HIV providers' perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study

HIV Preexposure Prophylaxis Among Adolescents in the US: A Review

IMPORTANCE

Many adolescents and young adults in the US are disproportionately affected by HIV. Several others who are uninfected are at risk and in need of effective preventive strategies. The uptake rate of preexposure prophylaxis (PrEP) for HIV prevention has remained low among US adolescents. This review assesses the current status of PrEP uptake among at-risk adolescents aged 13 to 19 years and recommendations for improving PrEP access, uptake, and future needed directions, including specific recommendations for health care professionals.

OBSERVATIONS

Of the 37 377 new HIV diagnoses made in 2018, 7734 diagnoses (21%) occurred in adolescents and young adults aged 12 to 24 years; of these, 1707 diagnoses (22%) occurred in adolescents aged 13 to 19 years. The greatest burden of HIV is found among young African American men who have sex with men, accounting for two-thirds of all HIV infections in adolescents and young adults. Preexposure prophylaxis awareness and engagement are lowest in adolescents with the greatest risk for HIV. Adolescent primary care clinicians and specialists do not routinely offer HIV testing as recommended by the Centers for Disease Control and Prevention or routinely assess sexual risk exposures of patients through sexual history taking. Clinicians' decision to prescribe PrEP for adolescents is often guided by their perceptions of the patient's HIV risk and their knowledge and acceptance of PrEP guidelines. State laws on consent, confidentiality, and the rights of the adolescent to independently access PrEP outside of parental influence differ across jurisdictions, often limiting access and uptake.

CONCLUSIONS AND RELEVANCE

Use of PrEP in adolescents at risk for HIV is an important component of HIV prevention. Optimizing uptake includes improving clinicians' knowledge about HIV risk and prevention strategies, enhancing sexual history taking and risk assessment through training and retraining, and improving PrEP knowledge and acceptance of prescribing among clinicians. Leveraging the ubiquity of social media, encouraging family support, and performing research aimed at finding lifestyle-congruent formulations can help mitigate HIV transmission in adolescents at greatest risk for HIV.

"You can't have a PrEP program without a PrEP Coordinator": Implementation of a PrEP panel management intervention

Lack of healthcare provider knowledge, capacity, and willingness to prescribe PrEP are barriers to PrEP delivery in clinical settings. We implemented the PrEP Optimization Intervention (PrEP-OI) combining a PrEP Coordinator with an online panel management tool to assist providers with PrEP uptake, persistence, and management in 12 San Francisco Department of Public Health Primary Care Clinics. Medical directors (N = 10) identified important factors to consider prior to implementation, including shortage of clinical space for coordinators, medical mistrust, language barriers, and limited lab hours, along with the need for education of providers and staff and patient outreach. Among 110 providers who completed a baseline survey, the majority had reservations in asking about sexual practices and having conversations about PrEP. Providers reported PrEP-OI increased their efficiency and capacity to manage PrEP patients, and served as a gateway to additional services. These results highlight the promise of a provider-based intervention to improve the PrEP continuum and maximize the impact of PrEP.

Knowledge, Attitudes, and Intentions towards HIV Pre-Exposure Prophylaxis among Nursing Students in Spain

Human immunodeficiency virus (HIV) infection is one of the main causes of morbidity and mortality worldwide. Among the preventive approaches proposed to control this disease is pre-exposure prophylaxis (PrEP), whose effectiveness depends on the medication adherence. The aim of the present study was to determine the knowledge and attitudes about PrEP among a sample of Spanish nursing students as well as their intentions of receiving it in case it was indicated. An observational cross-sectional descriptive study was carried out. A total of 570 nursing students from the University of Santiago de Compostela (Spain), ≥18 years old and of both sexes were invited to self-complete a questionnaire between February and March 2020. A total of 352 students decided to participate in the study. Participants had low knowledge [overall knowledge score 1(0-2)] and a neutral attitude towards PrEP. The intention of receiving PrEP improved significantly after the completion of the questionnaire and the administration of information about PrEP (p = 0.039; before: 23.58% and after: 93.77%). Nursing staff play an important role in the prevention of sexually transmitted diseases, so their training in preventive strategies, such as PrEP, could help to reduce the incidence of new cases of HIV infection.

