A Pilot Study to Evaluate a Novel Pre-exposure Prophylaxis Peer Outreach and Navigation Intervention for Women at High Risk for HIV Infection

Navigating Pre-exposure Prophylaxis Access: Qualitative Insights From Black Women at a Northeastern Historically Black College and University

ABSTRACT

Black women are essential to ending the HIV epidemic in the United States; yet prevention, access, testing, and structural racism affect how HIV disproportionately affects them. Limited public health research focuses on Black women attending Historically Black Colleges and Universities (HBCUs) and the ability to address HIV prevention, such as pre-exposure prophylaxis (PrEP) uptake. PrEP is a once-daily oral pill used to prevent HIV transmission and has suboptimal uptake within the Black community. This generic qualitative descriptive analysis identifies the barriers and facilitators of PrEP uptake among Black women attending an HBCU using the health belief model. Overall, 22 Black college women participated in a 60-minute focus group. Emergent categories were as follows: (a) Barriers-stigma, cost, and side effects; (b) Facilitators-PrEP's effectiveness, exposure to HIV, and unprotected sex. Our findings can inform future efforts to increase PrEP uptake among Black women attending an HBCU.

The barriers and enablers to accessing sexual health and sexual well-being services for midlife women (aged 40-65 years) in high-income countries: A mixed-methods systematic review

Midlife, beginning at 40 years and extending to 65 years, a range that encompasses the late reproductive to late menopausal stages, is a unique time in women's lives, when hormonal and physical changes are often accompanied by psychological and social evolution. Access to sexual health and sexual well-being (SHSW) services, which include the prevention and management of sexually transmitted infections, contraception and the support of sexual function, pleasure and safety, is important for the health of midlife women, their relationships and community cohesion. The objective was to use the socio-ecological model to synthesise the barriers and enablers to SHSW services for midlife women in high-income countries. A systematic review of the enablers and barriers to women (including trans-gender and non-binary people) aged 40-65 years accessing SHSW services in high-income countries was undertaken. Four databases (PubMed, PsycINFO, Web of Science and Google Scholar) were searched for peer-reviewed publications. Findings were thematically extracted and reported in a narrative synthesis. Eighty-one studies were included; a minority specifically set out to study SHSW care for midlife women. The key barriers that emerged were the intersecting disadvantage of under-served groups, poor knowledge, about SHSW, and SHSW services, among women and their healthcare professionals (HCPs), and the over-arching effect of stigma, social connections and psychological factors on access to care. Enablers included intergenerational learning, interdisciplinary and one-stop women-only services, integration of SHSW into other services, peer support programmes, representation of minoritised midlife women working in SHSW, local and free facilities and financial incentives to access services for under-served groups. Efforts are needed to enhance education about SHSW and related services among midlife women and their healthcare providers. This increased education should be leveraged to improve research, public health messaging, interventions, policy development and access to comprehensive services, especially for midlife women from underserved groups.

Awareness of and willingness to use oral pre-exposure prophylaxis (PrEP) for HIV prevention among sexually active adults in Malawi: results from the 2020 Malawi population-based HIV impact assessment

BACKGROUND

The World Health Organization recommends Pre-Exposure Prophylaxis (PrEP) for all populations at substantial risk of HIV infection. Understanding PrEP awareness and interest is crucial for designing PrEP programs; however, data are lacking in sub-Saharan Africa. In Malawi, oral PrEP was introduced in 2018. We analyzed data from the 2020 Malawi Population-based HIV Impact Assessment (MPHIA) to assess PrEP awareness and factors associated with PrEP interest in Malawi.

METHODS

MPHIA 2020 was a national cross-sectional household-based survey targeting adults aged 15 + years. Oral PrEP was first described to the survey participants as taking a daily pill to reduce the chance of getting HIV. To assess awareness, participants were asked if they had ever heard of PrEP and to assess interest, were asked if they would take PrEP to prevent HIV, regardless of previous PrEP knowledge. Only sexually active HIV-negative participants are included in this analysis. We used multivariable logistic regression to assess sociodemographic factors and behaviors associated with PrEP interest. All results were weighted.

RESULTS

We included 13,995 HIV-negative sexually active participants; median age was 29 years old. Overall, 15.0%, 95% confidence interval (CI): 14.2-15.9% of participants were aware of PrEP. More males (adjusted odds ratio (aOR): 1.3, 95% CI: 1.2-1.5), those with secondary (aOR: 1.5, 95% CI: 1.2-2.0) or post-secondary (aOR: 3.4, 95% CI: 2.4-4.9) education and the wealthiest (aOR: 1.6, 95% CI: 1.2-2.0) were aware of PrEP than female, those without education and least wealthy participants, respectively. Overall, 73.0% (95% CI: 71.8-74.1%) of participants were willing to use PrEP. Being male (aOR: 1.2; 95% CI: 1.1-1.3) and having more than one sexual partner (aOR: 1.7 95% CI: 1.4-1.9), were associated higher willingness to use PrEP.

