"Far More than Just a Prescription": Focus Groups With U.S. Family Planning Providers and Staff About Integrating PrEP for HIV Prevention Into Their Work

CDC Prioritizes HIV Prevention and Treatment to Reduce HIV Disparities Among Cis-Gender Black Women

To succeed in ending the HIV epidemic in the United States, the Centers for Disease Control and Prevention (CDC) focuses on delivering combinations of scientifically proven, cost-effective, and scalable interventions to priority populations. Systemic factors continue to contribute to persistent health disparities and disproportionately higher rates of HIV diagnosis in some communities. The National HIV/AIDS Strategy has designated cis-gender Black women (CgBW) as a priority population to address the racial and ethnic inequities in HIV. This report presents the portfolio of projects, programs, and initiatives funded by the CDC's Division of HIV Prevention (DHP) to address disparities in HIV and improve health and QOL among CgBW. These funded activities include the development, planning, and implementation of HIV prevention programs, mass media campaigns, and behavioral interventions focused on CgBW. This report also summarizes DHP's community engagement, capacity building, and partnership efforts, and highlights research and surveillance activities focusing on CgBW. Finally, this report outlines future directions for CDC's efforts to improve access to HIV testing, treatment, and prevention for CgBW in the United States.

Acceptability and appropriateness of information sessions to increase knowledge and awareness of PrEP and TelePrEP among Latina Women

Women of color are disproportionately impacted by HIV. Although PrEP effectively prevents HIV infection, PrEP coverage and knowledge remain low in this population. To address barriers to PrEP, we implemented women-centered and culturally appropriate Information Sessions (IS) delivered by staff from the population they serve to increase knowledge, awareness, and use of PrEP through telemedicine (e.g., PlushCare). Our analysis focuses on Latina women (LW) participants, given the dearth of literature dedicated to the needs of LW. We partnered with a woman-led community-based organization (CBO) to implement the strategy with LW clients. Health educators conducted 26 IS with 94 LW (20 in Spanish and 6 in English). Participants who completed the IS were invited for interviews to assess the acceptability and appropriateness of the IS to increase knowledge and awareness of PrEP and PlushCare. Four themes emerged from the thematic analysis: (1) IS increased knowledge and awareness of PrEP and PlushCare; (2) perceived acceptability and appropriateness of IS; (3) insufficient reasons to warrant use of PrEP; and (4) positive attitudes about PlushCare. Our findings suggest that a women-centered and culturally appropriate IS implemented through a trusted, woman-led CBO is an acceptable and appropriate implementation strategy to inform LW about PrEP.

Using audience segmentation to identify implementation strategies to improve PrEP uptake among at-risk cisgender women: a mixed-methods study protocol

BACKGROUND

In the USA, 19% of new HIV infections occur among cisgender women (cis women); however, only 10% of eligible cis women have been prescribed pre-exposure prophylaxis (PrEP) for the prevention of HIV infection (an evidence-based intervention). A fundamental challenge for expanding HIV prevention to cis women is ensuring implementation strategies are tailored to the various healthcare settings in which cis women seek care and the heterogeneous providers nested within these settings. This project's specific aims are to (1) explore clinician-level characteristics and organizational climate factors that are related to variability in adoption of PrEP service delivery as an evidence-based intervention for cis women; (2) identify latent audience segments of women's health providers as the related to PrEP acceptability, adoption, and maintenance and analyze demographic correlates of these segments; and (3) identify audience segment-specific implementation strategies to facilitate the adoption of PrEP as an evidence-based intervention among at-risk cis women.

METHODS

Using the i-PARIHS framework, this mixed-methods study examines three domains for guiding audience segmentation to facilitate PrEP implementation for cis women: innovation (degree of fit with existing practices, usability), recipient beliefs and knowledge and context factors (organizational culture, readiness for change), needs to determine appropriate facilitation methods. To achieve aim 1, qualitative interviews will be conducted with PrEP-eligible cis women, women's health providers, and other key stakeholders. Aim 2 will consist of a quantitative survey among 340 women's health providers. Latent class analysis will be used to facilitate audience segmentation. To achieve aim 3, a panel of 5-8 providers for each audience segment will meet and engage in iterative discussions guided by Fernandez's implementation mapping to identify (1) implementation outcomes and performance objectives, determinants, and change objectives and (2) determine and refine of implementation strategies for each audience segment.

DISCUSSION

This exploratory mixed methods study will provide an empirical foundation to inform the development implementations strategies aimed at increasing PrEP delivery to cis women among heterogenous groups of providers.

