The Acceptability of Pre-Exposure Prophylaxis: Beliefs of Health-Care Professionals Working in Sexually Transmitted Infections Clinics and HIV Treatment Centers

Introduction and integration of PrEP and sexual and reproductive health services for young people: Health provider perspectives from South Africa

South Africa has one of the largest HIV epidemics in the world, with particularly high prevalence among adolescent girls and young women (AGYW). Oral PrEP was introduced in the public sector in 2016 in a phased manner. Given the important role played by health providers, research was undertaken to understand their experiences of and attitudes towards introduction of PrEP as a new HIV prevention method, and its integration within broader sexual and reproductive health (SRH) services for youth. A survey was undertaken with 48 purposively sampled health providers working in primary health care facilities and mobile clinics in three provinces in South Africa. Qualitative analysis was performed on free-text responses to open-ended questions in the survey, using an inductive approach to code the data in NVivo v.12 software. Health providers expressed concerns about adding a new service to an already overburdened health system, and worried that young people seeking PrEP would divert staff from other critical services. While most recognised the benefits and opportunities afforded by HIV and SRH service integration, providers highlighted the extra time and resources such integration would require. Many were anxious that PrEP would encourage disinhibition and increase unprotected sex among AGYW, and held judgemental attitudes about young people, seen as largely incapable of taking responsibility for their health. Findings underscore the importance of consulting health providers about implementation design and providing channels for them to express their misgivings and concerns, and training needs to be designed to address provider attitudes and values. Opportunities need to be sought to strengthen the provision of adolescent and youth friendly services-including adolescent-health provider dialogues. Insights from this study can assist in guiding the introduction of new HIV prevention methods into the future.

Determinants of PrEP Uptake, Intention and Awareness in the Netherlands: A Socio-Spatial Analysis

PrEP uptake in the Netherlands is growing but remains at suboptimal levels. Hence, the analysis of hurdles is paramount. Given the initial focus of PrEP provision among men-who-have-sex-with-men (MSM) via a demonstration project that was launched in June 2015, AmPrEP in Amsterdam, and pharmacies in the main urban areas (so called "Randstad", entailing Amsterdam, Utrecht, Leiden, The Hague and Rotterdam), investigating regional differences is necessary. This study seeks to unravel regional differences jointly with the psycho-social determinants of PrEP uptake. This cross-sectional study included 3232 HIV-negative MSM recruited via the Dutch subsample of the European-MSM-Internet-Survey in late 2017 (EMIS-2017), which aimed to inform interventions for MSM who are highly affected by infections with HIV and other sexually transmitted infections. Prevalence and the standardised prevalence ratio (SPR) of PrEP awareness, intention and uptake were measured on a regional level (Randstad vs. the rest of the country). Multi-level logistic modelling was conducted to identify the association of PrEP uptake with PrEP awareness and intention, socio-demographic, psycho-social determinants and random effects from regional differences. MSM from the Randstad used more PrEP (SPR = 1.4 vs. 0.7) compared to the rest of the country, but there were minor differences for awareness and intention. The regional distinction was estimated to explain 4.6% of the PrEP use variance. We observed a greater influence from PrEP intention (aOR = 4.5, 95% CI 2.0-10.1), while there was limited influence from the awareness of PrEP (aOR = 0.4, 95% CI 0.04-4.4). Lower education (aOR = 0.4, 95% CI 0.2-0.9) was negatively associated with PrEP uptake; however, no significant difference was found between middle (aOR = 1.2, 95% CI 0.7-2.0) and high education. We showed that regional differences-MSM in non-urban regions-and other psycho-social determinants account for lower PrEP uptake. Based on these findings, more fine-tuned PrEP access with a focus on non-urban regions can be implemented, and tailored campaigns increasing intention/use can be conducted among target populations.

Applying implementation science frameworks to identify factors that influence the intention of healthcare providers to offer PrEP care and advocate for PrEP in HIV clinics in Colombia: a cross-sectional study

Background

Few studies have used implementation science frameworks to identify determinants of PrEP prescription by healthcare providers. In this work, we developed and psychometrically examined a questionnaire using the theoretical domains framework (TDF) and the consolidated framework for implementation research (CFIR). We used this questionnaire to investigate what factors influence the intention of healthcare providers to offer PrEP care and advocate for PrEP.

Methods

We conducted a cross-sectional study in 16 HIV healthcare organizations in Colombia. A 98-item questionnaire was administered online to 129 healthcare professionals. One hundred had complete data for this analysis. We used exploratory factor analysis to assess the psychometric properties of both frameworks, and multinomial regression analysis to evaluate the associations of the frameworks’ domains with two outcomes: (1) intention to offer PrEP care and (2) intention to advocate for PrEP impmentation.

