Differing Experiences with Pre-Exposure Prophylaxis in Boston Among Lesbian, Gay, Bisexual, and Transgender Specialists and Generalists in Primary Care: Implications for Scale-Up

Designing a blockchain technology platform for enhancing the pre-exposure prophylaxis care continuum

Objectives

Pre-exposure prophylaxis (PrEP) is a key biomedical intervention for ending the HIV epidemic in the United States, but its uptake is impeded by systemic barriers, including fragmented workflows and ineffective data coordination. This study aims to design PrEPLinker, a blockchain-based, client-centered platform to enhance care to address these challenges by improving care coordination and enabling clients to securely manage their identity and PrEP-related data.

Materials and Methods

Using Houston, Texas, as a use case, we conducted a needs assessment with PrEP collaborators to evaluate existing workflows and identify barriers in the PrEP care continuum. Based on these findings, we designed PrEPinker, a blockchain-based identity framework and digital wallet using self-sovereign identity and verifiable credentials (VCs). These features enable clients to securirely control their identity data and facilitate efficient, privacy-serving data sharing across PrEP service points, such as community testing sites, clinics, and pharmacies.

Results

The needs assessment identified significant gaps in data exchange for PrEP referrals and follow-up appointments. In response, PrEPLinker was designed to incorporate decentralized identifiers-unique, secure digital identifiers that are not linked to any centralized authority-and VCs for ensuring seamless transfer of digital medical records. Preliminary usability testing with 15 participants showed that over 70% rated the interactive design positively, finding it easy to use, learn, and navigate without technical support. Additionally, more than 80% expressed confidence in using the blockchain based platform to manage sensitive health information securely.

Discussion and Conclusion

Blockchain technology offers a promising, client-centered solution for addressing systemic barriers in PrEP care by improving data cordination, security, and client control over personal health information. The design of PrEPLinker demorates the potential to streamline PrEP referrals, follow-up processes, and data managent. These advancements in data coordination and secruity could improve PrEP uptake and adherence, supporting efforts to reduce HIV transmission in Houston and beyond.

Pre-exposure prophylaxis (PrEP) among people who use drugs: a qualitative scoping review of implementation determinants and change methods

Implementation of pre-exposure prophylaxis (PrEP) to prevent HIV transmission is suboptimal in the United States, particularly among people who use drugs (PWUD). PrEP research among PWUD is scarce, and the factors that impact implementation are largely unknown. Therefore, we conducted a scoping review of implementation determinants (i.e., barriers and facilitators), as well as the change methods (implementation strategies and adjunctive interventions) that have been evaluated to increase PrEP implementation and use among PWUD. We identified 32 peer-reviewed articles assessing determinants and five that evaluated change methods. Determinants were coded using the updated Consolidated Framework for Implementation Research (CFIR), which is an established framework to understand the multilevel barriers and facilitators associated with implementation. Findings indicate that most research was conducted among PrEP recipients (i.e., patients), focusing on awareness and willingness to use PrEP, with less focus on factors impacting clinicians and service delivery systems. Moreover, very few change methods have been evaluated to improve clinician adoption and adherence to CDC guidelines for PrEP provision and/or recipient uptake and adherence to PrEP. Future research is needed that focuses on factors impacting implementation from a clinician standpoint as well as innovative change methods to increase PrEP awareness, reach, adoption, and sustained adherence to guidelines. Implementation Science offers a wealth of knowledge to speed up the effort to end the HIV epidemic in the United States.

The Role of Emergency and Primary Care in Combating the Rise of Gonorrhea: Another Purview Paradox?

INTRODUCTION

Drug-resistant Neisseria gonorrhoeae is an urgent threat to public health. Novel prevention and treatment strategies are emerging, including immunizations, pharmacologic post-exposure prophylaxis, rapid molecular resistance assays, and novel antibiotics. However, where and how such strategies are optimally implemented remains unclear.

METHODS

We conducted a retrospective interrupted time series analysis of gonorrhea cases reported to the Massachusetts Department of Public Health. We collected names of treating providers from 2011 (n = 100) and 2022 (n = 108), and cross-referenced provider names with publicly available records from the Massachusetts Boards of Registration in Medicine and Nursing to identify provider type, specialty, year of terminal degree or licensure, and clinic type.

RESULTS

Of 208 providers, 111 (53.4%) were advanced care practitioners. Providers treated cases predominantly in community health centers (n = 65, 31.3%) and emergency departments or urgent care centers (n = 60, 28.8%). Only 11 (12.4%) of 89 physicians were trained in either adult or pediatric infectious diseases.

CONCLUSION

Our results indicate that the majority of gonorrhea cases in the Massachusetts are treated in non-specialty settings. The time is now to plan for implementation of the emerging strategies to avoid underutilization and assure uptake of interventions in settings positioned to reach persons diagnosed with gonorrhea who will benefit most.

"Sex without fear": exploring the psychosocial impact of oral HIV pre-exposure prophylaxis on gay men in England

Gay, bisexual, and other men who have sex with men (GBMSM) experience a high prevalence of psychosocial health problems, such as harmful substance use and depression, as well as being disproportionately affected by HIV. HIV Pre-Exposure Prophylaxis (PrEP) may provide psychosocial benefits beyond its intended purpose of reducing HIV infection. We explore the psychosocial impact of oral PrEP use on gay men in England using qualitative data from the PROUD study. From February 2014 to January 2016, semi-structured in-depth interviews were conducted with 40 gay men and one trans woman. Participants were purposively recruited based on trial arm allocation, adherence, and sexual risk behaviours. By removing HIV risk from sex, PrEP improves users' wellbeing by reducing HIV-related anxiety and internalised stigma and increasing HIV prevention self-efficacy, sexual pleasure, and intimacy. In turn, these psychological changes may influence behaviour in the form of greater sexual freedom, reduced harmful drug use, and more protective sexual health behaviours. However, PrEP may create internal conflict for some gay men, due to its disruption of social norms around condom use and its perceived influence on their sexual behaviour leading to reduced condom self-efficacy. These findings provide a baseline of PrEP's psychosocial impact amongst some of the first PrEP users in England and supports calls to consider the psychosocial impact of PrEP in prescribing guidelines.

