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McKay VR, Zamantakis A, Pachicano AM, Merle JL, Purrier MR, Swan M, Li DH, Mustanski B, Smith JD, Hirschhorn LR, Benbow N. Establishing evidence criteria for implementation strategies in the US: a Delphi study for HIV services. Implement Sci 2024; 19:50. [PMID: 39010153 PMCID: PMC11251241 DOI: 10.1186/s13012-024-01379-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/28/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND There are no criteria specifically for evaluating the quality of implementation research and recommending implementation strategies likely to have impact to practitioners. We describe the development and application of the Best Practices Tool, a set of criteria to evaluate the evidence supporting HIV-specific implementation strategies. METHODS We developed the Best Practices Tool from 2022-2023 in three phases. (1) We developed a draft tool and criteria based on a literature review and key informant interviews. We purposively selected and recruited by email interview participants representing a mix of expertise in HIV service delivery, quality improvement, and implementation science. (2) The tool was then informed and revised through two e-Delphi rounds using a survey delivered online through Qualtrics. The first and second round Delphi surveys consisted of 71 and 52 open and close-ended questions, respectively, asking participants to evaluate, confirm, and make suggestions on different aspects of the rubric. After each survey round, data were analyzed and synthesized as appropriate; and the tool and criteria were revised. (3) We then applied the tool to a set of research studies assessing implementation strategies designed to promote the adoption and uptake of evidence-based HIV interventions to assess reliable application of the tool and criteria. RESULTS Our initial literature review yielded existing tools for evaluating intervention-level evidence. For a strategy-level tool, additions emerged from interviews, for example, a need to consider the context and specification of strategies. Revisions were made after both Delphi rounds resulting in the confirmation of five evaluation domains - research design, implementation outcomes, limitations and rigor, strategy specification, and equity - and four evidence levels - best, promising, more evidence needed, and harmful. For most domains, criteria were specified at each evidence level. After an initial pilot round to develop an application process and provide training, we achieved 98% reliability when applying the criteria to 18 implementation strategies. CONCLUSIONS We developed a tool to evaluate the evidence supporting implementation strategies for HIV services. Although specific to HIV in the US, this tool is adaptable for evaluating strategies in other health areas.
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Affiliation(s)
- Virginia R McKay
- Center for Public Health Systems Science, Brown School, Washington University in St. Louis, St. Louis, MO, USA.
| | - Alithia Zamantakis
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
| | - Ana Michaela Pachicano
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
| | - James L Merle
- Department of Population Health Sciences, Division of Health System Innovation and Research, Spencer Fox Eccles School of Medicine, The University of Utah, Salt Lake City, UT, USA
| | - Morgan R Purrier
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
| | - McKenzie Swan
- Center for Public Health Systems Science, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Dennis H Li
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
- Center for Prevention Implementation Methodology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Center for Dissemination and Implementation Science, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Brian Mustanski
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
- Center for Prevention Implementation Methodology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Justin D Smith
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
| | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nanette Benbow
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
- Center for Prevention Implementation Methodology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Merle JL, Benbow N, Li DH, Zapata JP, Queiroz A, Zamantakis A, McKay V, Keiser B, Villamar JA, Mustanski B, Smith JD. Improving Delivery and Use of HIV Pre-Exposure Prophylaxis in the US: A Systematic Review of Implementation Strategies and Adjunctive Interventions. AIDS Behav 2024; 28:2321-2339. [PMID: 38564136 PMCID: PMC11199103 DOI: 10.1007/s10461-024-04331-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 04/04/2024]
Abstract
Implementation of pre-exposure prophylaxis (PrEP) to prevent HIV transmission is suboptimal in the United States. To date, the literature has focused on identifying determinants of PrEP use, with a lesser focus on developing and testing change methods to improve PrEP implementation. Moreover, the change methods available for improving the uptake and sustained use of PrEP have not been systematically categorized. To summarize the state of the literature, we conducted a systematic review of the implementation strategies used to improve PrEP implementation among delivery systems and providers, as well as the adjunctive interventions used to improve the uptake and persistent adherence to PrEP among patients. Between November 2020 and January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer reviewed articles. We identified 44 change methods (18 implementation strategies and 26 adjunctive interventions) across a variety of clinical and community-based service settings. We coded implementation strategies and adjunctive interventions in accordance with established taxonomies and reporting guidelines. Most studies focused on improving patient adherence to PrEP and most conducted pilot trials. Just over one-third of included studies demonstrated a positive effect on outcomes. In order to end the human immunodeficiency virus (HIV) epidemic in the U.S., future, large scale HIV prevention research is needed that develops and evaluates implementation strategies and adjunctive interventions for target populations disproportionately affected by HIV.