CONCLUSIONS

In this survey, prior PrEP knowledge and use were low while PrEP interest was high. High risk sexual behavior was associated with willingness to use PrEP. Strategies to increase PrEP awareness and universal access, may reduce HIV transmission.

PrEPare for Work: A Pilot Randomized Controlled Trial of an Intervention to Optimize HIV PrEP Outcomes Among Male Sex Workers

HIV pre-exposure prophylaxis (PrEP) use is limited among male sex workers, who are at exceptionally high-risk for HIV infection. We developed a theory-informed, two-pronged intervention ("PrEPare-for-Work") to optimize PrEP initiation and adherence among male sex workers, which was preliminarily evaluated in a two-stage pilot randomized controlled trial of 110 male sex workers in the US Northeast. Individuals randomized to the Stage 1 PrEPare-for-Work Case Management arm were three times as likely as those in the standard of care (SOC) arm to initiate PrEP (RR = 2.95, 95% CI = 1.57-5.57). Participants who initiated PrEP and were randomized to the Stage 2 PrEPare-for-Work Adherence Counseling arm had higher rates of prevention-effective adherence (measured via tenofovir in hair) compared to those in the SOC arm (RR = 1.7, 95% CI 0.64-4.77; 55.6% vs. 28.6%, respectively); though not statistically significant. Given the need and the promise of this pilot RCT, further efficacy testing is warranted and should be prioritized.

HIV risk perception, pre-exposure prophylaxis (PrEP) awareness, and PrEP initiation intention among women who use drugs

INTRODUCTION

Women who use drugs (WWUD) are prime candidates for pre-exposure prophylaxis (PrEP) due to their elevated risk of acquiring HIV through biological, behavioral, and contextual factors. However, PrEP uptake among WWUD remains low. The relationship between unhealthy drug use and correlates of PrEP uptake in this vulnerable population is not well defined. The purpose of this study is to characterize the relationships between specific types and routes of drug use and several precursors of PrEP uptake among WWUD.

METHODS

The study collected data via a computer-based survey from 233 women living in New York City and Philadelphia who participated in a study designed to develop and pilot a women-focused intervention for PrEP uptake. The sample of cisgender, HIV-negative women were not currently taking PrEP but considered PrEP eligible. This analysis is focused on women's HIV risk perception, PrEP awareness, PrEP initiation intention, and any use of the following drugs: barbiturates, benzodiazepines, crack cocaine, powder cocaine, hallucinogens, heroin, methamphetamines, and prescription opioids.

RESULTS

Within the three months prior to study enrollment, 63.1 % of participants reported any drug use; 42 % reported polydrug use; 19.8 % had injected drugs; 75 % reported getting high or drunk before sex; and 44 % had been enrolled in drug treatment. Of our total sample, 41.2 % perceived themselves at risk for HIV infection, 41.6 % were aware of PrEP prior to the study, and 62.7 % intended to initiate PrEP after they were informed. When compared to other PrEP-eligible women, women who reported prescription opioid use and polydrug use perceived themselves at higher risk for HIV infection and had higher intention to start PrEP. However, they and women who reported injecting drugs also reported lower awareness of PrEP.

CONCLUSION

These findings have implications for increasing education about PrEP and the various modes of HIV exposure to support PrEP uptake in this vulnerable population.

A Randomized Controlled Pilot Study of Just4Us, a Counseling and Navigation Intervention to Promote Oral HIV Prophylaxis Uptake Among PrEP-Eligible Cisgender Women

HIV pre-exposure prophylaxis (PrEP) uptake among cisgender women in the United States is low. Just4Us, a theory-based counseling and navigation intervention, was evaluated in a pilot randomized controlled trial among PrEP-eligible women (n = 83). The comparison arm was a brief information session. Women completed surveys at baseline, post-intervention, and at three months. In this sample, 79% were Black, and 26% were Latina. This report presents results on preliminary efficacy. At 3 months follow-up, 45% made an appointment to see a provider about PrEP; only 13% received a PrEP prescription. There were no differences in PrEP initiation by study arm (9% Info vs. 11% Just4Us). PrEP knowledge was significantly higher in the Just4Us group at post-intervention. Analysis revealed high PrEP interest with many personal and structural barriers along the PrEP continuum. Just4Us is a promising PrEP uptake intervention for cisgender women. Further research is needed to tailor intervention strategies to multilevel barriers.Clinicaltrials.gov registration NCT03699722: A Women-Focused PrEP Intervention (Just4Us).

HIV Prevention Services for Hispanic/Latino Persons in THRIVE, 2015-2020

INTRODUCTION

Hispanic/Latino men who have sex with men (MSM) and transgender women (TGW) are disproportionately affected by HIV in the U.S. This study evaluated HIV prevention services and outcomes among Hispanic/Latino MSM and TGW in the Targeted Highly Effective Interventions to Reduce the HIV Epidemic (THRIVE) demonstration project and consider lessons learned.

