Informing the future of PrEP navigation: Findings from a five-site cluster evaluation

Perceived risks and benefits of telePrEP interventions: An interview study with rural sexual minority men in Texas

PURPOSE

Many rural areas lack brick-and-mortar HIV prevention resources despite the increasing rates of HIV. Although online HIV pre-exposure prophylaxis (PrEP) programs can potentially increase uptake among rural sexual minority men (SMM), their attitudes and preferences regarding telehealth-based PrEP (telePrEP) programming are uncertain. This qualitative study examined rural SMM's perceived risks and benefits of participating in a hypothetical telePrEP program.

METHODS

Twenty rural SMM living in Texas completed a semi-structured online videoconferencing interview between April 12 and June 14, 2023. Data were analyzed with reflexive thematic analysis.

FINDINGS

Four themes were constructed: (1) telePrEP interventions increase accessibility but completely online services might be inadequate; (2) telePrEP and mail-order interventions are convenient but face challenges; (3) telePrEP interventions need to address confidentiality and privacy within the context of the sociopolitical climate; and (4) telePrEP interventions need to address trustworthiness and transparency.

CONCLUSIONS

Overall, our results indicate that rural SMM perceive telePrEP interventions that provide at-home and telehealth PrEP, HIV testing, and HIV care services as beneficial. However, overall utility and acceptability depend on perceptions of privacy, confidentiality, trustworthiness, and transparency. Given the HIV prevention and treatment service deserts in which many rural SMM live, telePrEP interventions must purposefully demonstrate how their operations and data will remain safe and secure. Further work should explore contextual or situational factors that influence the willingness and acceptability of rural SMM to participate in online HIV prevention intervention research studies.

Perceived Versus Actual Costs of HIV Pre-Exposure Prophylaxis Among Gay, Bisexual, and Other Men Who Have Sex with Men in the United States

Gay, bisexual, and other men who have sex with men (GBMSM) account for the highest proportion of HIV diagnoses in the United States, with daily pre-exposure prophylaxis (PrEP) significantly reducing transmission risk. Since 2021, the Affordable Care Act rules have required PrEP and accompanying care visits to be free for most Americans; nevertheless, insurers have found ways to circumvent no-cost PrEP and some employers are receiving exemptions from including it in their formularies. Despite this, perceived costs and indirect expenses still hinder PrEP adoption. This study examines the differences between perceived and actual costs among GBMSM who have and have not used PrEP. We conducted a one-time online survey with 692 adults from six New England states between May 2020 and October 2021. Participants who had never used PrEP estimated its cost, while those with prior PrEP experience reported their actual expenses. Bivariate analysis and multi-variable logistic regression were used to assess the data. Results showed a 60% difference between perceived ($48) and actual ($30) median monthly costs. Higher perceived costs among nonusers were linked to race and income, while high actual costs for prior users were associated with insurance type, income, wealth, race, and self-rated consumer credit. This significant disparity in PrEP cost perceptions highlights the need for targeted outreach and messaging to improve PrEP uptake among at-risk populations who have not yet accessed it.

PrEP facilitators and barriers in substance use bridge clinics for women who engage in sex work and who use drugs

BACKGROUND

Women who engage in sex work and use drugs (WSWUD) experience disproportionate HIV risks. Substance use treatment bridge clinics offer an opportunity to increase HIV pre-exposure prophylaxis (PrEP) delivery to WSWUD, but research on best practices is lacking. Therefore, we explored facilitators and barriers to PrEP across the PrEP care continuum in these settings.

METHODS

Bridge clinic and affiliated harm reduction health service providers and WSWUD from Boston were recruited using passive and active outreach between December 2021 and August 2022. Participants were invited to take part in semi-structured phone or in-person interviews to explore HIV prevention and PrEP care experiences overall and within bridge clinic settings. Deductive codes were developed based on HIV risk environment frameworks and the Information-Motivation-Behavioral Skills model and inductive codes were added based on transcript review. Grounded content analysis was used to generate themes organized around the PrEP care continuum.