Health Care Providers' Views on Clinic Infrastructure and Practice Models That May Facilitate HIV Preexposure Prophylaxis (PrEP) Prescribing: A Qualitative Meta-Synthesis

HIV (human immunodeficiency virus) preexposure prophylaxis (PrEP) is an effective biomedical HIV prevention tool. Increasing PrEP use among populations disproportionately affected by HIV is one of the key efforts in the United States' Ending the HIV Epidemic (EHE) initiative and the HIV National Strategic Plan for the United States. Given that PrEP is available only through prescription, it is important to explore structural, organizational, or environmental factors that could facilitate or impede health care provider's PrEP prescribing behavior. The purpose of this systematic review (PROSPERO [CRD: 42019138889]) is to identify qualitative studies that addressed this topic and conduct meta-synthesis using the thematic synthesis method to identify major themes on the characteristics of clinic infrastructure or clinic models that providers consider as facilitators of PrEP prescribing in the United States. Eighteen citations representing 15 studies were included in this review. Five overarching themes were identified: (1) routinized HIV risk assessment; (2) interdisciplinary/coordinated PrEP teams or services; (3) clinic capacity to provide essential PrEP-related services; (4) low out-of-pocket patient costs; and (5) access to the priority populations. Some of these themes are consistent with the recommendations of CDC's PrEP clinical guidelines and the EHE initiative. More recent studies that include perspectives of diverse providers, timely analysis of these studies, and implementation research to assess strategies to address the current practice gaps are needed to further promote PrEP prescribing among providers in the United States.

Shared decision making for HIV pre-exposure prophylaxis (PrEP) with black transgender women

Shared decision making is a collaborative process intended to develop a treatment plan that considers both the patient's preferences and the health provider's medical recommendations. It is one approach to reducing healthcare disparities by improving patient-provider communication and subsequent health outcomes. This study examines shared decision making about HIV pre-exposure prophylaxis (PrEP) with Black transgender women in Chicago, Illinois, USA, given high prevalence of HIV and disparities in PrEP use. Black transgender women were recruited online and in-person to participate in semi-structured interviews (n = 24) and focus groups (2; n = 14 total), conducted between 2016 and 2017. Iterative thematic content analysis took place. Analysis revealed that internalised transphobia and racism, combined with stigma from service providers, prevented disclosure of gender and sexual identity to providers. Stigma about PrEP as it relates to Black transgender women results in stereotype threat, which undermines patient-provider trust and deters shared decision making for PrEP. Shared decision making promotes cultural competence and humility and builds trust within the patient-provider relationship, leading to better communication and less stigma. The involvement of peers may be one way to mitigate stigma for Black transgender women around PrEP, promote cultural competence within organisations, and empower engagement in shared decision making for HIV prevention.

"Let's Be a Person to Person and Have a Genuine Conversation": Comparing Perspectives on PrEP and Sexual Health Communication Between Black Sexual Minority Men and Healthcare Providers

Patient-provider communication is a key factor affecting HIV pre-exposure prophylaxis (PrEP) awareness and access among Black sexual minority men (SMM). Optimizing patient-provider communication requires a deeper understanding of communication dynamics. In this study, we investigated the perspectives of both HIV-negative/status-unknown Black SMM and practicing community healthcare providers regarding patient-provider communication about PrEP and sexual health. We conducted eleven semi-structured qualitative focus groups (six with Black SMM; five with providers) in the Northeastern USA and thematically analyzed transcripts. A total of 36 Black SMM and 27 providers participated in the focus groups. Our analysis revealed points of alignment and divergence in the two groups' perspectives related to patient-provider communication. Points of alignment included: (1) the importance ascribed to maximizing patients' comfort and (2) belief in patients' right to non-discriminatory healthcare. Points of divergence included: (1) Black SMM's preference for sexual privacy versus providers' preference that patients share sexual information, (2) Black SMM's perception that providers have an ethical responsibility to initiate conversations about PrEP with patients versus providers' perception of such conversations as being optional, and (3) Black SMM's preference for personalized sexual health conversations versus providers' preference for standardized conversations. Findings underscore a need for providers to offer more patient-centered sexual healthcare to Black SMM, which should entail routinely presenting all prevention options available-including PrEP-and inviting open dialogue about sex, while also respecting patients' preferences for privacy about their sexuality. This approach could increase PrEP access and improve equity in the US healthcare system.

HIV PrEP Clinician Communication Preferences Among Black Sexual Minority Men

Black sexual minority men (BSMM) are substantially less likely than White SMM to accept a clinician's recommendation to initiate HIV pre-exposure prophylaxis (PrEP). The purpose of this study is to identify PrEP messaging preferences among BSMM. Data were obtained from 12 focus groups and one in-depth interview among BSMM in Baltimore, MD (N = 39). Focus groups were stratified (18-24, 25-34, and 35 and older), and facilitators probed on ways clinicians could discuss PrEP with BSMM. An adapted pile sorting approach was used to identify themes. Most identified as homosexual, gay, or same-gender-loving (68%), were employed (69%), and single (66%). Thematic analysis revealed that BSMM wanted clinicians to explain PrEP efficacy and side effects, tailor messaging, provide prevention messaging with care, and disclose PrEP use. Clinicians could increase uptake and adherence among BSMM by implementing PrEP communication preferences. Discussing PrEP efficacy and safety is also necessary. When possible, clinicians should disclose PrEP use history to build trust.