METHODS

The authors described the THRIVE demonstration project services provided to Hispanic/Latino MSM and TGW in 7 U.S. jurisdictions from 2015 to 2020. HIV prevention service outcomes were compared between 1 site with (2,147 total participants) and 6 sites without (1,129 total participants) Hispanic/Latino-oriented pre-exposure prophylaxis clinical services, and Poisson regression was used to estimate the adjusted RR between sites and pre-exposure prophylaxis outcomes. Analyses were conducted from 2021 to 2022.

RESULTS

The THRIVE demonstration project served 2,898 and 378 Hispanic/Latino MSM and TGW, respectively, with 2,519 MSM (87%) and 320 TGW (85%) receiving ≥1 HIV screening test. Among 2,002 MSM and 178 TGW eligible for pre-exposure prophylaxis, 1,011 (50%) MSM and 98 (55%) TGW received pre-exposure prophylaxis prescriptions, respectively. MSM and TGW were each 2.0 times more likely to be linked to pre-exposure prophylaxis (95% CI=1.4, 2.9 and 95% CI=1.2, 3.6, respectively) and 1.6 and 2.1 times more likely to be prescribed pre-exposure prophylaxis (95% CI=1.1, 2.2 and 95% CI=1.1, 4.1), respectively, at the site providing Hispanic/Latino-oriented pre-exposure prophylaxis clinical services than at other sites and adjusted for age group.

CONCLUSIONS

The THRIVE demonstration project delivered comprehensive HIV prevention services to Hispanic/Latino MSM and TGW. Hispanic/Latino-oriented clinical settings may improve HIV prevention service delivery to persons in Hispanic/Latino communities.

Peer-based interventions to support transgender and gender diverse people's health and healthcare access: A scoping review

Background: Pervasive health and healthcare disparities experienced by transgender (trans) and gender diverse (TGD) people require innovative solutions. Peer-based interventions may address disparities, and are an approach endorsed by TGD communities. However, the scope of the literature examining peer-based interventions to address health and healthcare access inclusive of TGD people is uncharted. Aim: This scoping review aimed to understand the extent of the literature about peer-based interventions conducted with and/or inclusive of TGD populations; specifically, study participants (e.g. sociodemographics), study designs/outcomes, intervention components (e.g. facilitator characteristics), and intervention effectiveness. Methods: Underpinned by Arksey and O'Malley's framework: (1) identifying the research question; (2) identifying studies; (3) study selection; (4) charting data; and (5) collating, summarizing, and reporting results, eligible studies were identified, charted, and thematically analyzed. Databases (e.g. ProQuest) and snowball searching were utilized to identify peer-reviewed literature published within 15 years of February 2023. Extracted data included overarching study characteristics (e.g. author[s]), methodological characteristics (e.g. type of research), intervention characteristics (e.g. delivery modality), and study findings. Results: Thirty-six eligible studies documented in 38 peer-reviewed articles detailing 40 unique peer-based interventions were identified. Forty-four percent (n = 16/36) of studies took place in United States (U.S.) urban centers. Over half (n = 23/40, 58%) focused exclusively on TGD people, nearly three-quarters of which (n = 17/23, 74%) focused exclusively on trans women/transfeminine people. Ninety-two percent (n = 33/36) included quantitative methods, of which 30% (n = 10/33) were randomized controlled trials. HIV was a primary focus (n = 30/36, 83.3%). Few interventions discussed promotion of gender affirmation for TGD participants. Most studies showed positive impacts of peer-based intervention. Discussion: Although promising in their effectiveness, limited peer-based interventions have been developed and/or evaluated that are inclusive of gender-diverse TGD people (e.g. trans men and nonbinary people). Studies are urgently need that expand this literature beyond HIV to address holistic needs and healthcare barriers among TGD communities.

A Capacity-Strengthening Intervention to Support HIV Pre-exposure Prophylaxis (PrEP) Awareness-Building and Promotion by Frontline Harm Reduction Workers in Baltimore, Maryland: A Mixed Methods Evaluation

Pre-exposure prophylaxis (PrEP) is a promising but underutilized HIV prevention tool among people who inject drugs (PWID). We developed and piloted an intervention to bolster PrEP promotion competencies among frontline harm reduction workers (FHRW) serving PWID clients in Baltimore, Maryland. Between December 2021 and February 2022, we developed and facilitated four trainings, which included didactic and practice-based/role-playing components, with 37 FHRW from four organizations. FHRW completed three structured surveys (pretest, posttest, 6-week posttest) and in-depth interviews (n = 14) to measure changes in PrEP promotion competencies attributable to training participation. PrEP knowledge and self-efficacy increased significantly (p < 0.001) from pretest to posttest, sustained through 6-week posttest. The proportion of FHRW discussing PrEP with clients doubled during the evaluation period (30-67%, p = 0.006). Feeling empowered to discuss PrEP and provision of population-tailored PrEP information were facilitators of PrEP promotion, while limited client interaction frequency/duration, privacy/confidentiality concerns, and anticipated PrEP stigma by clients inhibited PrEP promotion. Our capacity-strengthening intervention successfully increased PrEP knowledge, self-efficacy, and promotion among FHRW, affirming the adaptability and feasibility of integrating our training toolkit into FHRW practice across implementation settings.

