What Community-Based HIV Prevention Organizations Say About Their Role in Biomedical HIV Prevention

PIVOT: A New Approach to HIV Capacity-Building Assistance

In 2004, a national nonprofit established a capacity-building assistance (CBA) program aimed at bolstering the capabilities of health departments and community-based organizations in implementing and evaluating HIV prevention interventions for racial and minority populations. Recognizing the need for a specialized CBA model to support HIV prevention programs, the program developed the Customized Holistic Analytical Networking Grassroots Evaluatory (CHANGE) approach. This article introduces the Prioritizing Intersectional Values for Organizational Technical Assistance (PIVOT) approach as a progressive evolution of CBA strategies tailored to the contemporary HIV landscape. PIVOT, founded on seven core values and focused on four key areas, is structured across three stages of CBA delivery. Effective capacity building mandates the CBA partners to be well versed in HIV organizational culture and capable of delivering strategies ensuring long-term sustainability. This article offers invaluable insights and lessons that inform the development and implementation of the PIVOT approach, drawing from two decades of service delivery.

HIV Linkage to Care and Pre-Exposure Prophylaxis Among Persons in Non-Health Care Sites Who Are Tested for HIV for the First Time, United States, 2019

CONTEXT

The Centers for Disease Control and Prevention recommends that all persons aged 13 to 64 years are tested for human immunodeficiency virus (HIV). However, results from US surveys show that 50% of persons and less had ever tested for HIV.

PROGRAM

The Centers for Disease Control and Prevention annually funds 60 health departments to conduct comprehensive HIV prevention and surveillance activities that include HIV testing.

IMPLEMENTATION

We selected the 31 health departments with quality data (ie, ≤20% missing or invalid values for variables to verify linkage to HIV medical care and new HIV diagnoses) in 2019. Main outcomes were new HIV diagnoses, linkage, and pre-exposure prophylaxis (PrEP) awareness and referrals. We used SAS 9.4 to conduct descriptive, chi-square, and multivariate regression analyses. Our objectives were to determine outcomes and characteristics of persons in non-health care settings who tested for HIV for the first time.

EVALUATION

Compared with persons who previously tested for HIV, persons who tested for the first time were more likely to be aged 13 to 29 years than aged 30 years and older (62.0% [24 295/39 192] vs 42.1% [61 911/147 087], P < .001) and have a higher percentage of new HIV diagnoses (0.6% [242/39 320] vs 0.5% [667/147 475], P < .001). Among persons who tested for the first time, overall percentages of linkage, PrEP awareness, and PrEP referral were 73.4%, 33.3%, and 30.8%, respectively. Compared with referent groups, persons who tested for the first time in the South and had a new HIV diagnosis were less likely to be linked (adjusted prevalence ratio [aPR] = 0.72, 95% confidence interval [CI]: 0.59-0.89); persons who inject drugs were less likely to be aware of PrEP (aPR = 0.84, 95% CI: 0.77-0.91); and persons in the Northeast were less likely to receive PrEP referrals (aPR = 0.28, 95% CI: 0.26-0.31).

DISCUSSION

Non-health care sites should consider increasing HIV testing, PrEP awareness, and prompt referrals to PrEP and HIV treatment services for persons who have never previously tested.

An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers' PrEP-Related Clinical Judgments

Social biases may influence providers' judgments related to pre-exposure prophylaxis (PrEP) and patients' consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.

Structural Inequities, HIV Community-Based Organizations, and the End of the HIV Epidemic

Community-based organizations (CBOs) are integral to achieving the goal of Ending the HIV epidemic (EHE). Their familiarity with and proximity to communities position them to effectively implement strategies necessary to address determinants of health through their formal and informal medical and social services. However, structural inequities have contributed to the demise of many organizations that were instrumental in early responses to the HIV epidemic. We define structural inequities for HIV CBOs as systems in which policies, institutional practices, organizational (mis)representations, and other norms work to produce and maintain inequities that affect CBOs' ability to survive and thrive. In this discussion, we describe the organizational threats to grassroots HIV CBOs and the risks to livelihood and longevity, including examples. The invaluable role of HIV CBOs in EHE and their role in responding to existing and novel infectious diseases like COVID-19 should not be overlooked. Recommendations to promote structural equity are offered. (Am J Public Health. 2022;112(3):417-425. https://doi.org/10.2105/AJPH.2021.306688).