Healthcare practitioner experiences and willingness to prescribe pre-exposure prophylaxis in the US

Background and objectives

Less than 10 percent of the more than one million people vulnerable to HIV are using pre-exposure prophylaxis (PrEP). Practitioners are critical to ensuring the delivery of PrEP across care settings. In this study, we target a group of prescribers focused on providing HIV care and seeking up-to-date information about HIV. We assessed their experiences prescribing PrEP, whether these experiences differed by clinical specialty, and examined associations between willingness to prescribe PrEP as a “best first step” and different hypothetical prescribing scenarios.

Setting and methods

Between March and May 2015, we circulated a paper survey to 954 participants ((652 of whom met our inclusion criteria of being independent prescribers and 519 of those (80%) responded to the survey)) at continuing medical education advanced-level HIV courses in five locations across the US on practitioner practices and preferences of PrEP. We employed multivariable logistic regression analysis for binary and collapsed ordinal outcomes.

Results

Among this highly motivated group of practitioners, only 54% reported ever prescribing PrEP. Internal medicine practitioners were 1.6 times more likely than infectious disease practitioners to have prescribed PrEP (95% CI: 0.99–2.60, p = .0524) and age, years of training, and sex were significantly associated with prescribing experience. Based on clinical vignettes describing different hypothetical prescribing scenarios, practitioners who viewed PrEP as the first clinical step for persons who inject drugs (PWID) were twice as likely to have also considered PrEP as the first clinical option for safer conception, and vice-a-versa (95% CI: 1.4–3.2, p < .001). Practitioners considering PrEP as the first preventive option for MSM were nearly six times as likely to also consider PrEP as the first clinical step for PWID, and vice-a-versa (95% CI: 2.28–13.56, p = .0002).

Conclusions

Our findings indicate that even among a subset of HIV-focused practitioners, PrEP prescribing is not routine. This group of practitioners could be an optimal group to engage individuals that could most benefit from PrEP.

Perceptions of African American Women and Health Care Professionals Related to Pre-Exposure Prophylaxis to Prevent HIV

OBJECTIVE

To describe the perceptions of African American women and health care professionals (HCPs) about factors that likely influence the use of pre-exposure prophylaxis (PrEP) to prevent HIV among African American women.

DESIGN

Prospective mixed methods.

SETTING

Chicago, IL.

PARTICIPANTS

Fifty-eight participants included HCPs (n = 10) and African American women (n = 48).

METHODS

Following the six steps of concept mapping, participants identified and rated factors they perceived to influence decisions to use PrEP among African American women.

RESULTS

African American women generated a list of statements, and we grouped the statements into eight clusters: access, financial, best benefits, protection, medication, setbacks, network, and fear. HCPs ranked having an HIV-positive partner as the most influential factor that affected African American women's decisions to use PrEP (network cluster). African American women ranked ability to prevent HIV when condom use cannot be negotiated as their top reason (best benefits cluster) for using PrEP.

CONCLUSION

African American women wanted to know how they could protect themselves and were open to using PrEP. For African American women considering the use of PrEP, the most influential factors were related to the benefits and accessibility of PrEP. HCPs should know that African American women are not afraid to discuss HIV risk and testing.

Facilitators and Barriers of Pre-exposure Prophylaxis (PrEP) Uptake Among Rural Men who have Sex with Men Living in the Midwestern U.S

Facilitators and barriers of Pre-exposure Prophylaxis (PrEP) uptake have been established in prior studies; however, most of these studies comprise samples of MSM from metropolitan cities and hypothetical PrEP use. There is a dearth of literature on the uptake factors among rural U.S. MSM who are prescribed PrEP. Thirty-four rural Midwestern MSM who currently take PrEP participated in semi-structured telephone interviews about their barriers and facilitators to their PrEP use. Interviews were analyzed using an inductive thematic analysis approach. There were four barriers: (1) lack of rural dissemination of PrEP information, (2) concern about side and adverse effects of using PrEP, (3) cost of PrEP uptake and engagement, and (4) lack of access to PrEP care and PrEP care quality. Individual and social facilitators that participants utilized to overcome these barriers are discussed. Findings elevate the importance of multilevel interventions that address PrEP adoption from a patient, provider, and healthcare system perspective.