Community-based respondent-driven sampling as a strategy for drug use surveillance in a large French urban area

BACKGROUND

Understanding drug use and behavior within the PWUD population is crucial to adapt harm reduction and prevention strategies, and provide improved addiction and medical treatment. However, in most countries such as France, the knowledge of drug use behaviors is likely biased as it originates from addiction centers which are attended by only an unknown proportion of PWUD. The objectives of this study were to describe drug use behavior in a population of active PWUD in the urban area of Montpellier, South of France.

METHODS

We implemented a community-based respondent-driven sampling survey (RDSS), a validated strategy to obtain a representative sample of a population, to recruit PWUD in the city. Adult individuals reporting frequent psychoactive drug use other than cannabis, with confirmation by urine test, were eligible. Beside HCV and HIV testing, trained peers interviewed participants on their drug consumption and behavior using standardized questionnaires. Fifteen seeds launched the RDSS.

RESULTS

During the 11 weeks of the RDSS, 554 actives PWUD were consecutively included. They were mostly men (78.8%), had a median age of 39 years, and only 25.6% had a stable living place. On average, participants consumed 4.7 (± 3.1) different drugs, and 42.6% smoked free-base cocaine. Unexpectedly, heroin and methamphetamine were consumed by 46.8% and 21.5% of participants, respectively. Among the 194 participants injecting drugs, 33% declared sharing their equipment.

CONCLUSION

This RDSS highlighted a high consumption of heroin, crack and methamphetamine in this PWUD population. These unexpected results can be explained by low attendance to addiction centers, the source of drug use reports. Despite free care and risk reduction equipment in the city, sharing was very frequent among injectors, challenging the current program of harm reduction.

A Novel Capacity-Strengthening Intervention for Frontline Harm Reduction Workers to Support Pre-exposure Prophylaxis Awareness-Building and Promotion Among People Who Use Drugs: Formative Research and Intervention Development

BACKGROUND

HIV prevalence among people who use drugs (PWUD) in Baltimore, Maryland, is higher than among the general population. Pre-exposure prophylaxis (PrEP) is a widely available medication that prevents HIV transmission, yet its usefulness is low among PWUD in Baltimore City and the United States. Community-level interventions to promote PrEP uptake and adherence among PWUD are limited.

OBJECTIVE

We describe the development of a capacity-strengthening intervention designed for frontline harm reduction workers (FHRWs) to support PrEP awareness-building and promotion among PWUD.

METHODS

Our study was implemented in 2 phases in Baltimore City, Maryland. The formative phase focused on a qualitative exploration of the PrEP implementation environment, as well as facilitators and barriers to PrEP willingness and uptake, among cisgender women who use drugs. This work, as well as the existing literature, theory, and feedback from our community partners, informed the intervention development phase, which used an academic-community partnership model. The intervention involved a 1-time, 2-hour training with FHRWs aimed at increasing general PrEP knowledge and developing self-efficacy promoting PrEP in practice (eg, facilitating PrEP dialogues with clients, supporting client advancement along a model of PrEP readiness, and referring clients to PrEP services). In a separate paper, we describe the conduct and results of a mixed methods evaluation to assess changes in PrEP-related knowledge, attitudes, self-efficacy, and promotion practices among FHRWs participating in the training.

RESULTS

The pilot was developed from October to December 2021 and implemented from December 2021 through April 2022. We leveraged existing relationships with community-based harm reduction organizations to recruit FHRWs into the intervention. A total of 39 FHRWs from 4 community-based organizations participated in the training across 4 sessions (1 in-person, 2 online synchronous, and 1 online asynchronous). FHRW training attendees represented a diverse range of work cadres, including peer workers, case managers, and organizational administrators.

CONCLUSIONS

This intervention could prevent the HIV burden among PWUD by leveraging the relationships that FHRWs have with PWUD and by supporting advancement along the PrEP continuum. Given suboptimal PrEP uptake among PWUD and the limited number of interventions designed to address this gap, our intervention offers an innovative approach to a burgeoning public health problem. If effective, our intervention has the potential to be further developed and scaled up to increase PrEP awareness and uptake among PWUD worldwide.

Experiences of Black Women in the United States Along the PrEP Care Continuum: A Scoping Review

Black women are disproportionately affected by HIV in the U.S. PrEP could decrease the risk of acquiring HIV. This scoping review seeks to understand the experiences of Black women along the PrEP Care Continuum. We searched PubMed, Embase, PsycInfo, and Google Scholar to identify peer-reviewed studies published between July 16, 2012, and December 15, 2021. Articles were included if they discussed PrEP among Black women in the U.S. Two authors screened titles/abstracts and full-text articles. One author extracted and thematically summarized findings (n = 33). Black women reported low levels of PrEP awareness and knowledge, and negative experiences with providers. Women also experienced negative perceptions of PrEP from their social networks, stigma, and mistrust. Future research should focus on helping Black women to overcome PrEP-related barriers. Additionally, future research should further examine barriers to PrEP initiation, adherence, and retention for Black women, as only three studies discussed these aspects of the Continuum.