Academic Detailing to Increase Prescribing of HIV Pre-exposure Prophylaxis

Although HIV pre-exposure prophylaxis can decrease new cases of HIV by up to 99%, many patients who could benefit from pre-exposure prophylaxis never receive prescriptions for it. Because pre-exposure prophylaxis is indicated for patients who do not have an infectious disease, increasing pre-exposure prophylaxis prescribing by primary care and generalist clinicians represents a key element of the Ending the HIV Epidemic in the U.S. initiative. This review provides an overview of academic detailing and how it is currently being used to increase pre-exposure prophylaxis prescribing. Academic detailing is outreach education that engages with clinicians in 1-to-1 or small group interactions focused on identifying and addressing an individual clinician's needs to increase their use of evidence-based practices. Academic detailing has been proven in multiple previous research studies, and the principles required for successful implementation include interactivity, clinical relevance of content, and focus on defined behavior change objectives. Clinician barriers to pre-exposure prophylaxis prescribing may occur in the domains of knowledge, attitudes, or behavior, and academic detailing has the potential to address all of these areas. State and local health departments have developed academic detailing programs focused on pre-exposure prophylaxis prescribing and other elements of HIV prevention-sometimes describing the approach as public health detailing. Few studies of academic detailing for pre-exposure prophylaxis have been published to date; rigorous evaluation of HIV-specific adaptations and innovations of the approach would represent an important contribution. In the setting of the COVID-19 pandemic, interest in virtual delivery of academic detailing has grown, which could inform efforts to implement academic detailing in rural communities and other underserved areas. Increasing this capacity could make an important contribution to Ending the HIV Epidemic in the U.S. and other HIV prevention efforts.

High Levels of Prevention-Effective Adherence to HIV PrEP: An Analysis of Substudy Data From the EPIC-NSW Trial

BACKGROUND

Preexposure prophylaxis (PrEP) prevents HIV infection but relies on good adherence at times of risk, termed "prevention-effective adherence." Most studies assess adherence without reference to sexual behaviur, making it challenging to determine if poor adherence coincides with HIV risk.

SETTING

We examined data from a behavioral substudy of a large-scale PrEP implementation trial in New South Wales, Australia.

METHODS

Trial participants completed optional brief quarterly surveys, reporting the number of pills taken and sexual behavior with male partners for each day of the "last full week" before each survey. Condomless sex (CLS) was defined as "higher risk" for HIV when with HIV-positive men with detectable/unknown viral loads or unknown HIV status men. Adequate PrEP protection was defined as ≥4 pills for participants assigned male sex at birth and ≥6 pills for participants assigned female sex at birth (including transgender men).

RESULTS

Of 9596 participants dispensed PrEP, 4401 completed baseline and ≥1 follow-up survey. Participants reported on 12,399 "last full weeks": 7485 weeks (60.4%) involved CLS and 2521 weeks (33.7% of CLS-weeks) involved higher risk CLS. There were 103 weeks in which participants did not have adequate PrEP protection and had higher risk CLS: 4.1% of higher-risk CLS weeks (n = 103/2521), 1.4% of all CLS weeks (n = 103/7485), and 0.8% of all observed weeks (n = 103/12,399).

CONCLUSIONS

In a large PrEP trial, prevention-effective adherence to PrEP was very high at 99%. Our findings illustrate the importance of measuring pill-taking and sexual behavior in the same period so that prevention-effective adherence can be better estimated.

Implementation of HIV Preexposure Prophylaxis in a Homeless Primary Care Setting at the Veterans Affairs

Objective: Oral preexposure prophylaxis (PrEP) is highly effective in preventing HIV-1 acquisition, yet it is underutilized among at-risk populations. In this pilot quality improvement (QI) initiative, we sought to identify barriers to PrEP implementation and create interventions to improve access to PrEP in a primary care clinic for homeless veterans. Methods: The setting was a large homeless primary care clinic at the Veterans Affairs in an urban area with high HIV prevalence. A root cause analysis was performed to identify barriers to PrEP expansion in the primary care clinic. Targeted interventions to improve provider knowledge and patient access to PrEP were implemented by the QI team. Results: Root cause analysis revealed 3 primary barriers to PrEP expansion in the primary care clinic: institutional limitations for prescribing PrEP, inconsistent screening and recognition of eligible patients by clinic staff, and lack of clinic workflow processes to support PrEP prescription. A multidisciplinary focus group found low levels of PrEP awareness and knowledge, with only 22% of providers reporting comfort discussing PrEP with patients. This improved to 40% of providers following targeted clinic educational interventions. The QI team also developed a pathway for primary care providers to obtain institutional PrEP prescribing privileges and used work groups to develop clinic workflows and protocols for PrEP. At the end of the intervention, at least 50% of primary care providers in the clinic had initiated PrEP in a new patient. Conclusions: We describe a multidisciplinary QI model to implement PrEP within a primary care setting serving Veterans and persons experiencing homelessness. Our program successfully addressed provider knowledge deficits and improved primary care capacity to prescribe PrEP. The primary care clinic can be a viable and important clinical setting to improve access to PrEP for HIV prevention, especially for vulnerable populations.

Issues Associated With Prescribing HIV Pre-exposure Prophylaxis for HIV Anxiety: A Qualitative Analysis of Australian Providers' Views

ABSTRACT

HIV pre-exposure prophylaxis (PrEP) can alleviate anxiety about acquiring HIV, particularly for gay men and other men who have sex with men. However, research with PrEP providers has rarely examined HIV anxiety. We conducted 25 semistructured interviews in 2019-2020 with PrEP providers in New South Wales and Western Australia, and analyzed data thematically. Participants included general practitioners and sexual health nurses and doctors. Our analysis explores providers' views on providing PrEP to reduce HIV anxiety for gay men, serodiscordant couples where the partner with HIV has an undetectable viral load, and for "worried well" individuals who the providers speculated might have undisclosed risk. Although providers viewed PrEP as beneficial for many people's personal lives and relationships, they felt cautious about prescribing PrEP solely for HIV anxiety, while at the same time reporting that they prescribed PrEP if individuals insisted on it and had no medical contraindications.