Characterizing Awareness of Pre-Exposure Prophylaxis for HIV Prevention in Manila and Cebu, Philippines: Web-Based Survey of Filipino Cisgender Men Who Have Sex With Men

Background

The Philippines is experiencing an HIV crisis and is considering implementing pre-exposure prophylaxis (PrEP) as a national public health strategy for HIV prevention for cisgender men who have sex with men (cis-MSM). However, critical information on the awareness of PrEP among cis-MSM is needed to roll out this public health initiative.

Objective

This study aims to assess PrEP awareness and related correlates (ie, sociodemographic variables, social factors, and health care access and use) among Filipino cis-MSM.

Methods

We conducted a web-based survey with Filipino cis-MSM (n=179) residing in the cities of Manila and Cebu, Philippines. Multivariable analysis procedures were performed to examine the factors associated with PrEP awareness.

Results

Our sample demonstrated high awareness (134/179, 74.9%) and interest (159/179, 88.8%) in taking PrEP. The adjusted model showed that greater odds of PrEP awareness were associated with having a college education or higher versus a high school education or lower (adjusted odds ratio [aOR] 7.30, 95% CI 1.01-52.47), earning between PHP 10,000 (US $198.6) and PHP 20,000 (US $397.2) versus <PHP 10,000 (US $198.60; aOR 9.32, 95% CI 1.41-6.22), having had a prior HIV test (aOR 6.06, 95% CI 1.20-13.55), having high HIV knowledge (aOR 3.50, 95% CI 1.11-10.98), and having friends who discussed PrEP (aOR 11.17, 95% CI 2.73-14.5).

Conclusions

Our findings demonstrate that Filipino cis-MSM are aware of and interested in taking PrEP, but there is currently an unmet need for such biomedical HIV prevention technologies among this population. Incorporating PrEP education into routine HIV screening and leveraging cis-MSM social networks may be useful in optimizing potential PrEP implementation in the Philippines.

Examining the Factors Affecting PrEP Implementation Within Community-Based HIV Testing Sites in Florida: A Mixed Methods Study Applying the Consolidated Framework for Implementation Research

HIV testing/counseling is a critical point during which non-clinical staff could intervene, discuss and/or refer clients for pre-exposure prophylaxis (PrEP). This analysis investigated the contextual factors affecting PrEP implementation within HIV testing sites. Two generalized linear mixed models were conducted to estimate PrEP implementation as a function of constructs from the Consolidated Framework for Implementation Research (CFIR). Qualitative interviews were analyzed thematically. Data integration occurred via joint analysis and triangulation. Constructs from the CFIR domain Characteristics of Individuals did not predict PrEP implementation when controlling for demographic characteristics; qualitative data signaled divergent findings in PrEP knowledge. Within the CFIR domains Inner and Outer Settings, relevant priority and available resources predicted PrEP implementation; qualitative data confirmed the importance of available resources and provided insight into the impact of cosmopolitanism and leadership. Addressing the contextual factors that affect PrEP implementation may help HIV testing staff to better implement PrEP programs.

PrEP Implementation Behaviors of Community-Based HIV Testing Staff: A Mixed-Methods Approach Using Latent Class Analysis

BACKGROUND

Pre-exposure Prophylaxis (PrEP) is an important option for HIV prevention, but the approach has reached a limited number of people at risk of HIV infection.

METHODS

A mixed-methods concurrent triangulation design was used to investigate unobserved subgroups of staff who provide community-based, publicly funded HIV testing in Florida (USA). PrEP implementation groups, or classes, were determined using latent class analysis. Generalized linear mixed models were used to estimate PrEP implementation as a function of staff characteristics. In-depth interviews based on the Consolidated Framework for Implementation Research were analyzed thematically.

