Clinician attitudes toward CDC interim pre-exposure prophylaxis (PrEP) guidance and operationalizing PrEP for adolescents

Patient and Provider Perceptions of Barriers and Facilitators to Pre-exposure Prophylaxis Access and Adherence in Black and Latinx Young Men Who Have Sex with Men

In the United States, the use of pre-exposure prophylaxis (PrEP) has led to a substantial decrease in HIV prevalence and incidence. However, some populations, including young men who have sex with men (YMSM) of color, continue to be disproportionately impacted, highlighting the need for tailored interventions addressing barriers to adequate PrEP access. In collaboration with partner clinics, we recruited 19 PrEP clients and 19 PrEP providers (n = 35) to participate in hour-long in-depth interviews. Although client interviews explored personal experiences with stigma, barriers, and motivators to PrEP and information preferences, provider interviews explored providers' perceived stigma in their clinic, perceived barriers and motivators to meeting clients' PrEP needs, and rapport building with clients. Most participants were affiliated with one of the southern partner clinics. Clients and providers noted similar determinants to PrEP access, uptake, and adherence. Both recognized the impact of personal barriers such as routine adjustments and perception of need, as well as institutional barriers such as transportation and financial difficulties. Clients emphasized the role of the client-provider relationship as part of contributing to willingness to disclose information such as HIV status and sexual practices. Providers noted the importance of sexual health and LGBTQ+ topics in their training. Despite limited geographical scope and the sensitive nature of HIV-related topics, this study has several implications. PrEP clinics may benefit from hiring providers who share identities and experiences with YMSM clients of color and operating with a flexible schedule. Medical provider training should include comprehensive sexual health and LGBTQ+ competencies to reduce bias in care.

Attitudes and Intentions toward Use of HIV Pre-Exposure Prophylaxis (PrEP) among Adults Receiving Treatment for Opioid Use

Background: Although pre-exposure prophylaxis (PrEP) prevents HIV, little is known about PrEP awareness and factors associated with intention to take PrEP among people with opioid use disorder (OUD). Methods: HIV-negative adults recruited from an outpatient treatment program in Cincinnati, Ohio completed self-administered surveys. Items derived from literature and health behavioral theory included demographics, sexual and drug use behaviors, HIV prevention practices, PrEP knowledge, and attitudes toward PrEP. Primary outcomes were 1) intention to ask a clinician about PrEP and 2) intention to accept PrEP if recommended by a clinician. Outcomes were dichotomized into higher vs. lower intention for analyses in logistic regression models. Results: Among 198 participants, 60.3% reported past injection drug use. Among 58 participants (29.3%) meeting criteria for PrEP, 24% were aware of PrEP, 15.5% had discussed it with a clinician, and 5% had taken it. Factors associated with intention to ask a clinician about PrEP included being somewhat confident about consistent condom use (p < 0.01), motivation to comply with normative beliefs (p < 0.01), and reporting that PrEP fits very well (p < 0.01) and is easy to fit (p < 0.01) into current prevention practices. Factors associated with intention to accept PrEP if recommended by a clinician included motivation to comply with normative beliefs (p < 0.01) and PrEP being easy to fit into current prevention practices (p < 0.01). Conclusion: Among participants meeting indications for PrEP, only 24% were aware of it and few had taken it. Interventions that normalize PrEP and target incorporating PrEP into current prevention practices may improve uptake among individuals with OUD.

Barriers and facilitators to pre-exposure prophylaxis uptake among Black/African American men who have sex with other men in Iowa: COM-B model analysis

Background

In Iowa, men who have sex with men (MSM) accounted for 54% of persons with HIV in 2022 and Non-Hispanic Black/African Americans were over 10 times more likely to be diagnosed with HIV than Non-Hispanic white Iowans. To address this disparity in HIV incidence and prevalence, the United States (US) government ending the HIV epidemic (EHE) initiative seeks to expand pre-exposure prophylaxis (PrEP) coverage across the United States. Recent data showed that PrEP coverage is suboptimal in Iowa (a rural state), and Black Iowans were less likely to engage with PrEP services.

Objectives

Using capability, opportunity, motivation and behavior (COM-B) model for behavior change, this study sought to identify the key barriers and facilitators to PrEP uptake among Black/African American MSM in small urban areas in Iowa.

Design

This was a phenomenological study aimed to explore subjective views of Black MSM on PrEP use.

Methods

In-depth semistructured interviews were conducted with 12 Black MSM aged 20-42 years in two small urban counties. Broad themes identified from the interview transcripts were analyzed inductively and mapped onto the COM-B constructs deductively.

Results

Results showed that barriers to PrEP uptake were closely associated with five (of six) COM-B subcomponents: physical capability, psychological capability, social opportunity, reflective motivation, and automatic motivation. The thematized barriers were (1) lack of medical insurance; (2) limited PrEP awareness; (3) PrEP stigma; (4) fear of distrust among partners; (5) anticipated side effects; and (6) doubt about PrEP effectiveness. Similarly, facilitators to PrEP uptake were aligned with four subcomponents of COM-B model: physical capability, psychological capability, social opportunity, and physical opportunity. The thematized facilitators were (1) increased PrEP awareness; (2) PrEP access without discrimination; (3) state provision of PrEP to uninsured; and (4) physicians buy-in and recommendation. No motivation-related facilitators were reported.

Conclusion

To reduce the current disparity in HIV incidence and to achieve the EHE goals of expanding PrEP coverage in Iowa, efforts should be directed toward the provision of low-cost or free PrEP services, healthcare providers' training on cultural competence, and the development of culturally appropriate strategies to deliver PrEP to the Black MSM community.

Primary Care Providers' Information Needs for Prescribing Adolescents HIV Pre-Exposure Prophylaxis

Although knowledge is a salient determinant in primary care providers (PCPs) prescribing HIV pre-exposure prophylaxis (PrEP) to adolescents, we know little about what information PCPs want about PrEP. We conducted an online mixed-method study to explore the PrEP information needs of a national sample of 351 PCPs. We analyzed data with deductive content analysis and compared themes between respondents who were aware and not aware of PrEP, knowledgeable and not knowledgeable of the prescribing guidelines, and prescribed and never prescribed PrEP to an adolescent. PCPs who were unknowledgeable about PrEP and never prescribed PrEP to an adolescent mentioned manufacturing information, indications and dosing, and contraindications and adverse reactions more so than PCPs who were aware of and prescribed PrEP. A better understanding of the information needs of PCPs could inform provider education interventions. Future research must examine the facilitators and barriers to integrating PrEP information into medical education and clinical settings.

How a menu of adherence support strategies facilitated high adherence to HIV prevention products among adolescent girls and young women in sub-Saharan Africa: a mixed methods analysis

INTRODUCTION

Effective use of pre-exposure prophylaxis (PrEP) has been low among adolescent girls and young women (AGYW) in sub-Saharan Africa. The MTN-034/REACH trial offered AGYW a menu of adherence support strategies and achieved high adherence to both daily oral PrEP and the monthly dapivirine vaginal ring. Understanding how these strategies promoted product use could inform the design of adherence support systems in programmatic settings.

METHODS

REACH was a randomized crossover trial evaluating the safety of and adherence to the ring and oral PrEP among 247 HIV-negative AGYW (ages 16-21) in South Africa, Uganda and Zimbabwe from January 2019 to September 2021 (NCT03593655). Adherence support included monthly counselling sessions with drug-level feedback (DLF) plus optional daily short message service (SMS) reminders, weekly phone or SMS check-ins, peer support clubs, "peer buddies" and additional counselling. Counsellors documented adherence support choices and counselling content on standardized forms. Through focus groups, serial in-depth interviews (IDIs) and single IDIs (n = 119 total), we explored participants' experiences with adherence support and how it encouraged product use.

RESULTS

Participants received counselling at nearly all visits. DLF was provided at 54.3% of sessions and, across sites, 49%-68% received results showing high adherence for oral PrEP, and 73%-89% for the ring. The most popular support strategies were in-person clubs and weekly calls, followed by online clubs, additional counselling and SMS. Preferences differed across sites but were similar for both products. Qualitative results demonstrated that the REACH strategies supported adherence by providing information about HIV and PrEP, continually motivating participants, and supporting the development of behavioural skills and self-efficacy, aligning with the Information, Motivation, and Behavioural Skills (IMB) model. Effectiveness was supported by three foundational pillars: strong interpersonal relationships with counsellors; ongoing, easily accessible support and resources; and establishing trust in the counsellors and study products through counsellor relationships, peer-to-peer exchange and DLF.

CONCLUSIONS

Implementation programmes could support effective PrEP use by offering a small menu of counsellor- and peer-based support options that are youth-friendly and developmentally appropriate. The same menu options can support both ring and oral PrEP users, though content should be tailored to the individual products.

