Access to HIV Pre-exposure Prophylaxis in Practice Settings: a Qualitative Study of Sexual and Gender Minority Adults' Perspectives

Advancing the community plan to end the HIV Epidemic in Philadelphia: a qualitative descriptive evaluation of low-threshold PrEP services in sexual health clinics

BACKGROUND

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method and a key component of Philadelphia's Community Plan to End the HIV Epidemic (EHE). However, significant barriers to accessing PrEP exist among people at risk for HIV. Low-threshold models for PrEP services that minimize barriers to entry and service engagement could help bolster access to PrEP through community-based clinics. This study aimed to describe the initial implementation of low-threshold PrEP services in three sexual health clinics funded by the Philadelphia Department of Public Health and explore strategies for delivering low-threshold PrEP services.

METHODS

We conducted three focus groups with staff (i.e., providers, prevention navigators, and administrative staff, N = 21) at each of three participating PDPH-funded sexual health clinics from November 2021 to January 2022. Discussion topics included details about the PrEP delivery process, clinic strengths and assets, resource gaps, and PrEP implementation goals. Follow-up interviews with staff members (N = 8) between March 2022 and May 2022 focused on identifying successful strategies for PrEP delivery and adaptations needed to optimize low-threshold PrEP service delivery. Rapid qualitative methods and the Consolidated Framework for Implementation Science were used to analyze data from focus groups and interviews.

RESULTS

Participants collaborated to create process maps that visualized the steps involved in delivering PrEP services within their respective settings. These maps highlighted several stages in PrEP service delivery, such as connecting individuals to services, providing prevention navigation, conducting clinical encounters, and ensuring follow-up care. Participants described effective strategies for implementing PrEP, which included integrating and co-locating services on-site, strengthening staffing resources and capacity, and addressing barriers experienced by clients.

CONCLUSIONS

Lessons from the implementation of low-threshold PrEP service delivery in Philadelphia can guide ongoing local adaptations and future scale-up of these models to improve access to PrEP and advance the goals of the EHE initiative.

Barriers to Pre-Exposure Prophylaxis (PrEP) use for HIV: an integrative review

OBJECTIVES

to identify and synthesize scientific evidence on the barriers and difficulties for Pre-exposure Prophylaxis (PrEP) use and compliance for HIV.

METHODS

an integrative literature review, using the MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier and Scopus (Elsevier) databases.

RESULTS

all (100%) the articles included identified that PrEP users experience some type of structural barrier related to health services such as long distance from the units, suboptimal logistics for taking pills and professional resistance to prescribing PrEP. Furthermore, 63.21% identified social barriers, such as stigma about sexuality and HIV, in addition to individual barriers such as alcohol use, adverse effects, and concerns about long-term toxicity.

CONCLUSIONS

the barriers to PrEP use are multifactorial. Effective interventions are needed to support PrEP users in accessing, complying with, and retaining health services.

Loss to Follow-Up from HIV Pre-Exposure Prophylaxis Care in Men Who Have Sex with Men in West Africa

Loss to follow-up (LTFU) from HIV pre-exposure prophylaxis (PrEP) care compromises the goal of HIV elimination. We investigated the proportion of LTFU and associated risk factors among men who have sex with men (MSM) enrolled in a PrEP demonstration project in Burkina Faso, Côte d'Ivoire, Mali, and Togo. CohMSM-PrEP, a prospective cohort study, was conducted between November 2017 and June 2021 in community-based clinics. MSM aged 18 years or older at substantial risk of HIV infection received a comprehensive prevention package, including PrEP and peer education. LTFU was defined as not returning to the clinic for six months. Associated risk factors were investigated using a time-varying Cox's model. Of 647 participants followed up for a median time of 15 months, 372 were LTFU (57.5%). LTFU was associated with younger age (adjusted hazard ratio [95% Confidence Interval]; 1.50 [1.17-1.94]), unemployment (1.33 [1.03-1.71]), depression (1.63 [1.12-2.38]), and perceiving no HIV risk with stable male partners (1.61 [1.23-2.10]). Contacting peer educators outside of scheduled visits was protective (0.74 [0.56-0.97]). Our findings show that LTFU from PrEP care in West African MSM is a major challenge to achieving HIV elimination, but that the involvement of peer educators in PrEP delivery helps to limit LTFU by providing users with adequate support.