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Affiliation(s)
- James L Merle
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Nanette Benbow
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Seattle, WA, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Dennis H Li
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Seattle, WA, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Juan P Zapata
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Artur Queiroz
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Alithia Zamantakis
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Virginia McKay
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Brennan Keiser
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Juan A Villamar
- Public Health and Epidemiology Unit, Westat, Rockville, MD, USA
| | - Brian Mustanski
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Seattle, WA, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
- Department of Infectious Diseases, Northwestern University, Seattle, WA, USA
- Medical Social Sciences Department, Northwestern University, Seattle, WA, USA
| | - Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
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Mckay V, Zamantakis A, Pachicano AM, Merle J, Purrier M, Swan M, Li D, Mustanski B, Smith JD, Hirschhorn L, Benbow N. Establishing Evidence Criteria for Implementation Strategies: A Delphi Study for HIV Services. RESEARCH SQUARE 2024:rs.3.rs-3979631. [PMID: 38464091 PMCID: PMC10925451 DOI: 10.21203/rs.3.rs-3979631/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background There are no criteria specifically for evaluating the quality of implementation research and recommend implementation strategies likely to have impact to practitioners. We describe the development and application of the Best Practices Rubric, a set of criteria to evaluate the evidence supporting implementation strategies, in the context of HIV. Methods We developed the Best Practices Rubric from 2022-2023 in three phases. (1) We purposively selected and recruited by email participants representing a mix of expertise in HIV service delivery, quality improvement, and implementation science. We developed a draft rubric and criteria based on a literature review and key informant interviews. (2) The rubric was then informed and revised through two e-Delphi rounds using a survey delivered online through Qualtrics. The first and second round Delphi surveys consisted of 71 and 52 open and close-ended questions, respectively, asking participants to evaluate, confirm, and make suggestions on different aspects of the rubric. After each survey round, data were analyzed and synthesized as appropriate, and the rubric and criteria were revised. (3) We then applied the rubric to a set of research studies assessing 18 implementation strategies designed to promote the adoption and uptake of pre-exposure prophylaxis, an HIV prevention medication, to assess reliable application of the rubric and criteria. Results Our initial literature review yielded existing rubrics and criteria for evaluating intervention-level evidence. For a strategy-level rubric, additions emerged from interviews, for example, a need to consider the context and specification of strategies. Revisions were made after both Delphi rounds resulting in the confirmation of five evaluation domains - research design, implementation outcomes, limitations and rigor, strategy specification, and equity - and four evidence levels - best practice, promising practice, more evidence needed, and harmful practices. For most domains, criteria were specified at each evidence level. After an initial pilot round to develop an application process and provide training, we achieved 98% reliability when applying the criteria to 18 implementation strategies. Conclusions We developed a rubric to evaluate the evidence supporting implementation strategies for HIV services. Although the rubric is specific to HIV, this tool is adaptable for evaluating strategies in other health areas.
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Mustanski B, Queiroz A, Merle JL, Zamantakis A, Zapata JP, Li DH, Benbow N, Pyra M, Smith JD. A Systematic Review of Implementation Research on Determinants and Strategies of Effective HIV Interventions for Men Who Have Sex with Men in the United States. Annu Rev Psychol 2024; 75:55-85. [PMID: 37722749 PMCID: PMC10872355 DOI: 10.1146/annurev-psych-032620-035725] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Men who have sex with men (MSM) are disproportionately affected by HIV, accounting for two-thirds of HIV cases in the United States despite representing ∼5% of the adult population. Delivery and use of existing and highly effective HIV prevention and treatment strategies remain suboptimal among MSM. To summarize the state of the science, we systematically review implementation determinants and strategies of HIV-related health interventions using implementation science frameworks. Research on implementation barriers has focused predominantly on characteristics of individual recipients (e.g., ethnicity, age, drug use) and less so on deliverers (e.g., nurses, physicians), with little focus on system-level factors. Similarly, most strategies target recipients to influence their uptake and adherence, rather than improving and supporting implementation systems. HIV implementation research is burgeoning; future research is needed to broaden the examination of barriers at the provider and system levels, as well as expand knowledge on how to match strategies to barriers-particularly to address stigma. Collaboration and coordination among federal, state, and local public health agencies; community-based organizations; health care providers; and scientists are important for successful implementation of HIV-related health innovations.
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Affiliation(s)
- Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Third Coast Center for AIDS Research, Chicago, Illinois, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Artur Queiroz
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - James L Merle
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Alithia Zamantakis
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Juan Pablo Zapata
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dennis H Li
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Third Coast Center for AIDS Research, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nanette Benbow
- Third Coast Center for AIDS Research, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Maria Pyra
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
| | - Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
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Nelson A, Bheemraj K, Dean SS, de Voux A, Hlatshwayo L, Mvududu R, Berkowitz N, Neumuller C, Jacobs S, Fourie S, Coates T, Bekker LG, Myer L, Davey DJ. Integration of HIV pre-exposure prophylaxis (PrEP) services for pregnant and breastfeeding women in eight primary care clinics: results of an implementation science study. RESEARCH SQUARE 2023:rs.3.rs-3648622. [PMID: 38045335 PMCID: PMC10690321 DOI: 10.21203/rs.3.rs-3648622/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Background Although HIV vertical transmission (VT) has declined significantly in sub-Saharan Africa, incident HIV infection in pregnant and postpartum women is estimated to account for roughly one-third of VT. Oral pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women (PBFW) is part of the recommended guidelines in South Africa since 2021; however, integration of PrEP services within antenatal (ANC) and postnatal care (PNC) remains limited. Methods Between March 2022 and September 2023, we evaluated the acceptability, feasibility and sustainability of integrating PrEP for PBFW in high-HIV prevalence clinics after training and mentoring health care providers (HCP). We used the Reach Effectiveness-Adoption Implementation Maintenance (RE-AIM) framework to evaluate the intervention. Acceptability and maintenance were defined as the proportion of PBFW without HIV who initiated PrEP and the proportion of women continuing PrEP at 3 months in ANC or PNC services. Feasibility was defined as the proportion of trained HCPs (HIV lay counsellors and nurses/ midwives) who provided PrEP according to national guidelines, measured through post-training surveys and in-service assessments. Sustainability was defined as number of facilities and providers that continued to provide PrEP for PBFW past the mentoring period. Results In 8 facilities providing ANC and PNC, we trained 224 HCP (127 nurses and 37 counsellors). Of those, we mentored 60 nurses, midwives and HIV counsellors working with PBFW, with 72% of nurse/midwives and 65% of counsellors scoring over 8/10 on the final mentoring assessment Overall, 12% (1493/12,614) of HIV-negative pregnant women started PrEP and 41% of those continued PrEP at 3-months. Among the HIV-negative breastfeeding women in postnatal care, 179/1315 (14%) initiated PrEP and 25% continued PrEP at 3-months. All 8 facilities continued providing PrEP 3-months after handover of the clinics. Conclusion Integration of PrEP services in ANC and services for breastfeeding women was feasible, acceptable and sustainable. Acceptability and PrEP continuation showed improvement over time. Barriers to the PrEP integration were observed including the lack of regular HIV testing of breastfeeding mothers and need for ART-trained nurses to prescribe PrEP. Enablers included motivated and dedicated staff.