Gaps in Sexually Transmitted Infection Screening among Men who Have Sex with Men in PrEP Care in the United States

BACKGROUND

The U.S. Centers for Disease Control and Prevention (CDC) recommends comprehensive sexually transmitted infection (STI) screening every 3-6 months for men who have sex with men (MSM) using HIV preexposure prophylaxis (PrEP). The gaps between these recommendations and clinical practice by region have not been quantified.

METHODS

We used survey data collected from the internet-based ARTnet study between 2017 and 2019 on STI screening among MSM across the U.S., stratified by current, prior, and never PrEP use. Poisson regression models with robust error variance were used to model factors, including residence in the Southeast, associated with consistent ("always" or "sometimes") exposure site-specific STI screening during PrEP care.

RESULTS

Of 3259 HIV-negative MSM, 19% were currently using PrEP, 6% had used PrEP in the past, and 75% had never used PrEP. Among ever PrEP users, 87%, 78%, 57%, and 64% reported consistent screening for STIs by blood sample, urine sample or urethral swab, rectal swab, or pharyngeal swab, respectively, during PrEP care. Compared to PrEP users in all other regions, PrEP users in the Southeast were significantly less likely to be consistently screened for urogenital (adjusted prevalence ratio [aPR], 0.86; 95% confidence interval [CI], 0.76-0.98) and rectal STIs (aPR, 0.76; 95% CI, 0.62-0.93) during PrEP care.

CONCLUSIONS

Substantial gaps exist between CDC recommendations for STI screening during PrEP care and current clinical practice, particularly for rectal and pharyngeal exposure sites that can harbor asymptomatic infections and for MSM in Southeast states where the STI burden is substantial.

Improving the HIV PrEP continuum of care using an intervention for healthcare providers: a stepped-wedge study protocol

INTRODUCTION

Pre-exposure prophylaxis (PrEP) has demonstrated to be a highly effective method for preventing HIV; however, many individuals with PrEP indications are not receiving PrEP. Primary care settings provide an opportunity to offer PrEP to a wide range of patients. In this paper, we describe the PrEP Optimisation Intervention (PrEP-OI), which includes a PrEP Coordinator and a web-based panel management tool (called PrEP-Rx), and is targeted at healthcare providers (HCPs) to increase PrEP uptake and persistence among those at risk for acquiring HIV.

METHODS AND ANALYSIS

The PrEP-OI study evaluates the efficacy of the PrEP intervention (PrEP Coordinator + PrEP-Rx) to increase PrEP prescriptions through a stepped-wedge design among 10 primary care clinical sites in the San Francisco Department of Public Health. The number of PrEP initiation prescriptions constitute the primary outcome, and we hypothesise that the mean number of PrEP prescriptions written will significantly increase after the clinics initiate PrEP-OI versus before this intervention. Secondary objectives include: 1-differences in PrEP initiation, duration of use and reasons for discontinuation based on patient's age, race/ethnicity and sex/gender, and by clinic and HCP characteristics, 2-sustainability of the intervention during a 12-month follow-up after the stepped-wedge phase, and 3-facilitators and barriers of PrEP delivery and experiences with the proposed PrEP intervention through qualitative interviews with HCPs. The results of this study can provide valuable insight into methods to reduce the burden of PrEP care on HCPs and improve PrEP continuum of care.

ETHICS AND DISSEMINATION

This study and its protocols have been approved by the University of California, San Francisco (UCSF) Institutional Review Board. Study staff will disseminate findings locally (eg, the UCSF Centre for AIDS Prevention Studies' Community Engagement Core), statewide (eg, the California Department of Public Health's Office of AIDS) and nationally and internationally at conferences related to HIV.

TRIAL REGISTRATION NUMBER

NCT03532191.

