Primary Care Provider HIV PrEP Knowledge, Attitudes, and Prescribing Habits: A Cross-Sectional Survey of Late Adopters in Rural and Suburban Practice

Feasibility and assessment of a comprehensive emergency department-based intervention for patients at risk of HIV

Behavioral factors increase the risk of contracting HIV. A comprehensive prevention services (CPS) intervention includes risk assessment and referral for those with confirmed risk. This project sought to assess the feasibility of an emergency department (ED)-based CPS program. A prospective cross-sectional assessment was conducted from October, 2021 through May, 2023, at a single ED in Birmingham, Alabama. Either of two screening methods were subjected to HIV negative adults: 1) manual chief complaint review or 2) objective electronic medical record (EMR) query. Manual and EMR screening methods considered sexually transmitted infections (STIs) or a positive urine drug test (to observe for commonly injectable drugs) within 12 months of current ED visit. Identified patients were approached in the ED (manual review) or via phone (EMR alert). Persons confirmed at risk for HIV following engagement questionnaire completion were made aware of their risk and offered referral to local CPS clinics. Primary outcome was CPS linkage. Descriptive analysis was performed. Of 184 patients approached, 147 agreed to engagement (79.9%), 117 in-person and 30 via phone; 125 (85.1%) were confirmed at risk for HIV; majority were white (66.4%), male (63.2%), between the ages of 30 and 49 (64.8%), uninsured (78.4%), and without a primary care provider (93.6%). Sexual behavior was identified as a recent (within six months) risk factor in 97 (77.6%) patients. Injection drug use was identified as a recent (within six months) risk factor in 71 (56.8%) patients. Fifty-four (43.2%) expressed interest in obtaining CPS follow-up. To-date, ten patients (18.5%) have connected with a CPS counsellor via phone and five (9.3%) have had a subsequent follow-up appointment to discuss CPS with a medical provider. Thirty at-risk patients (24.0%) received ED-initiated buprenorphine/naloxone. Targeted screening tools can aid in the identification of persons at risk for HIV in the ED; further, subsequent engagement and CPS implementation amongst this cohort is feasible. CPS clinic linkage may be challenging however, a CPS definition inclusive of ED-initiated medication for opioid use disorder, may offer opportunity for increased uptake.

Adaptation of a Theory-Based Mobile App to Improve Access to HIV Prevention Services for Transgender Women in Malaysia: Focus Group Study

BACKGROUND

Globally, transgender women have been disproportionately affected by the HIV epidemic, including in Malaysia, where an estimated 11% of transgender women are living with HIV. Available interventions designed specifically to meet transgender women's needs for HIV prevention are limited. Mobile health, particularly smartphone mobile apps, is an innovative and cost-effective strategy for reaching transgender women and delivering interventions to reduce HIV vulnerability.

OBJECTIVE

This study aims to adapt a theory-based mobile health HIV prevention smartphone app, HealthMindr, to meet the unique needs of transgender women in Malaysia. We conducted theater testing of the HealthMindr app with transgender women and key stakeholders and explored barriers to transgender women's uptake of HIV pre-exposure prophylaxis (PrEP).

METHODS

From February to April 2022, a total of 6 focus group (FG) sessions were conducted with 29 participants: 4 FG sessions with transgender women (n=18, 62%) and 2 FG sessions with stakeholders (n=11, 38%) providing HIV prevention services to transgender women in Malaysia. Barriers to PrEP uptake and gender-affirming care services among transgender women in Malaysia were explored. Participants were then introduced to the HealthMindr app and provided a comprehensive tour of the app's features and functions. Participants provided feedback on the app and on how existing features should be adapted to meet the needs of transgender women, as well as any features that should be removed or added. Each FG was digitally recorded and transcribed. Transcripts were coded inductively using Dedoose software (version 9.0.54; SocioCultural Research Consultants, LLC) and analyzed to identify and interpret emerging themes.