Knowledge, sex, and region associated with primary care providers prescribing adolescents HIV pre-exposure prophylaxis

Although HIV pre-exposure prophylaxis (PrEP) effectively and safely prevents HIV among adolescents, uptake of PrEP is low. Adolescents must have primary care providers (PCPs) prescribe them PrEP, making PCPs critical actors in PrEP delivery. However, research has primarily investigated determinants of PCPs' intention to prescribe adolescents PrEP rather than the determinants of performing the behavior itself. We examined the demographic, clinical practice, and implementation determinants of PCPs previously prescribing PrEP to adolescents. PCPs were recruited from a national Qualtrics panel of licensed medical providers in the United States from July 15-August 19, 2022. The Theoretical Domains Framework informed the implementation determinants measured. A multivariable logistic regression was used. PCPs who were more knowledgeable of the CDC guidelines (aOR 2.97, 95% CI 2.16-4.10), who were assigned male at birth (aOR 1.64, 95% CI 1.03-2.59), and who practiced in the Western region (aOR 1.85, 95% CI 1.04-3.30) had greater odds of prior prescribing adolescents PrEP. Provider-based educational interventions should be designed, implemented, and tested to encourage PCPs to prescribe PrEP to eligible adolescents.

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.

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.

PreexposureProphylaxis at School-Based Health Centers: Awareness and Interest in Starting Preexposure Prophylaxis While Attending a School-Based Health Center in New York City

INTRODUCTION

Youth aged 13-29 years represent 23% of the population but account for 40% of new HIV diagnoses, with risk peaking at ages 22-23 years. We assessed sexual behaviors, PrEP knowledge and attitudes among patients of 6 School-Based-Health-Centers (SBHCs) located in Northern Manhattan and the Bronx.

METHOD

667 patients, aged 13-19 years, completed a survey in the SBHCs waiting rooms between 10/2018 - 4/2019 RESULTS: Of the survey respondents attending SBHCs, 32% reported ever having heard of PrEP and, upon learning of PrEP, 67% stated that would be very likely (35%) or somewhat likely (32%) to take PrEP if it was offered to them free of charge.

DISCUSSION

Youth of color are disproportionately infected by HIV throughout the US. Efforts are needed to educate adolescents on the benefits of PrEP, SBHCs are well situated to reduce barriers in providing PrEP directly to those who would benefit from its protection..

Brief Report: Transgender Women and Preexposure Prophylaxis Care: High Preexposure Prophylaxis Adherence in a Real-World Health Care Setting in New York City

BACKGROUND

Transgender women and trans feminine individuals (TGW/TFI) are a high priority population for the provision of HIV preexposure prophylaxis (PrEP) care within the United States, but there is limited research that focuses specifically on PrEP adherence within this population.

SETTING

Observational study of patients prescribed PrEP at a community-based health center.

METHODS

We enrolled 100 TGW/TFI PrEP patients at a community health center during clinic visits. Adherence data were collected at 3 time points, using self-report surveys, patient interviews, and urine assays measuring tenofovir. Data were summarized descriptively.

RESULTS

The sample was diverse in age, race/ethnicity, and socioeconomic characteristics. Participants demonstrated strong PrEP adherence; at least 80% of the sample reported 90% or greater adherence at each time point. Concordance between self-report and urine assay was high. Among patients who reported taking PrEP within the past 48 hours, 82%-92% had detectable urine tenofovir. However, many patients reported PrEP stop periods of 4 or more days (28%-39% per time point).

CONCLUSIONS

Our data highlight TGW/TFI's capacity to adhere to daily PrEP and sustain PrEP use over time. The concordance between patient self-report and urine TFV levels suggest that providers can trust patient reports of PrEP adherence behavior and support the use of adherence conversations in clinical settings, without the need for point of care biological monitoring. Findings also underscore the importance of continued attention to drivers of PrEP stops at the patient, clinic, and systems levels and the development of strategies that support sustained PrEP use.

Brief Report: Transgender Women and Preexposure Prophylaxis Care: High Preexposure Prophylaxis Adherence in a Real-World Health Care Setting in New York City

BACKGROUND

Transgender women and trans feminine individuals (TGW/TFI) are a high priority population for the provision of HIV preexposure prophylaxis (PrEP) care within the United States, but there is limited research that focuses specifically on PrEP adherence within this population.

SETTING

Observational study of patients prescribed PrEP at a community-based health center.

METHODS

We enrolled 100 TGW/TFI PrEP patients at a community health center during clinic visits. Adherence data were collected at 3 time points, using self-report surveys, patient interviews, and urine assays measuring tenofovir. Data were summarized descriptively.

RESULTS

The sample was diverse in age, race/ethnicity, and socioeconomic characteristics. Participants demonstrated strong PrEP adherence; at least 80% of the sample reported 90% or greater adherence at each time point. Concordance between self-report and urine assay was high. Among patients who reported taking PrEP within the past 48 hours, 82%-92% had detectable urine tenofovir. However, many patients reported PrEP stop periods of 4 or more days (28%-39% per time point).

CONCLUSIONS

Our data highlight TGW/TFI's capacity to adhere to daily PrEP and sustain PrEP use over time. The concordance between patient self-report and urine TFV levels suggest that providers can trust patient reports of PrEP adherence behavior and support the use of adherence conversations in clinical settings, without the need for point of care biological monitoring. Findings also underscore the importance of continued attention to drivers of PrEP stops at the patient, clinic, and systems levels and the development of strategies that support sustained PrEP use.

Living at the Confluence of Stigmas: PrEP Awareness and Feasibility Among People Who Inject Drugs in Two Predominantly Rural States

We explored knowledge, beliefs, and acceptability of pre-exposure prophylaxis (PrEP) for HIV prevention with reference to stigma among people who inject drugs (PWID) in two predominately rural U.S. states. We conducted interviews with 65 current or former PWID aged 18 years or older and living in Arizona or Indiana. Most (63%) of the interviewees were not aware of PrEP. They often confused PrEP with HIV treatment, and many believed that PrEP was only for sexual risk or gay sexual risk. Once they understood that PrEP was recommended for PWID, the participants held a positive view of PrEP and felt that a once-daily pill was feasible. Experiences of stigma about drug use remained a crucial barrier to accessing healthcare and PrEP. This was often linked with anticipated or expressed homophobia. PrEP interventions among PWID must focus on education and the confluence of stigmas in which PWID find themselves when considering PrEP.

Pre-Exposure Prophylaxis (PrEP) Uptake among Black Men Who Have Sex with Men (BMSM) in the Southern U.S

Black men who have sex with men (BMSM) living in the United States (U.S.) South are disproportionately affected by HIV and experience significant disparities in HIV incidence, access to HIV care, and prevention across ages and socio-economic statuses. The aim of this commentary is to critically review current literature on the state of PrEP use among BMSM in the U.S. South, including identifying barriers and facilitators to PrEP use in order to inform intervention development. Extant literature shows that despite the documented benefits of PrEP as an effective HIV-prevention method, its uptake among BMSM is limited across the U.S. South. Common barriers to PrEP uptake included stigma, homophobia, mistrust of healthcare systems, negative attitudes from healthcare providers, access and transportation issues, poverty, and misinformation about PrEP. These barriers are likely to have been further exacerbated by the COVID-19 pandemic. Limited access to PrEP and other HIV-prevention programs, such as HIV testing, post-exposure prophylaxis (PEP), and condoms for BMSM are likely increase HIV incidence in this community. Moreover, the rapid expansion of telehealth services during the COVID-19 period may offer increased opportunity to scale-up PrEP through telehealth interventions, especially if in-person services remain limited due to pandemic precautions. Given the intersectional barriers that limit the access and uptake of PrEP among BMSM, we suggest that tailored programs or interventions that seek to address PrEP disparities among Southern BMSM should adopt intersectional and interdisciplinary approaches to better understand the complex challenges of scaling up PrEP. More studies are needed to investigate the impact of COVID-19 on HIV-prevention services among BMSM and to understand how to co-develop—with the BMSM community and healthcare providers—culturally acceptable interventions to reduce the identified challenges using intersectional and interdisciplinary approaches.

Models of HIV Pre-Exposure Prophylaxis Care Used in Title X Family Planning Clinics in the Southern U.S

PURPOSE

HIV pre-exposure prophylaxis (PrEP) is underutilized by adolescent and young adult women, especially in the Southern U.S. Family planning (FP) clinics are potentially ideal PrEP delivery sites for adolescent and young adult women, but little is known about their PrEP services. We describe models of PrEP care in Title X FP clinics in the South and explore clinic resources that are needed to facilitate PrEP provision.

METHODS

Providers and administrators from 38 clinics participated in qualitative interviews. We assessed five steps of PrEP care: (1) HIV risk assessment; (2) PrEP education; (3) laboratory testing; (4) PrEP prescription; and (5) PrEP monitoring.