Perceptions of HIV risk screening strategies among patients seeking abortion, contraception, and pregnancy loss management in the United States

OBJECTIVES

Women make up nearly a fifth of new human immunodeficiency virus (HIV) infections yearly in the United States, more than half of which could have been prevented with broader use of HIV pre-exposure prophylaxis (PrEP). We aimed to qualitatively assess (1) acceptability of an HIV risk screening strategy and PrEP provision in a family planning setting, and (2) the influence of family planning visit type (abortion, pregnancy loss management, or contraception) on HIV risk screening acceptability.

STUDY DESIGN

Guided by the P3 (practice-, provider-, and patient-level) model for preventive care interventions, we conducted three focus group discussions including patients who had experienced induced abortion, early pregnancy loss (EPL), or contraception care. We developed a codebook of a priori and inductive concepts, and categorized themes by practice, provider, and patient considerations.

RESULTS

We included 24 participants. Practice-level considerations included overall positive feelings about being screened for PrEP eligibility during family planning visits, though some expressed reservations about screening during EPL visits. Provider-level themes included the concept of screening tools as entry points into conversation and education, and the importance of nonjudgment in discussing sexually transmitted infection (STI) prevention. Participants often had to initiate STI prevention discussions and felt that contraception was overemphasized by their providers compared with STI prevention and PrEP care. Patient-level themes included the stigma of STIs and oral PrEP, and the dynamic nature of STI risk.

CONCLUSIONS

Participants in our research had genuine interest in learning about PrEP during family planning visits. Findings from our research support the consistent inclusion of STI prevention education into family planning clinical practice using patient-centered STI screening methods.

IMPLICATIONS

Family planning encounters, including visits for contraception and abortion, are generally appropriate times to discuss HIV PrEP. Patient-centered conversations are an important adjunct to HIV risk screening tools.

Using qualitative comparative analysis to understand the conditions that produce successful PrEP implementation in family planning clinics

BACKGROUND

Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention to U.S. women. However, PrEP has not been widely integrated into family planning services, especially in the Southern U.S., and data suggest there may be significant implementation challenges in this setting.

METHODS

To understand contextual factors that are key to successful PrEP implementation in family planning clinics, we conducted in-depth qualitative interviews with key informants from 38 family planning clinics (11 clinics prescribed PrEP and 27 did not). Interviews were guided by constructs from the Consolidated Framework for Implementation Research (CFIR), and qualitative comparative analysis (QCA) was used to uncover the configurations of CFIR factors that led to PrEP implementation.

RESULTS

We identified 3 distinct construct configurations, or pathways, that led to successful PrEP implementation: (1) high "Leadership Engagement" AND high "Available Resources"; OR (2) high "Leadership Engagement" AND NOT located in the Southeast region; OR (3) high "Access to Knowledge and Information" AND NOT located in the Southeast region. Additionally, there were 2 solution paths that led to absence of PrEP implementation: (1) low "Access to Knowledge and Information" AND low "Leadership Engagement"; OR (2) low "Available Resources" AND high "External Partnerships".

DISCUSSION

We identified the most salient combinations of co-occurring organizational barriers or facilitators associated with PrEP implementation across Title X clinics in the Southern U.S. We discuss implementation strategies to promote pathways that led to implementation success, as well as strategies to overcome pathways to implementation failure. Notably, we identified regional differences in the pathways that led to PrEP implementation, with Southeastern clinics facing the most obstacles to implementation, specifically substantial resource constraints. Identifying implementation pathways is an important first step for packaging multiple implementation strategies that could be employed by state-level Title X grantees to help scale up PrEP.

Provision of HIV preexposure prophylaxis to female patients seeking family planning services in the United States

OBJECTIVE

We conducted a scoping review to assess barriers to and facilitators of integrating HIV preexposure prophylaxis (PrEP) and family planning (FP) at the patient, provider, and implementation levels, and to identify gaps in knowledge.

METHODS

We conducted a search of five bibliographic databases from database inception to March 2022: PubMed, CINAHL, Embase, Web of Science and Scopus. Two reviewers screened abstracts and full texts to determine eligibility based on a priori inclusion and exclusion criteria. We categorized studies by their relevance to patient, provider, and implementation barriers, and extracted data based on prespecified elements.