RESULTS

Six subthemes related to PrEP barriers were found: stigma and discrimination, limited PrEP knowledge, high PrEP cost, accessibility concerns, alternative prevention methods, and perceived adverse effects. Participants suggested several recommendations regarding the attributes and app features that would be the most useful for transgender women in Malaysia. Adaptation and refinement of the app were related to the attributes of the app (user interface, security, customizable colors, themes, and avatars), feedback, and requests for additional mobile app functional (appointment booking, e-consultation, e-pharmacy, medicine tracker, mood tracker, resources, and service site locator) and communication (peer support group, live chat, and discussion forum) features.

CONCLUSIONS

The results reveal that multifaceted barriers hinder PrEP uptake and use among transgender women in Malaysia. The findings also provide detailed recommendations for successfully adapting the HealthMindr app to the context of Malaysian transgender women, with a potential solution for delivering tailored HIV prevention, including PrEP, and increasing accessibility to gender-affirming care services.

Ending the HIV Epidemic in Metropolitan Atlanta: a mixed-methods study to support the local HIV/AIDS response

INTRODUCTION

Four counties within the Atlanta, Georgia 20-county eligible metropolitan area (EMA) are currently prioritized by the US "Ending the HIV Epidemic" (EHE) initiative which aims for a 90% reduction in HIV incidence by 2030. Disparities driving Atlanta's HIV epidemic warrant an examination of local service availability, unmet needs and organizational capacity to reach EHE targets. We conducted a mixed-methods evaluation of the Atlanta EMA to examine geographic HIV epidemiology and distribution of services, service needs and organization infrastructure for each pillar of the EHE initiative.

METHODS

We collected 2021 county-level data (during June 2022), from multiple sources including: AIDSVu (HIV prevalence and new diagnoses), the Centers for Disease Control and Prevention web-based tools (HIV testing and pre-exposure prophylaxis [PrEP] locations) and the Georgia Department of Public Health (HIV testing, PrEP screenings, viral suppression and partner service interviews). We additionally distributed an online survey to key local stakeholders working at major HIV care agencies across the EMA to assess the availability of services, unmet needs and organization infrastructure (June-December 2022). The Organizational Readiness for Implementing Change questionnaire assessed the organization climate for services in need of scale-up or implementation.

RESULTS

We found racial/ethnic and geographic disparities in HIV disease burden and service availability across the EMA-particularly for HIV testing and PrEP in the EMA's southern counties. Five counties not currently prioritized by EHE (Clayton, Douglas, Henry, Newton and Rockdale) accounted for 16% of the EMA's new diagnoses, but <9% of its 177 testing sites and <7% of its 130 PrEP sites. Survey respondents (N = 48; 42% health agency managers/directors) reported high unmet need for HIV self-testing kits, mobile clinic testing, HIV case management, peer outreach and navigation, integrated care, housing support and transportation services. Respondents highlighted insufficient existing staffing and infrastructure to facilitate the necessary expansion of services, and the need to reduce inequities and address intersectional stigma.

CONCLUSIONS

Service delivery across all EHE pillars must substantially expand to reach national goals and address HIV disparities in metro Atlanta. High-resolution geographic data on HIV epidemiology and service delivery with community input can provide targeted guidance to support local EHE efforts.

Need for informed providers: exploring LA-PrEP access in focus groups with PrEP-indicated communities in Baltimore, Maryland

BACKGROUND

The approval of long-acting pre-exposure prophylaxis PrEP (LA-PrEP) in the United States brings opportunities to overcome barriers of oral PrEP, particularly among sexual and gender minority communities who bear a higher HIV burden. Little is known about real-time decision-making among potential PrEP users of LA-PrEP post-licensure.

METHODS

We held focus group discussions with people assigned male at birth who have sex with men in Baltimore, Maryland to explore decision-making, values, and priorities surrounding PrEP usage. A sexual and gender minority-affirming health center that provides PrEP services supported recruitment. Discussions included a pile-sorting activity and were audio-recorded. Recordings were transcribed and analyzed iteratively, combining an inductive and deductive approach.