RESULTS

Among 38 clinics, 23 conducted at least one step and were classified into three models. Model 1 (n = 8) and Model 2 (n = 4) clinics provided up to Steps 1 and 2, respectively, but referred to an external PrEP provider. Model 3 clinics (n = 11) conducted all steps. Few barriers were identified for Step 1; using an HIV risk assessment tool was a key facilitator. PrEP educational materials facilitated Step 2; clinics not providing education believed they could easily do so with training and educational resources. Funding- and staff-related resource barriers were noted for Steps 3-5, including costs of laboratory tests and lack of time for longitudinal visits.

CONCLUSIONS

PrEP-providing publicly funded FP clinics in the Southern U.S. use referral services for many steps of PrEP care, which introduce patient burden. Increasing onsite PrEP services will require addressing concerns related to training, educational materials, cost, and staffing.

The Cost-effectiveness of Human Immunodeficiency Virus (HIV) Preexposure Prophylaxis and HIV Testing Strategies in High-risk Groups in India

BACKGROUND

The human immunodeficiency virus (HIV) epidemic in India is concentrated among 3.1 million men who have sex with men (MSM) and 1.1 million people who inject drugs (PWID), with a mean incidence of 0.9-1.4 per 100 person-years. We examined the cost-effectiveness of both preexposure prophylaxis (PrEP) and HIV testing strategies for MSM and PWID in India.

METHODS

We populated an HIV microsimulation model with India-specific data and projected clinical and economic outcomes of 7 strategies for MSM/PWID, including status quo; a 1-time HIV test; routine HIV testing every 3, 6, or 12 months; and PrEP with HIV testing every 3 or 6 months. We used a willingness-to-pay threshold of US$1950, the 2017 Indian per capita gross domestic product, to define cost-effectiveness.

RESULTS

HIV testing alone increased life expectancy by 0.07-0.30 years in MSM; PrEP added approximately 0.90 life-years to status quo. Results were similar in PWID. PrEP with 6-month testing was cost-effective for both MSM (incremental cost-effectiveness ratio [ICER], $1000/year of life saved [YLS]) and PWID (ICER, $500/YLS). Results were most sensitive to HIV incidence. PrEP with 6-month testing would increase HIV-related expenditures by US$708 million (MSM) and US$218 million (PWID) over 5 years compared to status quo.

CONCLUSIONS

While the World Health Organization recommends PrEP with quarterly HIV testing, our analysis identifies PrEP with semiannual testing as the cost-effective HIV prevention strategy for Indian MSM and PWID. Since nationwide scale-up would require a substantial fiscal investment, areas of highest HIV incidence may be the appropriate initial targets for PrEP scale-up.

The ongoing HIV epidemic in American youth: challenges and opportunities

The incidence of human immunodeficiency virus (HIV) infection has been decreasing in the United States overall, except among youth, and in particular among Black and Latinx young men who have sex with men (MSM). In this review we summarize key drivers of the HIV epidemic among youth, as well as novel interventions geared specifically towards combating the epidemic among high-risk populations. Many factors driving the HIV epidemic among youth are related to systemic inequities, including lack of access to healthcare, inadequate education, and internalized and experience homophobia and racism. Developmentally, youth may feel that they are invulnerable and be willing to engage in risks. Moreover, HIV is often invisible for youth given advances in treatment and community stigma, limiting open discussion of risk and new preventive modalities. Outcomes from the HIV treatment cascade suggest that youth are less likely to be aware of their HIV infection status, less likely to link to and be engaged in care, and less likely to be virologically suppressed than older MSM and other populations of people living with HIV. Importantly, pre-exposure prophylaxis (PrEP) has been shown to be an effective tool for prevention of HIV infection that also appears to have disproportionately poor uptake among youth. Barriers to PrEP utilization appear to be quite heterogeneous, and include patient-, provider-, and structural-level barriers. Interventions important in improving HIV prevention will thus have to be multipronged and developed for culturally diverse populations. Cognitive behavioral therapy-based interventions are promising strategies as they are able to address a diverse array of barriers. New formulations of PrEP will also likely be instrumental in improving adherence. Since youth spend considerable amounts of time accessing digital media, the deployment of apps and other mobile phone-based interfaces offer unique opportunities to increase education and to facilitate HIV prevention for at risk youth. Multiple studies are underway to better inform the optimal delivery of treatment and prevention services for this complex and diverse population, and include novel sociobiological interventions and new modes of medication delivery that may lend themselves to overcoming obstacles specific to youth.

HIV Preexposure Prophylaxis Among Adolescents in the US: A Review

IMPORTANCE

Many adolescents and young adults in the US are disproportionately affected by HIV. Several others who are uninfected are at risk and in need of effective preventive strategies. The uptake rate of preexposure prophylaxis (PrEP) for HIV prevention has remained low among US adolescents. This review assesses the current status of PrEP uptake among at-risk adolescents aged 13 to 19 years and recommendations for improving PrEP access, uptake, and future needed directions, including specific recommendations for health care professionals.

OBSERVATIONS

Of the 37 377 new HIV diagnoses made in 2018, 7734 diagnoses (21%) occurred in adolescents and young adults aged 12 to 24 years; of these, 1707 diagnoses (22%) occurred in adolescents aged 13 to 19 years. The greatest burden of HIV is found among young African American men who have sex with men, accounting for two-thirds of all HIV infections in adolescents and young adults. Preexposure prophylaxis awareness and engagement are lowest in adolescents with the greatest risk for HIV. Adolescent primary care clinicians and specialists do not routinely offer HIV testing as recommended by the Centers for Disease Control and Prevention or routinely assess sexual risk exposures of patients through sexual history taking. Clinicians' decision to prescribe PrEP for adolescents is often guided by their perceptions of the patient's HIV risk and their knowledge and acceptance of PrEP guidelines. State laws on consent, confidentiality, and the rights of the adolescent to independently access PrEP outside of parental influence differ across jurisdictions, often limiting access and uptake.

CONCLUSIONS AND RELEVANCE

Use of PrEP in adolescents at risk for HIV is an important component of HIV prevention. Optimizing uptake includes improving clinicians' knowledge about HIV risk and prevention strategies, enhancing sexual history taking and risk assessment through training and retraining, and improving PrEP knowledge and acceptance of prescribing among clinicians. Leveraging the ubiquity of social media, encouraging family support, and performing research aimed at finding lifestyle-congruent formulations can help mitigate HIV transmission in adolescents at greatest risk for HIV.

Oral preexposure prophylaxis continuation, measurement and reporting

Objective:

The aim of this study was to appropriately plan for rollout and monitor impact of oral preexposure prophylaxis (PrEP). It is important to understand PrEP continuation and come to a consensus on how best to measure PrEP continuation. This study reviews data on PrEP continuation to document how it is reported, and to compare continuation over time and across populations.

Design:

A systematic review and meta-analysis.

Methods:

We searched MEDLINE, Embase and Global Health and reviewed abstracts from HIV conferences from 2017 to 2018 for studies reporting primary data on PrEP continuation. Findings were summarized along a PrEP cascade and continuation was presented by population at months 1, 6 and 12, with random-effects meta-analysis.

Results:

Of 2578 articles and 596 abstracts identified, 41 studies were eligible covering 22 034 individuals. Continuation data were measured and reported inconsistently. Results showed high discontinuation at month 1 and persistent discontinuation at later time points in many studies. Pooled continuation estimates were 66% at month 1 [n = 5348; 95% confidence interval (95% CI): 48–82], 63% at month 6 (n = 13 629; 95% CI: 48–77) and 71% at month 12 (n = 14 933; 95% CI: 60–81; higher estimate than previous timepoints due to inclusion of different studies). Adequate data were not available to reliably compare estimates across populations.

Conclusion:

This review found that discontinuation at one month was high, suggesting PrEP initiations may be a poor measure of effectiveness. Continuation declined further over time in many studies, indicating existing cross-sectional indicators may not be adequate to understand PrEP use patterns. Studies do not measure continuation consistently, and consensus is needed.

Healthcare practitioner experiences and willingness to prescribe pre-exposure prophylaxis in the US

Background and objectives

Less than 10 percent of the more than one million people vulnerable to HIV are using pre-exposure prophylaxis (PrEP). Practitioners are critical to ensuring the delivery of PrEP across care settings. In this study, we target a group of prescribers focused on providing HIV care and seeking up-to-date information about HIV. We assessed their experiences prescribing PrEP, whether these experiences differed by clinical specialty, and examined associations between willingness to prescribe PrEP as a “best first step” and different hypothetical prescribing scenarios.

Setting and methods

Between March and May 2015, we circulated a paper survey to 954 participants ((652 of whom met our inclusion criteria of being independent prescribers and 519 of those (80%) responded to the survey)) at continuing medical education advanced-level HIV courses in five locations across the US on practitioner practices and preferences of PrEP. We employed multivariable logistic regression analysis for binary and collapsed ordinal outcomes.