Pharmacy-Based Interventions to Increase Use of HIV Pre-exposure Prophylaxis in the United States: A Scoping Review

HIV pre-exposure prophylaxis (PrEP) remains underutilized in the U.S. Since greater than 85% of PrEP prescriptions are filled at commercial pharmacies, pharmacists are uniquely positioned to increase PrEP use. This scoping review explores pharmacy-based initiatives to increase PrEP use. We searched PubMed, PsycINFO, CINAHL, and Scopus for peer-reviewed studies on pharmacist-led interventions to increase PrEP use or pharmacy-based PrEP initiatives. Forty-nine articles were included in this review. Overall, studies demonstrated that patients expressed strong support for pharmacist prescription of PrEP. Three intervention designs compared changes in PrEP initiation or knowledge pre- and post-intervention. Commentary/review studies recommended PrEP training for pharmacists, policy changes to support pharmacist screening for HIV and PrEP prescription, and telemedicine to increase prescriptions. Pharmacists could play key roles in improving PrEP use in the U.S. Studies that assess improvements in PrEP use after interventions such as PrEP prescription, PrEP-specific training, and adherence monitoring by pharmacists are needed.

Prevalence and correlates of having sexual and reproductive health priorities met by HIV providers among women living with HIV in a Canadian setting

OBJECTIVE

To: (1) describe the prevalence of key reproductive health outcomes (e.g., pregnancy, unintended pregnancy; abortion); and (2) examine social-structural correlates, including HIV stigma, of having key sexual and reproductive health (SRH) priorities met by participants' primary HIV provider, among women living with HIV.

METHODS

Data were drawn from a longitudinal community-based open cohort (SHAWNA) of women living with HIV. The associations between social-structural factors and two outcomes representing having SRH priorities met by HIV providers ('being comfortable discussing sexual health [SH] and/or getting a Papanicolaou test' and 'being comfortable discussing reproductive health [RH] and/or pregnancy needs') were analyzed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios (AOR) and 95% confidence intervals [95% CIs] are reported.

RESULTS

Of 314 participants, 77.1% reported having SH priorities met while 64.7% reported having RH priorities met by their primary HIV provider at baseline. In multivariable analysis, having SH priorities met was inversely associated with: sexual minority identity (AOR: 0.59, 95% CI: 0.37-0.94), gender minority identity (AOR: 0.52, 95% CI: 0.29-0.95) and recent verbal or physical violence related to HIV status (AOR: 0.55, 95% CI: 0.31-0.97) and positively associated with recently accessing women-centred services (Oak Tree Clinic) (AOR: 4.25, 95% CI: 2.20-8.23). Having RH priorities met was inversely associated with: sexual minority identity (AOR: 0.56, 95% CI: 0.40-0.79), gender minority identity (AOR: 0.45, 95% CI: 0.25-0.81) and being born in Canada (AOR: 0.29, 95% CI: 0.15-0.56) and positively associated with recently accessing women-centred services (AOR: 1.81, 95% CI: 1.29-2.53) and a history of pregnancy (AOR: 2.25, 95% CI: 1.47-3.44).

CONCLUSION

Our findings suggest that there remain unmet priorities for safe SRH care and practice among women living with HIV, and in particular, for women living with HIV with sexual and/or gender minority identity and those who experience enacted HIV stigma. HIV providers should create safe, non-judgmental environments to facilitate discussions on SRH. These environments should be affirming of all sexual orientations and gender identities, culturally safe, culturally humble and use trauma-informed approaches.