RESULTS

Our initial search strategy yielded 1151 results, and 34 publications were included. Barriers to PrEP implementation in family planning settings included low PrEP knowledge among patients, hesitance to take PrEP due to perceived stigma, decreased willingness of providers unfamiliar with PrEP to prescribe PrEP, and limited financial and staffing resources that make prescribing and monitoring PrEP difficult. Facilitators included robust training for providers, stigma reduction efforts, leadership engagement, and increased resources specifically in settings with processes in place that ease the process of prescribing and monitoring PrEP.

CONCLUSIONS

Advances in implementation strategy development, stigma reduction, and drug development will be essential to reinforcing PrEP care in family planning settings and thereby reducing the incidence of HIV in women through highly effective pharmacologic HIV prevention methods.

Implementation of an HIV Pre-exposure Prophylaxis Strategy Into Abortion and Early Pregnancy Loss Care

BACKGROUND

Family planning and abortion clinics routinely address sexual health. We sought to evaluate implementation outcomes of an HIV pre-exposure prophylaxis (PrEP) care strategy for patients seeking management of induced abortion and pregnancy loss.

SETTING

Single-center, urban, academic, hospital-based family planning service.

METHODS

We used a multifaceted implementation strategy directed toward family planning providers comprised of educational sessions, an electronic medical record-prompted verbal assessment of HIV risk, electronic medical record shortcuts for PrEP prescription, and support of a PrEP navigator. We assessed penetration of the intervention by calculating the penetration of a PrEP offer, measured as the proportion of encounters in which PrEP was offered to PrEP-eligible individuals. We evaluated feasibility, acceptability, and appropriateness of the intervention using belief elicitation interviews with providers.

RESULTS

From November 2018 to April 2019, the proportion of PrEP eligible patients who were offered PrEP, was 87.9% (29/33). Providers found the intervention acceptable and appropriate, but reported barriers including time constraints, and disappointment if patients did not adhere to PrEP. Providers liked that PrEP provision in abortion care settings felt innovative, and that they could contribute to HIV prevention.

CONCLUSION

Family planning providers in an academic center found HIV risk assessment and PrEP provision to be feasible, acceptable, and appropriate. Further research should evaluate implementation outcomes of PrEP care strategies in additional abortion care contexts, including clinics offering reproductive health care outside of academia.

Reimagining Preexposure Prophylaxis Provision for Women in the United States

Structural determinants of health drive inequities in the acquisition of human immunodeficiency virus (HIV) and the use of preexposure prophylaxis (PrEP) for HIV prevention among cisgender women in the United States. However, current PrEP clinical guidance and implementation paradigms largely focus on individual behaviors and characteristics, resulting in missed opportunities to improve PrEP access, and the implicit transferring of prevention work from health systems to individuals. In this viewpoint article, we outline ways to apply a structural lens to clinical guidance and PrEP implementation for women and propose areas for future work.

Incorporating HIV Pre-Exposure Prophylaxis Care for Patients Seeking Induced Abortion and Pregnancy Loss Management

BACKGROUND

Family planning clinical encounters are important opportunities for HIV prevention. Our objectives were to 1) estimate the proportion of patients seeking induced abortion and early pregnancy loss management eligible for HIV pre-exposure prophylaxis (PrEP) and 2) compare PrEP eligibility and uptake between patients with unintended and intended pregnancy.

METHODS

We conducted a cross-sectional survey and a nested prospective cohort study of patients seeking an induced abortion or early pregnancy loss management. We assessed pregnancy intendedness, PrEP awareness, HIV risk and risk perception, desire for same-day PrEP start, and PrEP continuation at 30 days. We used the χ² and Fisher's exact tests to assess differences between the participants with intended and unintended pregnancy. We had 80% power to detect a 14% difference in PrEP eligibility between the groups.

RESULTS

We enrolled 250 women. Fifty-six percent (139) had an unintended pregnancy and 44% (110) had an intended pregnancy. PrEP eligibility did not differ significantly between the patients with intended and unintended pregnancy (16% vs. 10%; p = .18). More than one-half (54%, 135/250) were unaware of PrEP before their study visit, and 93% (232/250) considered themselves unlikely to acquire HIV. Of 33 women who were PrEP eligible, 11 accepted same-day start and 1 continued PrEP at 30 days.

CONCLUSIONS

Intendedness of pregnancy was unrelated to PrEP eligibility in women seeking induced abortion and early pregnancy loss management. Most patients seeking these services are unaware of PrEP. Integrating PrEP into family planning care is likely to increase awareness and uptake of PrEP in women.