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Vanhamel J, Reyniers T, Vuylsteke B, Callens S, Nöstlinger C, Huis in ’t Veld D, Kenyon C, Van Praet J, Libois A, Vincent A, Demeester R, Henrard S, Messiaen P, Allard SD, Rotsaert A, Kielmann K. Understanding adaptive responses in PrEP service delivery in Belgian HIV clinics: a multiple case study using an implementation science framework. J Int AIDS Soc 2024; 27 Suppl 1:e26260. [PMID: 38965986 PMCID: PMC11224588 DOI: 10.1002/jia2.26260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 04/19/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION In Belgium, oral HIV pre-exposure prophylaxis (PrEP) is primarily provided in specialized clinical settings. Optimal implementation of PrEP services can help to substantially reduce HIV transmission. However, insights into implementation processes, and their complex interactions with local context, are limited. This study examined factors that influence providers' adaptive responses in the implementation of PrEP services in Belgian HIV clinics. METHODS We conducted a qualitative multiple case study on PrEP care implementation in eight HIV clinics. Thirty-six semi-structured interviews were conducted between January 2021 and May 2022 with a purposive sample of PrEP care providers (e.g. physicians, nurses, psychologists), supplemented by 50 hours of observations of healthcare settings and clinical interactions. Field notes from observations and verbatim interview transcripts were thematically analysed guided by a refined iteration of extended Normalisation Process Theory. RESULTS Implementing PrEP care in a centralized service delivery system required considerable adaptive capacity of providers to balance the increasing workload with an adequate response to PrEP users' individual care needs. As a result, clinic structures were re-organized to allow for more efficient PrEP care processes, compatible with other clinic-level priorities. Providers adapted clinical and policy norms on PrEP care (e.g. related to PrEP prescribing practices and which providers can deliver PrEP services), to flexibly tailor care to individual clients' situations. Interprofessional relationships were reconfigured in line with organizational and clinical adaptations; these included task-shifting from physicians to nurses, leading them to become increasingly trained and specialized in PrEP care. As nurse involvement grew, they adopted a crucial role in responding to PrEP users' non-medical needs (e.g. providing psychosocial support). Moreover, clinicians' growing collaboration with sexologists and psychologists, and interactions with PrEP users' family physician, became crucial in addressing complex psychosocial needs of PrEP clients, while also alleviating the burden of care on busy HIV clinics. CONCLUSIONS Our study in Belgian HIV clinics reveals that the implementation of PrEP care presents a complex-multifaceted-undertaking that requires substantial adaptive work to ensure seamless integration within existing health services. To optimize integration in different settings, policies and guidelines governing PrEP care implementation should allow for sufficient flexibility and tailoring according to respective local health systems.
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Affiliation(s)
- Jef Vanhamel
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Thijs Reyniers
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Bea Vuylsteke
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Steven Callens
- Department of General Internal Medicine and Infectious DiseasesGhent University HospitalGhentBelgium
| | | | - Diana Huis in ’t Veld
- Department of General Internal Medicine and Infectious DiseasesGhent University HospitalGhentBelgium
| | - Chris Kenyon
- Department of Clinical SciencesInstitute of Tropical MedicineAntwerpBelgium
| | - Jens Van Praet
- Department of Nephrology and Infectious DiseasesAZ Sint‐Jan Brugge‐Oostende AVBruggeBelgium
| | - Agnes Libois
- Department of Infectious DiseasesSaint Pierre University HospitalUniversité Libre de BruxellesBrusselsBelgium
| | - Anne Vincent
- Department of Internal Medicine and Infectious DiseasesCliniques Universitaires Saint‐LucBrusselsBelgium
| | - Rémy Demeester
- HIV Reference CentreUniversity Hospital of CharleroiCharleroiBelgium
| | - Sophie Henrard
- HIV Reference Centre and Internal MedicineErasme HospitalUniversité Libre de BruxellesBrusselsBelgium
| | - Peter Messiaen
- Department of Infectious Diseases and ImmunityJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesLCRCHasselt UniversityHasseltBelgium
| | - Sabine D. Allard
- Department of Internal Medicine and Infectious DiseasesUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Anke Rotsaert