Salient Constructs for the Development of Shared Decision-Making Tools for HIV Pre-Exposure Prophylaxis Uptake and Regimen Choice: Behaviors, Behavioral Skills, and Beliefs

The availability of multiple pre-exposure prophylaxis (PrEP) regimens creates a preference-sensitive choice for individuals weighing alternative HIV prevention strategies. Investigating factors that are associated with PrEP uptake and regimen choice are key to developing tools to support that decision. A cross-sectional survey was offered to 536 participants in a PrEP demonstration project for gay, bisexual, and other men who have sex with men across 3 cities in China, of which 412 completed surveys and were included in the analysis. We conducted bivariable analyses followed by multi-variable logistic regressions to examine factors associated with overall PrEP uptake and PrEP regimen choice. Among the 412 participants, 36.9% were daily PrEP users, 28.4% were event-driven users, and 34.7% were non-PrEP users. Higher levels of education, lower PrEP use stigma, and higher perceived benefits of PrEP were associated with greater PrEP uptake. More frequent sex, higher PrEP adherence self-efficacy, higher endorsement of the belief in elevated efficacy of daily over on-demand PrEP, and lower endorsement of a desire for a PrEP method that is only taken when needed led to greater odds of choosing the daily PrEP regimen. As multiple HIV prevention modalities become available, there is a greater need for a shared decision-making approach to support this preference-sensitive choice of HIV prevention method. Our findings suggest salient constructs to inform the development of shared decision-making tools to support regimen choice.

"I Just Decided to Stop:" Understanding PrEP Discontinuation Among Individuals Initiating PrEP in HIV Care Centers in Kenya

BACKGROUND

Preexposure prophylaxis (PrEP) discontinuation rates in clinical trials and demonstration projects have been well characterized; however, little is known about discontinuation in routine public health settings in sub-Saharan Africa. Understanding discontinuation in nonstudy settings is important for establishing expectations for PrEP continuation in national programs and for facilitating effective PrEP scale-up.

METHODS

We conducted in-depth interviews with 46 individuals who had initiated PrEP at 25 HIV comprehensive care clinics (CCCs) in central and western Kenya and whose clinic records indicated they had discontinued.

RESULTS

Many of our study participants discontinued PrEP when their perceived risk decreased (eg, hiatus or end of a sexual relationship or partner known to be living with HIV became virally suppressed). Others reported discontinuation due to side effects, daily pill burden, preference for condoms, or their partner's insistence. Participant narratives frequently described facility level factors such as stigma-related discomforts with accessing PrEP at CCCs, inconvenient clinic location or operating hours, long wait times, and short refill dates as discouraging factors, suggesting actionable areas for improving PrEP access and continuation.

CONCLUSION

Clients frequently make intentional decisions to discontinue PrEP as they weigh different prevention options within the context of complex lives. Many clients will decide to discontinue PrEP when perceiving themselves to be at reduced risk and PrEP counseling must include provisions for addressing seasons of risk. PrEP will not be the right prevention method for everyone, or forever. Expanding PrEP access points and increasing sex-positive messaging may facilitate PrEP being a better option for many.

"Belt and braces approach; added benefit and … extra reassurance": a multi-stakeholder examination of the challenges to effective provision of pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Northern and Central England

Pre-exposure prophylaxis (PrEP) involves HIV negative individuals taking antiretroviral drugs to reduce the probability of infection if exposed and is available through the IMPACT trial in England. This study aimed to explore men who have sex with men (MSM) and service provider (SP) perspectives on provision and accessibility of PrEP in Northern and Central England. Twenty MSM and 25 SPs from four Northern cities and one city in the West Midlands region were recruited for semi-structured interviews (December 2018 to October 2019). Interviews were analysed using Interpretative Phenomenological Analysis (IPA). Three key themes emerged: "Self-sourcing PrEP"; "Service delivery learnings"; and "Impact of using PrEP". Problems with equity of access and accessibility were noted, and recommendations for the future of PrEP programming and equitable service delivery were also presented. The study highlighted divergence in PrEP service experience from patients and providers, with results informing policy, practice and professional training.