Towards an ontology-based medication conversational agent for PrEP and PEP

HIV (human immunodeficiency virus) can damage a human's immune system and cause Acquired Immunodeficiency Syndrome (AIDS) which could lead to severe outcomes, including death. While HIV infections have decreased over the last decade, there is still a significant population where the infection permeates. PrEP and PEP are two proven preventive measures introduced that involve periodic dosage to stop the onset of HIV infection. However, the adherence rates for this medication is low in part due to the lack of information about the medication. There exist several communication barriers that prevent patient-provider communication from happening. In this work, we present our ontology-based method for automating the communication of this medication that can be deployed for live conversational agents for PrEP and PEP. This method facilitates a model of automated conversation between the machine and user can also answer relevant questions.

PrEP 1.0 and Beyond: Optimizing a Biobehavioral Intervention

Tenofovir disoproxil fumarate coformulated with emtricitabine (TDF/FTC) was shown to be effective in preventing HIV acquisition when used for pre-exposure prophylaxis (PrEP), but questions have arisen regarding optimal PrEP implementation strategies.

Perspectives on HIV PrEP care in Germany: qualitative insights from primary care physicians and specialists

Recently, research has shifted from investigating the effectiveness of HIV pre-exposure prophylaxis (PrEP) to strategizing its implementation. Several European studies have explored physicians' perspectives on implementing PrEP in diverse settings, yet there are no data on the situation in Germany. The purpose of this study was to explore physicians' perspectives on current PrEP care in Germany. From April to July 2018, we conducted 16 semi-structured interviews with HIV providers (HIVPs) and primary care physicians (PCPs). Transcripts were analyzed using thematic content analysis. Physicians showed varying levels of PrEP expertise. Many PCPs lacked knowledge about PrEP. Some PCPs did not support the idea of PrEP as a prophylactic option. Opinions about PCPs' role in PrEP care were diverging, yet most PCPs favored referring PrEP clients to an HIVP or opted for a shared-care arrangement. Perceived problems included stigma and lack of privacy for PrEP care in rural areas. Our findings highlight the need for tailored physician training, which should be addressed in PrEP implementation in Germany.

Health Care-Seeking Behaviors and Perceptions of Provider-Initiated Discussion of Pre-exposure Prophylaxis Among PrEP-Naïve HIV-Negative Men Who Have Sex With Men in Atlanta, Georgia

BACKGROUND

Given high rates of HIV among men who have sex with men (MSM) in the United States, there is a need to more effectively leverage the health care system to bolster promotion of pre-exposure prophylaxis (PrEP) to at-risk MSM.

METHODS

Using data collected from a 2018 venue-based cross-sectional survey, we examined factors associated with health care-seeking behaviors, discussing PrEP with a provider, and barriers to PrEP uptake among MSM. Associations between outcomes and respondents' sociodemographic characteristics and sexual behaviors were assessed using log binomial regression.

RESULTS

Of 478 MSM, 247 (51%) were PrEP-naïve and HIV-negative. Although 85% of PrEP-naïve MSM reported visiting a health care provider in the past year, only 31% recalled having any provider discuss PrEP. The most frequently cited reasons for not taking PrEP were low perception of personal risk of acquiring HIV (37%) and not knowing enough about PrEP (35%). Those who saw a provider in the last year were less likely than those who did not to cite lack of knowledge as a barrier to use (prevalence rate, 0.66, 95% confidence interval, 0.45-0.96).

CONCLUSIONS

Despite the majority of PrEP-naïve MSM interfacing with the health care system, recollection of discussing PrEP with providers was limited. Increased efforts to equip providers with the tools to discuss PrEP and address pressing concerns with at-risk individuals may help improve PrEP uptake among priority populations.

