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Surratt HL, Brown S, Burton AL, Cranford W, Green C, Mersch SM, Rains R, Westgate PM. Examining HIV pre-exposure prophylaxis (PrEP) acceptability among rural people who inject drugs: predictors of PrEP interest among syringe service program clients. AIDS Care 2024:1-11. [PMID: 39137923 DOI: 10.1080/09540121.2024.2390067] [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: 04/20/2024] [Accepted: 08/02/2024] [Indexed: 08/15/2024]
Abstract
Rural communities in the US have increasing HIV burden tied to injection drug use, yet engagement in pre-exposure prophylaxis (PrEP) care has been low among people who inject drugs (PWID). Syringe service programs (SSPs) are widely implemented in Kentucky's Appalachian region, presenting an important opportunity to scale PrEP services. This paper examines PrEP awareness, interest and preferences among PWID attending community-based SSPs in Appalachia. Eighty participants were enrolled from two SSP locations. Eligibility included: ≥ 18 years old, current injection drug use and SSP use, and an indication for PrEP as defined by CDC guidelines. Participants completed a structured baseline interview. Predictors of PrEP awareness, interest and formulation preferences were examined. 38.8% reported baseline awareness of PrEP, 50% expressed high interest in PrEP, and 48.1%reported a preference for injectable PrEP. Significant bivariate predictors of PrEP interest included: current worry about health, higher perceived HIV risk, higher community HIV stigma, and higher enacted substance use stigma in the past year; in the adjusted model, enacted substance use stigma remained significant. Findings demonstrate substantial interest in PrEP among rural PWID. Intrapersonal and social determinant factors were associated with PrEP interest, which suggests the importance of multi-level intervention targets to increase PrEP uptake.
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Affiliation(s)
- Hilary L Surratt
- University of Kentucky, Department of Behavioral Science, College of Medicine, Lexington, Kentucky, USA
| | - Sarah Brown
- Appalachian Regional Healthcare, Barbourville, Kentucky, USA
| | - Abby L Burton
- University of Kentucky, Department of Behavioral Science, College of Medicine, Lexington, Kentucky, USA
| | - Will Cranford
- University of Kentucky, Department of Biostatistics, College of Public Health, Lexington, Kentucky, USA
| | - Christie Green
- Cumberland Valley District Health Department, Manchester, Kentucky, USA
| | - Stephanie M Mersch
- University of Kentucky, Department of Behavioral Science, College of Medicine, Lexington, Kentucky, USA
| | - Rebecca Rains
- Knox County Health Department, Barbourville, Kentucky, USA
| | - Philip M Westgate
- University of Kentucky, Department of Biostatistics, College of Public Health, Lexington, Kentucky, USA
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2
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Drezner K, Coleman M, Visconti A, Thomas C, Beverley J, Harold RE, Furness BW. Predictors of PrEP Retention and Attrition in an Urban Publicly Funded Safety-net Specialty Clinic. AIDS Behav 2024; 28:2598-2606. [PMID: 38801502 PMCID: PMC11325486 DOI: 10.1007/s10461-024-04378-z] [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: 05/15/2024] [Indexed: 05/29/2024]
Abstract
Pre-exposure prophylaxis (PrEP) is an effective tool for human immunodeficiency virus (HIV) prevention. The purpose of this study is to identify correlates of PrEP retention using patient data from an urban, publicly funded safety-net clinic in Washington, DC. Cox proportional hazards regression, logistical regression, and survival curves were used to assess the association of age, gender, race/ethnicity, insurance, number of partners, and sexually transmitted infection (STI) diagnosis at PrEP initiation with time on PrEP. From August 2016-December 2020, 1,126 people were prescribed PrEP - patients were mostly Black (44.8%) or Latinx (30.4%) and identified as cisgender men (84.6%). Half had no insurance (49.1%), with the remaining patients reporting private (28.9%) or public (21.5%) insurance. Age at PrEP prescription ranged from 15 to 66 with 80% being 20 to 39 years. For the 87.7% (n = 987) of patients who discontinued PrEP, mean PrEP time was 158 days and median was 28 days. The highest rates of discontinuation were observed within the first month with 44.3% discontinuing by day 30, 52.3% by 3 months, and 73.2% by 1 year. Cisgender women, transgender persons, and those younger than 30 years were more likely to discontinue PrEP. Latinx and patients with less than 3 male partners in the last 90 days were less likely to discontinue PrEP. We demonstrated a high level of PrEP uptake among populations disproportionally affected by HIV. Future analyses are needed to examine ways of reducing barriers to PrEP initiation and improving PrEP adherence.
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Affiliation(s)
- Kate Drezner
- District of Columbia Department of Health, Washington, DC, USA.
- , 2201 Shannon Place, SE, Washington, DC, 20020, USA.
| | - Megan Coleman
- District of Columbia Department of Health, Washington, DC, USA
| | - Adam Visconti
- Department of Family Medicine, MedStar Georgetown University, Washington, DC, USA
| | - Chantil Thomas
- District of Columbia Department of Health, Washington, DC, USA
| | - Jason Beverley
- District of Columbia Department of Health, Washington, DC, USA
| | - Rachel E Harold
- District of Columbia Department of Health, Washington, DC, USA
| | - B W Furness
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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3
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Valente PK, Rusley JC, Operario D, Biello KB. Readiness to Provide Oral and Injectable PrEP for Sexual and Gender Minority Youth Among Healthcare Providers and Clinics in the U.S. Northeast. J Adolesc Health 2023; 72:722-729. [PMID: 36604205 PMCID: PMC10121770 DOI: 10.1016/j.jadohealth.2022.11.246] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/19/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To examine readiness to provide oral and injectable pre-exposure prophylaxis (PrEP) for sexual and gender minority youth (SGMY) and to explore decision-making for HIV prevention strategies (e.g., condom use, daily and event-driven oral PrEP, and injectable PrEP) among healthcare providers. METHODS Between February and April 2022, we recruited 31 prescribing providers (M.Ds, D.Os, P.As, and N.Ps) practicing in primary care and specialized clinics in the U.S. Northeast for focus groups or individual interviews. Focus groups and interview transcripts were analyzed using thematic analysis. RESULTS Most providers specialized in Pediatrics (42%) or Adolescent Medicine (23%) and 58% had previously prescribed PrEP. Main barriers to PrEP readiness were low PrEP knowledge, limited time for visits, and competing clinical priorities. Organizational factors such as routine HIV/STI testing, PrEP-specific electronic health records templates, and specialized staff (e.g., PrEP navigators) promoted PrEP readiness. Providers held positive attitudes toward injectable PrEP to promote adherence among SGMY, yet barriers to implementation of this modality were identified (e.g., patient anxiety about needles, additional staffing needs). Providers described event-driven oral PrEP as an option for SGMY with episodic HIV risk. Assurances of conditional confidentiality, including preventing disclosure of sensitive information through insurance forms, and shared decision-making facilitated conversations about HIV prevention with SGMY. DISCUSSION Future PrEP implementation efforts for SGMY should consider combined efforts targeting provider knowledge about PrEP modalities (e.g., decision aids) and clinic organizational factors (e.g., routine HIV/STI testing, resources to assist providers and patients in navigating the multiple steps between prescription and adherence to PrEP).