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Kaul CM, Moore BE, Kaplan-Lewis E, Casey E, Pitts RA, Pagan Pirallo P, Lim S, Kapadia F, Cohen GM, Khan M, Mgbako O. EquiPrEP: An implementation science protocol for promoting equitable access and uptake of long-acting injectable HIV pre-exposure prophylaxis (LAI-PrEP). PLoS One 2023; 18:e0291657. [PMID: 37725628 PMCID: PMC10508596 DOI: 10.1371/journal.pone.0291657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/03/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Long-acting injectable HIV pre-exposure prophylaxis (LAI-PrEP) was approved by the U.S. Food and Drug Administration in December 2021. This initial phase of implementation represents a prime opportunity to ensure equitable LAI-PrEP provision to communities often underrepresented in PrEP care before disparities in access and uptake emerge. Herein, we describe the EquiPrEP Project which utilizes an equity-oriented implementation science framework to optimize LAI-PrEP rollout in an urban safety-net clinic in New York City. METHODS The primary objectives of this project are to: (1) increase LAI-PrEP initiation overall; (2) increase uptake among groups disproportionately impacted by the HIV epidemic; (3) preserve high PrEP retention while expanding use; and (4) identify barriers and facilitators to LAI-PrEP use. EquiPrEP will enroll 210 PrEP-eligible participants into LAI-PrEP care with planned follow-up for one year. We will recruit from the following priority populations: Black and/or Latine men who have sex with men, Black and/or Latine cisgender women, and transgender women and nonbinary individuals. To evaluate implementation of LAI-PrEP, we will utilize equity-focused iterations of the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework and the Consolidated Framework for Implementation Research (CFIR), in addition to longitudinal surveys and qualitative interviews. DISCUSSION Novel LAI-PrEP formulations carry tremendous potential to revolutionize the field of HIV prevention. Implementation strategies rooted in equity are needed to ensure that marginalized populations have access to LAI-PrEP and to address the structural factors that hinder initiation and retention in care.
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Affiliation(s)
- Christina M. Kaul
- Office of Ambulatory Care and Population Health, HIV Services, NYC Health + Hospitals, New York, New York, United States of America
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Brandi E. Moore
- Department of Epidemiology, New York University School of Global Public Health, New York, New York, United States of America
| | - Emma Kaplan-Lewis
- Office of Ambulatory Care and Population Health, HIV Services, NYC Health + Hospitals, New York, New York, United States of America
| | - Eunice Casey
- Office of Ambulatory Care and Population Health, HIV Services, NYC Health + Hospitals, New York, New York, United States of America
| | - Robert A. Pitts
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
- NYC Health + Hospitals/Bellevue, New York, New York, United States of America
| | - Patricia Pagan Pirallo
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Sahnah Lim
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Farzana Kapadia
- Department of Epidemiology, New York University School of Global Public Health, New York, New York, United States of America
| | - Gabriel M. Cohen
- Office of Ambulatory Care and Population Health, HIV Services, NYC Health + Hospitals, New York, New York, United States of America
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
- NYC Health + Hospitals/Bellevue, New York, New York, United States of America
| | - Maria Khan
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Ofole Mgbako
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States of America
- NYC Health + Hospitals/Bellevue, New York, New York, United States of America
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
- NYU Langone Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York, United States of America
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Scott RK, Deyarmond M, Marwitz S, Huang JC, Moriarty P, Visconti AJ, Beverley J, Elion R, Coleman M, Hull SJ. Implementation of an Educational Intervention to Improve HIV Pre-Exposure Prophylaxis Services for Women in an Urban Sexual Health Clinic. AIDS Patient Care STDS 2023; 37:447-457. [PMID: 37713289 PMCID: PMC10623070 DOI: 10.1089/apc.2023.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
To test the hypothesis that implementation of a multicomponent, educational HIV pre-exposure prophylaxis (PrEP) intervention to promote universal PrEP services for cisgender women (subsequently "women") in sexual and reproductive health centers would improve the proportion of women screened, offered, and prescribed PrEP, we implemented a multicomponent, educational intervention in a Washington D.C. Department of Health-sponsored sexual health clinic. The clinic serves a patient population with high-potential exposure to HIV. The intervention included clinic-wide PrEP trainings, an electronic health record prompt for PrEP counseling by providers, and educational videos in the waiting room. We collected preimplementation data from March 22, 2018 to July 4, 2018, including 331 clinical encounters for 329 women. Between July 5, 2018 and July 1, 2019, there were 1733 clinical encounters for 1720 HIV-negative women. We used mixed methods to systematically assess intervention implementation using the Reach Effectiveness Adoption Implementation Maintenance framework. Additionally, we assessed the interventions' acceptability and feasibility among providers through semistructured interviews. The proportion of women screened by providers for PrEP (5.6% preimplementation to a mean of 89.2% of women during the implementation period, p < 0.01), offered (6.2 to 69.8%, p < 0.01), and prescribed PrEP (2.6 to 8.1%, p < 0.01) by providers increased significantly in the implementation period. Providers and clinic staff found the intervention both highly feasible and acceptable and demonstrated increased knowledge of PrEP and HIV prevention associated with the clinic-wide trainings. Our results demonstrate the effectiveness of a low-cost educational intervention to increase provision of integrated PrEP services in an urban sexual health clinic serving women with high-potential exposure to HIV. ClinicalTrials.gov ID NCT03705663.