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Karina Kielmann
- Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
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Erenrich RK, Braun RA, Torres-Mendoza DM, Stevenson OL, Doan THP, Klausner JD. Effectiveness of PrEPTECH: Findings From a 180-Day Randomized Controlled Trial of a Pre-Exposure Prophylaxis Telehealth Intervention. J Acquir Immune Defic Syndr 2024; 95:463-469. [PMID: 38133600 PMCID: PMC10927298 DOI: 10.1097/qai.0000000000003375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Telehealth approaches are increasingly being used to provide access to pre-exposure prophylaxis (PrEP), an effective but underused HIV prevention modality. This randomized controlled trial of PrEPTECH, a telehealth intervention for the provision of HIV PrEP, seeks to assess its effects on PrEP access. METHODS Young men who have sex with men and transgender women in Florida and California with an indication for PrEP were randomly assigned in a 1:1 allocation to receive access to PrEPTECH or a control condition, access to an online listing of PrEP resources in their communities. This intent-to-treat analysis used logistic and linear regression to compare self-reported PrEP initiation, use, and coverage between control and intervention arm participants at 90 days and 180 days of follow-up. RESULTS A total of 229 participants with a mean age of 23.7 years, 77.3% people of color enrolled in PrEPTECH. At 90 days, postbaseline initiation of PrEP was significantly higher among those in the PrEPTECH arm than among controls (odds ratio [OR]: 6.63, 95% confidence interval [CI]: 2.54 to 17.35), and this held true by 180 days post baseline. The count of sex acts for which participants were not protected by PrEP, PrEP adherence, and recent PrEP use at 180 days post baseline were not significantly different between the study arms. CONCLUSIONS Receiving access to a telehealth platform for PrEP access increased PrEP initiation in this cohort of young, predominantly non-White sexual and gender minorities. PrEP telehealth may be a worthy avenue for providing access to PrEP for these populations, but additional strategies may be needed to promote adherence and persistence of PrEP use.
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Affiliation(s)
- Rebecca K. Erenrich
- ETR Associates, Scotts Valley, CA
- Currently, Milken Institute School of Public Health, The George Washington University, Washington, DC
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Rutstein SE, Muessig KE. Leveling Up PrEP: Implementation Strategies at System and Structural Levels to Expand PrEP Use in the United States. Curr HIV/AIDS Rep 2024; 21:52-61. [PMID: 38517670 DOI: 10.1007/s11904-024-00697-x] [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: 02/24/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW Despite highly effective biomedical HIV pre-exposure prophylaxis (PrEP) options, suboptimal PrEP uptake impedes progress towards ending the epidemic in the United States of America (USA). Implementation science bridges what we know works in controlled clinical trial settings to the context and environment in which efficacious tools are intended to be deployed. In this review, we focus on strategies that target PrEP use barriers at the system or structural level, exploring the implications and opportunities in the context of the fragmented USA healthcare system. RECENT FINDINGS Task shifting could increase PrEP prescribers, but effectiveness evidence is scarce in the USA, and generally focused in urban settings. Integration of PrEP within existing healthcare infrastructure concentrates related resources, but demonstration projects rarely present the resource implications of redirecting staff. Changing the site of service via expanded telehealth could improve access to more rural populations, though internet connectivity, technology access, and challenges associated with determining biomedical eligibility remain logistical barriers for some of the highest burden communities in the USA. Finally, a tailored care navigation and coordination approach has emerged as a highly effective component of PrEP service provision, attempting to directly modify the system-level determinants of PrEP use experienced by the individual. We highlight recent advances and evidence surrounding task shifting, integration, service delivery, and tailoring. With the exception of tailored care navigation, evidence is mixed, and the downstream impact and sustainability of task shifting and care integration require further attention. To maximize PrEP outcomes, research will need to continue to examine the interplay between individuals, clinics, and the healthcare system and associated policies within which they operate.