The Impact of HIV Pre-Exposure Prophylaxis (PrEP) Counseling on PrEP Knowledge and Attitudes Among Women Seeking Family Planning Care

Background: Adult women account for >19% of all new HIV diagnoses in the United States, but receive only 7%-8% of new prescriptions for HIV pre-exposure prophylaxis (PrEP), and report low awareness of PrEP even within communities with high risk of HIV transmission. Family planning (FP) programs are a promising, underutilized setting for the provision of PrEP counseling to women, especially the 40% of women FP clients who receive no other form of health care. This study tested the feasibility of integrating routine PrEP counseling in a high-volume FP clinic with no previous PrEP experience. Materials and Methods: Trained FP counselors at a FP clinic in Philadelphia surveyed women about knowledge and attitudes related to PrEP, then provided a brief PrEP counseling intervention. After counseling, knowledge and attitudes were reassessed. In response to counselor requests, we developed the Women's PrEP Counseling Checklist (WPCC) tool to structure and standardize each counseling session. We then compared baseline and postintervention data among participants overall and in two cohorts: those receiving unguided counseling (initial design) and those receiving WPCC-guided counseling (enhanced design). Results: Both cohorts displayed significant (p < 0.0001) gains in PrEP knowledge and acceptability after counseling. Participants receiving WPCC-guided counseling reported higher knowledge scores postintervention (p = 0.031) and greater gains in PrEP acceptability (p = 0.000) than their peers receiving unguided counseling. Conclusions: Introducing PrEP counseling into routine FP care is feasible, and effectively improves knowledge and attitudes about PrEP within a large population of women, broadening access to PrEP on individual and population levels. The WPCC tool both enhances the impact of counseling on patients and reduces the work burden on providers.

Development of a 10-Item Tool to Identify Advanced Practice Nurse Readiness to Prescribe Pre-exposure Prophylaxis

Pre-exposure prophylaxis (PrEP), a biomedical tool to prevent the acquisition of HIV, reduces the risk of HIV in high-risk individuals by more than 90%. An online questionnaire was fielded from March 2017 to May 2017 to a random sample of licensed advanced practice nurses (APNs) from the U.S. state of Indiana. Discriminant function analysis was performed to reveal willingness to prescribe PrEP. Two discriminant functions were identified: Sexual Risk Assessment (r = .686), PrEP Barriers (r = .587), Evidence-Based Practice Implementation (r = .545), Community Awareness (r = .446), Perceived Risk (r = .356), and Organizational Climate (r = .346) were loaded on the first function, whereas PrEP Skills (r = .837) was loaded on the second function. The results suggest APN's willingness to learn and knowledge about PrEP-influenced implementation. Findings demonstrated that readiness to prescribe PrEP by APNs in Indiana could be predicted with a high level of certainty using identified variables.

Unlocking HIV Pre-Exposure Prophylaxis Delivery: Examining the Role of HIV Providers in Pre-Exposure Prophylaxis Care

Despite being a promising prevention strategy for populations at risk for HIV acquisition, there has not been rapid uptake of HIV antiretroviral pre-exposure prophylaxis (PrEP). Yet, HIV clinics within the Mount Sinai Health System in New York City have successfully incorporated PrEP. HIV care providers (n = 18), who practice in these clinics and were early PrEP adopters, participated in a survey and semistructured interview. Qualitative thematic analysis revealed that barriers and facilitators to PrEP uptake were identified on multiple levels from broader systemic to provider-and-patient-level concerns. The following themes were identified: (1) to reach a greater proportion of patients at risk for HIV and address racial/ethnic and gender disparities, PrEP should be available in a variety of settings and provided by different types of providers within proximity to affected populations; (2) financial support is needed beyond addressing medication cost; and (3) multidisciplinary teams and population-specific clinic protocols can assist providers in conducting high-quality visits and addressing these barriers to PrEP.

Health Care Provider Perspectives on Pre-exposure Prophylaxis: A Qualitative Study

Although pre-exposure prophylaxis (PrEP) requires a prescription from a health care provider, we lack unanimity in guidelines for the identification of the ideal provider type to prescribe PrEP. The purpose of our study was to understand clinician perspectives on provider categories to determine who is best suited to prescribe this medication to HIV-uninfected patients. We conducted 28 in-depth interviews between September 2017 and January 2018 with current prescribers of PrEP. Qualitative findings indicated that providers were split on recommended PrEP prescriber type. Five themes emerged that centered on the explicit identification of the issue of opportunity for providers to educate their patients on PrEP and offer this medication to at-risk populations. To effectively maximize presentation for care and subsequently amplify uptake of PrEP, growing the base of providers who offer PrEP to eligible patients can provide a meaningful public health impact on reducing HIV incidence.