Trends in preexposure prophylaxis use among sex partners as reported by persons with HIV - United States, May 2015-June 2020

OBJECTIVE

To estimate trends in the proportion of sexually active U.S. adults with HIV (PWH) reporting an HIV-discordant sexual partner taking preexposure prophylaxis (PrEP) and proportion of partners taking PrEP.

DESIGN

The Medical Monitoring Project is a complex sample survey of U.S. adults with diagnosed HIV.

METHODS

We used annual cross-sectional data collected during June 2015-May 2020 to estimate the annual percentage change (EAPC), overall and by selected characteristics, in reported partner PrEP use among PWH with HIV-discordant partners (N = 8707) and reported PrEP use among these partners (N = 15 844).

RESULTS

The proportion of PWH reporting PrEP use by one or more HIV-discordant sex partner rose 19.5% annually (11.3 to 24.4%). The prevalence rose from 6.0 to 17.4% (EAPC, 25.8%) among Black PWH, 10.1 to 26.0% (EAPC, 19.5%) among Hispanic/Latino PWH, and 20.8 to 34.6% (EAPC, 16.3%) among White PWH. Among MSM with HIV, the prevalence increased from 9.6 to 32.6% (EAPC, 28.2%) among Black MSM, 16.6 to 36.0% (EAPC, 15.6%) among Hispanic/Latino MSM, and 24.9 to 44.1% (EAPC, 17.9%) among White MSM. Among HIV-discordant sex partners, the proportion reported to be taking PrEP increased 21.1% annually (7.8 to 18.8%). Reported PrEP use rose from 4.9 to 14.2% (EAPC, 29.9%) among Black partners, 6.5 to 16.8% (EAPC, 20.3%) among Hispanic/Latino partners, and 12.7 to 26.1% (EAPC, 17.0%) among White partners.

CONCLUSIONS

One in five HIV-discordant sexual partners of PWH was reported to be taking PrEP. PrEP use rose among all examined populations, although the increases did not eliminate disparities in PrEP use.

Telemedicine Experience for PrEP Care among PrEP-Eligible Women and Their Primary Care Providers during the First Year of the COVID-19 Pandemic in the United States

(1) Background: During the two-year-long siege from the COVID-19 pandemic, a significant proportion of doctor visits transitioned from in-person to virtual. Scare evidence is available to assess the quality of patient-provider communication via the platform of telemedicine, especially for PrEP care within primary care settings. (2) Methods: Participants included 18 primary care providers and 29 PrEP-eligible women. Through content analysis and thematic analysis, facilitators and barriers embedded at different levels of telemedicine were identified and assessed. (3) Results: Women and providers reported pros and cons regarding their telemedicine experiences during the initial wave of COVID-19. Both groups of participants agreed that telemedicine visits were more convenient, efficient, and comfortable than in-person visits. However, without face-to-face interactions, some women felt less empathy, caring, and connected with their providers during virtual visits. Health providers expressed concerns with telemedicine, including patients’ privacy, lack of intimacy between patients and providers, and delayed lab work. (4) Conclusions: Our data indicate multi-level factors may affect telemedicine experience among PrEP-eligible women and health providers. Participants expressed concerns that may further entrench these long-existing health disparities in healthcare. Proactive efforts from policymakers, health professionals, researchers, and stakeholders are urgently required to tackle identified barriers and to pave the way for the new infrastructure that ensures health equity in society.

Where's the "Everyday Black Woman"? An intersectional qualitative analysis of Black Women's decision-making regarding HIV pre-exposure prophylaxis (PrEP) in Mississippi

BACKGROUND

Black cisgender women in the U.S. South bear a disproportionate burden of HIV compared to cisgender women in other racial and ethnic groups and in any other part of the US. Critical to decreasing new HIV infections is the improved delivery of pre-exposure prophylaxis (PrEP) for Black cisgender women as it remains underutilized in 2021. Informed by intersectionality, the study sought to characterize the sociostructural influences on Black cisgender women's deliberations about PrEP within the context of interlocking systems of oppression including racism, sexism, and classism.

METHODS

Six focus groups were conducted with 37 Black women residing in Jackson, Mississippi. This sample was purposively recruited to include Black cisgender women who were eligible for PrEP but had never received a PrEP prescription.

RESULTS

Six themes were identified as concerns during PrEP deliberation among Black women: 1) limited PrEP awareness, 2) low perceived HIV risk, 3) concerns about side effects, 4) concerns about costs, 5) limited marketing, and 6) distrust in the healthcare system. Three themes were identified as facilitators during PrEP deliberations: 1) women's empowerment and advocacy, 2) need for increased PrEP-specific education, and 3) the positive influence of PrEP-engaged women's testimonials. Black women shared a limited awareness of PrEP exacerbated by the lack of Black women-specific marketing. Opportunities to support Black women-specific social marketing could increase awareness and knowledge regarding PrEP's benefits and costs. Black women also shared their concerns about discrimination in healthcare and distrust, but they felt that these barriers may be addressed by patient testimonials from PrEP-engaged Black women, empowerment strategies, and directly addressing provider biases.