Results

Among this highly motivated group of practitioners, only 54% reported ever prescribing PrEP. Internal medicine practitioners were 1.6 times more likely than infectious disease practitioners to have prescribed PrEP (95% CI: 0.99–2.60, p = .0524) and age, years of training, and sex were significantly associated with prescribing experience. Based on clinical vignettes describing different hypothetical prescribing scenarios, practitioners who viewed PrEP as the first clinical step for persons who inject drugs (PWID) were twice as likely to have also considered PrEP as the first clinical option for safer conception, and vice-a-versa (95% CI: 1.4–3.2, p < .001). Practitioners considering PrEP as the first preventive option for MSM were nearly six times as likely to also consider PrEP as the first clinical step for PWID, and vice-a-versa (95% CI: 2.28–13.56, p = .0002).

Conclusions

Our findings indicate that even among a subset of HIV-focused practitioners, PrEP prescribing is not routine. This group of practitioners could be an optimal group to engage individuals that could most benefit from PrEP.

Initiation of HIV pre-exposure prophylaxis in adolescents and young adults: Barriers and opportunities

BACKGROUND

Adolescents and young adults (AYA) ages 13 to 24 years comprise a quarter of the new HIV diagnoses in the United States. Lack of access to HIV-preventive biomedical tools such as pre-exposure prophylaxis (PrEP) reduces opportunities to prevent HIV infection in this population. Initiating PrEP in AYA significantly reduces the negative health outcomes of HIV, but many providers are still reluctant to initiate PrEP in their AYA patients based on perceived threats and barriers.

OBJECTIVES

This review aims to highlight the barriers and opportunities for initiating PrEP services in AYA and provides recommendations for PrEP services in this population.

DATA SOURCES

Ten scholarly articles rated levels IIA through IIIB were identified using the Johns Hopkins Evidence-Based Practice ratings. These included quasi-experimental and nonexperimental publications. Both quantitative and qualitative data contributed to identifying perceived barriers, opportunities, and recommendations for increased PrEP access and prescription in AYA.

CONCLUSIONS

Pre-exposure prophylaxis is a vital component of a robust HIV prevention program. Themes that emerged hindering optimal PrEP utilization in AYA included provider-related barriers (e.g., knowledge deficit, lack of familiarity with PrEP guidelines, and protocols), patient-related barriers (e.g., lack of awareness, confidentiality issue, and HIV stigma), and structure-related barriers (e.g., lack of AYA-friendly clinics and insurance coverage).

IMPLICATIONS FOR PRACTICE

Providers in any setting should be able identify at-risk AYA and prescribe PrEP accordingly. Nurse practitioners should make PrEP accessible to AYA by addressing the barriers to PrEP utilization, prescribing, and continuity of care. Nurse practitioner curriculum, training, and continuing education should include PrEP for AYA.

The Influence of Peers on PrEP Perceptions and Use Among Young Black Gay, Bisexual, and Other Men Who Have Sex with Men: A Qualitative Examination

Pre-exposure prophylaxis (PrEP) is a promising part of HIV prevention, yet racial disparities in PrEP uptake persist. Evidence indicates that Black gay, bisexual, and other men who have sex with men (GBM) face numerous social and structural barriers to PrEP, including stigma, medical mistrust, and exclusion from the healthcare system. However, little research has examined how social networks can influence PrEP use and help Black GBM overcome these identified barriers. To understand the influence of peers and social networks on Black GBM's perceptions of and decisions about PrEP use, we conducted in-depth interviews with 46 Black GBM in Milwaukee, WI and Cleveland, OH. Data were analyzed using multistage inductive coding and thematic content analysis, using MAXQDA software. Results indicate that participants' primary source of information on PrEP was other Black GBM in their communities. Peers and social networks served three primary functions with regard to PrEP: (1) filling informational gaps left by healthcare providers, (2) increasing trust of PrEP, and (3) reducing PrEP stigma. Participants described the "movers and shakers" in Black LGBT communities who have been influential in educating others and advocating for PrEP. Well-respected vocal advocates for PrEP have emerged in the Black LGBT community as PrEP champions who have successfully influenced young Black GBM's views on PrEP. Our results reveal the role social networks and peer groups can play in increasing PrEP use among Black GBM. Social network interventions may help overcome the stigma and mistrust that are contributing to PrEP disparities.

The pre-exposure prophylaxis (PrEP) consciousness of black college women and the perceived hesitancy of public health institutions to curtail HIV in black women

BACKGROUND

Consistent use of Pre-Exposure Prophylaxis (PrEP), a biomedical intervention for HIV seronegative persons, has been shown to significantly decrease HIV acquisition. Black women are a viable population segment to consider for PrEP use as their HIV incidence is overwhelmingly higher than all other women groups.

METHODS

We developed and piloted a cultural- and age- appropriate PrEP education intervention to determine Black college women's: 1) perceptions of and receptivity to PrEP use; and 2) preferences for PrEP information delivery.

RESULTS

We recruited N = 43 Black college women. Most of our sample were sophomore and Juniors of whom identified as heterosexual (83%) and single (67%). Over 50% of young women had never been HIV tested and only 28% had been tested in the last 6 months; however, 100% of the women believed their HIV status was negative. Prior to participating in the study, most Black college women (67%) had not heard about PrEP and were unsure or apprehensive (72%) to initiate PrEP. The Black college women indicated that our educational intervention was extremely helpful (67%) for understanding and learning about PrEP. Post participating in our PrEP education module, regardless of delivery modality, participants reported being likely (62.55-70%) to initiate PrEP in the future.

CONCLUSIONS

Results indicate that Black college women would strongly consider PrEP when provided with basic knowledge, regardless of delivery modality. Participants also showed greater appreciation for in-person delivery and found it to be significantly more helpful and of greater quality for learning about PrEP; comprehension or perceived usefulness of PrEP-related content was relatively the same between groups. PrEP content delivery -- via in-person or online methods - is contingent on learning style and presentation.

TRIAL REGISTRATION

This study has been registered under the ISRCTN Registry as of July 6, 2020. The trial registration number is ISRCTN14792715 . This study was retrospectively registered.

A review of HIV pre-exposure prophylaxis (PrEP) programmes by delivery models in the Asia-Pacific through the healthcare accessibility framework

INTRODUCTION

In the Asia-Pacific, pre-exposure prophylaxis (PrEP) is a newly introduced public health intervention for minimizing HIV transmission, the coverage of which has remained limited. The best delivery models and strategies for broadening access of the vulnerable communities are not fully known. This review identified PrEP programmes reported in the Asia-Pacific, which were classified by delivery models and assessed with a healthcare accessibility framework.

METHODS

We performed a literature search on PubMed and Ovid MEDLINE using relevant search terms, manual searched grey literature by visiting relevant websites, examined reference lists and contacted authors for clarification of included PrEP programmes reported through July 2019. A structured table was used for data extraction and summarizing findings in accordance with the five constructs of approachability, acceptability, availability, affordability and appropriateness grounded in the conceptual framework of Healthcare Accessibility.

RESULTS AND DISCUSSION

This literature search yielded a total of 1308 publications; 119 full texts and abstracts were screened, and 24 publications were included in the review. We identified 11 programmes implemented in seven cities/countries in the Asia-Pacific. A typology of four PrEP delivery models was delineated: (a) fee-based public service model; (b) fee-based community setting model; (c) free public service model; and (d) free community setting model. Overall, the free community setting model was most commonly adopted in the Asia-Pacific, with the strength to boost the capacity of facility and human resources, which enhanced "approachability", "availability" and "acceptability." The free public service model was characterized by components designed in improving "approachability," "availability" and "appropriateness," with attention on equity in accessing PrEP. Among free-based models, long-term affordability both to the government and PrEP users would need to be maximized to increase accessibility. Alongside the need for raising awareness, supportive environments and ensuring timely access were means for enabling the development of a sustainable PrEP service.

CONCLUSION

PrEP programmes could be classified by delivery models through the five constructs of healthcare accessibility. While the coverage of PrEP remains limited in the Asia-Pacific, an evaluation of these models could benchmark best practices, which would in turn allow effective models to be designed.