RESULTS

We held five focus groups from Jan-June 2023 with 23 participants (21 cisgender men who have sex with men, two transgender women who have sex with men; mean age 37). Among participants, 21 were on oral PrEP, one was on injectable PrEP, and one had never taken PrEP. Most had never heard about LA-PrEP. When making decisions about PrEP, participants particularly valued efficacy in preventing HIV, side effects, feeling a sense of security, and ease of use. Perceptions varied between whether oral or injectable PrEP was more convenient, but participants valued the new opportunity for a choice in modality. Factors influencing PrEP access included cost, individual awareness, provider awareness, and level of comfort in a healthcare environment. Participants emphasized how few providers are informed about PrEP, placing the burden of being informed about PrEP on them. Comfort and trust in a provider superseded proximity as considerations for if and where to access PrEP.

CONCLUSIONS

There is still low awareness about LA-PrEP among sexual and gender minority communities; thus, healthcare providers have a critical role in influencing access to LA-PrEP. Despite this, providers are still vastly underinformed about PrEP and underprepared to support clients in contextualized ways. Clients are more likely to engage in care with affirming providers who offer non-judgmental conversations about sex and life experiences. Provider education in the United States is urgently needed to better support clients in choosing a PrEP modality that is right for them and supporting adherence for effective HIV prevention.

Analysis of HIV drug prophylaxis services cascade in healthcare workers: a cross-sectional study in China

BACKGROUND

Human immunodeficiency virus (HIV) drug prophylaxis, including post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), has not yet been generally recognized and accepted by the whole society in China, and the utilization coverage among high-risk populations is low. Healthcare workers (HCWs) are important to the promotion and implementation of HIV drug prophylaxis strategy. This study analyzed the HIV drug prophylaxis services cascade (knowledge, attitude, and service) in HCWs, and explored the correlations between PEP and PrEP.

METHODS

A cross-sectional study was conducted among 1066 HCWs in 20 designated hospitals for HIV antiretroviral therapy in 20 cities in China. We collected information on participants' essential characteristics, HIV drug prophylaxis services cascade (knowledge, attitude, and service) and so on. The Chi-square test was used to analyse whether the differences and correlations between categorical variables were statistically significant, and Pearson contingency coefficient was used to analyse the strength of correlations. Multivariable logistic regression was used to analyse associated factors.

RESULTS

Among three stages of HIV drug prophylaxis services cascade, a high percentage of 1066 participants had knowledge of HIV drug prophylaxis (PEP: 78.2%, PrEP: 80.0%). Of them, almost all had supportive attitudes towards HIV drug prophylaxis (PEP: 99.6%, PrEP: 98.6%). Only about half of them would provide HIV drug prophylaxis services (PEP: 53.5%, PrEP: 48.5%). There were positive correlations between knowledge of PEP and PrEP (r = 0.292), between attitudes toward PEP and PrEP (r = 0.325), and between provision of PEP services and PrEP services (r = 0.555) in HCWs.

CONCLUSIONS

There was a positive correlation between PEP and PrEP in HCWs. At the stage of providing HIV drug prophylaxis services, training, advocacy and education for HCWs, should be targeted and also combine PEP and PrEP to maximize the effects, so as to improve the enthusiasm of HCWs to provide HIV drug prophylaxis services.

Adapting Provider Training and Pre-Exposure Prophylaxis Advertising to Increase Pre-Exposure Prophylaxis Awareness and Uptake Among Black Cisgender Women

Black cisgender women (hereafter referred to as "women") have disproportionately high rates of HIV infection yet low rates of pre-exposure prophylaxis (PrEP) utilization. Barriers to PrEP uptake exist at the system, provider, and individual/client level. To learn how existing training and advertising can be adapted to address race- and sex-based gaps within PrEP service delivery, we conducted focus groups with providers and Black women. Participants were recruited at three health care organizations in the Midwest and South, screened for eligibility, and consented verbally. Focus groups occurred from August 2022 to February 2023. Women were asked about their knowledge and thoughts on PrEP. Providers were asked about factors influencing their decision-making about PrEP. A codebook was developed based on the Consolidated Framework for Implementation Research. Transcripts were coded using the Stanford Lightning Report Method. We completed four focus groups with 10 providers and 9 focus groups with 25 women. Three major themes emerged: (1) low comfort level and limited cultural sensitivity/competency among providers discussing HIV risk and PrEP with Black women, (2) women's concerns about PrEP's side effects and safety during pregnancy, and (3) lack of Black women representation in PrEP advertisement/educational materials. In addition, women in the South reported general medical mistrust and specific misconceptions about PrEP. PrEP trainings for providers need detailed information about the safety of PrEP for women and should include role-playing to enhance cultural competency. Likewise, PrEP advertisements/materials should incorporate information regarding side effects and images/experiences of Black women to increase PrEP awareness and uptake among this population. Clinical Trial Registration Number: NCT05626452.