CONCLUSIONS

An effective response to PrEP implementation among Black women in the South requires developing programs to center the needs of Black women and carry out active strategies that prioritize peer advocacy while reinforcing positive and mitigating negative influences from broader social and historical contexts.

Examining the Influencing Factors of Chronic Hepatitis B Monitoring Behaviors among Asian Americans: Application of the Information-Motivation-Behavioral Model

Background: Compared to non-Hispanic whites, Asian Americans are 60% more likely to die from the disease. Doctor visitation for chronic hepatitis B (CHB) infection every six months is an effective approach to preventing liver cancer. Methods: This study utilized baseline data from an ongoing randomized controlled clinical trial aimed at improving long-term adherence to CHB monitoring/treatment. Guided by the information-motivation-behavioral skills (IMB) model, we examined factors associated with CHB monitoring adherence among Asian Americans with CHB. Multivariable logistic regression was conducted to test the associations. Results: The analysis sample consisted of 382 participants. Multivariable logistic regression showed that HBV knowledge (OR = 1.24, p < 0.01) and CHB-management motivation (OR = 1.06, p < 0.05) are significant predictors of having a doctor’s visit in the past six months. Both factors were positively associated with the likelihood of having had blood tests for HBV in the past six months. Conclusion: We found that greater HBV-related knowledge and CHB-management motivation are significantly associated with performing CHB-monitoring behaviors in the past six months. The findings have critical implications for the development and implementation of evidence-based interventions for CHB monitoring and liver cancer prevention in the Asian American community.

PrEP Care Continuum Engagement Among Persons Who Inject Drugs: Rural and Urban Differences in Stigma and Social Infrastructure

Pre-exposure prophylaxis (PrEP) is a medication that prevents HIV acquisition, yet PrEP uptake has been low among people who inject drugs. Stigma has been identified as a fundamental driver of population health and may be a significant barrier to PrEP care engagement among PWID. However, there has been limited research on how stigma operates in rural and urban settings in relation to PrEP. Using in-depth semi-structured qualitative interviews (n = 57) we explore PrEP continuum engagement among people actively injecting drugs in rural and urban settings. Urban participants had more awareness and knowledge. Willingness to use PrEP was similar in both settings. However, no participant was currently using PrEP. Stigmas against drug use, HIV, and sexualities were identified as barriers to PrEP uptake, particularly in the rural setting. Syringe service programs in the urban setting were highlighted as a welcoming space where PWID could socialize and therefore mitigate stigma and foster information sharing.

Individual, social and structural factors influencing PrEP uptake among cisgender women: a theory-informed elicitation study

The underutilization of pre-exposure prophylaxis (PrEP) among cisgender women in the U.S. limits this population's ability to reduce their risk for HIV infection, especially within the unique individual, social and structural systems they navigate. There is a need to identify the relevant multi-level barriers and facilitators to PrEP use among cisgender women to inform theory-guided efforts that address HIV disparities by race/ethnicity among cisgender women. Guided by the Integrated Behavioral Model and the Behavioral Model of Vulnerble Populations we conducted 41 interviews with PrEP eligible cisgender women in New York City and Philadelphia. Directed content analysis identified 11 modal behavioral beliefs crucial to PrEP uptake, including anticipated negative social consequences, 5 normative beliefs centered on available social supports, and 9 control beliefs such as anticipated barriers such as cost. Awareness and knowledge of PrEP as a biobehavioral HIV prevention method is limited for this sample. Through conventional content analysis we identified interpersonal and structural barriers to PrEP uptake including lack of partner support, transportation, mental health challenges, and challenges in accessing PrEP care. Potential solutions to structural barriers were enumerated along with implications for future intervention work and public health programming.

A Primary Care Intervention to Increase HIV Pre-Exposure Prophylaxis (PrEP) Uptake in Patients with Syphilis

Identifying candidates for HIV pre-exposure prophylaxis (PrEP) is a barrier to improving PrEP uptake in priority populations. Syphilis infection is an indication for PrEP in all individuals and can be easily assessed by primary care providers (PCP) and health systems. This retrospective study evaluated the impact of a multidisciplinary provider outreach intervention on PrEP uptake in patients with a positive syphilis test result in a safety-net hospital-based primary care practice. The PCPs of PrEP-eligible patients with a positive syphilis result were notified via the electronic medical record (EMR) about potential PrEP eligibility and institutional HIV PrEP resources. Rates of PrEP offers and prescriptions were compared in the pre (8/1/2018-12/31/2018, n = 60) and post (1/1/2019-5/31/2019, n = 86) intervention periods. Secondary analyzes evaluated receipt of appropriate syphilis treatment and contemporaneous screening for HIV, gonorrhea, and chlamydia. No significant differences in the overall proportion of patients offered (15% vs 19%) and prescribed (7% vs 5%) PrEP were observed between the pre- and post-periods. Overall, 7% of positive tests represented infectious syphilis. The rate of appropriate syphilis treatment was equivalent (57% vs 56%) and contemporaneous screening for other sexually transmitted infections was suboptimal across the entire study period. Although any positive syphilis test may be an easily abstracted metric from the EMR, this approach was inclusive of many patients without current HIV risk and did not increase PrEP uptake significantly. Future research into population health approaches to increase HIV prevention should focus on patients with infectious syphilis and other current risk factors for incident HIV infection.