Preexposure Prophylaxis for Prevention of HIV Acquisition Among Adolescents: Clinical Considerations, 2020

Preexposure prophylaxis (PrEP) with antiretroviral medication has been proven effective in reducing the risk for acquiring human immunodeficiency virus (HIV). The fixed-dose combination tablet of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) was approved by the U.S. Food and Drug Administration (FDA) for use as PrEP for adults in 2012. Since then, recognition has been increasing that adolescents at risk for acquiring HIV can benefit from PrEP. In 2018, FDA approved revised labeling for TDF/FTC that expanded the indication for PrEP to include adolescents weighing at least 77 lb (35 kg) who are at risk for acquiring HIV. In 2019, FDA approved the combination product tenofovir alafenamide (TAF)/FTC as PrEP for adolescents and adults weighing at least 77 lb (35 kg), excluding those at risk for acquiring HIV through receptive vaginal sex. This exclusion is due to the lack of clinical data regarding the efficacy of TAF/FTC in cisgender women.Clinical providers who evaluate adolescents for PrEP use must consider certain topics that are unique to the adolescent population. Important considerations related to adolescents include PrEP safety data, legal issues about consent for clinical care and confidentiality, the therapeutic partnership with adolescents and their parents or guardians, the approach to the adolescent patient's clinical visit, and medication initiation, adherence, and persistence during adolescence. Overall, data support the safety of PrEP for adolescents. PrEP providers should be familiar with the statutes and regulations about the provision of health care to minors in their states. Providers should partner with the adolescent patient for PrEP decisions, recognizing the adolescent's autonomy to the extent allowable by law and including parents in the conversation about PrEP when it is safe and reasonable to do so. A comprehensive approach to adolescent health is recommended, including considering PrEP as one possible component of providing medical care to adolescents who inject drugs or engage in sexual behaviors that place them at risk for acquiring HIV. PrEP adherence declined over time in the studies evaluating PrEP among adolescents, a trend that also has been observed among adult patients. Clinicians should implement strategies to address medication adherence as a routine part of prescribing PrEP; more frequent clinical follow-up is one possible approach.PrEP is an effective HIV prevention tool for protecting adolescents at risk for HIV acquisition. For providers, unique considerations that are part of providing PrEP to adolescents include the possible need for more frequent, supportive interactions to promote medication adherence. Recommendations for PrEP medical management and additional resources for providers are available in the U.S. Public Health Service clinical practice guideline Preexposure Prophylaxis for the Prevention of HIV Infection in the United States - 2017 Update and the clinical providers' supplement Preexposure Prophylaxis for the Prevention of HIV Infection in the United States - 2017 Update: Clinical Providers' Supplement (https://www.cdc.gov/hiv/clinicians/prevention/prep.html).

HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis

Although pre-exposure prophylaxis (PrEP) has been approved for primary HIV prevention for individuals aged 18 years or older since 2012, PrEP utilization has been suboptimal. To understand trends in PrEP provision from the health care providers' perspective, we systematically assessed each specific stage along the PrEP implementation cascade (i.e., awareness, willingness, consultation, and prescription) among health care professionals (HCPs) in the United States. Between June and December 2018, we conducted a systematic review of published studies on this topic. A total of 36 eligible studies were identified and included in the analyses. Random-effect models were employed to examine the pooled prevalence of each key stage along the cascade. Time trend and subgroup analyses were conducted. A thematic analysis was used to identify barriers and facilitators along the PrEP cascade. In this study, a total of 18,265 HCPs representing diverse demographics were included. The pooled prevalence of PrEP awareness was 68% [95% confidence interval (CI) = 55-80%], willingness to prescribe PrEP was 66% (95% CI = 54-77%), PrEP consultation was 37% (95% CI = 25-51%), and prescription provision was 24% (95% CI = 17-32%). Subgroup analyses revealed that PrEP provision among HCPs was lowest in the south, but has been improving annually nationwide. Infectious disease specialists [odds ratio (OR) = 4.06, 95% CI = 3.12-5.28; compared with primary care providers] and advanced practice registered nurses/physician assistants (OR = 1.51, 95% CI = 1.09-2.09; compared with physicians) had higher odds of prescribing PrEP. Barriers and facilitators regarding optimal PrEP implementation were embedded within individual, dyadic, social, and structural levels. This meta-analysis has comprehensively examined the trend and pattern of PrEP implementation among HCPs. To achieve optimal implementation of the PrEP cascade in the United States, tailored training and programs need to be provided to HCPs.

Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama

Limited studies to date assess barriers to and facilitators of PrEP uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. We examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama. Participants were 32 years old on average, 66% Black, 66% gay or lesbian, 70% male, and 66% single. Perceived barriers to PrEP access included: lack of PrEP awareness and advertisement; sexuality-related stigma; time and resource constraints; and concerns about the adequacy and technical quality of PrEP services. Perceived facilitators to PrEP access were: PrEP-related information gathering and sharing; increased dialogue and visibility around PrEP; social, programmatic, and clinical support; and, lastly, self-preservation; personal motivation; and treatment self-efficacy. Results point to opportunities to address complex barriers to equitable PrEP access using multilevel and multimodal solutions.

US Guideline Criteria for Human Immunodeficiency Virus Preexposure Prophylaxis: Clinical Considerations and Caveats

Clinical guidelines for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) developed by the US Centers for Disease Control and Prevention have been instrumental in the implementation of PrEP in medical practices throughout the country. However, the eligibility criteria contained within may inadvertently limit PrEP access for some patients. We describe the following key considerations and caveats related to these criteria: promotion of a selective vs universal approach to sexual health education involving PrEP; misalignment between criteria stated in the table and text boxes; problematic categorization and confounding of sexual orientation, gender identity, and risk behavior; underemphasis of network/community-level drivers of HIV transmission; oversimplification of serodiscordant risk; and lack of clarity surrounding the relevance of condoms to PrEP eligibility. We offer concrete recommendations to address the identified issues and strengthen future iterations of the guidelines, applying these recommendations in an alternative table of "criteria."

Factors Affecting Pre-Exposure Prophylaxis Implementation for Women in the United States: A Systematic Review

Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective pill that HIV-negative individuals can take once daily to prevent HIV infection. Although PrEP is a private, user-controlled method that empowers women to protect themselves without relying on a partner's behavior, women's PrEP use has been extremely low. We systematically reviewed the literature to identify and summarize factors that may be affecting PrEP implementation for women in the United States. We conducted a search of the Centers for Disease Control and Prevention HIV/AIDS Prevention Research Synthesis Project database (MEDLINE, EMBASE, and CINAHL) and PubMed to identify peer-reviewed studies published between January 2000 and April 2018 that reported U.S. women's or health care providers' PrEP knowledge or awareness, willingness to use or prescribe, attitudes, barriers and facilitators to use or prescription, or PrEP adherence and discontinuation influences. Thirty-nine studies (26 women, 13 providers) met the eligibility criteria. In these studies, 0%-33% of women had heard of PrEP. Between 51% and 97% of women were willing to try PrEP, and 60%-92% of providers were willing to prescribe PrEP to women. Implementation barriers included access, cost, stigma, and medical distrust. Three studies addressed adherence or discontinuation. PrEP knowledge is low among women and providers. However, women and providers generally have positive views when aware of PrEP, including a willingness to use or prescribe PrEP to women. Most of the implementation barriers highlighted in studies were social or structural factors (e.g., access). Additional studies are needed to address research gaps, including studies of PrEP adherence and discontinuation.

HIV pre-exposure prophylaxis uptake by advanced practice nurses: Interplay of agency, community and attitudinal factors

AIMS

To identify associations among agency, community, personal and attitudinal factors that affect advanced practice nurses' uptake of HIV pre-exposure prophylaxis, an intervention consists of emtricitabine/tenofovir once-daily pill, along with sexual risk reduction education.

DESIGN

Cross-sectional.

METHODS

During March-May 2017, randomly selected Indiana advanced practice nurses were invited to complete an online survey, consisted of several validated self-rating measures (N = 1,358; response = 32.3%). Final sample (N = 369) was predominantly White, non-Hispanic, female advanced practice nurses in urban practices (mean age = 46). Conceptual model for structural equation model included 29 original/composite variables and five latent factors.

RESULTS

Final model consisted of 11 variables and four factors: agency, community, HIV prevention practices (including screening) and motivation to adopt evidence-based practices overall. Community had direct effects on HIV prevention practices (estimate = 0.28) and agency (estimate = 0.29). Agency had direct effects on HIV prevention practices (estimate = 0.74) and motivation to adopt evidence-based practices (estimate = 0.24). Community had indirect effects, through agency, on the two remaining factors.

CONCLUSION

Barriers exist against pre-exposure prophylaxis implementation, although practice guidelines are available. HIV prevention practices must be integrated across organizational structures, especially in high-risk communities, whereas practice change is more effective when focused on changing providers' attitudes towards intervention. When planning a pre-exposure prophylaxis intervention, advancing inputs from healthcare professionals, organizational leadership and community members, is crucial to success.

IMPACT

In settings where advanced practice nurses are primary contact points for health care, they may be best positioned to have an impact on implementation of HIV risk reduction strategies. Further research is needed to optimize their contributions to pre-exposure prophylaxis implementation.

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

BACKGROUND

Sexual and gender minority (SGM) populations remain at disproportionate risk of HIV infection. Despite the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV, PrEP uptake has been slow.

OBJECTIVE

To identify barriers and facilitators of PrEP access by examining SGM patients' experiences with accessing health care systems and engaging with providers about PrEP in a variety of practice settings.

DESIGN

Semi-structured, individual, qualitative interviews.

PARTICIPANTS

Twenty-seven sexual and gender minority adults residing in Oregon.