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Affiliation(s)
- Rachel K. Scott
- Department of Women's and Infants' Services, MedStar Washington Hospital Center, Division of Women's Health Research, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Megan Deyarmond
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Shannon Marwitz
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jim C. Huang
- Department of Business Management, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Patricia Moriarty
- Division of Women's Health Research, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Adam J. Visconti
- HIV/AIDS, Hepatitis, STD and TB Administration, DC Health, Washington, District of Columbia, USA
| | - Jason Beverley
- HIV/AIDS, Hepatitis, STD and TB Administration, DC Health, Washington, District of Columbia, USA
| | - Rick Elion
- HIV/AIDS, Hepatitis, STD and TB Administration, DC Health, Washington, District of Columbia, USA
| | - Megan Coleman
- Whitman Walker Health, Washington, District of Columbia, USA
| | - Shawnika J. Hull
- Department of Prevention and Community Medicine, George Washington University, Washington, District of Columbia, USA
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Sonalkar S, Kete C, McAllister A, Afreen R, Kaufman J, Short W, Keddem S. Perceptions of HIV risk screening strategies among patients seeking abortion, contraception, and pregnancy loss management in the United States. Contraception 2023; 124:110063. [PMID: 37210025 DOI: 10.1016/j.contraception.2023.110063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVES Women make up nearly a fifth of new human immunodeficiency virus (HIV) infections yearly in the United States, more than half of which could have been prevented with broader use of HIV pre-exposure prophylaxis (PrEP). We aimed to qualitatively assess (1) acceptability of an HIV risk screening strategy and PrEP provision in a family planning setting, and (2) the influence of family planning visit type (abortion, pregnancy loss management, or contraception) on HIV risk screening acceptability. STUDY DESIGN Guided by the P3 (practice-, provider-, and patient-level) model for preventive care interventions, we conducted three focus group discussions including patients who had experienced induced abortion, early pregnancy loss (EPL), or contraception care. We developed a codebook of a priori and inductive concepts, and categorized themes by practice, provider, and patient considerations. RESULTS We included 24 participants. Practice-level considerations included overall positive feelings about being screened for PrEP eligibility during family planning visits, though some expressed reservations about screening during EPL visits. Provider-level themes included the concept of screening tools as entry points into conversation and education, and the importance of nonjudgment in discussing sexually transmitted infection (STI) prevention. Participants often had to initiate STI prevention discussions and felt that contraception was overemphasized by their providers compared with STI prevention and PrEP care. Patient-level themes included the stigma of STIs and oral PrEP, and the dynamic nature of STI risk. CONCLUSIONS Participants in our research had genuine interest in learning about PrEP during family planning visits. Findings from our research support the consistent inclusion of STI prevention education into family planning clinical practice using patient-centered STI screening methods. IMPLICATIONS Family planning encounters, including visits for contraception and abortion, are generally appropriate times to discuss HIV PrEP. Patient-centered conversations are an important adjunct to HIV risk screening tools.
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Affiliation(s)
- Sarita Sonalkar
- Department of Obstetrics and Gynecology, Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
| | - Corinne Kete
- Department of Obstetrics and Gynecology, Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ryan Afreen
- University of Pennsylvania, School of Arts and Sciences, Philadelphia, USA
| | - Jason Kaufman
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - William Short
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Shimrit Keddem
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Veterans Affairs Center for Health Equity, Research & Promotion, Micheal J. Crescenz Veterans Affairs Medical Center, Philadelphia, USA
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Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37466272 PMCID: PMC10355136 DOI: 10.1002/14651858.cd013603.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
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Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
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Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37434293 PMCID: PMC10335778 DOI: 10.1002/14651858.cd013603.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
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Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
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Gotsche CI, Steyn PS, Narasimhan M, Rodolph M, Baggaley R, Kiarie JN. Integrating pre-exposure prophylaxis of HIV infection into family planning services: a scoping review. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:210-218. [PMID: 36581443 PMCID: PMC10359582 DOI: 10.1136/bmjsrh-2021-201356] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/12/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION The aim of this review was to map evidence of integrating pre-exposure prophylaxis (PrEP) for HIV prevention into family planning services. A comprehensive package, using a combination of PrEP and contraceptive delivery, could reduce the number of new HIV infections and/or unintended pregnancies for at-risk women and adolescent girls. METHODS A scoping literature search was conducted between August 2020 and October 2020. After developing the review question, electronic databases (MEDLINE, Embase, Cochrane Library, Global Health, Web of Science) were systematically reviewed. All types of articles published from 2012 to August 2020 in English were included. The intended outcome was to identify barriers and enablers of integrating services at the client-level and provider-level. RESULTS 38 articles met inclusion criteria, with 16 from low-and middle-income countries and 22 from high-income countries. Barriers at the client-level included a lack of risk perception associated with low uptake and continuation of PrEP and pill burden; and at the provider-level, barriers included a lack of studies on cost-effectiveness of integrating services and provider training and knowledge. Facilitators included the initiation of PrEP and contraception at the same time and by the same provider or HIV self-testing. CONCLUSION Mapping and synthesising current evidence, this review identified key barriers and facilitators for the integration of PrEP into family planning services for women and adolescent girls. In order to address these factors, more implementation research in a variety of settings is needed to meet women's sexual and reproductive health needs globally.