RESULTS

Based on fit statistics and theoretical relevance, a 3-class latent class analysis was selected. Class 1 ("Universal") staff were highly likely to talk about PrEP with their clients, regardless of client eligibility. Class 2 ("Eligibility dependent") staff were most likely to discuss PrEP if they believed their client was eligible. Class 3 ("Limited") staff sometimes spoke to clients about PrEP, but not systematically. In multivariate analyses, only race and sexual orientation remained significant predictors of the PrEP implementation group. Staff who identified as a racial or sexual minority were less likely to be in the Limited group than their heterosexual or white counterparts. Age, gender, ever having taken PrEP, and HIV status did not impact the odds of being in a specific PrEP implementation group.

CONCLUSIONS

A subset of HIV testing staff differentially discuss PrEP based on perceived client eligibility; others inconsistently talk to clients about PrEP. Targeted training based on PrEP implementation groups may be beneficial.

Community Members' Pre-exposure Prophylaxis Awareness, Attitudes, and Trusted Sources for PrEP Information and Provision, Context Matters Survey, 2015-2016

Men and women of color have had low pre-exposure prophylaxis (PrEP) uptake. How one's preferred source of health information shapes attitudes toward PrEP is unclear. We conducted cross-sectional surveys to assess changes in PrEP awareness, knowledge, and attitudes, trusted sources for PrEP information, and associations between trusted source of information and PrEP knowledge and attitudes. Participants were recruited from six areas served by community health centers in Chicago, IL (two health centers); Jackson, MS; Newark, NJ; Philadelphia, PA; and Washington, D.C. during June-September 2015 (n = 160) and June-September 2016 (n = 200). Participants were Black (74%), heterosexual (81%), and largely unaware of PrEP (72%). Participants who trusted health experts and community organizations for PrEP information had lower percentages of agreeing with statements indicative of negative PrEP attitudes. Interventions that increase PrEP awareness as well as knowledge and favorable attitudes might help increase PrEP use in communities with high HIV prevalence.

Differentiated service delivery: a qualitative study of people living with HIV and accessing care in a tertiary facility in Ghana

BACKGROUND

In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) set out a treatment target with the objective to help end the AIDS epidemic by 2030. This was supported by the UNAIDS '90-90-90' target that by 2020, 90% of all people living with HIV (PLHIV) will know their HIV status; 90% of all those diagnosed with HIV will be on sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression. The concept of offering differentiated care services using community-based models is evidence-based and is suggested as a means to bring this target into reality. This study sought to explore the possible predictors and acceptability of Community-based health service provision among PLHIV accessing ART services at the Cape Coast Teaching Hospital (CCTH) in Ghana.

METHODS

A qualitative study, using 5 focus group discussions (FGD) of 8 participants per group, was conducted at the HIV Clinic in CCTH, in the Central Region of Ghana. Facilitators administered open-ended topic-guided questions. Answers were audio recorded, later transcribed and combined with notes taken during the discussions. Themes around Facility-based and Community-based service delivery and sub-themes developed from the codes, were verified and analyzed by the authors, with the group as the unit for analysis.

RESULTS

Participants expressed preference for facility-based service provision with the construct that, it ensures comprehensive health checks before provision of necessary medications. PLHIV in this study wished that the facility-based visits be more streamlined so "stable clients" could visit twice in a year to reduce the associated time and financial cost. The main barrier to community-based service delivery was concerns about stigmatization and abandonment in the community upon inadvertent disclosure of status.

CONCLUSIONS

Although existing evidence suggests that facility-based care was relatively more expensive and time consuming, PLHIV preferred facility-based individualized differentiated model to a community-based model. The fear of stigma and discrimination was very strong and is the main barrier to community-based model among PLHIV in this study and this needs to be explored further and managed.

Post-exposure Prophylaxis Awareness, Knowledge, Access and Use Among Three Populations in New York City, 2016-17

Post-exposure prophylaxis (PEP) is a cost-effective, but underused HIV prevention strategy. PEP awareness, knowledge, access, and usage was assessed among young men of color who have sex with men (YMSMOC; n = 177), transgender women (TW; n = 182), and cisgender women of color (CWOC; n = 170) in New York City. 59% were aware of PEP: 80% among YMSMOC, 63% among TW and 34% among CWOC (p < 0.001). 13% had ever used PEP. PEP awareness was higher among YMSMOC with a recent HIV test and lower among those with ≥ 4 partners. PEP awareness was lower among TW who anticipated stigma and reported barriers to taking PEP, and higher among TW who exchanged sex for resources. Among CWOC, more barriers to taking PEP reduced the odds of PEP awareness. PEP education and outreach needs to be deliberate about population-specific campaigns, with a need to focus on reducing PEP stigma and other barriers which impede PEP access.