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Affiliation(s)
- Sarah E Rutstein
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, 130 Mason Farm Road, Chapel Hill, NC, 27599, USA.
| | - Kathryn E Muessig
- Institute On Digital Health and Innovation, College of Nursing, Florida State University, Tallahassee, USA
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Zinck MJ, Minichiello SN, Fick CA, Sawry S, Fonner VA. Virtual case management: a differentiated approach to HIV prevention, treatment, and care. AIDS 2024; 38:145-151. [PMID: 37861692 PMCID: PMC10734782 DOI: 10.1097/qad.0000000000003762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/15/2023] [Accepted: 10/13/2023] [Indexed: 10/21/2023]
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Lee JJ, Li Verdugo J, Xiao AY, Vo K. Digital Interventions to Enhance PrEP Uptake and Adherence Through Stigma Reduction. Curr HIV/AIDS Rep 2023; 20:458-469. [PMID: 38057685 DOI: 10.1007/s11904-023-00685-7] [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: 11/21/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF REVIEW Although pre-exposure prophylaxis (PrEP) is effective for reducing risk of HIV transmission, stigma persists as a barrier to HIV prevention. Digital technologies present opportunities to access hard-to-reach populations and increase the efficiency of established interventions. This review examines current digital interventions addressing stigma to improve PrEP-related outcomes. RECENT FINDINGS Digital technologies are increasingly used for HIV prevention and include a wide range of formats. Recent interventions focused on stigma and PrEP tend to engage mobile phone-related technology and focus on younger populations with particular attention to men who have sex with men and transgender women. Digital interventions that address stigma are promising for improving PrEP-related outcomes. No single technology currently demonstrates consistent superiority. Limited access to PrEP and heightened stigma in under-resourced countries present challenges for interventions supporting diverse communities. Further research should examine how digital interventions can reduce stigma beyond the individual level to enhance PrEP use and explore opportunities to improve and integrate approaches to stigma measurement.
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Affiliation(s)
- Jane J Lee
- School of Social Work, University of Washington, 4101 15th Avenue NE, Seattle, WA, 98105, USA.
| | - Juliann Li Verdugo
- School of Social Work, University of Washington, 4101 15th Avenue NE, Seattle, WA, 98105, USA
| | | | - Katie Vo
- School of Public Health, University of Washington, Seattle, WA, USA
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Groot Bruinderink ML, Boyd A, Coyer L, Boers S, Blitz L, Brand JM, Götz HM, Stip M, Woudstra J, Yap K, Vermey K, Matser A, Feddes AR, Jongen VW, Prins M, Hoornenborg E, van Harreveld F, Schim van der Loeff MF, Davidovich U. Online-Mediated HIV Pre-exposure Prophylaxis Care and Reduced Monitoring Frequency for Men Who Have Sex With Men: Protocol for a Randomized Controlled Noninferiority Trial (EZI-PrEP Study). JMIR Res Protoc 2023; 12:e51023. [PMID: 37938875 PMCID: PMC10666015 DOI: 10.2196/51023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Daily and event-driven HIV pre-exposure prophylaxis (PrEP) with oral tenofovir-emtricitabine is highly effective to prevent HIV in men who have sex with men (MSM). PrEP care generally consists of in-clinic monitoring every 3 months that includes PrEP dispensing, counseling, and screening for HIV and sexually transmitted infections (STIs). However, the optimal frequency for monitoring remains undetermined. Attending a clinic every 3 months for monitoring may be a barrier for PrEP. Online-mediated PrEP care and reduced frequency of monitoring may lower this barrier. OBJECTIVE The primary objective of this study is to establish the noninferiority of online PrEP care (vs in-clinic care) and monitoring every 6 months (vs every 3 months). The secondary objectives are to (1) examine differences between PrEP care modalities regarding incidences of STIs, HIV infection, and hepatitis C virus infection; retention in PrEP care; intracellular tenofovir-diphosphate concentration; and satisfaction, usability, and acceptability of PrEP care modalities; and (2) evaluate associations of these study outcomes with sociodemographic, behavioral, and psychological characteristics. METHODS This study is a 2×2 factorial, 4-arm, open-label, multi-center, randomized, controlled, noninferiority trial. The 4 arms are (1) in-clinic monitoring every 3 months, (2) in-clinic monitoring every 6 months, (3) online monitoring every 3 months, and (4) online monitoring every 6 months. The primary outcome is a condomless anal sex act with a casual partner not covered or insufficiently covered by PrEP (ie, "unprotected act") as a proxy for HIV infection risk. Eligible individuals are MSM, and transgender and gender diverse people aged ≥18 years who are eligible for PrEP care at 1 of 4 participating sexual health centers in the Netherlands. The required sample size is 442 participants, and the planned observation time is 24 months. All study participants will receive access to a smartphone app, which contains a diary. Participants are requested to complete the diary on a daily basis during the first 18 months of participation. Participants will complete questionnaires at baseline and 6, 12, 18, and 24 months. Dried blood spots will be collected at 6 and 12 months for assessment of intracellular tenofovir-diphosphate concentration. Incidence rates of unprotected acts will be compared between the online and in-clinic arms, and between the 6-month and 3-month arms. Noninferiority will be concluded if the upper limit of the 2-sided 97.5% CI of the incidence rate ratio is <1.8. RESULTS The results of the main analysis are expected in 2024. CONCLUSIONS This trial will demonstrate whether online PrEP care and monitoring every 6 months is noninferior to standard PrEP care in terms of PrEP adherence. If noninferiority is established, these modalities may lower barriers for initiating and continuing PrEP use and potentially reduce the systemic burden for PrEP providers. TRIAL REGISTRATION ClinicalTrials.gov NCT05093036; https://tinyurl.com/28b8ndvj. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51023.