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Affiliation(s)
- Caroline I Gotsche
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Petrus S Steyn
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
| | - Michelle Rodolph
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneve, Switzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneve, Switzerland
| | - James N Kiarie
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
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Piper KN, Anderson KM, Kokubun CW, Sheth AN, Sales J. Using qualitative comparative analysis to understand the conditions that produce successful PrEP implementation in family planning clinics. Implement Sci Commun 2023; 4:64. [PMID: 37296455 DOI: 10.1186/s43058-023-00450-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention to U.S. women. However, PrEP has not been widely integrated into family planning services, especially in the Southern U.S., and data suggest there may be significant implementation challenges in this setting. METHODS To understand contextual factors that are key to successful PrEP implementation in family planning clinics, we conducted in-depth qualitative interviews with key informants from 38 family planning clinics (11 clinics prescribed PrEP and 27 did not). Interviews were guided by constructs from the Consolidated Framework for Implementation Research (CFIR), and qualitative comparative analysis (QCA) was used to uncover the configurations of CFIR factors that led to PrEP implementation. RESULTS We identified 3 distinct construct configurations, or pathways, that led to successful PrEP implementation: (1) high "Leadership Engagement" AND high "Available Resources"; OR (2) high "Leadership Engagement" AND NOT located in the Southeast region; OR (3) high "Access to Knowledge and Information" AND NOT located in the Southeast region. Additionally, there were 2 solution paths that led to absence of PrEP implementation: (1) low "Access to Knowledge and Information" AND low "Leadership Engagement"; OR (2) low "Available Resources" AND high "External Partnerships". DISCUSSION We identified the most salient combinations of co-occurring organizational barriers or facilitators associated with PrEP implementation across Title X clinics in the Southern U.S. We discuss implementation strategies to promote pathways that led to implementation success, as well as strategies to overcome pathways to implementation failure. Notably, we identified regional differences in the pathways that led to PrEP implementation, with Southeastern clinics facing the most obstacles to implementation, specifically substantial resource constraints. Identifying implementation pathways is an important first step for packaging multiple implementation strategies that could be employed by state-level Title X grantees to help scale up PrEP.
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Affiliation(s)
- Kaitlin N Piper
- Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | | | | | - Anandi N Sheth
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica Sales
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Provision of HIV preexposure prophylaxis to female patients seeking family planning services in the United States. AIDS 2023; 37:137-148. [PMID: 36172845 DOI: 10.1097/qad.0000000000003398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We conducted a scoping review to assess barriers to and facilitators of integrating HIV preexposure prophylaxis (PrEP) and family planning (FP) at the patient, provider, and implementation levels, and to identify gaps in knowledge. METHODS We conducted a search of five bibliographic databases from database inception to March 2022: PubMed, CINAHL, Embase, Web of Science and Scopus. Two reviewers screened abstracts and full texts to determine eligibility based on a priori inclusion and exclusion criteria. We categorized studies by their relevance to patient, provider, and implementation barriers, and extracted data based on prespecified elements. RESULTS Our initial search strategy yielded 1151 results, and 34 publications were included. Barriers to PrEP implementation in family planning settings included low PrEP knowledge among patients, hesitance to take PrEP due to perceived stigma, decreased willingness of providers unfamiliar with PrEP to prescribe PrEP, and limited financial and staffing resources that make prescribing and monitoring PrEP difficult. Facilitators included robust training for providers, stigma reduction efforts, leadership engagement, and increased resources specifically in settings with processes in place that ease the process of prescribing and monitoring PrEP. CONCLUSIONS Advances in implementation strategy development, stigma reduction, and drug development will be essential to reinforcing PrEP care in family planning settings and thereby reducing the incidence of HIV in women through highly effective pharmacologic HIV prevention methods.
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Beer L, Tie Y, Dasgupta S, McManus T, Smith DK, Shouse RL. Trends in preexposure prophylaxis use among sex partners as reported by persons with HIV - United States, May 2015-June 2020. AIDS 2022; 36:2161-2169. [PMID: 36382435 PMCID: PMC11057891 DOI: 10.1097/qad.0000000000003366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To estimate trends in the proportion of sexually active U.S. adults with HIV (PWH) reporting an HIV-discordant sexual partner taking preexposure prophylaxis (PrEP) and proportion of partners taking PrEP. DESIGN The Medical Monitoring Project is a complex sample survey of U.S. adults with diagnosed HIV. METHODS We used annual cross-sectional data collected during June 2015-May 2020 to estimate the annual percentage change (EAPC), overall and by selected characteristics, in reported partner PrEP use among PWH with HIV-discordant partners (N = 8707) and reported PrEP use among these partners (N = 15 844). RESULTS The proportion of PWH reporting PrEP use by one or more HIV-discordant sex partner rose 19.5% annually (11.3 to 24.4%). The prevalence rose from 6.0 to 17.4% (EAPC, 25.8%) among Black PWH, 10.1 to 26.0% (EAPC, 19.5%) among Hispanic/Latino PWH, and 20.8 to 34.6% (EAPC, 16.3%) among White PWH. Among MSM with HIV, the prevalence increased from 9.6 to 32.6% (EAPC, 28.2%) among Black MSM, 16.6 to 36.0% (EAPC, 15.6%) among Hispanic/Latino MSM, and 24.9 to 44.1% (EAPC, 17.9%) among White MSM. Among HIV-discordant sex partners, the proportion reported to be taking PrEP increased 21.1% annually (7.8 to 18.8%). Reported PrEP use rose from 4.9 to 14.2% (EAPC, 29.9%) among Black partners, 6.5 to 16.8% (EAPC, 20.3%) among Hispanic/Latino partners, and 12.7 to 26.1% (EAPC, 17.0%) among White partners. CONCLUSIONS One in five HIV-discordant sexual partners of PWH was reported to be taking PrEP. PrEP use rose among all examined populations, although the increases did not eliminate disparities in PrEP use.
