEP, concerns about the role of the healthcare systems, knowledge, beliefs about capabilities, professional role, social influence, and beliefs about consequences. Notably, only 57% of the participants were likely to have a plan to care for people in PrEP and 66.7% were likely to advocate for PrEP. The perception of the need for PrEP in populations, the value of PrEP as a practice, the influence of colleagues, and seeing PrEP care as a priority was related to being less likely to be unwilling to provide or advocate for PrEP care.

Conclusion

Our findings suggested the importance of multilevel strategies to increase the provision of PrEP care by healthcare providers including adquisition of new skills, training of PrEP champions, and strength the capacity of the health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00278-2.

"It's Very Inconvenient for Me": A Mixed-Method Study Assessing Barriers and Facilitators of Adolescent Sexual Minority Males Attending PrEP Follow-Up Appointments

Researching PrEP retention in adolescent sexual minority men (ASMM) is critical to increasing persistence of PrEP in this priority population, yet this research is lacking. ASMM (N = 1433) completed a baseline survey for an online HIV prevention program between 2018 and 2020. Open- and closed-ended survey items identified their beliefs about attending 3-month PrEP follow-up appointments and examined the association of Andersen's Behavioral Model factors (predisposing, enabling, and need) and confidence to attend these appointments. Qualitative and quantitative findings show that perceived parental support is a salient factor in ASMM attending PrEP follow-up appointments. Participants did not want to have to go to the doctor and get bloodwork done trimonthly, and qualitative findings elucidated rationales for this, such as perceptions that follow-ups might be time-consuming, costly, and could out their sexuality to their parents. This study suggests that parents are gatekeepers for ASMM to initiate and sustain the PrEP care continuum.

Using an on-site modular training approach to amplify prep service delivery in public health facilities in Kenya

Delivery of oral PrEP, a potent HIV prevention intervention, has begun within public health systems in many countries in Africa. Training as many health providers as possible expeditiously is necessary to efficiently and rapidly scale up PrEP delivery among at risk populations and thereby realize the greatest impact of PrEP. We designed and implemented an innovative on-site modular training approach delivered in five two-hour modules. The modules could be covered in two consecutive days or be broken across several days enabling flexibility to accommodate health provider work schedules. We assessed knowledge gain comparing pre-and post-training test scores and determined monthly PrEP uptake for six months following the training intervention. We also evaluated the cost of this training approach and conducted key informant interviews to explore acceptability among health providers. Between January 2019 and December 2020, 2111 health providers from 104 health facilities were trained on PrEP. Of 1821 (83%) providers who completed both pre- and post-tests, 505 (28%) were nurses, 333 (18%) were HIV counsellors, 276 (15%) were clinical officers and 255 (14%) were lay providers. The mean score prior to and after training was 58% and 82% respectively (p <0.001). On average, health facilities initiated an average of 2.7 (SD 4.7) people on PrEP each month after the training, a number that did not decline over six months post-training (p = 0.62). Assuming Ministry of Health costs, the costs per provider trained was $16.27. Health providers expressed satisfaction with this training approach because it enabled many providers within a facility receive training. On-site modular training is an effective approach for improving PrEP education for health workers in public health facilities, It is also acceptable and low-cost. This method of training can be scaled up to rapidly amplify the number of health workers able to offer PrEP services.

Knowledge and attitudes about HIV pre-exposure prophylaxis: Evidence from in-depth interviews and focus group discussions with policy makers, healthcare providers, and end-users in Lesotho

Studies on knowledge and attitudes about HIV pre-exposure prophylaxis (PrEP) have mostly focused on key populations in North America and Europe. To inform Lesotho's national rollout of PrEP to the general population, this study aimed to characterize knowledge and attitudes about PrEP among policy makers, implementing partners, healthcare providers, and PrEP end-users in Lesotho. Respondents were purposively selected to participate based on personal experience in the development and implementation of Lesotho's PrEP program, or the personal use of PrEP. We conducted 106 in-depth interviews with policy makers (n = 5), implementing partners (n = 4), and end-users (current PrEP users = 55; former PrEP users = 36; and PrEP "decliners" = 6). In addition, we held 11 focus group discussions (FGDs) with a total of 105 healthcare providers. Interview and FGD transcripts were analyzed following the tenets of Grounded Theory. Respondents expressed positive attitudes toward PrEP, owing to experienced and perceived personal, familial, and societal benefits. PrEP was viewed as i) an opportunity for serodiscordant couples to remain together, ii) a means of conceiving children with minimized risk of HIV infection, iii) providing a sense of agency and control, and iv) an avenue for addressing the HIV epidemic in Lesotho. Respondents demonstrated understanding of PrEP's intended use, eligibility requirements, and modality of use. However, respondents also reported that several important misconceptions of PrEP were common among adults in Lesotho, including a belief that PrEP protects against sexually transmitted infections other than HIV, promotes promiscuity, prevents pregnancy, causes seroconversion, and provides lifelong protection from taking the pill just once. In addition to building on the perceived advantages of PrEP to shape a positive message, Lesotho's national rollout of PrEP will likely benefit from a communication strategy that specifically addresses the common misconceptions of PrEP identified in this study.