“I do the she and her”: A qualitative exploration of HIV care providers’ considerations of trans women in gender-specific HIV care

Objectives:

Women of all genders, including cisgender (cis) and transgender (trans) women, experience social and structural drivers of HIV inequities and pervasive barriers to HIV care. Yet, little is known about how HIV care providers address gender diversity in health care. Through a critical feminist lens informed by intersectionality theory, medical anthropology, and critical sociology, we explored (1) how do HIV care providers describe women living with HIV’s care needs and barriers; (2) what are their perspectives on optimal HIV care for women; and (3) to what extent do these conceptualizations include/exclude trans women.

Methods:

Utilizing a community-based exploratory qualitative study design, we conducted 60–90 minute semi-structured individual interviews from March 2019–April 2020 with eight HIV care providers (n = 4 social service providers; n = 4 physicians) practicing across seven counties representative of rural, suburban, and urban Michigan, United States. Data were analyzed utilizing a reflexive thematic approach.

Results:

Three overarching themes emerged: (1) Emphasis on (different) clinical needs: key considerations in cis and trans women’s HIV care; (2) Recognition of the structural: barriers to HIV care affecting women of all genders; and (3) Proposed solutions: piecing together individual, social, and organizational interventions to increase access to HIV care that may benefit women living with HIV of all genders but are disproportionately framed as being for cis women. While HIV care providers recognized both cis and trans women living with HIV’s clinical care needs and structural barriers to care, they rarely envisioned optimal HIV care inclusive of gender affirmation and structural interventions.

Conclusions:

Findings suggest that HIV care providers can avoid reducing gender to biology and making assumptions about reproductive care needs, endocrinological care needs, caregiving responsibilities, and other life circumstances; provide gender-affirming medical care; and address structural barriers to HIV care to enhance intersectional and structurally focused gender-affirming—that is, trans-inclusive—women-centered HIV care.

An Integrated Conceptual Framework of Behavioral Intervention Technologies to Promote Healthcare Utilization Among Socially-Marginalized Populations in the United States

In the U.S., socially marginalized groups disproportionately shoulder the burden of health outcomes. The evolving development of behavioral intervention technologies provides opportunities to support users in changing behaviors and improving health. No conceptual model is available to guide technology-based behavioral interventions among vulnerable groups in the new era of digitalization. Our conceptual framework combines the Behavioral Model of Healthcare Utilization (HCU) for Vulnerable Populations and the Integrated Model of Behavioral Prediction (IMBP). With the Socioecological Model leading the vertical direction, the overarching HCU-IBMP model is incorporated by the Behavioral Intervention Technology-Technological Instantiation Framework (BIT-Tech). The HCU model explains how vulnerable populations influence healthcare access and utilization behaviors by personal and contextual factors. Through the lens of the IMBP, healthcare utilization intention is highly predictable and maybe even causally correlated with the corresponding behavior. To assist the healthcare utilization intention translates into the corresponding behaviors, we employ a medium using the technological implementation in a system that can assist the end-users in adopting the desired behavior. With the integrated model that combines a technological framework with the behavioral components, the BIT-Tech guides the procedure intervention development. Our integrated conceptual framework indicated that theoretical and technical components should be considered during a technological tool development to support the research community. A real-world intervention design has been demonstrated using the framework to guide behavioral intervention technologies to promote PrEP care and utilization among racial/ethnic minority women in the U.S.

Novel Platforms for Biomedical HIV Prevention Delivery to Key Populations - Community Mobile Clinics, Peer-Supported, Pharmacy-Led PrEP Delivery, and the Use of Telemedicine

PURPOSE OF REVIEW

A gap exists between PrEP interest and PrEP uptake in key populations (KP) for HIV prevention that may be ascribed to PrEP delivery services not being acceptable. This review summarizes novel platforms for HIV prevention outside of the traditional health facilities environment.

RECENT FINDINGS

Mobile health clinics provide highly acceptable integrated, KP-focused services at convenient locations with the potential of high PrEP uptake. Telemedicine and health apps decongest health systems and allow for personal agency and informed decision-making on personal health. Pharmacy-led PrEP delivery provides de-medicalized, confidential PrEP services at extended hours in community locations, from trusted medical professionals. Peer-supported delivery encourages continued PrEP use. Community-based, differentiated and de-medicalized PrEP delivery can address uptake and continued use barriers in key populations. Future research should assess scalability, cost-effectiveness and sustainability of these PrEP delivery platforms, as well as focus on ways to simplify PrEP provision.

Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention

Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention’s women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women’s focus; and consider providing same-day PrEP.