Epidemiological Characteristics of Infectious Diseases Among Travelers Between China and Foreign Countries Before and During the Early Stage of the COVID-19 Pandemic

Background: International travel during the Coronavirus disease 2019 (COVID-19) pandemic carries a certain magnitude of infection risk both to travelers and their destination, which may be difficult to assess in the early stage. The characteristics of common infectious diseases of tourists may provide some clues to identify the high-risk travelers and protect susceptible population. Methods: From among 48,444 travelers screened at Shanghai Port, we analyzed 577 travelers with 590 infectious diseases for age, sex, disease type, and World Health Organization (WHO) regions. We used the Joinpoint Regression Program to identify the average percent changes (APC) in the various trends among these individuals. Results: Hepatitis B, syphilis, and HIV were the most common infectious diseases in travelers entering China, and Hepatitis B, pulmonary tuberculosis, and syphilis in Chinese nationals traveling abroad (overall detection rates, 1.43 and 0.74%, respectively; P < 0.05). Africa (2.96%), the Americas (1.68%), and the Western Pacific (1.62%) exhibited the highest detection rates. This trend did not decrease since the COVID-19 pandemic (P > 0.05) and rather showed an upward trend with increasing age [APC 95% CI = 5.46 (3.41,7.56)%, P < 0.05]. However, there were no evident trends in monthly infection rates of travelers exiting and entering China from different WHO regions (all P > 0.05). Conclusion: Travelers always carry a transmission risk of common infectious diseases. It may be reasonable to adjust strategies for airport screening and quarantine according to the age and departure area of travelers to prevent and control new infectious diseases.

Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Men Who Have Sex with Men (MSM): A Scoping Review on PrEP Service Delivery and Programming

Pre-exposure prophylaxis (PrEP) is an evidence-based new biomedical HIV prevention intervention, which involves the pre-emptive use of daily (or event-based) antiretroviral drugs, to reduce risk of HIV acquisition if exposed. PrEP has recently been positioned as an integral prevention tool to reduce HIV acquisition risk among men who have sex with men (MSM) at country-level and within global prevention strategies. Given this global scale up of PrEP, we conducted a scoping review of extant international literature documenting service related perspectives, models and lessons learnt in PrEP programming for MSM. A systematic search of literature was conducted, and restricted to English language records in the timeframe 2008 to February 2019. Eligibility criteria centered on whether studies broadly described PrEP programming and service delivery for MSM as well as health communication. Following exclusion of ineligible records and removal of duplicates, 84 records were charted and thematically analysed according to scoping review methods. Four themes emerged from the thematic analysis of data; 'PrEP service aspects, settings and staff'; 'PrEP prescriber experiences, therapeutic alliance and care planning'; 'PrEP adherence within formal service structures'; and 'Multi-disciplinary and innovative PrEP care pathways'. The review highlights the complexities in providing optimal PrEP services for MSM by mapping and illustrating the importance of understanding the informal and formal routes to PrEP use among this HIV risk population; the barriers to uptake; the requirement for the presence of a positive therapeutic alliance between patient and prescriber in supporting patient initiation and adherence to PrEP regimes; and the need for availability in different culturally and ethnically sensitive models of PrEP service delivery according to low to high risk groups within the MSM communities.

Facilitators and Barriers of Pre-exposure Prophylaxis (PrEP) Uptake Among Rural Men who have Sex with Men Living in the Midwestern U.S

Facilitators and barriers of Pre-exposure Prophylaxis (PrEP) uptake have been established in prior studies; however, most of these studies comprise samples of MSM from metropolitan cities and hypothetical PrEP use. There is a dearth of literature on the uptake factors among rural U.S. MSM who are prescribed PrEP. Thirty-four rural Midwestern MSM who currently take PrEP participated in semi-structured telephone interviews about their barriers and facilitators to their PrEP use. Interviews were analyzed using an inductive thematic analysis approach. There were four barriers: (1) lack of rural dissemination of PrEP information, (2) concern about side and adverse effects of using PrEP, (3) cost of PrEP uptake and engagement, and (4) lack of access to PrEP care and PrEP care quality. Individual and social facilitators that participants utilized to overcome these barriers are discussed. Findings elevate the importance of multilevel interventions that address PrEP adoption from a patient, provider, and healthcare system perspective.