PrEP implementation by local health departments in US cities and counties: Findings from a 2015 assessment of local health departments

Objective

The United States Public Health Service released clinical practice guidelines for daily oral preexposure prophylaxis (PrEP) in May 2014. Local health departments (LHDs) are expected to play a critical role in PrEP implementation. We surveyed LHDs to assess awareness of and interest in supporting PrEP implementation, what roles they were taking, or believed they should take, in supporting PrEP, and what resources would be required to do so.

Methods

LHDs were surveyed in 2015 to assess their engagement in PrEP implementation (n = 500). The study employed a cross-sectional survey design with a randomly selected stratified sample.

Results

Among responding LHDs (n = 284), 109 (29%, weighted proportion) reported engagement in PrEP implementation. LHDs serving large jurisdictions (population 500,000+) and located in the West were more likely to be engaged in PrEP implementation. Making referrals for PrEP (74%) and conducting education and outreach to community members (51%) were the activities most frequently reported by LHDs engaged in PrEP implementation; 45% anticipated expanding their level of engagement. Among LHDs not engaged in PrEP implementation, 13% expected to become engaged over the next four years, 46% were undecided, and 41% reported it was unlikely. Information about PrEP for health care providers and information about PrEP for health department staff were the most frequently reported resource needs for LHDs engaged and not engaged in PrEP implementation, respectively.

Conclusions

PrEP implementation by LHDs was limited in 2015, three years after Food and Drug Administration approval and one year after the U.S. Public Health Service issued clinical practice guidelines. PrEP is a recently available intervention that is requiring LHDs to adjust existing HIV prevention efforts and service delivery models. Additional resources and implementation research is needed to effectively support PrEP scale-up by LHDs. Efforts must also be undertaken to increase PrEP awareness, knowledge, and implementation capacity among LHDs.

Pre-exposure prophylaxis for MSM and transgender persons in early adopting countries

: Pre-exposure prophylaxis (PrEP) is a potent and underutilized HIV prevention tool. In this paper we review the state of knowledge regarding PrEP implementation for men who have sex with men and transgender persons in early adopting countries. We focus on implementation of PrEP in demonstration projects and clinical care, and describe the status of PrEP availability and uptake. We report on approaches to identifying appropriate PrEP candidates in real-world settings and on best practices for clinical monitoring. This includes the exclusion of undiagnosed HIV infection prior to PrEP initiation and longitudinal measurement of renal function, in light of safety data. Since adherence is the primary factor moderating the effectiveness of PrEP, we discuss effective adherence support interventions. Additionally, we review the evidence for risk compensation with PrEP use and opportunities to provide PrEP as part of comprehensive and inclusive preventive health programs. We summarize cost-effectiveness studies, including their variable conclusions because of differing underlying assumptions, and discuss the importance of budgetary impact for public health programs and health care insurers. Further, we emphasize a need for greater engagement of health care providers in PrEP to increase access. We conclude with recommendations for ways to improve future efforts at implementing PrEP.

Promoting Pre-exposure Prophylaxis to Prevent HIV Infections Among Sexual and Gender Minority Hispanics/Latinxs

Sexual and gender minority Hispanics/Latinxs (henceforth: Latinxs) continue to be disproportionately impacted by HIV/AIDS in the U.S. Pre-exposure prophylaxis (PrEP) is a biomedical prevention approach which holds significant promise for at risk and vulnerable populations. We discuss barriers and facilitators to uptake of PrEP among sexual and gender minority Latinxs living in the U.S. through an ecosocial lens that takes into account structural, community, and individual contexts. The impact of immigration status on PrEP uptake emerges as a major and recurrent theme that must be understood and addressed by HIV prevention programs aiming to promote an inclusive strategy for sexual and gender minority Latinxs living in the U.S.