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Affiliation(s)
- Pablo K Valente
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island; Department of Allied Health Sciences, University of Connecticut, Waterbury, Connecticut.
| | - Jack C Rusley
- Division of Adolescent Medicine, Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island; Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Katie B Biello
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island; Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island; The Fenway Institute, Fenway Health, Boston, Massachusetts
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4
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Sell J, Chen R, Huber C, Parascando J, Nunez J. Primary Care Provider HIV PrEP Knowledge, Attitudes, and Prescribing Habits: A Cross-Sectional Survey of Late Adopters in Rural and Suburban Practice. J Prim Care Community Health 2023; 14:21501319221147254. [PMID: 36625276 PMCID: PMC9834790 DOI: 10.1177/21501319221147254] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Pre-exposure prophylaxis (PrEP) is a recommended strategy for HIV prevention, yet PrEP prescribing rates in primary care remain low. The aim of this study was to further describe the current knowledge, attitudes, and prescribing behaviors of HIV PrEP in primary care providers with a focus on the perceived barriers and facilitators to PrEP prescribing. METHODS Cross-sectional survey of primary care providers at rural and suburban practices in a large academic institution. RESULTS Survey response rate was 48.0% (n = 134). Most respondents (96.3%) reported little clinical experience in care of persons living with HIV. Respondents self-reported positive attitudes and high overall knowledge of PrEP with low prescribing rates and less comfort with lab testing. More respondents are asked about PrEP by patients (54%) than start conversations about PrEP with patients (39%). Family Physicians and providers 5 to 10 years from completion of training overall reported higher knowledge, attitudes and prescribing behaviors. Lack of PrEP education was identified as the greatest barrier and an electronic medical record order set as the greatest facilitator to prescribing PrEP. CONCLUSIONS With the goal to end the HIV epidemic, PrEP provision in nonurban primary care settings may be an important strategy for increased access to PrEP and reduced HIV transmission. This study, which includes a variety of providers that possess high knowledge, yet low experience prescribing PrEP, likely demonstrates the limitations of interventions which solely focus on provider education. System-based practice solutions, such as order sets, may be needed to target infrequent prescribers of PrEP.
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Affiliation(s)
- Jarrett Sell
- Penn State Health Hershey Medical
Center, Hershey, PA, USA,Jarrett Sell, Department of Family and
Community Medicine, Penn State Health Hershey Medical Center, 500 University
Dr., Hershey, PA 17033, USA.
| | - Rensa Chen
- Penn State Health Hershey Medical
Center, Hershey, PA, USA
| | | | | | - Jonathan Nunez
- Penn State Health Hershey Medical
Center, Hershey, PA, USA
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5
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Test-of-Cure after Treatment of Pharyngeal Gonorrhea in Durham, North Carolina, 2021 - 2022. Sex Transm Dis 2022; 49:677-681. [PMID: 35858472 DOI: 10.1097/olq.0000000000001679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In December 2020 the Centers for Disease Control and Prevention updated its treatment guidelines for gonococcal infection and, for the first time, recommended universal test-of-cure for all individuals treated for pharyngeal gonorrhea. Following the release of these guidelines, data is lacking on rates of return for the test-of-cure, particularly in populations other than men who have sex with men (MSM). METHODS We analyzed the demographic characteristics, clinical characteristics, rate of return for the recommended test-of-cure, and percent positivity for Neisseria gonorrhoeae on repeat pharyngeal specimens at a local public health department in Durham, North Carolina. RESULTS Of 101 individuals treated for pharyngeal gonorrhea between 03/2021 - 04/2022, 54.5% were male, 71.2% Black or African American, and 58.4% between the ages of 20 to 29 years. Most identified as either women who have sex with men (38.6%), MSM (24.8%), or men who have sex with women (22.8%). Of these individuals, 41 (40.6%) returned for a test-of-cure, with LGBTQ+ individuals more likely to return than men who have sex with women and women who have sex with men. Of those who returned for the test-of-cure, 4.9% of pharyngeal samples were equivocal and 2.4% positive for N. gonorrhoeae by nucleic acid amplification testing, likely reflecting false positive tests. CONCLUSION Despite recommendations to perform a test-of-cure 7-14 days following treatment of pharyngeal gonorrhea, rates of return continue to be low. Alternative strategies should be investigated to increase test-of-cure rates.
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Harless C, Lugo B, Ostrach B. Hepatitis C and HIV Screening, Testing, and Risk Perceptions among South-Central Appalachian County Health Department Staff. South Med J 2022; 115:422-428. [PMID: 35777748 DOI: 10.14423/smj.0000000000001409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are significant public health concerns, especially given the risks for disease interactions. Rates of HCV and HIV are increasing, especially in rural areas. Local health departments (LHDs) play an important role in rural health care, offering screening, testing, and treatment for HCV and HIV. Gaps persist in LHD resources for meeting these demands, especially in Appalachia and the US South. METHODS To explore HCV/HIV screening, testing, and treatment approaches and perspectives in south-central Appalachian North Carolina, structured telephone questionnaires were administered to communicable disease nurses and other health department staff directly involved in screening and testing. Mixed-methods data analyses were conducted and triangulated with stakeholders. RESULTS Eighteen participants representing 19 counties completed the questionnaire, achieving a saturation sample. Participants reported barriers to screening and testing, including housing insecurity, lack of transportation and insurance, unemployment, and the isolation of living in a rural area. Divergence in perceptions of barriers between public health regions emerged, as did perceptions of who is at risk and use of stigmatizing language about people at risk for HCV/HIV. CONCLUSIONS This study highlights the impact of LHD behaviors and perceptions on screening and testing, and offers recommendations to improve HCV/HIV screening and testing accessibility in south-central Appalachia, a high-risk region.