Results

We found support for nine indices with good internal consistency, reflecting PrEP characteristics, attitudes towards population needs, concerns about the use of PrEP, concerns about the role of the healthcare systems, knowledge, beliefs about capabilities, professional role, social influence, and beliefs about consequences. Notably, only 57% of the participants were likely to have a plan to care for people in PrEP and 66.7% were likely to advocate for PrEP. The perception of the need for PrEP in populations, the value of PrEP as a practice, the influence of colleagues, and seeing PrEP care as a priority was related to being less likely to be unwilling to provide or advocate for PrEP care.

Conclusion

Our findings suggested the importance of multilevel strategies to increase the provision of PrEP care by healthcare providers including adquisition of new skills, training of PrEP champions, and strength the capacity of the health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00278-2.

A cross-sectional survey of general practitioner knowledge, attitudes, and clinical experience of HIV PrEP

Aim

Norway’s health scheme provides no-cost HIV pre-exposure prophylaxis (PrEP) when prescribed by a specialist, typically preceded by a general practitioner’s (GP) referral. The GP perspective with regard to PrEP implementation in Norway has yet to be captured.

Subject and methods

We explored PrEP knowledge, attitudes, and clinical experience of GPs in the Norwegian capital of Oslo, where HIV incidence and PrEP demand are highest. An anonymous survey was designed and distributed between November 2019 and February 2020. Univariate and multivariate logistic regression analyses were performed to identify determinants of GPs’ previous clinical PrEP experience (PrEP adoption).

Results

One hundred and seventeen GPs responded to the survey. GP PrEP adopters were more likely to: identify as men (aOR 2.1; 95% CI: 1.0–4.5); identify as lesbian, gay, or bisexual (LGB) (aOR 4.4; 95% CI: 1.4–14.5); have ≥ 10 LGB identifying patients on their list (aOR 4.4; 95% CI:1.8–10.4); and self-report higher levels of PrEP knowledge (aOR 2.4; 95% CI: 1.3–4.4).

Conclusion

Our findings suggest that GP PrEP knowledge is crucial to patient PrEP access. Educational interventions ought to be considered to enhance GP PrEP adoption capacities, such as easy-to-access PrEP guidelines and peer-based training opportunities in both online and in-person formats.

Health Care Providers as Agents of Change: Integrating PrEP With Other Sexual and Reproductive Health Services for Adolescent Girls and Young Women

Background: Successful integration of pre-exposure prophylaxis (PrEP) with existing reproductive health services will require iterative learning and adaptation. The interaction between the problem-solving required to implement new interventions and health worker motivation has been well-described in the public health literature. This study describes structural and motivational challenges faced by health care providers delivering PrEP to adolescent girls and young women (AGYW) alongside other SRH services, and the strategies used to overcome them. Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with HCWs from two demonstration projects delivering PrEP to AGYW alongside other SRH services. The Prevention Options for the Women Evaluation Research (POWER) is an open label PrEP study with a focus on learning about PrEP delivery in Kenyan and South African family planning, youth mobile services, and public clinics at six facilities. PrIYA focused on PrEP delivery to AGYW via maternal and child health (MCH) and family planning (FP) clinics in Kenya across 37 facilities. IDIs and FGDs were transcribed verbatim and analyzed using a combination of inductive and deductive methods. Results: We conducted IDIs with 36 participants and 8 FGDs with 50 participants. HCW described a dynamic process of operationalizing PrEP delivery to better respond to patient needs, including modifying patient flow, pill packaging, and counseling. HCWs believed the biggest challenge to sustained integration and scaling of PrEP for AGYW would be lack of health care worker motivation, primarily due to a misalignment of personal and professional values and expectations. HCWs frequently described concerns of PrEP provision being seen as condoning or promoting unprotected sex among young unmarried, sexually active women. Persuasive techniques used to overcome these reservations included emphasizing the social realities of HIV risk, health care worker professional identities, and vocational commitments to keeping young women healthy. Conclusion: Sustained scale-up of PrEP will require HCWs to value and prioritize its incorporation into daily practice. As with the provision of other SRH services, HCWs may have moral reservations about providing PrEP to AGYW. Strategies that strengthen alignment of HCW personal values with professional goals will be important for strengthening motivation to overcome delivery challenges.

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

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.

"Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.

Australian interdisciplinary healthcare providers' perspectives on the effects of broader pre-exposure prophylaxis (PrEP) access on uptake and service delivery: a qualitative study

Background The addition of pre-exposure prophylaxis (PrEP) for HIV prevention to the Australian Government-subsidised Pharmaceutical Benefits Scheme (PBS) enables any doctor or nurse practitioner to prescribe it and has increased accessibility options. However, understanding of Australian healthcare providers' (HCP) knowledge and preparedness to prescribe PrEP remains limited.

METHODS

Semistructured interviews, conducted before PBS listing (October 2016-April 2017), explored PrEP knowledge and prescription experiences of 51 multidisciplinary HCPs involved with the Queensland Pre-Exposure Prophylaxis Demonstration study.