RESULTS

The sample included 14 providers and 25 WSWUD. Most WSWUD were aware of PrEP and more than half had initiated PrEP at some point. However, most who initiated PrEP did not report success with daily oral adherence. Providers and WSWUD described facilitators and barriers to PrEP across the steps of the care continuum: Awareness, uptake, adherence, and retention. Facilitators for WSWUD included non-stigmatizing communication with providers, rapid wraparound substance use treatment and HIV services, having a PrEP routine, and service structures to support PrEP adherence. Barriers included low HIV risk perceptions and competing drug use and survival priorities. Provider facilitators included clinical note templates prompting HIV risk assessments and training. Barriers included discomfort discussing sex work risks, competing clinical priorities, and a lack of PrEP adherence infrastructure.

CONCLUSION

WSWUD and bridge clinic providers favored integrated HIV prevention and substance use services in harm reduction and bridge clinic settings. Harm reduction and bridge clinic programs played a key role in HIV prevention and PrEP education for WSWUD. Effective behavioral and structural interventions are still needed to improve PrEP adherence for WSWUD.

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.

Implementation Facilitators and Barriers for Primary Care Providers Prescribing Daily Oral PrEP to Adolescents in the United States

Primary care providers (PCPs) are critical in prescribing human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) to adolescents at risk of HIV. More research is needed to identify facilitators and barriers PCPs encounter in prescribing PrEP to eligible adolescents post-Food and Drug Administration (FDA) approval. This online cross-sectional survey examined the PrEP implementation facilitators and barriers among a national sample of PCPs in the United States. PCPs (n = 502) specializing in family medicine or pediatrics were recruited from a Qualtrics panel from July 15 to August 9, 2022. We analyzed the collected data using content analysis and applied the Expert Recommendations for Implementing Change (ERIC) to codebook creation and data analysis. We conducted a Fisher's exact chi-square test of independence to compare facilitator and barrier prevalence differences between participants who had and had not prescribed PrEP to an adolescent patient. Results demonstrate that (1) distributing prescriber-focused educational materials, (2) involving parents, (3) changing liability laws, (4) enhancing adolescent PrEP uptake and adherence, (5) changing clinical resources, and (6) using mass/social media to change community norms might be strategies that influence PCPs prescribing PrEP to eligible adolescent patients. Results from this study could facilitate the planning of hybrid implementation-effectiveness trials designed to determine the acceptability, feasibility, and effectiveness of implementation strategies in improving the practices of PCPs prescribing PrEP to at-risk adolescents.

Associations Between Sexual History Documentation in Electronic Health Records and Referral to Pre-Exposure Prophylaxis Navigator on Prescription of Pre-Exposure Prophylaxis at a Multi-Site Federally Qualified Health Center

This cross-sectional study examined the relationships between sexual history screening (SHS) and referrals to a pre-exposure prophylaxis (PrEP) navigator (non-clinical staff member who assists patients in overcoming structural barriers to PrEP) on the proportion of days covered by PrEP for adult patients at a federally qualified health center. Patients' sociodemographics, PrEP prescriptions, referral to a PrEP navigator, and SHS data were extracted from the electronic health record (EHR). The analytic sample was 214 adult patients who were human immunodeficiency virus (HIV) negative and taking PrEP to prevent infection from January 2016 to December 2019. Mixed-effects negative binomial models were conducted accounting for clustering by patients' primary care providers. Documentation of SHS was associated with a higher proportion of days covered by PrEP (incidence rate ratio = 1.44, 95% confidence interval: 1.17-1.77). There was no significant effect of having a referral to the PrEP navigator on the proportion of days covered by PrEP, nor did having a referral to the PrEP navigator moderate the relationship between having SHS documented in the EHR and the proportion of days covered by PrEP. This study is the first to investigate the relationship between having sexual history documented in the EHR, referrals to a PrEP navigator, and their combined effect on the proportion of days covered by PrEP. Results of this study provide foundational evidence for future studies examining SHS as an opportunity to improve PrEP access and adherence and indicate the need for additional research exploring the value of PrEP navigators as an implementation strategy to overcome social and structural barriers to care.

Implementation Factors Associated With Primary Care Providers' Intention to Prescribe HIV PrEP to Adolescents in the United States

PURPOSE

In the United States, adolescents (those 13-18 years old) are a key age group of those at risk for and affected by HIV. Although HIV pre-exposure prophylaxis (PrEP), one promising HIV prevention tool, is approved for eligible adolescents to use, adolescent access to PrEP is limited by primary care providers' (PCPs) willingness to prescribe it. This study examined which Theoretical Domains Framework factors are associated with PCPs' intention to prescribe PrEP to sexually active adolescents.