The Influence of PrEP-Related Stigma and Social Support on PrEP-Use Disclosure among Women Who Inject Drugs and Social Network Members

Pre-exposure prophylaxis (PrEP) is a promising but underutilized HIV prevention strategy for Women who Inject Drugs (WWID). Stigma and disclosure concerns have been key barriers to PrEP use among women in PrEP efficacy trials. Social support has been found to buffer against some PrEP stigma, though these factors have been largely unexplored among WWID. Investigating how WWID disclose PrEP use is important given evidence that disclosure is associated with higher adherence. We aimed to identify the impact of stigma and support on PrEP disclosure within social networks of WWID participating in a PrEP demonstration project in Philadelphia, PA, USA. PrEP-using WWID ≥ 18 years completed social network surveys. Generalized estimating equations were used to account for the correlation of network structure. Thirty-nine WWID (i.e. egos) named an average of 9.5 ± 3.3 network members (i.e. alters), for a total sample of 371 unique relationships. Egos disclosed their PrEP use to an average of 4.0 alters (SD = 2.8). Related to PrEP stigma, participants had 0.4 times decreased odds of PrEP disclosure with alters who would disapprove of them taking PrEP (95% CI: 0.1-0.9). Related to support, participants had 2.5 times higher odds of disclosure among peers who could provide PrEP advice (95% CI: 1.0-6.0). Interventions that increase social support and decrease stigma are pivotal for increasing PrEP use disclosure among WWID.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.

Toward Greater Pre-exposure Prophylaxis Equity: Increasing Provision and Uptake for Black and Hispanic/Latino Individuals in the U.S

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition and is a critical tool in the Ending the HIV Epidemic in the U.S. initiative. However, major racial and ethnic disparities across the pre-exposure prophylaxis continuum, secondary to structural inequities and systemic racism, threaten progress. Many barriers, operating at the individual, network, healthcare, and structural levels, impede PrEP access and uptake within Black and Hispanic/Latino communities. This review provides an overview of those barriers and the innovative and collaborative solutions that health departments, healthcare organizations, and community partners have implemented to increase PrEP provision and uptake among disproportionately affected communities. Promising strategies at the individual and network levels focus on increasing patient support throughout the PrEP continuum, positioning and training community members to expand knowledge of and interest in PrEP, and leveraging mobile technologies to support PrEP uptake. Healthcare-level solutions include expanding the venues and types of healthcare professionals that can provide PrEP, and structural- and policy-level options focus on financial assistance programs and health insurance expansion. Key research gaps include demonstrating that pilot studies and interventions remain effective at scale and across varied contexts. Although the last 2 decades have provided effective tools to end the HIV epidemic, realizing this vision for the U.S. will require addressing persistent and pervasive HIV-related disparities in Black and Hispanic/Latino communities. Federal, state, and local partners should expand efforts to address longstanding health and structural inequities and partner with disproportionately affected communities to rapidly expand PrEP scale-up.

A Scoping Review Investigating Relationships between Depression, Anxiety, and the PrEP Care Continuum in the United States

Men who have sex with men and transgender women in the United States are at increased risk for HIV and may benefit from pre-exposure prophylaxis (PrEP), a once-a-day pill to prevent HIV. Due to stigma and discrimination, sexual and gender minority (SGM) populations are also at risk for depression and anxiety. This scoping review sought to identify literature addressing relationships between the PrEP care continuum, depression, and anxiety among SGM individuals and others at high risk for HIV. We conducted a systematic review of four databases (i.e., PubMed, PsycInfo, Web of Science, Google Scholar) and identified 692 unique articles that were screened for inclusion criteria, with 51 articles meeting the final inclusion criteria. Data were extracted for key study criteria (e.g., geographic location, participant demographics, study design, main findings). Results suggest that while depression and anxiety are not associated with PrEP awareness or willingness to use, they can be barriers to seeking care and to PrEP adherence. However, empirical studies show that taking PrEP is associated with reductions in anxiety. Findings suggest the need to implement mental health screenings in PrEP clinical care. In addition, addressing systemic and structural issues that contribute to mental health disorders, as well as PrEP-related barriers, is critical.

The Past, Present, and Future of PrEP implementation Among People Who Use Drugs

PURPOSE OF REVIEW

Recent HIV outbreaks among people who use drugs (PWUD) necessitate additional HIV prevention tools. Pre-exposure prophylaxis (PrEP) is highly efficacious yet uptake among PWUD remains exceedingly low. To address multilevel, complex barriers to PrEP use among PWUD, a range of intervention strategies are needed.

RECENT FINDINGS

The literature on interventions to optimize PrEP use among PWUD is nascent, comprising small pilots and demonstration projects in early phases of intervention development. Initial studies suggest that structural, healthcare, interpersonal, and individual-level interventions can improve PrEP use for PWUD, and a number of efficacy trials are underway. Future studies are needed to optimize the use of new PrEP modalities (e.g., injectable PrEP), simultaneously target multilevel challenges to PrEP use, and evaluate the integration of PrEP into other service settings and substance use treatment modalities.