Characteristics Associated with Trust in and Disclosure of Sexual Behavior to Primary Care Providers Among Gay, Bisexual, and Other Men Who Have Sex with Men in the United States

Purpose: Characteristics associated with having a primary care provider (PCP), patient-provider trust, and sexual behavior disclosure were examined among men who have sex with men (MSM). Methods: MSM (N = 4239) were surveyed regarding demographic, behavioral, and medical characteristics. Multivariable logistic regression analyses were used. Results: Among 86.3% of MSM with a PCP, characteristics associated with lower patient-provider trust included younger age, Asian, bisexual, HIV-negative-not-on-pre-exposure prophylaxis, HIV-unknown, and lower medical literacy; with nondisclosure: Asian, bisexual, straight, HIV-negative, HIV-unknown, fewer partners, recruitment source, lower medical literacy, and lower patient-provider trust. Conclusion: Medical literacy and patient-provider trust are promising points of intervention to improve health outcomes among MSM.

"Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.

Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis

BACKGROUND

Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV; however, its uptake remains modest. Given that there are fewer cost barriers to receiving PrEP within VHA than via commercial insurance, VHA represents an ideal setting in which to study other barriers that may impact patients seeking PrEP.

OBJECTIVE

We sought to understand potential barriers to obtaining PrEP within the Veterans Health Administration (VHA) through examination of documentation in electronic medical records.

DESIGN

Retrospective structured chart review, including chart abstractions of notes, referrals, and communications; content analysis of charts from a subsample of patients receiving PrEP in VHA.

PARTICIPANTS

One hundred sixty-one patients prescribed PrEP at 90 sites varying in PrEP prescribing rates.

APPROACH

We extracted descriptive information and conducted a qualitative analysis of all PrEP-relevant free-text notes including who initiated the PrEP conversation (patient vs. provider), time interval between request and prescription, reasons for denying PrEP, and patient responses to barriers.

KEY RESULTS

Patients initiated 94% of PrEP conversations and 35% of patients experienced delays receiving PrEP ranging from six weeks to 16 months. Over 70% of cases evidenced barriers to access. Barriers included provider knowledge gaps about PrEP, provider knowledge gaps about VHA systems related to PrEP, confusion or disagreement over clinic purview for PrEP, and provider attitudes or stigma associated with patients seeking PrEP.

CONCLUSIONS

Although PrEP is recommended for HIV prevention in high-risk persons, many PrEP-eligible individuals faced barriers to obtaining a prescription. Current practices place substantial responsibility on patients to request and advocate for this service, in contrast to many other preventive services. Understanding the prevalence and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission.

Exploring the Pre-exposure Prophylaxis (PrEP) Health Care Experiences Among Men Who Have Sex With Men (MSM) Who Live in Rural Areas of the Midwest

Most pre-exposure prophylaxis (PrEP) research samples men who have sex with men (MSM) who live in metropolitan cities. There is a limited understanding of the PrEP experiences among rural MSM. Thirty-four semi-structured interviews were conducted to explore the PrEP health care experiences among 34 rural Midwestern MSM. Of the 34 participants, 23 obtained PrEP from their non-primary care provider (PCP). Three themes were present: (1) PrEP is unavailable in rural areas, (2) PrEP is inaccessible in rural areas due to PCPs being unwilling to prescribe PrEP, and (3) PrEP services are unamicable in rural areas due to stigmatizing attitudes and behaviors of PCPs. It is important to address PrEP care continuum factors in all settings; however, these factors are often exacerbated in rural areas due to social determinants. Without further research and programming, organizational and social determinants may contribute to lower rates of PrEP outcomes in rural areas.