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Affiliation(s)
- Chase Harless
- From the Department of Public Health, East Tennessee State University, Johnson City, Tennessee, Adams School of Dentistry, University of North Carolina, Chapel Hill, North Carolina, and Medical Anthropology & Family Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Brunilda Lugo
- From the Department of Public Health, East Tennessee State University, Johnson City, Tennessee, Adams School of Dentistry, University of North Carolina, Chapel Hill, North Carolina, and Medical Anthropology & Family Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Bayla Ostrach
- From the Department of Public Health, East Tennessee State University, Johnson City, Tennessee, Adams School of Dentistry, University of North Carolina, Chapel Hill, North Carolina, and Medical Anthropology & Family Medicine, Boston University School of Medicine, Boston, Massachusetts
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Schexnayder J, Elamin F, Mayes E, Cox L, Martin E, Webel AR. Is Tailoring of PrEP Programs Needed to Overcome Racial Disparities in PrEP Uptake in Local Health Departments? A Mixed-Methods Evaluation of PrEP Implementation in Virginia. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2022; 28:282-291. [PMID: 35045008 DOI: 10.1097/phh.0000000000001463] [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] [Indexed: 11/26/2022]
Abstract
CONTEXT African American and Hispanic adults share a disproportionate burden of HIV infections in the United States but continue to experience suboptimal uptake of HIV pre-exposure prophylaxis (PrEP). Increasing PrEP accessibility in nontraditional care settings is a potential strategy to increase PrEP uptake in these high-risk groups. PrEP implementation in local health departments (LHDs) is not well characterized. OBJECTIVE To evaluate HIV PrEP implementation for African American and Hispanic adults receiving medical care in Virginia's LHDs. DESIGN We conducted a retrospective, mixed-methods evaluation of PrEP services implementation at LHDs completing their first PrEP program year between June 1, 2016, and June 30, 2019. Using pharmacy records, we estimated PrEP coverage and adherence using PrEP to need ratios (PnRs) and medication possession ratios (MPRs), respectively. Thematic analysis was used to identify barriers to PrEP delivery in interviews with 6 multidisciplinary LHD workers. RESULTS Of the 433 PrEP clients receiving an emtricitabine/tenofovir disoproxil fumarate (Truvada) prescription in year 1, 52.0% self-identified as African American and 8.9% self-identified as Hispanic. PnRs were greater for White adults in 50.0% of clinics. The average MPR (0.79) was consistent with protective medication adherence levels; however, 25.0% of clients filled only one prescription in the program year. Qualitative findings suggest incompatibilities between health PrEP services delivery and community preferences for African American and Hispanic adults; however, LHDs in one health region were able to link communities of color to PrEP at similar rates as Whites. CONCLUSIONS Incorporating a metric sensitive to racial/ethnic differences in the burden of HIV infection improved recognition of PrEP disparities; however, population-specific targets are needed to enhance use of the PnR for program evaluation. Tailoring of PrEP services to communities with the greatest local PrEP burden may be needed to optimize the effectiveness of PrEP programs in LHDs.
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Affiliation(s)
- Julie Schexnayder
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina (Dr Schexnayder); Division of Disease Prevention (Mss Martin and Elamin), Virginia Department of Health (Mr Mayes), Richmond, Virginia; University of Virginia, Charlottesville, Virginia (Ms Cox); and Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio (Dr Webel)
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8
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Burns CM, Endres K, Farrow L, Mhina C, Cooper A, Silverberg B, McKellar MS, Okeke NL. Perceptions on HIV Pre-Exposure Prophylaxis Among Urgent Care Clinicians in the Southern United States. Curr HIV Res 2022; 20:204-212. [PMID: 35473523 PMCID: PMC9562460 DOI: 10.2174/1570162x20666220426094920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/30/2022] [Accepted: 02/16/2022] [Indexed: 11/22/2022]
Abstract
Background: Underutilization of HIV pre-exposure prophylaxis (PrEP) in the Southern United States (US) is well-documented. Urgent care (UC) centers are positioned as community-facing access points to PrEP, but the feasibility of integrating PrEP services into this setting is unclear. We conducted a survey of UC clinicians in the Southern US to better understand their perceptions of the feasibility of providing PrEP in their practice setting. Objective: The study aims to determine the feasibility and acceptability of providing PrEP services in the UC setting through a cross-sectional survey of UC clinicians. Methods: We conducted a 48-item cross-sectional survey of UC clinicians in the Southern US, between July and September 2020. The survey was distributed through the Urgent Care Association (UCA) and American Academy of Urgent Care Medicine (AAUCM) professional listservs as well as directly to publicly listed e-mail addresses. Results: Eighty-two clinicians responded to the survey. Most clinicians had familiarity with PrEP (97%). All respondents rated PrEP as an effective way to prevent HIV. However, less than half felt UC facilities were an appropriate place to prescribe PrEP. Few respondents (8%) expressed doubts that expansion of PrEP access would decrease the incidence of HIV in their community. Conclusion: These findings show UC clinicians are familiar with PrEP, and many believe it would benefit their patients; however, provider opinions on the appropriateness of providing PrEP in the UC setting differ. Further studies on PrEP implementation in UC centers are needed.
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Affiliation(s)
- Charles M Burns
- Division of Infectious Diseases, Duke University, Durham, North Carolina, United States of America
| | - Kyle Endres
- Center for Social and Behavioral Research, University of Northern Iowa, Cedar Falls, Iowa, United States of America
| | - Laura Farrow
- Division of Infectious Diseases, Duke University, Durham, North Carolina, United States of America
| | - Carl Mhina
- Department of Population Health Sciences, Duke University, Durham, North Carolina, United States of America
| | - Alexandra Cooper
- Duke Initiative on Survey Methodology, Duke University, Durham, North Carolina, United States of America
| | - Benjamin Silverberg
- Department of Emergency Medicine, West Virginia University Health Sciences Center, Morgantown, West Virginia, United States of America
| | - Mehri S McKellar
- Division of Infectious Diseases, Duke University, Durham, North Carolina, United States of America
| | - Nwora Lance Okeke
- Division of Infectious Diseases, Duke University, Durham, North Carolina, United States of America
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9
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Surratt HL, Yeager HJ, Adu A, González EA, Nelson EO, Walker T. Pre-Exposure Prophylaxis Barriers, Facilitators and Unmet Need Among Rural People Who Inject Drugs: A Qualitative Examination of Syringe Service Program Client Perspectives. Front Psychiatry 2022; 13:905314. [PMID: 35706473 PMCID: PMC9189386 DOI: 10.3389/fpsyt.2022.905314] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/03/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) are at high risk for HIV infection, yet in rural areas PWID are understudied with respect to prevention strategies. Kentucky is notable for heavy rural HIV burden and increasing rates of new HIV diagnoses attributable to injection drug use. Despite high need and the strong evidence for Pre-Exposure Prophylaxis (PrEP) as a gold-standard biomedical HIV prevention tool, scale up has been limited among PWID in Kentucky and elsewhere. This paper explores individual, environmental, and structural barriers and facilitators of PrEP care from the perspective of PWID in rural Kentucky. METHODS Data are drawn from an ongoing NIH-funded study designed to adapt and integrate a PrEP initiation intervention for high-risk PWID at point of care in two rural syringe service programs (SSPs) in southeastern Kentucky. As part of this initiative, a qualitative study guided by PRISM (Practical, Robust, Implementation, and Sustainability Model) was undertaken to gather SSP client perspectives on intervention needs related to PrEP, competing needs related to substance use disorder, as well as tangible supports for and barriers to PrEP uptake. Recruitment and interviews were conducted during September-November 2021 with 26 SSP clients, 13 from each of