Responding to the HIV Health Literacy Needs of Clients in Substance Use Treatment: The Role of Universal PrEP Education in HIV Health and Prevention

Health literacy, particularly HIV health literacy, is a key social determinant of health and can be significantly improved through targeted health education. This paper explores the often-overlooked potential of pre-exposure prophylaxis (PrEP) education as a powerful tool to enhance HIV health literacy among people with substance use disorders (PWSUD), a population notably susceptible to HIV. Given the syndemic interplay of substance use disorders (SUDs) and HIV, health professionals, especially substance use counselors, are uniquely positioned to bolster HIV health literacy and positively influence health outcomes. This article offers a brief introduction to PrEP, delineates potential barriers and facilitators to its use and education, and proposes strategies for effective PrEP education, implementation, and adherence. By equipping substance use counselors with essential knowledge and skills, we aim to encourage and promote the integration of PrEP education into substance use treatment. The overarching objective is to empower counselors to proactively engage in HIV prevention efforts, thereby fulfilling pressing health literacy needs and contributing to improved health outcomes among PWSUD.

Overcoming structural barriers to diffusion of HIV pre-exposure prophylaxis

HIV prevention with antiretroviral medication in the form of pre-exposure prophylaxis (PrEP) offers a critical tool to halt the HIV pandemic. Barriers to PrEP access across drug types, formulations, and delivery systems share remarkable commonalities and are likely to be generalizable to future novel PrEP strategies. Appreciation of these barriers allows for planning earlier in the drug-development pathway rather than waiting for the demonstration of efficacy. The purpose of this article is to propose a core set of considerations that should be included in the drug-development process for future PrEP interventions. A literature synthesis of key barriers to PrEP uptake in the United States was conducted to elucidate commonalities across PrEP agents and delivery methods. Based on the published literature, we divided challenges into three main categories of structural barriers: (1) provider and clinic characteristics; (2) cost considerations; and (3) disparities and social constructs, with potential solutions provided for each. Pragmatic strategies for examining and overcoming these barriers before future PrEP regulatory approval are recommended. If these strategies are considered well before the time of commercial availability, the potential for PrEP to interrupt the HIV pandemic will be greatly enhanced.

Integrating HIV Pre-Exposure Prophylaxis (PrEP) Education During Medical Residency: Training Outcomes and Suggestions for Learning Effectiveness

Human immunodeficiency virus (HIV) infection is now preventable with pre-exposure prophylaxis (PrEP) drugs, however, barriers to PrEP implementation include primary-care physician (PCP) knowledge-gap and lack of comfort prescribing and managing PrEP. We hypothesized that integrating HIV-PrEP education during medical-residency would help address these problems and developed a 40-minute case-based lecture focused on the 2021 United States Preventative Services Taskforce (USPSTF) oral HIV-PrEP guidelines and integrated this into our residency's core curriculum. We analyzed data from physician-trainees who voluntarily completed a pre- and post-lecture survey measuring HIV-PrEP "knowledge" and "self-assessed readiness to independently initiate and manage PrEP." Independent group analysis was completed via the Mann-Whitney U and Pearson Chi-square 2-sided test with P-value <0.05 deemed significant. Of the total of 189 residents invited to the lecture, 130 (69%) completed the pre-survey while 107 (57%) completed the post-survey. Per knowledge-assessment: the median number of correctly answered questions rose from a pre-lecture baseline of 4/9 (44%) to 8/9 (89%) following the education intervention (P < .001). When asked about comfort initiating and managing HIV-PrEP on their own, 7/130 (5.4%) responded in agreement pre-lecture, but this rose to 55/107 (51.4%) post-lecture (P < .001). Our study revealed PrEP training during residency was effective per stated objectives and may be an important tool to increase PrEP delivery/uptake to achieve the target goals for the National HIV/AIDS Strategy.