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Affiliation(s)
- Linda Beer
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Scott RK, Hull SJ, Huang JC, Coleman M, Ye P, Lotke P, Beverley J, Moriarty P, Balaji D, Ward A, Holiday J, Brant AR, Cameron M, Elion R, Visconti A. Factors Associated with Intention to Initiate Pre-exposure Prophylaxis in Cisgender Women at High Behavioral Risk for HIV in Washington, D.C. ARCHIVES OF SEXUAL BEHAVIOR 2022; 51:2613-2624. [PMID: 35622077 PMCID: PMC9308717 DOI: 10.1007/s10508-021-02274-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 06/15/2023]
Abstract
Pre-exposure prophylaxis (PrEP) for HIV prevention is underutilized by cisgender women at risk for HIV in the USA. Published research on PrEP initiation among cisgender women at risk for HIV focuses on identifying barriers and facilitators associated with intention to initiate, but few apply a behavioral theoretical lens to understand the relative importance of these diverse factors. This study provides a theoretically grounded view of the relative importance of factors associated with intention to initiate PrEP. We conducted an anonymous, cross-sectional survey of 1437 cisgender women seeking care at family planning and sexual health clinics to evaluate hypothesized barriers and facilitators of PrEP initiation. We categorized cisgender women with ≥ 3 behavioral risk-factors as "high-risk" for HIV acquisition; 26.9% (N = 387) met high-risk criterion. Among cisgender women in the high-risk sample, the majority were Black and single. Perceived risk of HIV acquisition was low and 13.7% reported intention to initiate PrEP. Positive attitudes toward PrEP, self-efficacy, perceived support from medical providers and social networks, and prior discussion about PrEP with medical providers were associated with intention to initiate PrEP; stigma was negatively associated. Background characteristics (other than age), risk factors for HIV acquisition, prior awareness of PrEP, and perceived risk of HIV were not associated with uptake intention. These findings support interventions that center on the role of providers in the provision of PrEP and on social networks in destigmatization of PrEP use.
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Affiliation(s)
- Rachel K Scott
- MedStar Health Research Institute, 6525 Belcrest Road, Hyattsville, MD, 20782, USA.
- MedStar Washington Hospital Center, Washington, DC, USA.
| | - Shawnika J Hull
- Department of Communication, Rutgers University, New Brunswick, NJ, USA
| | - Jim C Huang
- Department of Business Management, National Sun Yat-sen University, Kaohsiung, Taiwan
| | | | - Peggy Ye
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Pam Lotke
- MedStar Washington Hospital Center, Washington, DC, USA
| | | | - Patricia Moriarty
- MedStar Health Research Institute, 6525 Belcrest Road, Hyattsville, MD, 20782, USA
| | - Dhikshitha Balaji
- MedStar Health Research Institute, 6525 Belcrest Road, Hyattsville, MD, 20782, USA
| | - Allison Ward
- MedStar Health Research Institute, 6525 Belcrest Road, Hyattsville, MD, 20782, USA
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Jennifer Holiday
- MedStar Health Research Institute, 6525 Belcrest Road, Hyattsville, MD, 20782, USA
| | - Ashley R Brant
- Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Martha Cameron
- International Community of Women Living with HIV, Washington, DC, USA
| | | | - Adam Visconti
- MedStar Georgetown University, NW Washington, DC, USA
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Danvers AA, Chew Murphy E, Avila K, Gonzalez-Argoti T, Edwards AR, Hoffman S, Mantell JE, Bauman LJ, Dolan SM. Women Trust Their OBGYNs to Provide Preexposure Prophylaxis: An Opportunity for HIV Prevention. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:832287. [PMID: 36303639 PMCID: PMC9580770 DOI: 10.3389/frph.2022.832287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/15/2022] [Indexed: 12/05/2022] Open
Abstract
Objective The objective of this study was to understand how women perceive the role of their Obstetrician and Gynecologist (OBGYN) in screening for and providing preexposure prophylaxis (PrEP) for HIV prevention. Methods We recruited women ages 18–45 years receiving obstetric or gynecological care at an academic medical center in the Bronx, NY. Thirty participants were enrolled: 10 seeking care for family planning, 10 seeking prenatal care, and 10 seeking care for a sexually transmitted infection. We screened participants for HIV acquisition risk using a PrEP screening tool. We conducted face-to-face, semi-structured interviews, which were audio-recorded, transcribed, and entered into Dedoose for analysis of themes using a grounded theory approach. Results Sixty percent of the participants were Latinx and 33% African American. Seventy percent had one or more risk factors for HIV acquisition based on the PrEP screening tool, indicating they would benefit from a PrEP discussion. Three main themes emerged from the analysis of interview data. Participants viewed OBGYNs as experts in sexual and reproductive healthcare and believed they were experts in PrEP. Participants were concerned about “PrEP stigma”, being judged by their clinicians as being sexually promiscuous if they expressed a need for PrEP. Lastly, when participants trusted their OBGYN, that trust became a facilitator for women to consider PrEP and offset stigma as a barrier to identifying patients who are candidates for PrEP. Conclusion Women established in care with an OBGYN are enthusiastic about having access to PrEP services incorporated into their sexual and reproductive healthcare. A universal approach to HIV prevention would avert stigma surrounding HIV care and prevention.