the two SSP sites. A semi-structured guide explored injection behaviors, SSP use, knowledge of PrEP, perceived barriers to PrEP, as well as aspects of the risk environment (e.g., housing instability, community stigma) that may impact PrEP uptake. Interviews were digitally recorded, transcribed verbatim and verified by project staff. A detailed coding scheme was developed and applied by independent coders using NVivo. Coded transcripts were synthesized to identify salient themes in the data using the principles of thematic analysis All study procedures were approved by the University IRB. RESULTS Participants were 96% white, 42% female, with a median age of 41 years (range 21-62); all reported injection use within the past month. Overall, we found low PrEP awareness among this sample, yet interest in PrEP was high, with several indicating PrEP is urgently needed. Clients reported overwhelmingly positive experiences at the SSPs, considering them trusted and safe locations to receive health services, and were enthusiastic about the integration of co-located PrEP services. Lack of basic HIV and PrEP knowledge and health literacy were in evidence, which contributed to common misperceptions about personal risk for HIV. Situational risks related to substance use disorder, particularly in the context of withdrawal symptoms and craving, often lead to heightened HIV injection and sexual risk behaviors. Stigma related to substance use and HIV arose as a concern for PrEP uptake, with several participants reflecting that privacy issues would impact their preferences for education, prescribing and monitoring of PrEP. Noted tangible barriers included inconsistent access to phone service and transportation. Primary supports included high levels of insurance coverage, consistent pharmacy access, and histories with successful medication management for other health conditions. CONCLUSIONS Drawing on the critical perspectives of people with substance use disorder, our findings provide important and actionable information on individual and environmental barriers and facilitators of PrEP uptake among rural PWID at high risk for HIV infection. These data will drive the adaptation and implementation of a client-centered approach to integrated PrEP care within rurally located SSP settings to address unmet needs for PrEP care.
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Affiliation(s)
- Hilary L Surratt
- Department of Behavioral Science, University of Kentucky, Lexington, KY, United States.,Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, United States
| | - Hannah J Yeager
- Department of Anthropology, University of Rochester, Rochester, NY, United States
| | - Akosua Adu
- Department of Behavioral Science, University of Kentucky, Lexington, KY, United States
| | - Evelyn A González
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, United States
| | - Elizabeth O Nelson
- Department of Behavioral Science, University of Kentucky, Lexington, KY, United States
| | - Tamara Walker
- Department of Behavioral Science, University of Kentucky, Lexington, KY, United States
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10
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Jaiswal J, LoSchiavo C, Meanley S, Hascher K, Cox AB, Dunlap KB, Singer SN, Halkitis PN. Correlates of PrEP Uptake Among Young Sexual Minority Men and Transgender Women in New York City: The Need to Reframe "Risk" Messaging and Normalize Preventative Health. AIDS Behav 2021; 25:3057-3073. [PMID: 33830327 PMCID: PMC8419019 DOI: 10.1007/s10461-021-03254-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is an effective form of HIV prevention, but young sexual minority men face myriad barriers to PrEP uptake. Participants (n = 202) completed a survey on healthcare experiences and beliefs about HIV and PrEP. While 98% of the sample knew about PrEP, only 23.2% reported currently taking PrEP. Participants were more likely to be taking PrEP if they received PrEP information from a healthcare provider and endorsed STI-related risk compensation. Conversely, PrEP uptake was less likely among those with concerns about medication use and adherence. While there were no racial/ethnic differences in PrEP uptake, there were differences in correlates of PrEP use for White participants and participants of color. To facilitate PrEP uptake, clinicians should provide PrEP education and screen all patients for PrEP candidacy. Additionally, public health messaging must reframe HIV "risk", highlight benefits of STI testing, and emphasize the importance of preventive healthcare for SMM.
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Affiliation(s)
- J Jaiswal
- Department of Health Science, University of Alabama, 115 Russell Hall, 504 University Blvd, Tuscaloosa, AL, 35401, USA.
- Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, New Haven, CT, 06510, USA.
- Center for Health, Identity, Behavior and Prevention Studies (CHIBPS), Rutgers School of Public Health, Newark, NJ, 07102, USA.
| | - C LoSchiavo
- Center for Health, Identity, Behavior and Prevention Studies (CHIBPS), Rutgers School of Public Health, Newark, NJ, 07102, USA
- School of Public Health, Rutgers University, Piscataway, NJ, 08854, USA
| | - S Meanley
- Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, New Haven, CT, 06510, USA
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - K Hascher
- Department of Health Science, University of Alabama, 115 Russell Hall, 504 University Blvd, Tuscaloosa, AL, 35401, USA
| | - A B Cox
- Department of Health Science, University of Alabama, 115 Russell Hall, 504 University Blvd, Tuscaloosa, AL, 35401, USA
| | - K B Dunlap
- Department of Health Science, University of Alabama, 115 Russell Hall, 504 University Blvd, Tuscaloosa, AL, 35401, USA
| | - S N Singer
- Center for Health, Identity, Behavior and Prevention Studies (CHIBPS), Rutgers School of Public Health, Newark, NJ, 07102, USA
- Graduate School of Applied & Professional Psychology, Rutgers University, 152 Frelinghuysen Road, Busch Campus, Piscataway, NJ, 08854, USA
| | - P N Halkitis
- Center for Health, Identity, Behavior and Prevention Studies (CHIBPS), Rutgers School of Public Health, Newark, NJ, 07102, USA
- School of Public Health, Rutgers University, Piscataway, NJ, 08854, USA
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11
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Moore E, Kelly SG, Alexander L, Luther P, Cooper R, Rebeiro PF, Zuckerman AD, Hargreaves M, Bourgi K, Schlundt D, Bonnet K, Pettit AC. Tennessee Healthcare Provider Practices, Attitudes, and Knowledge Around HIV Pre-Exposure Prophylaxis. J Prim Care Community Health 2021; 11:2150132720984416. [PMID: 33356793 PMCID: PMC7768326 DOI: 10.1177/2150132720984416] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction/Objectives: Pre-exposure prophylaxis (PrEP) use in the southern United States is low despite its effectiveness in preventing HIV acquisition and high regional HIV prevalence. Our objectives were to assess PrEP knowledge, attitudes, and prescribing practices among Tennessee primary care providers. Methods: We developed an anonymous cross-sectional electronic survey from March to November 2019. Survey development was guided by the Capability, Opportunity, Motivation, and Behavior framework and refined through piloting and interviews. Participants included members of professional society and health center listservs licensed to practice in Tennessee. Respondents were excluded if they did not complete the question regarding PrEP prescription in the previous year or were not in a position to prescribe PrEP (e.g., hospital medicine). Metrics included PrEP prescription in the preceding year, PrEP knowledge scores (range 0-8), provider attitudes about PrEP, and provider and practice characteristics. Knowledge scores and categorical variables were compared across PrEP prescriber status with Wilcoxon rank-sum and Fisher’s exact tests, respectively. Results: Of 147 survey responses, 99 were included and 43 (43%) reported PrEP prescription in the preceding year. Compared with non-prescribers: prescribers had higher median PrEP knowledge scores (7.3 vs 5.6, P < .01), a higher proportion had self-reported patient PrEP inquiries (95% vs 21%, P < .01), and a higher proportion had self-reported good or excellent ability to take a sexual history (83% vs 58%, P = .01) and comfort taking a sexual history (92% vs 63%, P < .01) from men who have sex with men, a subgroup with high HIV risk. Most respondents felt obligated to provide PrEP (65%), and felt all primary care providers should provide PrEP (63%). Conclusion: PrEP provision is significantly associated with PrEP knowledge, patient PrEP inquiries, and provider sexual history taking ability and comfort. Future research should evaluate temporal relationships between these associations and PrEP prescription as potential routes to increase PrEP provision.