Tailored HIV Pre-exposure Prophylaxis (PrEP) Intervention Needs from a Latent Class Analysis Among U.S. Healthcare Providers

Interventions are needed to expand HIV pre-exposure prophylaxis (PrEP) prescribing practices among healthcare providers, but research classifying providers to determine tailored intervention needs is lacking. Providers reported demographics, factors related to HIV treatment and prevention experience, and PrEP-related factors such as knowledge and community protection beliefs via online survey. Latent class analysis grouped providers with similar patterns of HIV prevention- and treatment-related care and tested for associations with demographics and PrEP-related factors. Three distinct classes of providers emerged: (1) PrEP naïve, (2) PrEP aware, and (3) PrEP prescribers. Providers with lower community protection beliefs and staff capacity were more likely to be classified as PrEP naïve compared to aware (ps < 0.05). Providers with concerns about PrEP-related tasks and staff capacity were more likely to be classified as PrEP aware compared to prescribers (ps < 0.05). PrEP-naïve providers could benefit from continuing education, whereas PrEP-aware providers might benefit from capacity building and prescribing optimization interventions.

Prioritising pleasure and correcting misinformation in the era of U=U

There is widespread unawareness and disbelief regarding the evidence-based conclusion that people who have a sustained undetectable HIV viral load cannot sexually transmit HIV-ie, undetectable=untransmittable (U=U). Long-standing, misguided fear about HIV transmission persists; consequently, so does the policing of sexual expression and the penalisation of pleasure faced by people with HIV. Many people with HIV with an undetectable viral load have unnecessarily abstained from condomless sex, avoided serodifferent partnering, and had anxiety about onward sexual transmission due to perceived HIV risk that is now known to be non-existent. Some health professionals have refrained from correcting this misinformation because of concerns that people with HIV will engage in more condomless sex or have more sexual partners upon learning of U=U. Withholding information about U=U is thus rooted in behavioural assumptions and is scientifically unfounded. Moreover, withholding such information violates medical ethics, perpetuates health inequities, and infringes on the sexual health and human rights of people with HIV. Health professionals and the broader public health community have an ethical responsibility to actively address misinformation about HIV transmission and disseminate the U=U message to all people.

Attitudes and Practices of a Sample of Nova Scotian Physicians for the Implementation of HIV Pre-Exposure Prophylaxis

Introduction

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool that requires the ongoing support of physicians to be accessible. Recently, Nova Scotia experienced a 100% increase in HIV diagnoses. The purpose of this study is to explore the relationship between physicians' support of PrEP, knowledge of PrEP, and PrEP prescribing history using the information-motivation-behavioral (IMB) skills model.

Methods

An online survey was distributed to physicians in Nova Scotia, Canada, and eighty physicians participated. Two exploratory factor analyses were conducted with items from the Support of PrEP scale and Knowledge of PrEP scale. A mediation analysis was conducted to assess if knowledge of PrEP mediated the relationship between support of PrEP and whether physicians have prescribed PrEP in the past.

Results

On average, physicians reported strong support for PrEP, and as support for PrEP increased so did knowledge of PrEP. Further, physicians who had prescribed PrEP demonstrated strong knowledge of PrEP and physicians who had not prescribed PrEP reported feeling neutral. The 95% bootstrap confidence interval indirect effect of Support for PrEP on prescription history did not include zero (B = 1.59, 95% BsCI [0.83, 3.57]) demonstrating that the effect of support for PrEP is mediated by knowledge of PrEP. The most commonly identified barrier to prescribing PrEP was the lack of drug coverage among patients.

Conclusion

The results of the mediation analysis support the IMB skills model regarding support for PrEP, Knowledge of PrEP, and having prescribed PrEP in the past. Our findings suggest that to improve PrEP uptake in Nova Scotia, educational interventions for physicians and universal coverage of the drug would be necessary.

Research Priorities to End the Adolescent HIV Epidemic in the United States: Viewpoint

Youth represent 21% of new HIV diagnoses in the United States. Gay, bisexual, and transgender (GBT) youth, particularly those from communities of color, and youth who are homeless, incarcerated, in institutional settings, or engaging in transactional sex are most greatly impacted. Compared with adults, youth have lower levels of HIV serostatus awareness, uptake of antiretroviral therapy (ART), and adherence. Widespread availability of ART has revolutionized prevention and treatment for both youth at high risk for HIV acquisition and youth living with HIV, increasing the need to integrate behavioral interventions with biomedical strategies. The investigators of the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) completed a research prioritization process in 2019, focusing on research gaps to be addressed to effectively control HIV spread among American youth. The investigators prioritized research in the following areas: (1) innovative interventions for youth to increase screening, uptake, engagement, and retention in HIV prevention (eg, pre-exposure prophylaxis) and treatment services; (2) structural changes in health systems to facilitate routine delivery of HIV services; (3) biomedical strategies to increase ART impact, prevent HIV transmission, and cure HIV; (4) mobile technologies to reduce implementation costs and increase acceptability of HIV interventions; and (5) data-informed policies to reduce HIV-related disparities and increase support and services for GBT youth and youth living with HIV. ATN’s research priorities provide a roadmap for addressing the HIV epidemic among youth. To reach this goal, researchers, policy makers, and health care providers must work together to develop, test, and disseminate novel biobehavioral interventions for youth.

Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis: Implications for Medical Student Training

There is growing evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition. However, in the United States, approximately only 4% of people who could benefit from PrEP are currently receiving it, and it is estimated only 1 in 5 physicians has ever prescribed PrEP. We conducted a scoping review to gain an understanding of physician-identified barriers to PrEP provision. Four overarching barriers presented in the literature: Purview Paradox, Patient Financial Constraints, Risk Compensation, and Concern for ART Resistance. Considering the physician-identified barriers, we make recommendations for how physicians and students may work to increase PrEP knowledge and competence along each stage of the PrEP cascade. We recommend adopting HIV risk assessment as a standard of care, improving physician ability to identify PrEP candidates, improving physician interest and ability in encouraging PrEP uptake, and increasing utilization of continuous care management to ensure retention and adherence to PrEP.

HIV Post-Exposure Prophylaxis (PEP) Awareness and Non-Occupational PEP (nPEP) Prescribing History Among U.S. Healthcare Providers

Non-occupational post-exposure prophylaxis (nPEP) has been clinically recommended since 2005. HIV providers and non-HIV providers (n = 480) practicing within above-average HIV prevalence ZIP codes of the 10 U.S. cities with greatest overall HIV prevalence participated in a cross-sectional survey between July 2014 and May 2015. Providers were asked about their awareness of post-exposure prophylaxis (PEP) and nPEP prescribing experience for patients with potential sexual exposures to HIV, which we coded into a PEP prescribing cascade with three categories: (1) PEP unaware, (2) PEP aware, no nPEP prescribing experience, and (3) nPEP prescribing experience. Overall, 12.5% were unaware of PEP, 43.5% were aware but hadn't prescribed nPEP, and 44.0% had prescribed nPEP for potential sexual exposures to HIV. Fewer providers practicing in the U.S. South had ever prescribed nPEP compared to providers in other regions (χ2= 39.91, p < 0.001). HIV providers, compared to non-HIV providers, were more likely to be classified in the nPEP prescription group compared to the PEP aware without nPEP prescription group (RRR = 2.96, p < 0.001). PrEP prescribers, compared to those PrEP unaware, were more likely to be classified in the nPEP prescription group compared to PEP aware without nPEP prescription group (RRR = 12.49, p < 0.001).

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

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

Pre-exposure Prophylaxis Knowledge and Use Among Men Who Have Sex With Men in a Small Metropolitan Region of the Southeastern United States

Men who have sex with men (MSM) in the southeastern United States continue to be at high risk for HIV. Pre-exposure prophylaxis (PrEP) provides effective prevention, but PrEP awareness varies across communities. We assessed sexual risk, HIV/sexually transmitted infection (STI) testing history, health care experiences associated with PrEP awareness, provider discussions, and PrEP use in a sample of 164 MSM in the Central Savannah River Area of the South. Results revealed that 80.5% of participants were aware of PrEP, 16.4% had discussed PrEP with a provider, and 9.2% had used PrEP. Education, gay identity, HIV status, recent HIV testing, and lack of provider awareness about sexual minorities independently predicted PrEP awareness. Recent STI testing independently predicted increased odds of PrEP discussion. Recent HIV and STI testing and non-White identity were associated with PrEP use. Effective, tailored marketing, provider competence, and open communication can increase PrEP adoption by southern MSM.

Different guidelines for pre-exposure prophylaxis (PrEP) eligibility estimate HIV risk differently: an incidence study in a cohort of HIV-negative men who have sex with men, Portugal, 2014-2018

IntroductionGuidelines for pre-exposure prophylaxis (PrEP) provide criteria to identify individuals at higher risk of HIV infection. We compared the ability to predict HIV seroconversion of four guidelines: the World Health Organization (WHO), the United States Public Health Service and Centers for Disease Control and Prevention (US CDC), the European AIDS Clinical Society (EACS) and the Portuguese National Health Service (PNHS).AimWe aimed to measure the association between guideline-specific eligibility and HIV seroconversion.MethodsWe studied 1,254 participants from the Lisbon Cohort of men who have sex with men with at least two evaluations between March 2014 and March 2018, corresponding to 1,724.54 person-years (PY) of follow-up. We calculated incidence rates (IR) according to each guideline eligibility definition and incident rate ratios (IRR) to test the association between eligibility at baseline and HIV seroconversion.ResultsWe found 28 incident cases (IR: 1.62/100 PY; 95% confidence interval (CI) 1.12-2.35). Guidelines' sensitivity varied from 60.7% (EACS) to 85.7% (PNHS) and specificity varied from 31.8% (US CDC) to 51.5% (EACS). IR was highest among those defined as eligible by the PNHS guideline (2.46/100 PY; IRR = 4.61; 95% CI: 1.60-13.27) and lowest for the WHO guideline (1.89/100 PY; IRR = 1.52; 95% CI: 0.69-3.35).ConclusionsBeing identified as eligible for PrEP was associated with a higher risk of infection. The magnitude of risk varied according to the guideline used. However, the number of HIV infections identified among ineligible participants highlights the potential for missing people who need PrEP.

Health Care-Seeking Behaviors and Perceptions of Provider-Initiated Discussion of Pre-exposure Prophylaxis Among PrEP-Naïve HIV-Negative Men Who Have Sex With Men in Atlanta, Georgia

BACKGROUND

Given high rates of HIV among men who have sex with men (MSM) in the United States, there is a need to more effectively leverage the health care system to bolster promotion of pre-exposure prophylaxis (PrEP) to at-risk MSM.

METHODS

Using data collected from a 2018 venue-based cross-sectional survey, we examined factors associated with health care-seeking behaviors, discussing PrEP with a provider, and barriers to PrEP uptake among MSM. Associations between outcomes and respondents' sociodemographic characteristics and sexual behaviors were assessed using log binomial regression.

RESULTS

Of 478 MSM, 247 (51%) were PrEP-naïve and HIV-negative. Although 85% of PrEP-naïve MSM reported visiting a health care provider in the past year, only 31% recalled having any provider discuss PrEP. The most frequently cited reasons for not taking PrEP were low perception of personal risk of acquiring HIV (37%) and not knowing enough about PrEP (35%). Those who saw a provider in the last year were less likely than those who did not to cite lack of knowledge as a barrier to use (prevalence rate, 0.66, 95% confidence interval, 0.45-0.96).