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Affiliation(s)
- Antoinette A. Danvers
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
- *Correspondence: Antoinette A. Danvers
| | - Emma Chew Murphy
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Karina Avila
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Tatiana Gonzalez-Argoti
- Departments of Pediatrics and Psychiatry and Behavioral Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Angelic Rivera Edwards
- Montefiore School Health Program, Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Susie Hoffman
- Department of Epidemiology, Joseph L. Mailman School of Public Health at Columbia University, New York, NY, United States
- Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States
| | - Joanne E. Mantell
- Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States
| | - Laurie J. Bauman
- Departments of Pediatrics and Psychiatry and Behavioral Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Siobhan M. Dolan
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai and Mount Sinai Health System, New York, NY, United States
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Bonacci RA, Smith DK, Ojikutu BO. Toward Greater Pre-exposure Prophylaxis Equity: Increasing Provision and Uptake for Black and Hispanic/Latino Individuals in the U.S. Am J Prev Med 2021; 61:S60-S72. [PMID: 34686293 PMCID: PMC8668046 DOI: 10.1016/j.amepre.2021.05.027] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/06/2021] [Accepted: 05/10/2021] [Indexed: 01/16/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition and is a critical tool in the Ending the HIV Epidemic in the U.S. initiative. However, major racial and ethnic disparities across the pre-exposure prophylaxis continuum, secondary to structural inequities and systemic racism, threaten progress. Many barriers, operating at the individual, network, healthcare, and structural levels, impede PrEP access and uptake within Black and Hispanic/Latino communities. This review provides an overview of those barriers and the innovative and collaborative solutions that health departments, healthcare organizations, and community partners have implemented to increase PrEP provision and uptake among disproportionately affected communities. Promising strategies at the individual and network levels focus on increasing patient support throughout the PrEP continuum, positioning and training community members to expand knowledge of and interest in PrEP, and leveraging mobile technologies to support PrEP uptake. Healthcare-level solutions include expanding the venues and types of healthcare professionals that can provide PrEP, and structural- and policy-level options focus on financial assistance programs and health insurance expansion. Key research gaps include demonstrating that pilot studies and interventions remain effective at scale and across varied contexts. Although the last 2 decades have provided effective tools to end the HIV epidemic, realizing this vision for the U.S. will require addressing persistent and pervasive HIV-related disparities in Black and Hispanic/Latino communities. Federal, state, and local partners should expand efforts to address longstanding health and structural inequities and partner with disproportionately affected communities to rapidly expand PrEP scale-up.
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Affiliation(s)
- Robert A Bonacci
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia; Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Dawn K Smith
- Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bisola O Ojikutu
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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18
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Lillis R, Beckford J, Fegley J, Siren J, Hinton B, Gomez S, Taylor SN, Butler I, Halperin J, Clement ME. Evaluation of an HIV Pre-Exposure Prophylaxis Referral System: From Sexual Health Center to Federally Qualified Health Center Pre-Exposure Prophylaxis Clinic. AIDS Patient Care STDS 2021; 35:354-359. [PMID: 34448603 DOI: 10.1089/apc.2021.0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Innovative delivery strategies are needed to facilitate access to HIV pre-exposure prophylaxis (PrEP). The objective of this study was to evaluate a navigator-facilitated PrEP referral process from a sexual health center (SHC) to a co-located PrEP clinic as an alternative delivery model. Electronic health record (EHR) data were used to calculate the number of clients seen at the SHC in 2019. Charts were manually reviewed to determine whether a PrEP clinic referral was made and document type of referral method: face-to-face appointment scheduling with the navigator (warm handoff), EHR messaging to navigator to schedule the appointment at a later time (EHR message), or provision of navigator's contact information to the client (card only). In 2019, 2481 unique potentially PrEP-eligible clients were seen at the SHC; 220 (9%) received a PrEP referral. Of referred clients, median age was 30 years (interquartile range, 24-34), 182 (83%) were male, 89 (40%) were non-Hispanic Black, and 24 (11%) were Latinx. In total, 94/220 (43%) referred clients attended an initial PrEP visit with a provider, and the proportion attending by referral method was 81%, 36%, and 27% for warm handoff, EHR message, and card only, respectively (p < 0.0001). Despite co-location of these two clinics, there were significant drop-offs along the PrEP care continuum for this referral system. Warm handoff was the most effective referral method, but further efforts are needed to understand barriers to referral. Implementation of same-day PrEP services at SHCs is one potential solution to engaging additional clients.
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Affiliation(s)
- Rebecca Lillis
- Louisiana State University Health Sciences Center, Department of Medicine, Section of Infectious Diseases, New Orleans, Louisiana, USA
- LSU-CrescentCare Sexual Health Center, New Orleans, Louisiana, USA
| | - Jeremy Beckford
- Louisiana State University Health Sciences Center, Department of Medicine, Section of Infectious Diseases, New Orleans, Louisiana, USA
| | - Joshua Fegley
- CrescentCare Federally Qualified Health Center, New Orleans, Louisiana, USA
| | - Julia Siren
- CrescentCare Federally Qualified Health Center, New Orleans, Louisiana, USA
| | - Bruce Hinton
- CrescentCare Federally Qualified Health Center, New Orleans, Louisiana, USA
| | - Samuel Gomez
- CrescentCare Federally Qualified Health Center, New Orleans, Louisiana, USA
| | - Stephanie N. Taylor
- Louisiana State University Health Sciences Center, Department of Medicine, Section of Infectious Diseases, New Orleans, Louisiana, USA
- LSU-CrescentCare Sexual Health Center, New Orleans, Louisiana, USA
| | - Isolde Butler
- CrescentCare Federally Qualified Health Center, New Orleans, Louisiana, USA
| | - Jason Halperin
- CrescentCare Federally Qualified Health Center, New Orleans, Louisiana, USA
| | - Meredith Edwards Clement
- Louisiana State University Health Sciences Center, Department of Medicine, Section of Infectious Diseases, New Orleans, Louisiana, USA
- LSU-CrescentCare Sexual Health Center, New Orleans, Louisiana, USA
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19
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Electronic Dissemination of a Web-Based Video Promotes PrEP Contemplation and Conversation Among US Women Engaged in Care at Planned Parenthood. AIDS Behav 2021; 25:2483-2500. [PMID: 33704618 PMCID: PMC7947376 DOI: 10.1007/s10461-021-03210-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 11/11/2022]
Abstract
We evaluated the acceptability and impact of a web-based PrEP educational video among women (n = 126) by comparing two Planned Parenthood centers: one assigned to a Web Video Condition and one to a Standard Condition. Most women reported the video helped them better understand what PrEP is (92%), how PrEP works (93%), and how to take PrEP (92%). One month post-intervention, more women in the Web Video Condition reported a high level of comfort discussing PrEP with a provider (82% vs. 48%) and commonly thinking about PrEP (36% vs. 4%). No women with linked medical records initiated PrEP during 1-year follow-up.