APPROACH

Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

KEY RESULTS

We identified three main themes. Participants described the centrality of patient-provider relationships to positive experiences around PrEP, the necessity of personally advocating to access PrEP, and the experience of system-level barriers to PrEP access. Participants also made several suggestions to improve PrEP access including improving provider engagement with SGM patients, encouraging providers to initiate conversations about PrEP, and increasing awareness of medication financial support.

CONCLUSIONS

In order to reduce HIV disparities, improving PrEP access will require additional efforts by providers and resources across health care settings to reduce barriers. Interventions to improve provider education about PrEP and provider communication skills for discussing sexual health are needed. Additionally, there should be system-level improvements to increase coordination between patients, providers, pharmacies, and payers to facilitate PrEP access and uptake.

Implications for PrEP Uptake in Young Adults Experiencing Homelessness: A Mixed Methods Study

Youth experiencing homelessness (YEH) have a high risk of contracting HIV; however, they remain relatively unreached by pre-exposure prophylaxis (PrEP)-based HIV prevention initiatives. We used a cross-sectional mixed-methods study to explore PrEP knowledge, interest, facilitators, and barriers among YEH. Young adults were recruited from agencies serving YEH in Houston, TX (n = 30) and Los Angeles, CA (n = 15) to participate in an electronic self-report survey and a semistructured interview. Survey results indicate that 68.2% of YEH had low or no prior knowledge of PrEP, though 63.7% reported interest in taking PrEP. Qualitative results revealed facilitators of PrEP use, including high PrEP acceptability and awareness, and supportive social networks. Several barriers emerged, including medication-related barriers, adherence, cost, access barriers, low perceived HIV risk, perceived stigma of PrEP use, and low PrEP awareness. Despite high PrEP acceptability, PrEP use among YEH remains low partly due to low PrEP awareness, low perceived HIV risk, and medical mistrust.

Considering Stigma in the Provision of HIV Pre-Exposure Prophylaxis: Reflections from Current Prescribers

Efforts to identify and address social inequities in HIV pre-exposure prophylaxis (PrEP) access are urgently needed. We investigated early-adopting PrEP prescribers' beliefs about how stigma contributes to PrEP access disparities in health care and explored potential intervention strategies within the context of PrEP service delivery. US-based PrEP prescribers were recruited through professional networks and participant referrals. Qualitative interviews were conducted, transcribed, and thematically analyzed. Participants (n = 18) were primarily male (72%); white (39%) or Asian (33%); and heterosexual (56%). Most practiced in the Northeastern (67%) or Southern (22%) United States; were physicians (94%); and specialized in HIV/infectious disease (89%). Participants described multiple forms of structural and interpersonal stigma impeding PrEP access. The requirement that PrEP be prescribed was a perceived deterrent for populations with medical mistrust and/or low health literacy. Practice norms such as discussing PrEP only in response to patient requests were seen as favoring more privileged groups. When probed about personally held biases, age-related stereotypes were the most readily acknowledged, including assumptions about older adults being sexually inactive and uncomfortable discussing sex. Participants criticized providers who chose not to prescribe PrEP within their clinical practice, particularly those whose decision reflected personal values related to condomless sex or discomfort communicating about sex with their patients. Suggested solutions included standardizing PrEP service delivery across patients and increasing cultural competence training. These early insights from a select sample of early-adopting providers illuminate mechanisms through which stigma could compromise PrEP access for key populations and corresponding points of intervention within the health care system.

Prevention paradox: Medical students are less inclined to prescribe HIV pre-exposure prophylaxis for patients in highest need

INTRODUCTION

Despite healthcare providers' growing awareness of pre-exposure prophylaxis (PrEP), prescription rates remain low. PrEP is an efficacious HIV prevention strategy recommended for use with condoms but still protective in their absence. Concern about the impact of PrEP on condom use and other risk behaviour is, nonetheless, among the barriers to prescription commonly reported. To understand the implications of this concern for PrEP access, we examined how medical students' willingness to prescribe PrEP varied by patients' condom use and partnering practices. We also assessed the perceived acceptability of various reasons for condom discontinuation with PrEP.

METHODS

An online survey was distributed to 854 medical students in the Northeastern US in 2015. Participants (n = 111) were surveyed about their willingness to prescribe PrEP for each of six male patients who systematically differed in their reported condom use (sustained use, sustained nonuse, or discontinuation with PrEP) and partnering practices (single male partner with untreated HIV or multiple male partners of unknown HIV status). Participants also reported perceived acceptability of four reasons for condom discontinuation: pleasure, sexual functioning, intimacy, and conception.

RESULTS

Willingness to prescribe PrEP was inconsistent with patient risk: When the patient used condoms and planned to sustain condom use, most participants were willing to prescribe PrEP - 93% if the patient had a single partner and 86% if the patient had multiple partners. Fewer were willing to prescribe if the patient did not use condoms and planned to sustain nonuse (53% and 45%, respectively) or used condoms but planned to discontinue use (27% and 28%). Significantly fewer participants were willing to prescribe for a patient with multiple partners versus a single partner when the patient reported sustained condom use or sustained condom nonuse. The number of participants who were willing to prescribe was similarly low for a patient with multiple partners versus a single partner when the patient reported that he planned to discontinue condom use. More participants accepted a patient discontinuing condoms for conception (69%) than for intimacy (23%), pleasure (14%), or sexual functioning (13%).

CONCLUSION

Medical students' clinical judgments were misaligned with patient risk and suggest misconceptions or personal values may undermine provision of optimal HIV prevention services.

Oral Pre-Exposure Prophylaxis (PrEP) for HIV Prevention in Adolescents and Young Adults

Purpose of review

To review the literature about oral pre-exposure prophylaxis (PrEP) for HIV prevention, with specific focus on adolescents.

Recent findings

Use of PrEP reduces new HIV infections among men who have sex with men, heterosexuals, and people who inject drugs. One combination antiretroviral medication is approved for PrEP in the U.S. for adults. Limited data suggest that PrEP is safe for use in youth, although declines in adherence to PrEP over time suggest the need for adherence interventions specifically targeting youth. Safety concerns related to PrEP include potential negative impacts on bone density and renal function, as well as potential increases in riskier sexual behaviors. The U.S. Public Health Service has published guidelines for PrEP use in adults.

Summary

Current data suggest that PrEP use is safe in adolescents; however, further research is needed on the potential impact of long-term PrEP use on bone density and kidney function.

Linking HIV-Negative Youth to Prevention Services in 12 U.S. Cities: Barriers and Facilitators to Implementing the HIV Prevention Continuum

PURPOSE

Linkage of HIV-negative youth to prevention services is increasingly important with the development of effective pre-exposure prophylaxis that complements behavioral and other prevention-focused interventions. However, effective infrastructure for delivery of prevention services does not exist, leaving many programs to address HIV prevention without data to guide program development/implementation. The objective of this study was to provide a qualitative description of barriers and facilitators of linkage to prevention services among high-risk, HIV-negative youth.

DESIGN

Thematic analysis of structured interviews with staff implementing linkage to prevention services programs for youth aged 12-24 years.

METHODS

Twelve adolescent medicine HIV primary care programs as part of larger testing research program focused on young sexual minority men of color. The study included staff implementing linkage to prevention services programs along with community-based HIV testing programs. The main outcomes of the study were key barriers/facilitators to linkage to prevention services.

RESULTS

Eight themes summarized perspectives on linkage to prevention services: (1) relationships with community partners, (2) trust between providers and youth, (3) youth capacity to navigate prevention services, (4) pre-exposure prophylaxis specific issues, (5) privacy issues, (6) gaps in health records preventing tailored services, (7) confidentiality of care for youth accessing services through parents'/caretakers' insurance, and (8) need for health-care institutions to keep pace with models that prioritize HIV prevention among at-risk youth. Themes are discussed in the context of factors that facilitated/challenged linkage to prevention services.

CONCLUSIONS

Several evidence-based HIV prevention tools are available; infrastructures for coordinated service delivery to high-risk youth have not been developed. Implementation of such infrastructures requires attention to community-, provider-, and youth-related issues.

Preexposure Prophylaxis of HIV Infection: the Role of Clinical Practices in Ending the HIV Epidemic

PURPOSE OF REVIEW

The aim of this study is to summarise the recent evidence from high-income settings about providers' ability to deliver on the UNAIDS goal of at least three million people at substantial risk of HIV infection with PrEP by 2020, including awareness and knowledge about PrEP, willingness to prescribe PrEP, current levels of prescribing and service delivery models and issues.