CONCLUSIONS

Despite the majority of PrEP-naïve MSM interfacing with the health care system, recollection of discussing PrEP with providers was limited. Increased efforts to equip providers with the tools to discuss PrEP and address pressing concerns with at-risk individuals may help improve PrEP uptake among priority populations.

Health Care Provider Barriers to HIV Pre-Exposure Prophylaxis in the United States: A Systematic Review

Increasing prescription of pre-exposure prophylaxis (PrEP) is imperative to ending the HIV epidemic in the United States. The objective of this review was to identify health care provider barriers to PrEP implementation. A systematic review was conducted in February 2019 using PubMed to identify barriers to PrEP prescribing practices in the United States. Targeted search terms surrounding PrEP and providers resulted in 222 original studies, 28 of which were ultimately included in our review, with data collected between 2011 and 2018. Six themes were identified across reviewed studies: (i) a lack of PrEP knowledge, (ii) the presence of the Purview Paradox, which refers to discordance in beliefs between HIV specialists and primary care providers on who should prescribe PrEP, (iii) concerns about PrEP costs, (iv) concerns about behavioral and health consequences, (v) interpersonal stigma, and (vi) concerns about patient adherence. A majority of providers were lacking knowledge regarding PrEP, resulting in discomfort in prescribing PrEP, or limited awareness and understanding of PrEP clinical guidelines. Discrepant opinions were identified regarding whether PrEP was best managed within primary care or specialty clinics. Other barriers included concerns about cost, patient adherence, and follow-up maintenance care. Finally, concerns about risk compensation and discomfort discussing sexual activities with patients who would benefit most from PrEP were apparent. Additional work is needed to prepare providers to prescribe and manage patients on PrEP, optimize PrEP delivery, and reduce provider bias. Future research is needed to identify providers' attitudes and beliefs regarding innovations in PrEP dosing, task shifting, and novel strategies for PrEP care.

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.

Human Immunodeficiency Virus/Sexually Transmitted Infection Counseling and Testing Services Received by Gay and Bisexual Men Using Preexposure Prophylaxis at Their Last PrEP Care Visit

BACKGROUND

Preexposure prophylaxis (PrEP) reduces risk of human immunodeficiency virus infection for many gay and bisexual men (GBM); however, bacterial sexually transmitted infections associated with decreasing condom use among users is of concern. Center for Disease Control and Prevention's guidelines for PrEP use recommend bacterial sexually transmitted infection screening every 6 months. We sought to investigate comprehensive PrEP care, defined as: (1) discussion of sexual behavior, (2) blood sample, (3) urine sample, (4) rectal sample (rectal swab), and (5) throat sample (throat swab), provided at the user's last PrEP appointment.

METHODS

The PrEP-using GBM in New York City (n = 104) were asked about their last PrEP care visit. We examined associations of demographics (age, race/ethnicity, and education), recent number of condomless anal sex events, time on PrEP, and health care provider type on receiving comprehensive care at last visit using fully adjusted binary logistic regression.

RESULTS

At their last visit, nearly all men (94%) gave blood for testing, 88% provided a urine sample, and 77% discussed sexual behavior with their provider. However, only 51% reported having a rectal swab, and 48% an oral swab. Only 32% of men received comprehensive PrEP care at their last PrEP visit. Odds of receiving comprehensive care were significantly higher among younger men, men with a bachelor's degree or more education, and those who reported more condomless anal sex.

CONCLUSIONS

Less than one third of GBM received comprehensive human immunodeficiency virus/sexually transmitted infection counseling and testing at their last visit. These findings indicate further efforts are needed to prepare health care providers for prescribing and managing patients on PrEP.

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."

Using HIV Risk Prediction Tools to Identify Candidates for Pre-Exposure Prophylaxis: Perspectives from Patients and Primary Care Providers

Clinical guidelines for HIV pre-exposure prophylaxis (PrEP) include risk prediction tools to identify appropriate candidates. We conducted a qualitative interview study to explore the potential acceptability, interpretation, and anticipated impact of such tools from the perspectives of men who have sex with men (MSM) and primary care providers (PCPs). Our purposive sample of English-speaking participants included: (1) MSM reporting HIV risk behaviors (n = 32; median age = 38 years; 53% non-Hispanic white; 22% high school degree or less education); (2) PCPs specializing in health care for MSM (n = 12); and (3) PCPs in general practice (n = 19). MSM participants questioned the ability of risk tools to predict HIV acquisition, and their perceptions of what might constitute a high HIV risk score varied widely. Many MSM participants believed that receiving a high score would prompt them to consider PrEP or other risk reduction strategies. Some believed that the data would be useful, particularly if discussed with their providers, whereas others anticipated feeling fear, anxiety, or mistrust. PCPs expressed more confidence in HIV risk prediction and imagined integrating tools with medical histories and their clinical judgment to assess risk. PCPs were most enthusiastic about adopting HIV risk prediction as a teaching tool to help patients visualize and reduce risk, their concerns about time constraints notwithstanding. In conclusion, our findings suggest that PCPs' views of HIV risk prediction tools are generally positive, whereas MSM participants' are more mixed. Given that both groups emphasized the value of contextualizing risk, shared decision making may be needed to implement HIV risk prediction tools effectively.

Development and validation of an automated HIV prediction algorithm to identify candidates for pre-exposure prophylaxis: a modelling study

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is effective but underused, in part because clinicians do not have the tools to identify PrEP candidates. We developed and validated an automated prediction algorithm that uses electronic health record (EHR) data to identify individuals at increased risk for HIV acquisition.