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Affiliation(s)
- Marije L Groot Bruinderink
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- Department of Psychology, University of Amsterdam, Amsterdam, Netherlands
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- HIV Monitoring Foundation, Amsterdan, Netherlands
| | - Liza Coyer
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
| | - Sophie Boers
- Department of Sexual Health, Public Health Service of Gelderland-Zuid, Nijmegen, Netherlands
| | - Laura Blitz
- Department of Sexual Health, Public Health Service of Haaglanden, The Hague, Netherlands
| | - Jean-Marie Brand
- Department of Sexual Health, Public Health Service of Haaglanden, The Hague, Netherlands
| | - Hannelore M Götz
- Department of Infectious Diseases, Public Health Service of Rotterdam-Rijnmond, Rotterdam, Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Martijn Stip
- Department of Infectious Diseases, Public Health Service of Rotterdam-Rijnmond, Rotterdam, Netherlands
| | - Joey Woudstra
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
| | - Kenneth Yap
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
| | | | - Amy Matser
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- Amsterdam Institute for Infection & Immunity, Department of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Allard R Feddes
- Department of Psychology, University of Amsterdam, Amsterdam, Netherlands
| | - Vita W Jongen
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- HIV Monitoring Foundation, Amsterdan, Netherlands
| | - Maria Prins
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- Amsterdam Institute for Infection & Immunity, Department of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Elske Hoornenborg
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- Amsterdam Institute for Infection & Immunity, Department of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Frenk van Harreveld
- Department of Psychology, University of Amsterdam, Amsterdam, Netherlands
- National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Maarten F Schim van der Loeff
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- Amsterdam Institute for Infection & Immunity, Department of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Udi Davidovich
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- Department of Psychology, University of Amsterdam, Amsterdam, Netherlands
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Braun RA, Erenrich RK, Coyle KK, Doan THP, Klausner JD. Effectiveness, Acceptability, and Feasibility of a Telehealth HIV Pre-Exposure Prophylaxis Care Intervention Among Young Cisgender Men and Transgender Women Who Have Sex With Men: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e47932. [PMID: 37713244 PMCID: PMC10541640 DOI: 10.2196/47932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Despite its promise for HIV prevention, the uptake of pre-exposure prophylaxis (PrEP) has been slow, and there have been substantial inequities in PrEP access. Young men who have sex with men and transgender women of color are most in need of PrEP and least likely to have that need fulfilled. PrEP telehealth care, which provides remote PrEP care via electronic communication, seems well suited to address several of the challenges of PrEP provision, including discomfort with stigmatizing and difficult-to-access health care systems, transportation challenges, and privacy concerns, and address disparities in PrEP access. Research suggests that PrEP telehealth care has promise and is a favored option for many prospective recipients of PrEP. However, despite growing attention to telehealth approaches as an avenue for increasing access to PrEP amidst the COVID-19 pandemic, there have been no published randomized controlled trials (RCTs) on PrEP telehealth care to date, making it difficult to draw strong conclusions about the advantages or disadvantages of telehealth compared with usual PrEP care. We developed PrEPTECH, a telehealth intervention that focuses specifically on alleviating issues of