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20
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de Silva R, Huber-Krum S, Samarasekera A, Karra M, Pearson E, Senanayake H, Canning D, Shah I. Provider perspectives in implementing the Postpartum Intrauterine Device Initiative in Sri Lanka: a qualitative study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:193-199. [PMID: 33214196 DOI: 10.1136/bmjsrh-2020-200876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Integration of maternal care and family planning services has the potential to reduce unintended pregnancies and closely spaced births, leading to reductions in maternal mortality and morbidity. However, few models exist detailing how to implement/integrate such services. This study explored the implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Sri Lanka, which trained healthcare providers on how to counsel women about contraception during routine antenatal care and insert PPIUD immediately following delivery. METHODS We applied a qualitative design to ascertain the perspectives of maternal health service providers who participated in the PPIUD Initiative. We conducted 12 in-depth interviews with providers. We used thematic analysis to analyse the data and the results were interpreted within the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. RESULTS Findings indicated that providers were willing to adopt the intervention and reiterated the importance of postpartum family planning. However, the intervention was not consistently implemented as intended, including provider bias in counselling and lack of attention to women's preferences. Organisational barriers to implementation included time constraints and inadequate training. Providers suggested that a range of paramedical staff be trained in counselling and PPIUD insertion to mitigate barriers and to facilitate scaling up the intervention. CONCLUSIONS To improve and scale up the PPIUD Initiative, training efforts should be expanded to primary and secondary care facilities and implementation strategies better utilised (eg, on-the-job training). The training can be strengthened by improving providers' knowledge of all types of methods and interpersonal communication skills, and emphasising the importance of unbiased, evidence-based contraceptive counselling techniques.
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Affiliation(s)
- Ranjith de Silva
- Sri Lanka College of Obstetricians and Gynaecologists, Colombo, Sri Lanka
| | - Sarah Huber-Krum
- Harvard T H Chan School of Public Health, Harvard University, Cambridge, Massachusetts, USA
| | | | - Mahesh Karra
- Frederick S Pardee School of Global Studies, Boston University, Boston, Massachusetts, USA
| | | | | | - David Canning
- Harvard T H Chan School of Public Health, Harvard University, Cambridge, Massachusetts, USA
| | - Iqbal Shah
- Harvard T H Chan School of Public Health, Harvard University, Cambridge, Massachusetts, USA
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21
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Tao J, Montgomery MC, Williams R, Patil P, Rogers BG, Sosnowy C, Murphy M, Zanowick-Marr A, Maynard M, Napoleon SC, Chu C, Almonte A, Nunn AS, Chan PA. Loss to Follow-Up and Re-Engagement in HIV Pre-Exposure Prophylaxis Care in the United States, 2013-2019. AIDS Patient Care STDS 2021; 35:271-277. [PMID: 34242092 DOI: 10.1089/apc.2021.0074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Retention in HIV pre-exposure prophylaxis (PrEP) care is critical for effective PrEP implementation. Few studies have reported long-term lost to follow-up (LTFU) and re-engagement in PrEP care in the United States. Medical record data for all cisgender patients presenting to the major Rhode Island PrEP clinic from 2013 to 2019 were included. LTFU was defined as no PrEP follow-up appointment within 98 days. Re-engagement in care was defined as individuals who were ever LTFU and later attended a follow-up appointment. Recurrent event survival analysis was performed to explore factors associated with PrEP retention over time. Of 654 PrEP patients, the median age was 31 years old [interquartile range (IQR): 25, 43]. The majority were male (96%), White (64%), non-Hispanic (82%), and insured (97%). Overall, 72% patients were ever LTFU and 27% of those ever LTFU re-engaged in care. Female patients were 1.37 times [crude hazard ratio (cHR): 1.37; 95% confidence interval (CI): 0.86-2.18] more likely to be LTFU than male patients, and a 1-year increase in age was associated with a 1% lower hazard of being LTFU (cHR: 0.99; CI: 0.98-0.99). Being either heterosexual (aHR: 2.25, 95% (CI): 1.70-2.99] or bisexual (aHR: 2.35, 95% CI: 1.15-4.82) was associated with a higher hazard of loss to follow-up compared with having same-sex partners only. The majority of PrEP users were LTFU, especially at the first 6 months of PrEP initiation. Although a significant number were re-engaged in care, targeted interventions are needed to improve retention in PrEP care. This study characterized the natural projection of loss to follow-up and re-engagement in HIV PrEP care using a longitudinal clinic cohort data and explored associated factors for guiding future interventions to improve retention in PrEP care.
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Affiliation(s)
- Jun Tao
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Madeline C. Montgomery
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Robert Williams
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Prasad Patil
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Brooke G. Rogers
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Collette Sosnowy
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Matthew Murphy
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Alexandra Zanowick-Marr
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Michaela Maynard
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Siena C. Napoleon
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christina Chu
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Alexi Almonte
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Amy S. Nunn
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Philip A. Chan
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
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