METHODS

We used machine learning algorithms to predict incident HIV infections with 180 potential predictors of HIV risk drawn from EHR data from 2007-15 at Atrius Health, an ambulatory group practice in Massachusetts, USA. We included EHRs of all patients aged 15 years or older with at least one clinical encounter during 2007-15. We used ten-fold cross-validated area under the receiver operating characteristic curve (cv-AUC) with 95% CIs to assess the model's performance at identifying individuals with incident HIV and patients independently prescribed PrEP by clinicians. The best-performing model was validated prospectively with 2016 data from Atrius Health and externally with 2011-16 data from Fenway Health, a community health centre specialising in sexual health care in Boston (MA, USA). We calculated HIV risk scores (ie, probability of an incident HIV diagnosis) for every HIV-uninfected patient not on PrEP during 2007-15 at Atrius Health and assessed the distribution of scores for thresholds to determine possible candidates for PrEP in the three study cohorts.

FINDINGS

We included 1 155 966 Atrius Health patients from 2007-15 (150 [<0·1%] patients with incident HIV) in our development cohort, 537 257 Atrius Health patients in 2016 (16 [<0·1%] with incident HIV) in our prospective validation cohort, and 33 404 Fenway Health patients from 2011-16 (423 [1·3%] with incident HIV) in our external validation cohort. The best-performing algorithm was obtained with least absolute shrinkage and selection operator (LASSO) and had a cv-AUC of 0·86 (95% CI 0·82-0·90) for identification of incident HIV infections in the development cohort, 0·91 (0·81-1·00) on prospective validation, and 0·77 (0·74-0·79) on external validation. The LASSO model successfully identified patients independently prescribed PrEP by clinicians at Atrius Health in 2016 (cv-AUC 0·93, 95% CI 0·90-0·96) or Fenway Health (0·79, 0·78-0·80). HIV risk scores increased steeply at the 98th percentile. Using this score as a threshold, we prospectively identified 9515 (1·8%) of 536 384 patients at Atrius Health in 2016 and 4385 (15·3%) of 28 702 Fenway Health patients as potential PrEP candidates.

INTERPRETATION

Automated algorithms can efficiently identify patients at increased risk for HIV acquisition. Integrating these models into EHRs to alert providers about patients who might benefit from PrEP could improve prescribing and prevent new HIV infections.

FUNDING

Harvard University Center for AIDS Research, Providence/Boston Center for AIDS Research, Rhode Island IDeA-CTR, the National Institute of Mental Health, and the US Centers for Disease Control and Prevention.

Increasing Access to Pre-Exposure Prophylaxis Among Transgender Women and Transfeminine Nonbinary Individuals

In the United States, transgender women and transfeminine nonbinary individuals (TGWNBI) are a highly vulnerable and marginalized population at high risk for HIV. Despite disproportionate rates of HIV, a striking lack of research exists on pre-exposure prophylaxis (PrEP) use among TGWNBI. We conducted 30 semi-structured interviews with TGWNBI both on PrEP and those not on PrEP. Questions explored PrEP access, initiation, and factors to increase broad interest and participation in PrEP. Qualitative data were coded and analyzed using thematic analysis. Participants identified five components to increase PrEP use among TGWNBI: (1) eliminating the practice of conflating TGWNBI with cisgender men who have sex with men, (2) recognition of and support for the contextual factors associated with HIV risk among TGWNBI, (3) ensuring the design and development of transgender-inclusive and gender-affirming sexual health programs that include PrEP, (4) active provider engagement and assistance around PrEP, and (5) identification and implementation of strategies to bolster existing community mobilization/activism around PrEP.

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.

Decisional Balance and Contemplation Ladder to Support Interventions for HIV Pre-Exposure Prophylaxis Uptake and Persistence

Fewer than 60,000 males-inclusive of all sexual identities-were prescribed HIV pre-exposure prophylaxis (PrEP) by mid-2017 in the United States. Efforts to increase PrEP uptake among gay, bisexual, and other men who have sex with men (GBM), in particular, are ongoing in research and practice settings, but few tools exist to support interventions. We aimed to develop and validate tools to support motivational interviewing interventions for PrEP. In 2017, a national sample of HIV-negative GBM of relatively high socioeconomic status (n = 786) was asked about sexual behaviors that encompass Centers for Disease Control and Prevention guidelines for PrEP use, a 35-item decisional-balance scale (i.e., PrEP-DB) assessing benefits and consequences of PrEP use, and questions assessing location on the motivational PrEP cascade and derivative-the PrEP contemplation ladder. Principal axis factoring with oblique promax rotation was used for PrEP-DB construct identification and item reduction. The final 20-item PrEP-DB performed well; eigenvalues indicating a 4-factor solution provided an adequate fit to the data. Factors included the following: health benefits (α = 0.91), health consequences (α = 0.82), social benefits (α = 0.72), and social consequences (α = 0.86). Ladder scores increased across the cascade (ρ = 0.89, p < 0.001), and health benefits (β = 0.50, p < 0.001) and health consequences (β = -0.37, p < 0.001) were more strongly associated with ladder location than social benefits (β = 0.05, p > 0.05) and social consequences (β = -0.05, p > 0.05) in the fully adjusted regression model. The PrEP-DB demonstrated good reliability and predictive validity, and the ladder had strong construct validity with the motivational PrEP cascade. PrEP uptake and persistence interventions and additional empirical work could benefit from the utility of these measures.