stigma, access, cost, and confidentiality for young people with risk factors for HIV infection who are seeking PrEP care. Leveraging data from the 2017 observational pilot study, we redesigned and enhanced PrEPTECH. OBJECTIVE This study aims to assess the effectiveness, acceptability, and feasibility of a telehealth HIV PrEP care intervention, PrEPTECH, in increasing PrEP uptake. METHODS This is the protocol for an RCT of young cisgender men and transgender women who have sex with men in 4 regions within the United States: the San Francisco Bay Area, California; Los Angeles County, California; Miami-Dade County, Florida; and Broward County, Florida. Participants in the intervention arm received access to a web-based telehealth program, PrEPTECH, which offers a fully web-based pathway to PrEP, whereas those in the control arm received access to a dynamic web page containing publicly available informational resources about PrEP. Follow-up data collection occurred at 3 and 6 months. An analysis will be conducted on outcomes, including PrEP initiation, persistence, adherence, coverage, and medication prescription, as well as PrEPTECH acceptability and feasibility. RESULTS The study was funded in 2019 and received institutional review board approval in 2020. The PrEPTECH intervention was developed over the next 1.5 years. Study recruitment was launched in February 2022 and completed in September 2022, with 229 participants recruited in total. Data collection was completed in April 2023. CONCLUSIONS The results of this RCT will offer valuable evidence regarding the effectiveness, acceptability, and feasibility of telehealth HIV PrEP care interventions among young cisgender men and transgender women who have sex with men. TRIAL REGISTRATION ClinicalTrials.gov NCT04902820; https://clinicaltrials.gov/ct2/show/NCT04902820. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/47932.
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Affiliation(s)
| | | | | | | | - Jeffrey D Klausner
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Rosen AO, Wickersham JA, Altice FL, Khati A, Azwa I, Tee V, Jeri-Wahrhaftig A, Luces JR, Ni Z, Kamarulzaman A, Saifi R, Shrestha R. Barriers and Facilitators to Pre-Exposure Prophylaxis by Men Who Have Sex with Men and Community Stakeholders in Malaysia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5669. [PMID: 37174187 PMCID: PMC10177799 DOI: 10.3390/ijerph20095669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/10/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Men who have sex with men (MSM) in Malaysia are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy; yet, uptake remains low among Malaysian MSM, who have a limited understanding of barriers to PrEP. METHODS We employed the nominal group technique (NGT), a structured mixed-methods strategy to understand the barriers and facilitators to PrEP use among Malaysian MSM, combined with a qualitative focus group. Six virtual focus group sessions, three among MSM (n = 20) and three among stakeholders (n = 16), were conducted using a video-conferencing platform. Rank-ordering of barriers from NGT was recorded, and thematic analysis was conducted for content. RESULTS Similar barriers were reported by MSM and community stakeholders, with aggregated costs associated with PrEP care (e.g., consultation with a clinician, medication, laboratory testing) being the greatest barrier, followed by limited knowledge and awareness of PrEP. Additionally, the lack of access to PrEP providers, the complex clinical protocol for PrEP initiation and follow-up, and social stigma undermined PrEP delivery. Qualitative discussions identified potential new strategies to overcome these barriers, including expanded outreach efforts to reach hard-to-reach MSM, a 'one-stop' delivery model for PrEP services, a patient-centered decision aid to guide PrEP uptake, and easy access to LGBT-friendly PrEP providers. CONCLUSION Current barriers may be overcome through governmental subsidy for PrEP and evidence-informed shared decision aids to support both MSM and PrEP providers.