METHODS

A total of 770 licensed PCPs practicing family medicine, internal medicine, or pediatrics in the United States completed an online cross-sectional questionnaire. Participants were recruited through a Qualtrics panel. We used a hierarchical regression to assess the association of demographic characteristics, sexual health care practices, and the 10 Theoretical Domains Framework factors with intention to prescribe PrEP to sexually active adolescents aged 13-18 years old.

RESULTS

Although nearly all PCPs had heard about PrEP (90.9%), 30.6% ever prescribed PrEP to an adolescent. Intention to prescribe PrEP to sexually active adolescents was associated with seven out of the 10 Theoretical Domains Framework factors: knowledge, skills, professional role, belief capacity, belief consequence, environmental resource, social influence, and emotion.

DISCUSSION

Our findings demonstrate that the Theoretical Domains Framework can be employed to understand the intrapersonal, interpersonal, and environmental factors associated with PCPs' intention to prescribe sexually active adolescents PrEP. Implementation strategies are needed to implement interventions that improve provider knowledge, attitudes, and skills related to prescribing PrEP to eligible adolescents.

Expanding PrEP Services for Men Who Have Sex With Men and Transgender Persons Through Health Department Programs: Key Processes and Outcomes From Project PrIDE, 2015-2019

OBJECTIVE

Pre-exposure prophylaxis (PrEP) Implementation, Data to Care, and Evaluation (PrIDE) was a demonstration project implemented by 12 state and local health departments during 2015-2019 to expand PrEP services for men who have sex with men (MSM) and transgender persons at risk for HIV infection. We describe findings from the cross-jurisdictional evaluation of the project.

METHODS

We analyzed work plans, annual progress reports, and aggregate quantitative program data submitted by funded health departments (n = 12) to identify key activities implemented and summarize key project outcomes.

RESULTS

PrIDE jurisdictions implemented multiple health equity-focused activities to expand PrEP services to priority populations, including building program capacity, conducting knowledge and awareness campaigns, providing PrEP support services, and addressing barriers to PrEP use. Overall, PrIDE jurisdictions identified 44 813 persons with PrEP indications. Of these, 74.8% (n = 33 500) were referred and 33.1% (n = 14 821) were linked to PrEP providers, and 25.3% (n = 11 356) were prescribed PrEP. Most persons prescribed PrEP were MSM or transgender persons (87.9%) and persons from racial and ethnic minority groups (65.6%). However, among persons with PrEP indications, non-Hispanic Black/African American persons (14.9% of 18 782) were less likely than non-Hispanic White persons (31.0% of 11 633) to be prescribed PrEP (z = -33.57; P < .001).

CONCLUSIONS

PrIDE jurisdictions successfully expanded PrEP services for MSM, transgender persons, and racial and ethnic minority groups by implementing health equity-focused activities that addressed barriers to PrEP services. However, PrEP prescription was generally low, with significant disparities by demographic characteristics. Additional targeted interventions are needed to expand PrEP services, achieve equity in PrEP use, and contribute to ending the HIV epidemic in the United States.

The Effect of Navigation on Linkage to a PrEP Provider Among PrEP-Eligible Men who have Sex with Men in a U.S. Demonstration Project

Our objective is to evaluate the effect of navigation on linkage to a PrEP provider among PrEP-eligible men who have sex with men (MSM) in THRIVE, a demonstration project in seven U.S. public health jurisdictions during 2015-2020. We describe PrEP linkage and navigation use among MSM in THRIVE. We performed multivariable probit regression modeling, controlling for demographic covariates, to estimate the association between navigation and linkage to a PrEP provider among MSM and to assess for disparities in linkage to PrEP among MSM who used navigation. Among 9538 PrEP-eligible MSM, 51.3% used navigation and 53.8% were linked to PrEP. From the three sites where navigation was optional and the main form of PrEP support, MSM who used navigation were 16.69 times (95% CI 13.07-21.32) more likely to link to PrEP compared with MSM who did not use navigation. Among 4895 MSM who used navigation from all seven sites, Black MSM were 21% less likely to link to PrEP compared with White MSM (aRR 0.79; 95% CI 0.74-0.83). Navigation is a promising strategy for improving uptake of PrEP among U.S. MSM, but disparities persist. Addressing the underlying causes of inequities will be important to end the HIV epidemic.