RECENT FINDINGS

Awareness about PrEP among health providers is growing, but at different pace depending on provider type. HIV and sexual health specialists are more likely to have knowledge about PrEP than generalists, and to be willing to prescribe it, mainly because of their closer contact with people at high risk for HIV and better risk assessment skills. There is still no consensus as to who should be responsible for providing PrEP, but clearly all hands on deck will be useful in delivering on the international target of three million people at substantial risk for HIV on PrEP by 2020. Only about 5% of the target has been reached so far. Local guidance and large-scale education and information programs for clinicians will be necessary to upskill health providers. High cost of PrEP is still a major barrier for its broad implementation, even in countries were PrEP roll-out has started. Health services are facing major structural challenges due to implementation of PrEP services to a substantial volume of patients. The early implementation experiences demonstrated that PrEP can be successfully delivered across a variety of settings, and a broad range of strategies and models of care can streamline PrEP delivery. Education of the providers and PrEP cost solutions will be essential for rapid roll-out of PrEP.

Facilitators and Barriers to Pre-Exposure Prophylaxis Willingness Among Young Men Who Have Sex with Men Who Use Geosocial Networking Applications in California

While correlates of pre-exposure prophylaxis (PrEP) uptake have been explored among older men who have sex with men (MSM), less is known about the facilitators and barriers that encourage uptake among younger MSM (YMSM). This study explores the association between willingness to take PrEP and demographic characteristics, sexual risk, and substance use, and attitudinal factors among YMSM in California who use geosocial networking applications (GSN apps). Based on survey data from YMSM recruited through GSN apps (n = 687), PrEP willingness was positively associated with Hispanic ethnicity [adjusted odds ratio (aOR): 1.73; confidence interval (CI): 1.01-2.98; p = 0.046], concerns about drug effects (aOR: 0.46; CI: 0.33-0.65; p < 0.001), medical mistrust (aOR: 0.71; CI: 0.53-0.96; p < 0.001), and concerns about adherence (aOR: 0.65; CI: 0.49-0.89; p = 0.005). PrEP willingness was positively associated with medium (aOR: 1.87; CI: 1.14-3.07; p = 0.014) and high concern (aOR: 1.84; CI: 1.13-3.01; p < 0.001) about contracting HIV and perceived benefits of taking PrEP (aOR: 2.59; CI: 1.78-3.78; p < 0.001). In addition to emphasizing the benefits of using PrEP, campaigns that address concerns regarding adherence and side effects may increase interest in and demand for PrEP among YMSM. More opportunities are needed to educate YMSM about PrEP, including addressing their concerns about this new prevention strategy. Providers should speak openly and honestly to YMSM considering PrEP about what to do if side effects occur and how to handle missed doses. Outreach using GSN apps for PrEP education and screening may be an effective way to reach YMSM.

HIV Care Providers' Intentions to Prescribe and Actual Prescription of Pre-Exposure Prophylaxis to At-Risk Adolescents and Adults

Pre-exposure prophylaxis (PrEP) is indicated for use in US adults, and little is known about clinician intentions to prescribe and actual prescription of PrEP to adolescents younger than 18. Fifty-six clinicians who care for HIV-infected and at-risk youth completed an anonymous online survey in 2014. Primary outcomes were (1) intentions to prescribe PrEP to adolescents and adults in four risk categories [men who have sex with men (MSM), transgender women, heterosexuals with multiple partners of unknown HIV status, heterosexuals with HIV-infected partners]; and (2) actual prescription of PrEP to adolescents and adults in these risk groups. Independent variables included clinician characteristics, experience prescribing nonoccupational postexposure prophylaxis, familiarity with and knowledge of PrEP and PrEP guidance, attitudes toward PrEP, and facilitating factors for prescribing PrEP and incorporation of PrEP guidance into practice. Variables associated with intention to prescribe ("very likely to prescribe" vs. other responses) and actual prescription of PrEP stratified by age and risk category were identified in logistic regression models. Mean age was 45.9 years (standard deviation 10.7); 64% were physicians. More clinicians reported high intention to prescribe PrEP to adult versus adolescent MSM (p = 0.02) and transgender women (p = 0.001). Variables associated with intention to prescribe and prescription of PrEP differed by age and risk category. In adolescents, those variables included positive beliefs, higher number of facilitating factors, and fewer barriers to PrEP prescription. Designing strategies based on these findings that address both facilitating factors and barriers to PrEP prescription may improve PrEP uptake by at-risk youth.

Adolescent pre-exposure prophylaxis for HIV prevention: current perspectives

Adolescents are a critical population that is disproportionately impacted by the HIV epidemic. More than 2 million adolescents between the age group of 10 and 19 years are living with HIV, and millions are at risk of infection. HIV risks are considerably higher among girls, especially in high-prevalence settings such as eastern and southern Africa. In addition to girls, there are other vulnerable adolescent subgroups, such as teenagers, who use intravenous (IV) drugs, gay and bisexual boys, transgender youth, male sex workers, and people who fall into more than one of these categories. Pre-exposure prophylaxis (PrEP) is a new intervention for people at high risk for acquiring HIV, with an estimated HIV incidence of >3%. Recent data from trials show evidence of the efficacy of PrEP as a powerful HIV prevention tool in high-risk populations, including men who have sex with men, HIV-1-serodiscordant heterosexual couples, and IV drug users. The reported efficacy in those trials of the daily use of oral tenofovir, alone or in combination with emtricitabine, to prevent HIV infection ranged from 44% to 75% and was heavily dependent on adherence. Despite the proven efficacy of PrEP in adult trials, concerns remain about its feasibility in real-life scenarios due to stigma, cost, and limited clinician experience with PrEP delivery. Recent studies are attempting to expand the inquiry into the efficacy of such HIV prophylaxis approaches in adolescent populations, but there are still many gaps in knowledge, and no country has yet approved it for use with adolescents. The aim of this review was to identify and summarize the evidence from studies on PrEP for adolescents. We have compiled and reviewed published studies focusing on safety, feasibility, adherence to therapeutics, self-perception, and legal issues related to PrEP in people aged between 10 and 24 years.

Evaluating Testing Strategies for Identifying Youths With HIV Infection and Linking Youths to Biomedical and Other Prevention Services

IMPORTANCE

Most human immunodeficiency virus (HIV)-infected youths are unaware of their serostatus (approximately 60%) and therefore not linked to HIV medical or prevention services. The need to identify promising and scalable approaches to promote uptake of HIV testing among youths at risk is critical.

OBJECTIVE

To evaluate a multisite HIV testing program designed to encourage localized HIV testing programs focused on self-identified sexual minority males and to link youths to appropriate prevention services after receipt of their test results.

DESIGN, SETTING, AND PARTICIPANTS

Testing strategies were evaluated using an observational design during a 9-month period (June 1, 2015, through February 28, 2016). Testing strategies were implemented by 12 adolescent medicine HIV primary care programs and included targeted testing, universal testing, or a combination. Data were collected from local youth at high risk of HIV infection and, specifically, sexual minority males of color.

MAIN OUTCOMES AND MEASURES

Proportion of sexual minority males and sexual minority males of color tested, proportion of previously undiagnosed HIV-positive youths identified, and rates of linkage to prevention services.

RESULTS

A total of 3301 youths underwent HIV testing. Overall, 35 (3.6%) of those who underwent universal testing in primary care clinical settings, such as emergency departments and community health centers, were sexual minority males (35 [3.6%] were males of color) compared with 236 (46.7%) (201 [39.8%] were males of color) who were tested through targeted testing and 693 (37.8%) (503 [27.4%] were males of color) through combination efforts. Identification of new HIV-positive cases varied by strategy: 1 (0.1%) via universal testing, 39 (2.1%) through combination testing, and 16 (3.2%) through targeted testing. However, when targeted tests were separated from universal testing results for sites using a combined strategy, the rate of newly identified HIV-positive cases identified through universal testing decreased to 1 (0.1%). Rates of new HIV-positive cases identified through targeted testing increased to 49 (6.3%). Youths who tested through targeted testing (416 [85.1%]) were more likely to link successfully to local HIV prevention services, including preexposure prophylaxis, compared with those who underwent universal testing (328 [34.1%]).

CONCLUSIONS AND RELEVANCE

The findings suggest that community-based targeted approaches to HIV testing are more effective than universal screening for reaching young sexual minority males (especially males of color), identifying previously undiagnosed HIV-positive youths, and linking HIV-negative youths to relevant prevention services. Targeted, community-based HIV testing strategies hold promise as a scalable and effective means to identify high-risk youths who are unaware of their HIV status.

Values and Preferences on the Use of Oral Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Multiple Populations: A Systematic Review of the Literature

Daily oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by HIV-negative people to prevent HIV infection. WHO released new guidelines in 2015 recommending PrEP for all populations at substantial risk of HIV infection. To prepare these guidelines, we conducted a systematic review of values and preferences among populations that might benefit from PrEP, women, heterosexual men, young women and adolescent girls, female sex workers, serodiscordant couples, transgender people and people who inject drugs, and among healthcare providers who may prescribe PrEP. A comprehensive search strategy reviewed three electronic databases of articles and HIV-related conference abstracts (January 1990-April 2015). Data abstraction used standardised forms to categorise by population groups and relevant themes. Of 3068 citations screened, 76 peer-reviewed articles and 28 conference abstracts were included. Geographic coverage was global. Most studies (N = 78) evaluated hypothetical use of PrEP, while 26 studies included individuals who actually took PrEP or placebo. Awareness of PrEP was low, but once participants were presented with information about PrEP, the majority said they would consider using it. Concerns about safety, side effects, cost and effectiveness were the most frequently cited barriers to use. There was little indication of risk compensation. Healthcare providers would consider prescribing PrEP, but need more information before doing so. Findings from a rapidly expanding evidence base suggest that the majority of populations most likely to benefit from PrEP feel positively towards it. These same populations would benefit from overcoming current implementation challenges with the shortest possible delay.