Awareness and Interest in HIV Pre-Exposure Prophylaxis Among Street-Based Female Sex Workers: Results from a US Context

Pre-exposure prophylaxis (PrEP) has the potential to be an empowering HIV prevention tool among female sex workers (FSW), yet little is known about PrEP awareness and interest in this population. Sex workers and Police Promoting Health in Risky Environments (SAPPHIRE) is a prospective cohort study of street-based FSW in Baltimore, MD. A cross-sectional analysis explored awareness and interest in PrEP among HIV-negative FSW. Multivariable Poisson regressions modeled associations between individual, interpersonal, and structural variables and PrEP awareness and interest. Of n = 232 FSW, 66% were white, half were less than 35 years old, 59% injected drugs daily, and 66% sold sex daily. Only 21% of FSW were aware of PrEP, though 74% were interested. PrEP awareness was associated with experiencing client condom coercion [adjusted incidence rate ratio (aIRR) = 0.50, 95% CI: 0.28-0.90] and condomless sex with an intimate partner (aIRR = 0.54, 95% CI: 0.30-0.98). PrEP interest was associated with perceiving PrEP as "very easy" to take (aIRR = 1.91, 95% CI: 1.49-2.45) and moving to an unfamiliar geographic area to sell sex (aIRR = 1.20, 95% CI: 1.04-1.39). Women who had a current gonorrhea or chlamydia infection were less likely to be interested in PrEP (aIRR = 0.75, 95% CI: 0.59-0.95). Though PrEP awareness among FSW is low, there are FSW who are significantly more likely to express interest in PrEP and outreach efforts should target these women. Results suggest that women-controlled HIV prevention methods may be important for reducing incidence among FSW.

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.

Missed Opportunities to Prescribe HIV Pre-Exposure Prophylaxis by Primary Care Providers in Saint Louis, Missouri

PURPOSE

Optimal HIV pre-exposure prophylaxis (PrEP) scale-up in the United States requires prescribing by primary care providers (PCPs). We assessed barriers to patients obtaining PrEP from their PCPs.

METHODS

Patients seeking PrEP at an Infectious Diseases (ID) Clinic in St. Louis, Missouri from 2014 to 2016 were asked about demographics, sexual behaviors, whether PrEP was initially sought from their PCP, and barriers to obtaining PrEP from their PCP. Multivariable logistic regression was performed to identify predictors for having asked a PCP for PrEP.

RESULTS

Among 102 patients, the median age was 29 years, 58% were white, and 88% were men who have sex with men. Most (65%) had a PCP and, of these, 48% had asked their PCP for PrEP, but were not prescribed it. About half (52%) reported that their PCPs perceived prescribing PrEP as specialty care. Many (39%) indicated that they felt uncomfortable discussing their sexual behaviors with their PCP. Patients with an HIV-positive sex partner in the last 3 months were less likely to ask for PrEP from their PCPs than others (Adjusted Odds Ratio: 0.07; 95% CI: 0.01-0.53). Eighty-three percent of patients were referred to a new PCP with whom they could feel more comfortable discussing PrEP.

CONCLUSIONS

During initial PrEP implementation, ID specialists can play an important role in providing education and linking PrEP patients to PCPs. However, PCPs may need additional training about PrEP and how to provide culturally sensitive sexual healthcare, if widespread scale-up is to be effective in decreasing HIV incidence.

Evolving Models and Ongoing Challenges for HIV Preexposure Prophylaxis Implementation in the United States

BACKGROUND

The use of preexposure prophylaxis (PrEP) for HIV prevention was approved by the Food and Drug Administration in 2012, but delivery to at-risk persons has lagged. This critical review analyzes the current state of PrEP implementation in the United States, by reviewing barriers and innovative solutions to enhance PrEP access and uptake.

SETTING

Clinical care settings, public health programs, and community-based organizations (CBOs).

METHODS

Critical review of recent peer-reviewed literature.

RESULTS

More than 100 papers were reviewed. PrEP is currently provided in diverse settings. Care models include sexually transmitted disease clinics, community health centers, CBOs, pharmacies, and private primary care providers (PCPs). Sexually transmitted disease clinics have staff trained in sexual health counseling and are linked to public health programs (eg, partner notification services), whereas PCPs and community health centers may be less comfortable counseling and feel time-constrained in managing PrEP. However, PCPs may be ideal PrEP providers, given their long-term relationships with patients, integrating PrEP into routine care. Collaborations with CBOs can expand PrEP care through adherence support and insurance navigation. Pharmacies can deliver PrEP, given their experience with medication dispensing and counseling, and may be more accessible for some patients, but to address other health concerns, liaisons with PCPs may be needed.

CONCLUSIONS

PrEP implementation in the United States is moving forward with the development of diverse models of delivery. Optimal scale-up will require learning about the best features of each model and providing choices to consumers that enhance engagement and uptake.

Home-based pre-exposure prophylaxis (PrEP) services for gay and bisexual men: An opportunity to address barriers to PrEP uptake and persistence

Gay, bisexual, and other men who have sex with men (GBM) are disproportionately affected by the HIV epidemic. Despite the promise of pre-exposure prophylaxis (PrEP) in reducing HIV transmission risk, barriers for uptake and persistence exist. We sought to identify whether GBM in a nationwide cohort who have not yet initiated PrEP (n = 906) would prefer to get PrEP-related care from a primary care provider (PCP) compared to a specialist clinic or provider. We then sought to identify their level of interest and factors associated with preference for using home-based PrEP services (i.e., HB-PrEP), defined to participants as conducting HIV/STI self-testing from home with PrEP prescription mailing after an initial in-person clinic visit. We examined the associations of demographics, sexual HIV transmission risk, concern about frequent medical checkups associated with PrEP, health care access, and PrEP intentions with preferences for healthcare provider type and HB-PrEP. Concern about frequent medical checkups were associated with preferring a PCP for PrEP-related care, but men who perceived a barrier to bringing up the topic of PrEP with a doctor preferred a specialist clinic or provider more than a PCP. HB-PrEP was more appealing for younger men and those engaged in sexual HIV transmission risk, suggesting HB-PrEP could help reach GBM most vulnerable to HIV and in need of PrEP. HB-PrEP expansion has potential to increase PrEP uptake and persistence among GBM, particularly for men with barriers to clinic-based care and higher intentions to initiate PrEP. Clinical guidelines regarding HB-PrEP are needed to expand its use.