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Affiliation(s)
- Emily Moore
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sean G Kelly
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | | | | | | | - Kassem Bourgi
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - April C Pettit
- Vanderbilt University Medical Center, Nashville, TN, USA
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12
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Towe SL, Sullivan CA, McKellar MS, Meade CS. Examining the Potential of Pre-exposure Prophylaxis (PrEP) for HIV Prevention in a Community Sample of Persons Who Use Stimulants Living in the Southern United States. AIDS Behav 2021; 25:1480-1489. [PMID: 32757101 DOI: 10.1007/s10461-020-02987-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pre-exposure prophylaxis (PrEP), a highly effective HIV prevention strategy, is currently underutilized by several at-risk groups, including both persons who inject drugs and those who use drugs via other routes. Stimulant use is associated with increased HIV risk due to both sexual and injection risk behaviors. In this study, we examined PrEP awareness and acceptability in persons with biologically confirmed HIV-negative status who use stimulant drugs. We also examined HIV risk behaviors to identify how many participants met behavioral eligibility for PrEP. The sample of 352 participants was 46% female, 87% African American, and 45.69 years old on average. Over half the sample (n = 213) met criteria for PrEP candidacy, but less than 20% had heard of PrEP. Ratings for willingness to take PrEP were high. PrEP candidates reported more frequent and problematic stimulant use relative to non-candidates. Our results show that persons who use stimulants are a high-risk population that could benefit significantly from PrEP. Efforts to increase PrEP awareness among high-risk populations are critical for facilitating PrEP implementation and ensuring effective HIV prevention within these communities.
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Affiliation(s)
- Sheri L Towe
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Box 102848, Durham, NC, 27710, USA.
| | - Catherine A Sullivan
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Box 102848, Durham, NC, 27710, USA
| | - Mehri S McKellar
- Department of Medicine, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Christina S Meade
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Box 102848, Durham, NC, 27710, USA
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13
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Shende TC, Fisher JM, Perez-Velez CM, Guido AA, Sprowl KM, Drake TM, Adelus ML, Bedrick EJ, Fantry LE. PrEP Knowledge and Attitudes Among Adults Attending Public Health Clinics in Southern Arizona. J Community Health 2021; 45:400-406. [PMID: 31612368 DOI: 10.1007/s10900-019-00758-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
HIV pre-exposure prophylaxis (PrEP) is underutilized among Hispanics, women, and low-income individuals. To better understand PrEP barriers in this population, questionnaires were administered to 500 patients attending public health clinics in southern Arizona which provide family planning and sexually transmitted infections care. Sixty-three percent believed that they had no risk of HIV infection. When asked "Before today, did you know that there was a pill that can prevent HIV infection?" 80% of persons answered no. Among women, 88% answered no to this question. As expected, individuals with a higher perceived HIV risk (OR 1.76) or one HIV risk factor (OR 5.85) had a higher probability of knowledge. Among survey participants 87% would take a daily pill, 91% would visit a health-care provider every 3 months, and 92% would have laboratory testing every 3 months. Fifty-four percent would not be afraid or embarrassed if friends or family knew they were taking PrEP. Seventy-two percent would take PrEP despite temporary nausea. Sixty-two percent would pay ≥ $40 every 3 months for PrEP. Lack of knowledge, rather than patient attitudes, is the more important barrier to wider utilization of PrEP among individuals, especially women, attending public health clinics in Southern Arizona. Future efforts need to focus on education and access to PrEP in underserved populations including women and Hispanics.
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Affiliation(s)
- Tanwe C Shende
- University of Arizona Health Sciences Center, 1501 N Campbell Ave, P.O. Box 245039, Tucson, AZ, 85724, USA
| | - Julia M Fisher
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA
| | | | - Alyssa A Guido
- University of Arizona Health Sciences Center, 1501 N Campbell Ave, P.O. Box 245039, Tucson, AZ, 85724, USA
| | - Kristi M Sprowl
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA
| | - Taylor M Drake
- University of Arizona Health Sciences Center, 1501 N Campbell Ave, P.O. Box 245039, Tucson, AZ, 85724, USA
| | - Maria L Adelus
- University of Arizona Health Sciences Center, 1501 N Campbell Ave, P.O. Box 245039, Tucson, AZ, 85724, USA
| | - Edward J Bedrick
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA
| | - Lori E Fantry
- University of Arizona Health Sciences Center, 1501 N Campbell Ave, P.O. Box 245039, Tucson, AZ, 85724, USA.