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Affiliation(s)
- Aviana O. Rosen
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT 06269, USA
| | - Jeffrey A. Wickersham
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT 06510, USA
| | - Frederick L. Altice
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT 06510, USA
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Antoine Khati
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT 06510, USA
| | - Iskandar Azwa
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
- Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Vincent Tee
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Alma Jeri-Wahrhaftig
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT 06269, USA
| | - Jeffrey Ralph Luces
- Master of Health Research Ethics (MOHRE), Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Zhao Ni
- Yale School of Nursing, Yale University, Orange, CT 06477, USA
| | - Adeeba Kamarulzaman
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
- Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Rumana Saifi
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Roman Shrestha
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT 06269, USA
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT 06510, USA
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
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Saberi P, Mehtani NJ, Sayegh A, Camp CE, Chu C. Understanding HIV Pre-Exposure Prophylaxis Questions of U.S. Health Care Providers: Unique Perspectives from the PrEPline Clinical Teleconsultation Service. Telemed J E Health 2023; 29:376-383. [PMID: 35802493 PMCID: PMC10024264 DOI: 10.1089/tmj.2022.0145] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/18/2022] [Accepted: 05/31/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction: Fewer than a quarter of people considered to have factors associated with HIV acquisition are prescribed pre-exposure prophylaxis (PrEP) in the United States. Prior studies demonstrate disparities in provider comfort and knowledge regarding PrEP, suggesting a need for provider capacity building to support widespread PrEP availability. This study examined real-world PrEP clinical questions/cases from providers to a teleconsultation service to identify knowledge gaps and improve PrEP-related training materials and clinical guidelines. Methods: The National Clinician Consultation Center (NCCC) PrEPline provides educational teleconsultation services on clinical decision-making related to PrEP for U.S. health care providers. The NCCC PrEP consultation data collected between 2017 and 2020 were reviewed and systematically categorized by clinical topics, subtopics, and complexity levels (low, moderate, and high). Results: Within the study period, the PrEPline provided 1,754 teleconsultations. More than three quarters came from advanced practice nurses and physicians. The topics of questions commonly focused on medication-based HIV prevention strategies (22.7%), PrEP laboratory ordering/monitoring (17.4%), and side effects and contraindications (14.6%). The majority of teleconsultations (57.9%) involved sharing information that was directly available/addressed in the Centers for Disease Control and Prevention (CDC) 2017 PrEP Guidelines (i.e., low complexity). Discussion: The low frequency of consultations from nonphysician and non-nurse practitioner providers may suggest a need for increased training and collaborative opportunities for other types of providers. The high percentage of low-complexity inquiries may reveal a desire for capacity-building materials specifically designed for practicing providers (e.g., abridged versions of guidelines). This study may inform future research, best clinical practices, and aid in the development of training materials to increase providers' HIV prevention comfort and knowledge.
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Affiliation(s)
- Parya Saberi
- Department of Medicine and University of California, San Francisco, San Francisco, California, USA
| | - Nicky J. Mehtani
- Department of Medicine and University of California, San Francisco, San Francisco, California, USA
| | - Anthony Sayegh
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christina Elizabeth Camp
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Carolyn Chu
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA
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Characterizing the Impact of the COVID-19 Pandemic on HIV PrEP care: A Review and Synthesis of the Literature. AIDS Behav 2022; 27:2089-2102. [DOI: 10.1007/s10461-022-03941-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/03/2022]
Abstract
AbstractThe global COVID-19 pandemic and associated lockdown measures have caused disruptions to sexual health services and created additional barriers to the continuity of HIV pre-exposure prophylaxis (PrEP) among key populations. This review provides an examination of the influences of the pandemic on engagement in the PrEP care continuum. Using the PRISMA guideline, 46 studies were included in this review and the synthesis. Most of the studies were conducted in high-income settings through quantitative analysis. A majority of studies examining the changes in PrEP use suggested a decline or discontinuation in PrEP uptake during the pandemic. The most common reasons for stopping using PrEP were perceived barriers to PrEP-related care, having reduced sexual behaviors and fewer sexual partners, and reduced perceived risk of HIV infection. Limited studies documenting an increase in PrEP uptake were all in specific PrEP optimizing programs. During the pandemic, there is also an emerging trend of switching to on-demand PrEP from daily oral PrEP. Future studies should understand the mechanism of strategies that facilitated the improvements during the pandemic. PrEP implementation programs should consider alternative PrEP modalities and provide consistent and comprehensive knowledge about correct information.
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Abstract
PURPOSE OF REVIEW This review summarizes technology-based interventions for HIV in low- and middle-income countries (LMICs). We highlight potential benefits and challenges to using telehealth in LMICs and propose areas for future study. RECENT FINDINGS We identified several models for using telehealth to expand HIV health care access in LMICs, including telemedicine visits for pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) services, telementoring programs for providers, and virtual peer-support groups. Emerging data support the acceptability and feasibility of these strategies. However, further investigations are needed to determine whether these models are scalable and sustainable in the face of barriers related to cost, infrastructure, and regulatory approval. HIV telehealth interventions may be a valuable approach to addressing gaps along the HIV care cascade in LMICs. Future studies should focus on strategies for expanding existing programs to scale and for assessing long-term clinical outcomes.
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