A Medical Care Missed Opportunity: Preexposure Prophylaxis and Young Black Men Who Have Sex With Men

PURPOSE

HIV disproportionately impacts young black men who have sex with men (YBMSM). Preexposure prophylaxis (PrEP) is an effective strategy that can avert new HIV infections in YBMSM. Barriers exist for YBMSM to access PrEP.

METHODS

We sought to determine factors associated with awareness of and willingness to take PrEP in a sample of YBMSM.

RESULTS

Only 8% were currently on PrEP despite many (66%) reporting condomless anal sex, a recent provider visit (54%), disclosing their sexual orientation to their regular medical provider (62%), or a willingness to take PrEP (62%). In bivariate analysis, increased number of lifetime partners, current PrEP use, and disclosure of sexual orientation to a doctor were associated with awareness of PrEP, while condomless anal sex and higher perceived risk was associated with willingness to take PrEP. Sex with females was associated with lower willingness.

CONCLUSIONS

Providers may be missing key opportunities to educate YBMSM about PrEP and incorporate PrEP into comprehensive sexual health care.

Preventing HIV among adolescents with oral PrEP: observations and challenges in the United States and South Africa

INTRODUCTION

Adolescents and young adults aged <25 are a key population in the HIV epidemic, with very high HIV incidence rates in many geographic settings and a large number who have limited access to prevention services. Thus, any biomedical HIV prevention approach should prepare licensure and implementation strategies for young populations. Oral pre-exposure prophylaxis (PrEP) is the first antiretroviral-based prevention intervention with proven efficacy across many settings and populations, and regulatory and policy approvals at global and national levels are occurring rapidly. We discuss available data from studies in the United States and South Africa on the use of oral PrEP for HIV prevention in adolescent minors, along with some of the implementation challenges.

DISCUSSION

Ongoing studies in the United States and South Africa among youth under the age of 18 should provide the safety data needed by the end of 2016 to contribute to licensure of Truvada as daily PrEP in adolescents. The challenges of completing these studies as well as foreseeable broader challenges highlighted by this work are presented. Adherence to daily PrEP is a greater challenge for younger populations, and poor adherence was associated with decreased efficacy in all PrEP trials. Individual-level barriers include limited familiarity with antiretroviral-based prevention, stigma, product storage, and social support. Structural challenges include healthcare financing for PrEP, clinician acceptability and comfort with PrEP delivery, and the limited youth-friendly health services available. These challenges are discussed in the context of the work done to date in the United States and South Africa, but will likely be magnified in the setting of limited resources in many other countries that are heavily impacted by HIV.

CONCLUSIONS

Adolescent populations are particularly vulnerable to HIV, and oral PrEP in these populations is likely to have an impact on population-level HIV incidence. The challenges of disseminating an HIV biomedical prevention tool requiring daily usage in adolescents are formidable, but addressing these issues and starting dialogues will lay the groundwork for the many other HIV prevention tools now being developed and tested.

Adolescent Human Immunodeficiency Virus Care Providers' Attitudes Toward the Use of Oral Pre-Exposure Prophylaxis in Youth

Oral pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention is currently indicated for use in adults in the United States and may soon be indicated for minor adolescents. However, implementation of PrEP use among minors may present unique barriers. We conducted 15 individual, semi-structured interviews among US clinicians caring for HIV-infected and at-risk youth. The theory-driven interview guide assessed demographics, perceived role of oral PrEP in HIV prevention among adolescents, perceived barriers to and facilitating factors for use of PrEP in adolescents, and clinician-reported likelihood of prescribing PrEP. Transcripts were analyzed using framework analysis. Overall, clinicians viewed PrEP as a time-limited intervention that is one part of a comprehensive approach to HIV prevention among adolescents. Perceived barriers to prescribing to minors included concerns about: confidentiality, legality of minors consenting to PrEP without parental involvement, ability of minors to understand the risks/benefits of PrEP, the possible impact of PrEP on bone accrual, off-label use of PrEP medication in minors, and the high costs associated with PrEP use. Clinician-reported facilitating factors for prescribing PrEP to youth included educating communities and other clinicians about PrEP, ensuring adequate financial resources and infrastructure for delivering PrEP, developing formal guidance on effective behavioral interventions that should be delivered with PrEP, and gaining personal experience with prescribing PrEP. Clinicians indicated greater comfort with prescribing PrEP to adults versus minors. For PrEP to become more widely available to youth at risk for HIV infection, barriers that are unique to PrEP use in minors must be addressed.

Putting PrEP into Practice: Lessons Learned from Early-Adopting U.S. Providers' Firsthand Experiences Providing HIV Pre-Exposure Prophylaxis and Associated Care

Optimizing access to HIV pre-exposure prophylaxis (PrEP), an evidence-based HIV prevention resource, requires expanding healthcare providers' adoption of PrEP into clinical practice. This qualitative study explored PrEP providers' firsthand experiences relative to six commonly-cited barriers to prescription-financial coverage, implementation logistics, eligibility determination, adherence concerns, side effects, and anticipated behavior change (risk compensation)-as well as their recommendations for training PrEP-inexperienced providers. U.S.-based PrEP providers were recruited via direct outreach and referral from colleagues and other participants (2014-2015). One-on-one interviews were conducted in person or by phone, transcribed, and analyzed. The sample (n = 18) primarily practiced in the Northeastern (67%) or Southern (22%) U.S. Nearly all (94%) were medical doctors (MDs), most of whom self-identified as infectious disease specialists. Prior experience prescribing PrEP ranged from 2 to 325 patients. Overall, providers reported favorable experiences with PrEP implementation and indicated that commonly anticipated problems were minimal or manageable. PrEP was covered via insurance or other programs for most patients; however, pre-authorization requirements, laboratory/service provision costs, and high deductibles sometimes presented challenges. Various models of PrEP care and coordination with other providers were utilized, with several providers highlighting the value of clinical staff support. Eligibility was determined through joint decision-making with patients; CDC guidelines were commonly referenced but not considered absolute. Patient adherence was variable, with particularly strong adherence noted among patients who had actively sought PrEP (self-referred). Providers observed minimal adverse effects or increases in risk behavior. However, they identified several barriers with respect to accessing and engaging PrEP candidates. Providers offered a wide range of suggestions regarding content, strategy, and logistics surrounding PrEP training, highlighting sexual history-taking and sexual minority competence as areas to prioritize. These insights from early-adopting PrEP providers may facilitate adoption of PrEP into clinical practice by PrEP-inexperienced providers, thereby improving access for individuals at risk for HIV.

PrEP Awareness and Attitudes in a National Survey of Primary Care Clinicians in the United States, 2009-2015

Objectives

As trials were assessing the safety and efficacy of daily oral antiretroviral preexposure prophylaxis (PrEP) for the prevention of HIV infection, there was a clear need to understand the evolution of knowledge of, and attitudes toward, PrEP among primary care clinicians.

Methods

Physicians and nurse practitioners were surveyed in 2009 (n = 1500), 2010 (n = 1504), 2012 (n = 1503), 2013 (n = 1507), 2014 (n = 1508) and 2015 (n = 1501) to assess their awareness of PrEP, willingness to prescribe PrEP, and whether they support use of public funds to pay for PrEP. Pharmacists (n = 251) were surveyed about PrEP in 2012 only. Descriptive statistics were computed for physician demographics and PrEP-related questions. Prevalence ratios for willingness to prescribe PrEP were computed using Poisson regression analysis.

Results

Awareness of PrEP was low among clinicians (2009: 24%, 2010: 29%) but increased after trials reported effectiveness (2012: 49%, 2013: 51%, 2014: 61%, 2015: 66%). Following a description of PrEP with an estimated effectiveness of 75%, across 6 of the study years 91% of clinicians indicated a willingness to prescribe PrEP to at least one group at high risk of HIV acquisition. A smaller majority of clinicians indicated support for public funding of PrEP in 2009: 59%, 2010: 53%, and 2013: 63%.

Conclusions

In surveys conducted before and after the release of PrEP trial results, primary care clinicians were largely unaware of PrEP. They indicated high levels of willingness to prescribe it for patients at high risk of HIV acquisition and expressed interest in education about how to deliver this new clinical HIV prevention method. It will be important to continue monitoring clinician knowledge, attitudes, and practices as the use of PrEP increases in the US.