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14
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Matacotta JJ, Rosales-Perez FJ, Carrillo CM. HIV Preexposure Prophylaxis and Treatment as Prevention - Beliefs and Access Barriers in Men Who Have Sex With Men (MSM) and Transgender Women: A Systematic Review. J Patient Cent Res Rev 2020; 7:265-274. [PMID: 32760758 DOI: 10.17294/2330-0698.1737] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose While the annual rate of new HIV infections and diagnoses has remained stable for most groups, troubling increases are seen in transgender women and racial/ethnic-minority men who have sex with men (MSM), groups that are disproportionately affected by HIV. The primary purpose of this systematic review is to examine factors that impact attitudes and beliefs about preexposure prophylaxis (PrEP) and treatment as prevention (TasP) and to explore barriers to PrEP uptake in MSM and transgender women. Methods Using MeSH terms and relevant keywords, we conducted a systematic review of studies published between 2010 and 2019. We searched 4 literature databases and identified studies on MSM and transgender women to elucidate perceptions of PrEP and TasP as well as barriers to access. Results The search yielded several prominent themes associated with beliefs about HIV prevention approaches and barriers to PrEP access in MSM and transgender women. One was a lack of awareness or insufficient knowledge of PrEP and TasP. Structural barriers and geographic isolation also prevent access to HIV prevention. Sexual minority and HIV-related stigma, internalized homonegativity, and misinterpretations of messages within HIV prevention campaigns have negatively impacted PrEP uptake and beliefs about PrEP and TasP. Quality of the relationship MSM or transgender people have with their health care provider can facilitate or hinder HIV prevention. Finally, variability in beliefs about the efficacy of TasP has negatively affected the impact of TasP messaging campaigns. Conclusions Although there is evidence of increasing PrEP use in at-risk individuals, several barriers prevent wider acceptance and uptake. Misunderstanding about the meaning of "undetectable" and skepticism about the evidence behind TasP messaging campaigns are likely to delay the World Health Organization's stated goal of getting to zero transmissions.
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Affiliation(s)
- Joshua J Matacotta
- College of Health Sciences, Western University of Health Sciences, Pomona, CA
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15
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Kutscha F, Gaskins M, Sammons M, Nast A, Werner RN. HIV Pre-Exposure Prophylaxis (PrEP) Counseling in Germany: Knowledge, Attitudes and Practice in Non-governmental and in Public HIV and STI Testing and Counseling Centers. Front Public Health 2020; 8:298. [PMID: 32760688 PMCID: PMC7372106 DOI: 10.3389/fpubh.2020.00298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 06/04/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Providers of sexual health services play an important role in counseling persons at risk of acquiring HIV. The aim of the present study was to investigate the knowledge of and attitudes toward HIV pre-exposure prophylaxis (PrEP) among counselors in non-governmental counseling centers ("NG counseling centers") and in counseling centers of the local health authorities ("local health offices") in Germany and to determine the extent to which PrEP plays a role in their current counseling practice. Methods: An anonymous cross-sectional study using an online questionnaire was conducted among counselors from sexual health centers across Germany. All NG counseling centers in Germany offering HIV testing were asked to participate. For each NG counseling center, a local health office in the same city was also invited. A "knowledge score" and an "attitudes score" were calculated from single items on various relevant aspects. The association of these scores with the proportion of PrEP advice provided proactively in sessions with men who have sex with men (MSM) and trans persons who met the German and Austrian guideline criteria for being offered PrEP ('at-risk clients') was quantified. Results: From Oct. to Dec. 2018, 145 counselors completed the survey. Both self-assessed knowledge of PrEP and attitudes toward PrEP were greater or more positive among counselors from NG counseling centers compared with counselors from local health offices [Median knowledge score (range 0-20): 18.0 (IQR = 5.0) vs. 14.0 (IQR = 4.0), p < 0.001; median attitudes score (range 0-20): 18.0 (IQR = 4.0) vs. 14.0 (IQR = 6.8), p < 0.001]. The proportion of PrEP advice provided proactively in sessions with at-risk clients was larger in counseling centers than in local health offices [50.0% (IQR = 60.0) vs. 30.0% (IQR = 70.0); p = 0.003]. The results of the multiple linear regression model indicate that knowledge and attitudes of the individual counselors, but not the type of center in which they worked, were independent predictors of the proportion of proactive advice on PrEP. Conclusions: There is room for improvement in the current PrEP counseling practice of sexual health services in Germany. The findings of the present study suggest opportunities to improve the implementation of PrEP as part of a comprehensive HIV prevention strategy.
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Affiliation(s)
- Frank Kutscha
- Schwulenberatung Berlin, Berlin, Germany.,Alice Salomon Hochschule Berlin-University of Applied Sciences, Berlin, Germany
| | - Matthew Gaskins
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venerology and Allergy, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Mary Sammons
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venerology and Allergy, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Alexander Nast
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venerology and Allergy, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Ricardo Niklas Werner
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venerology and Allergy, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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16
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Carter G, Woodward B. The Relationship Between Perception of HIV Susceptibility and Willingness to Discuss PrEP With a Health Care Provider: A Pilot Study. Am J Mens Health 2020; 14:1557988320919661. [PMID: 32602784 PMCID: PMC7328224 DOI: 10.1177/1557988320919661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/11/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022] Open
Abstract
HIV continues to be a significant public health concern and despite recent reductions in new HIV diagnoses, certain demographics continue to be disproportionality affected. Men who have sex with other men (MSM) account for the largest percentage of new HIV diagnoses; however, 24% of new diagnoses can be attributed to male-to-female sex, highlighting the need to explore the HIV epidemic beyond the narrow scope of MSM. A multivariate linear regression model was used to explore the perception of HIV susceptibility and level of comfort discussing pre-exposure prophylaxis (PrEP) with a health care provider among a sample of men living in the United States (n = 377). Men who had an increased perception of HIV susceptibility were significantly more likely to feel comfortable discussing PrEP with a health care provider. Men who distinguish themselves to be at increased risk of acquiring HIV were significantly more likely to report having either insertive or receptive condomless anal intercourse within the previous 3 months, while men who reported condomless vaginal intercourse perceived low HIV susceptibility. Never being screened for HIV was significantly associated with a perception of low HIV susceptibility compared to those men who had been screened in the previous year. Understanding how men perceive HIV susceptibility and engage with HIV prevention may help to improve HIV prevention efforts such as PrEP.
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Affiliation(s)
- Gregory Carter
- Indiana University School of Nursing
Bloomington, Bloomington, IN, USA
| | - Brennan Woodward
- Indiana University School of Nursing
Bloomington, Bloomington, IN, USA
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17
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Mayer KH, Agwu A, Malebranche D. Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review. Adv Ther 2020; 37:1778-1811. [PMID: 32232664 PMCID: PMC7467490 DOI: 10.1007/s12325-020-01295-0] [Citation(s) in RCA: 210] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Indexed: 01/01/2023]
Abstract
Antiretroviral pre-exposure prophylaxis (PrEP) to prevent HIV transmission was first approved by the US Food and Drug Administration in 2012. Despite correlations of decreases in new HIV infections being greatest where PrEP has been deployed, the uptake of PrEP is lagging, particularly among populations with disproportionate HIV burden. This narrative review seeks to identify individual and systemic barriers to PrEP usage in the USA. A comprehensive search of recent literature uncovered a complex array of structural, social, clinical, and behavioral barriers, including knowledge/awareness of PrEP, perception of HIV risk, stigma from healthcare providers or family/partners/friends, distrust of healthcare providers/systems, access to PrEP, costs of PrEP, and concerns around PrEP side effects/medication interactions. Importantly, these barriers may have different effects on specific populations at risk. The full potential of PrEP for HIV prevention will not be realized until these issues are addressed. Strategies to achieve this goal should include educational interventions, innovative approaches to delivery of HIV care, financial support, and destigmatization of PrEP and PrEP users. Until then, PrEP uptake will continue to be suboptimal, particularly among those who need it most.