RESULTS

Thematic analysis revealed that participants viewed PrEP as a necessary HIV prevention option, but there was concern about confusing prevention messages and potential risk compensation. Clinical capacity, stigma, cultural norms, rural access and PrEP-associated costs were identified as barriers to access and uptake. Some of these barriers may be addressed by the PBS listing; nonetheless, there was strong specialist concern about the preparedness of general practitioners without sexual health experience to prescribe PrEP. Participants identified a need to educate all HCPs, implement multidisciplinary supply models and provide timely access to PrEP for vulnerable populations and those ineligible for Medicare (Australia's universal healthcare insurance system).

CONCLUSIONS

Although PrEP listing on the PBS addressed structural barriers to access, this study highlights the role of nurses and other interdisciplinary healthcare workers in the provision of PrEP in addressing the sociocultural barriers that still affect the access of certain populations to HIV prevention measures. These findings will inform further professional training as PrEP is more widely accessed and requested outside specialist sexual health services. Future work is needed to ensure that the primary healthcare workforce is prepared to provide competent and safe access to PrEP across diverse locations and population groups.

Influence of Stigma on Pre-Exposure Prophylaxis (PrEP) Care Continuum Among Men and Transwomen Who Have Sex with Men (MTWSM) in the United States

Despite evidence from recent trials of the efficacy of pre-exposure prophylaxis (PrEP) in reducing the risk of contracting HIV, PrEP uptake has been slow due to a range of social, structural, and behavioral factors. In this systematic review, we examined the influence of stigma on the PrEP care continuum among men and transwomen who have sex with men (MTWSM). We conducted a literature search in the PubMed electronic database (2012-2018) that focused on the PrEP care continuum among high-risk MTWSM. We explored studies that specifically looked at the influence of stigma on the PrEP cascade among these socially disadvantaged populations. Our search yielded 161 articles, of which nine were ultimately included in our systematic review. The results showed a significant association between stigma and unwillingness to seek or use PrEP suggesting that stigma may negatively affect willingness and uptake of PrEP among these high-risk groups.

Physicians' preparedness for pre-exposure prophylaxis: results of an online survey in Belgium

Background Physicians have a crucial role in the implementation and scale up of pre-exposure prophylaxis (PrEP). The objective of this study is to examine Belgian physicians' PrEP knowledge, concerns, acceptance and their willingness to prescribe PrEP.

METHODS

A cross-sectional online survey was conducted between March and June 2016. Dissemination targeted Belgian primary care physicians (PCPs) and HIV specialists. Sociodemographic characteristics, experience with HIV and PrEP, self-assessed PrEP knowledge, concerns about PrEP, and PrEP acceptance were stratified according to professional background. Associations with willingness to prescribe PrEP were examined using univariable and multivariable binary logistic regression analyses.

RESULTS

In total, 333 completed surveys were included in the analysis. Sixty-two physicians (18.6%) scored their knowledge of PrEP to be good, 263 (79.0%) had an accepting attitude towards PrEP and 198 (59.5%) were willing to prescribe PrEP if approved in Belgium. HIV specialists consistently reported having better knowledge of PrEP, less concerns and a more accepting attitude towards PrEP than PCPs. In multivariable logistic regression analysis, higher PrEP knowledge (OR 2.4; 95%CI: 1.0-5.7) and higher PrEP acceptance (OR: 3.8; 95%CI: 2.1-6.8) remained significantly associated with the willingness to prescribe PrEP.

CONCLUSIONS

HIV specialists are better prepared to provide PrEP than PCPs in Belgium. Interventions to improve PrEP knowledge and acceptance among all providers are needed. The role of PCPs could be very important in optimising the rollout of PrEP, but additional training and guidelines will be needed.

Congruence between Hypothetical Willingness to Use Pre-Exposure Prophylaxis (PrEP) and Eligibility: An Online Survey among Belgian Men Having Sex with Men

Men who have sex with men (MSM) are at high risk for acquiring HIV in Belgium. This study explores MSMs’ hypothetical willingness to use pre-exposure prophylaxis (PrEP), assesses it against formal PrEP eligibility criteria, and identifies factors associated with incongruence between eligibility and willingness. We used data from an online survey of n = 1444 self-reported HIV-negative MSM. Participants were recruited through social media of MSM organizations and dating apps. Univariate analysis described PrEP willingness and eligibility; bivariate analyses examined how specific co-variates (socio-demographic, knowledge-related, and attitudinal and behavioral factors) were associated with eligibility and willingness. About 44% were eligible for PrEP and about 70% were willing to use it. Those who were eligible were significantly more likely be willing to take PrEP (p < 0.001). Two incongruent groups emerged: 16% of eligible participants were unwilling and 58% of ineligible participants were willing to use PrEP. Factors associated with this incongruence were sexual risk behavior, HIV risk perception, partner status, PrEP knowledge, and attitudinal factors. Because the two groups differ in terms of profiles, it is important to tailor HIV prevention and sexual health promotion to their needs. Among those at risk but not willing to take PrEP, misconceptions about PrEP, and adequate risk perception should be addressed.

Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men

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.