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Affiliation(s)
- Kenneth H Mayer
- The Fenway Institute and Harvard Medical School, Boston, MA, USA.
| | - Allison Agwu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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HIV Seroconversion in the Era of Pharmacologic Prevention: A Case-Control Study at a San Francisco STD Clinic. J Acquir Immune Defic Syndr 2020; 82:159-165. [PMID: 31192823 DOI: 10.1097/qai.0000000000002107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The comparative effectiveness of pre- and post-exposure prophylaxis (PrEP and PEP) for men who have sex with men (MSM) is unclear. SETTING We conducted a case-control study of MSM who were initially HIV-uninfected during September 1, 2012-June 30, 2016 at San Francisco's only municipal sexually transmitted diseases (STDs) clinic. METHODS Each case was matched with up to 3 controls based on age, baseline visit date, and follow-up time. The primary dependent variable was HIV seroconversion; the primary independent variable was exposure to PrEP, PEP, or neither. Conditional logistic regression was used to calculate odds ratios and 95% confidence intervals. RESULTS Of 638 MSM (161 cases and 477 controls), 137 reported ever taking PrEP, 98 reported taking PEP-only, and 403 took neither. PrEP takers had more non-HIV sexually transmitted diseases during the analysis (72.3% vs. 55.1% vs. 42.4% P < 0.01) and were more likely to report receptive anal sex in the past 3 months (86.5% vs. 80.4% vs. 73.0%; P < 0.01). In the adjusted model, PrEP was associated with lower odds of HIV seroconversion (odds ratio 0.24; 95% confidence interval: 0.13 to 0.46) while PEP use had no effect on HIV acquisition compared with taking neither. CONCLUSIONS MSM who ever used PrEP demonstrated equal or higher sexual risk compared with those using neither PrEP nor PEP but had 76% lower odds of HIV seroconversion. MSM who used PEP but never PrEP were no less likely to seroconvert than those using neither. MSM should be offered PrEP. PEP users with ongoing risk of HIV infection should be connected to PrEP after PEP.
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19
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Rice WS, Stringer KL, Sohail M, Crockett KB, Atkins GC, Kudroff K, Batey DS, Hicks J, Turan JM, Mugavero MJ, Turan B. Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama. AIDS Behav 2019; 23:2966-2979. [PMID: 31297683 DOI: 10.1007/s10461-019-02591-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Limited studies to date assess barriers to and facilitators of PrEP uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. We examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama. Participants were 32 years old on average, 66% Black, 66% gay or lesbian, 70% male, and 66% single. Perceived barriers to PrEP access included: lack of PrEP awareness and advertisement; sexuality-related stigma; time and resource constraints; and concerns about the adequacy and technical quality of PrEP services. Perceived facilitators to PrEP access were: PrEP-related information gathering and sharing; increased dialogue and visibility around PrEP; social, programmatic, and clinical support; and, lastly, self-preservation; personal motivation; and treatment self-efficacy. Results point to opportunities to address complex barriers to equitable PrEP access using multilevel and multimodal solutions.
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Affiliation(s)
- Whitney S Rice
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, GCR 538, Atlanta, GA, 30322, USA.
| | - Kristi L Stringer
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA
| | - Maira Sohail
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kaylee B Crockett
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ghislaine C Atkins
- Department of Psychology, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kachina Kudroff
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - D Scott Batey
- Department of Social Work, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Janet M Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael J Mugavero
- Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bulent Turan
- Department of Psychology, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
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20
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Pinto RM, Lacombe-Duncan A, Kay ES, Berringer KR. Expanding Knowledge About Implementation of Pre-exposure Prophylaxis (PrEP): A Methodological Review. AIDS Behav 2019; 23:2761-2778. [PMID: 31292825 PMCID: PMC6789046 DOI: 10.1007/s10461-019-02577-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Methodological limitations in PrEP implementation studies may explain why PrEP implementation is lagging. This methodological review provides a description and critique of the methods used to identify barriers to PrEP implementation in the United States (2007-18). For each selected article, we provide: (1) research questions; (2) measures; (3) design; (4) sample (size and type); and (5) theoretical orientation. Among 79 articles which identified knowledge, attitudes, and behavioral and social/structural barriers to PrEP implementation, 51 (65%) were quantitative; 25 (32%) qualitative; and 3 (4%) were mixed-methods; overall, just one-half described a conceptual approach. About two-thirds of articles were conducted with patients and one-third with healthcare providers. Our review reveals a paucity of longitudinal, mixed-methods, and ethnographic/observational research and guiding theoretical frameworks; thus, the applicability of results are limited. We recommend that interventions aimed at PrEP implementation address barriers situated at multiple ecological domains, and thus improve PrEP access, uptake, and adherence.
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Affiliation(s)
- Rogério M Pinto
- University of Michigan, School of Social Work, Office 2850, 1080 South University, Ann Arbor, MI, 48109, USA.
| | - Ashley Lacombe-Duncan
- University of Michigan, School of Social Work, Office 2850, 1080 South University, Ann Arbor, MI, 48109, USA
| | - Emma Sophia Kay
- University of Michigan, School of Social Work, Office 2850, 1080 South University, Ann Arbor, MI, 48109, USA
| | - Kathryn R Berringer
- University of Michigan, School of Social Work, Office 2850, 1080 South University, Ann Arbor, MI, 48109, USA
- University of Michigan, Anthropology, Ann Arbor, MI, USA
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21
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Clement ME, Johnston BE, Eagle C, Taylor D, Rosengren AL, Goldstein BA, Seña AC. Advancing the HIV Pre-Exposure Prophylaxis Continuum: A Collaboration Between a Public Health Department and a Federally Qualified Health Center in the Southern United States. AIDS Patient Care STDS 2019; 33:366-371. [PMID: 31233329 DOI: 10.1089/apc.2019.0054] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Uptake of pre-exposure prophylaxis (PrEP) has been limited among black and Latino men who have sex with men (MSM), especially in the southern United States. Public health departments and federally qualified health centers (FQHCs) serving predominantly uninsured populations are uniquely positioned to improve access. We evaluated a novel PrEP collaboration between a public health department and an FQHC in North Carolina (NC). In May 2015, a PrEP program was initiated that included no-cost HIV/sexually transmitted infection screening at a public health department, followed by referral to a colocated FQHC for PrEP services. We profiled the PrEP continuum for patients entering the program until February 2018. PrEP initiators and noninitiators were compared using Wilcoxon rank-sum test for continuous variables and chi-square or Fisher's exact tests for categorical variables. Of 196 patients referred to the FQHC, 60% attended an initial appointment, 43% filled a prescription, 38% persisted in care for >3 months, and 30% reported >90% adherence at follow-up. Among those presenting for initial appointments (n = 117), most were MSM (n = 95, 81%) and black (n = 62, 53%); 21 (18%) were Latinx and 9 (8%) were trans persons. Almost half (n = 55) were uninsured. We found statistically significant differences between PrEP initiators versus noninitiators based on race/ethnicity (p = 0.02), insurance status (p = 0.05), and history of sex work (p = 0.05). In conclusion, this collaborative model of PrEP care was able to reach predominantly black and Latino MSM in the southern United States. Although sustainable, program strategies to improve steps along the PrEP care continuum are vital in this population.
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Affiliation(s)
- Meredith E Clement
- 1Infectious Diseases, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Barbara E Johnston
- 2Lincoln Community Health Center, Durham, North Carolina
- 3Duke University Medical Center, Durham, North Carolina
| | - Cedar Eagle
- 4Durham County Department of Public Health, Durham, North Carolina
| | - Destry Taylor
- 2Lincoln Community Health Center, Durham, North Carolina
| | - Anna Lina Rosengren
- 5Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Benjamin A Goldstein
- 6Department of Biostatistics and Bioinformatics, Duke University, Durham, North C1arolina
| | - Arlene C Seña
- 4Durham County Department of Public Health, Durham, North Carolina
- 7Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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22
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Golub SA, Myers JE. Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men. AIDS Patient Care STDS 2019; 33:253-261. [PMID: 31094576 DOI: 10.1089/apc.2018.0290] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Data indicate that diffusion of pre-exposure prophylaxis (PrEP) programs for HIV prevention is increasing in the United States; however, persistent disparities in PrEP access remain. Earlier waves of PrEP implementation focused on development (2012-2015) and diffusion (2016-2018). To reduce disparities, the next wave of PrEP implementation should focus on integration; that is, the assimilation of PrEP service as an integral part of HIV prevention, sexual health, and primary care. This review analyzes PrEP implementation literature in the context of three "next-wave" challenges: increasing patient demand, enhancing provider investment and competency, and improving health systems capacity. Our review revealed five activities we consider critical to successful next-wave PrEP implementation efforts: (1) redefining PrEP eligibility assessment, (2) de-emphasizing risk perception as a strategy to increase demand, (3) rejecting risk compensation arguments, (4) altering guidelines to make PrEP follow-up less onerous, and (5) focusing directly on strategies to reduce the cost of PrEP medication. This article ends with a case study of a research-practice partnership designed to instantiate new approaches to integrative implementation efforts.
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Affiliation(s)
- Sarit A. Golub
- Department of Psychology, Hunter College of the City University of New York, New York, New York
- Basic and Applied Social Psychology (BASP) PhD Program, Department of Psychology, Graduate Center of the City University of New York, New York, New York
| | - Julie E. Myers
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York
- Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
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Adams JL, Shelley K, Nicol MR. Review of Real-World Implementation Data on Emtricitabine-Tenofovir Disoproxil Fumarate as HIV Pre-exposure Prophylaxis in the United States. Pharmacotherapy 2019; 39:486-500. [PMID: 30815960 DOI: 10.1002/phar.2240] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The antiretroviral combination of emtricitabine-tenofovir disoproxil fumarate (FTC/TDF) was approved by the U.S. Food and Drug Administration for use as pre-exposure prophylaxis (PrEP) in individuals at high risk for acquiring human immunodeficiency virus (HIV) in July 2012. Since then, Centers for Disease Control and Prevention guidelines for the use of PrEP have been published and implemented into clinical practice throughout the United States. A number of published open-label and PrEP demonstration projects have evaluated the real-world use of PrEP including analysis of the barriers to its use and addressing major concerns. Despite the approval of FTC/TDF for PrEP, its use for this indication relies on patient and provider acceptance, and its effectiveness requires patient adherence and retention in care during periods of high-risk behaviors. Concerns regarding the use of PrEP in healthy individuals persist and include medication adverse effects including renal dysfunction and bone mineral density loss; risk compensation leading to HIV infections, sexually transmitted infections, and unintended pregnancies; and the development of drug resistance in the event of seroconversion. The cost-effectiveness of PrEP continues to be assessed with the greatest cost-effectiveness remaining in those at highest risk of acquiring HIV. Additionally, cases of HIV acquisition in individuals who are adherent to PrEP highlight scenarios in which PrEP is not 100% effective including against the transmission of drug-resistant HIV strains. This review examines data on the implementation of PrEP outside the setting of clinical trials with the aim of providing clinicians with a summary of the current barriers and opportunities for PrEP use with a specific focus on the role of pharmacists in the optimization of PrEP implementation.
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Affiliation(s)
- Jessica L Adams
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, Pennsylvania
| | - Karishma Shelley
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, Pennsylvania
| | - Melanie R Nicol
- University of Minnesota College of Pharmacy, Minneapolis, Minnesota
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Siegler AJ, Bratcher A, Weiss KM, Mouhanna F, Ahlschlager L, Sullivan PS. Location location location: an exploration of disparities in access to publicly listed pre-exposure prophylaxis clinics in the United States. Ann Epidemiol 2018; 28:858-864. [PMID: 30406756 PMCID: PMC6261794 DOI: 10.1016/j.annepidem.2018.05.006] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/13/2018] [Accepted: 05/19/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission. Finding a PrEP provider, however, can be a barrier to accessing care. This study explores the distribution of publicly listed PrEP-providing clinics in the United States. METHODS Data regarding 2094 PrEP-providing clinics come from PrEP Locator, a national database of PrEP-providing clinics. We compared the distribution of these PrEP clinics to the distribution of new HIV diagnoses within various geographical areas and by key populations. RESULTS Most (43/50) states had less than one PrEP-providing clinic per 100,000 population. Among states, the median was two clinics per 1000 PrEP-eligible men who have sex with men. Differences between disease burden and service provision were seen for counties with higher proportions of their residents living in poverty, lacking health insurance, identifying as African American, or identifying as Hispanic/Latino. The Southern region accounted for over half of all new HIV diagnoses but only one-quarter of PrEP-providing clinics. CONCLUSIONS The current number of PrEP-providing clinics is not sufficient to meet needs. In addition, PrEP-providing clinics are unevenly distributed compared to disease burden, with poor coverage in the Southern divisions and areas with higher poverty, uninsured, and larger minority populations. PrEP services should be expanded and targeted to address disparities.
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Affiliation(s)
- Aaron J Siegler
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Anna Bratcher
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Kevin M Weiss
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Farah Mouhanna
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Lauren Ahlschlager
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Patrick S Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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