Assessing the Potential for Nurse-Led HIV Pre- and Postexposure Prophylaxis in Ontario

BACKGROUND AND PURPOSE

HIV prevention efforts in Ontario require increased implementation of strategies including post- and pre-exposure prophylaxis. Access to these interventions could be improved by their provision through nurse-led models of care. We assessed nurses' readiness to deliver these interventions using a behavioral change framework.

METHODS

We distributed an online survey to nurses in every Ontario sexual health clinic, HIV clinic, and community health center between March-June 2018, to determine the level of support for nurse-led postexposure prophylaxis/pre-exposure prophylaxis; we also explored nurses' "capabilities," "opportunities," and "motivations" for providing postexposure prophylaxis/pre-exposure prophylaxis.

RESULTS

Overall, 72.7% of respondents supported implementation of both nurse-led postexposure prophylaxis and pre-exposure prophylaxis. More experienced nurses were less likely to support nurse-led postexposure prophylaxis and pre-exposure prophylaxis (adjusted odds ratio = 0.55 per decade nursing, 95% confidence interval (0.37, 0.82)). Nurses reported a high degree of knowledge of topics related to postexposure prophylaxis/pre-exposure prophylaxis, with the exception of creatinine interpretation.

CONCLUSIONS

Ontario nurses report high levels of support for nurse-led postexposure prophylaxis and pre-exposure prophylaxis and are well positioned to provide these interventions. Targeted education and implementation efforts are needed to engage these nurses in postexposure prophylaxis and pre-exposure prophylaxis delivery.

Interprofessional Collaboration Improves the Odds of Educating Patients About PrEP over Time

BACKGROUND

Low levels of pre-exposure prophylaxis (PrEP) uptake continue among the most vulnerable (e.g., men who have sex with men) for HIV exposure in the USA. Providers of social and public health services ("psychosocial providers") can help improve this situation by educating patients about PrEP before linking them to primary care providers (PCPs).

OBJECTIVE

To identify predictors of psychosocial providers offering PrEP education to patients vulnerable to HIV infection by determining the frequency with which psychosocial providers offer PrEP education to patients.

DESIGN

Longitudinal overview of PrEP implementation in New York City.

PARTICIPANTS

Psychosocial providers of HIV prevention and adjunct treatment services, such as medication adherence counseling in 34 community settings.

MAIN MEASURES

Longitudinal survey data collected in 2014-2016 (baseline) and 2015-2017 (1-year follow-up) from a 5-year longitudinal repeated measures study. Logistic regression modeling tested associations between baseline psychosocial provider-level and organization-level characteristics and frequency of PrEP education at baseline and 1-year follow-up.

KEY RESULTS

Out of 245 participants, the number of psychosocial providers offering PrEP education at least once in the past 6 months increased significantly from baseline (n = 127, 51.8%) to 1-year follow-up (n = 161, 65.7%). Participants with higher odds of offering PrEP education at baseline and at one1-year follow-up were more likely to have reported high levels of interprofessional collaboration (IPC) and were also more likely to have received formal HIV prevention training.

CONCLUSIONS

Both IPC and HIV training are predictive of PrEP education, and this association was maintained over time. We recommend expanding educational outreach efforts to psychosocial providers to further improve PrEP education and also training in interprofessional collaboration. This is an important first step toward linking patients to PCPs who prescribe PrEP and may help improve PrEP uptake.

Public Health Detailing for Human Immunodeficiency Virus Pre-exposure Prophylaxis

Despite the promise of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP), PrEP remains underutilized, often due to clinician factors. Academic or public health detailing is a process by which university and/or government groups employ the marketing practices of pharmaceutical companies to improve clinical practice. We describe the novel application of detailing to increase PrEP prescribing and related care in New York City and New England. Detailing can play a crucial role in PrEP implementation.

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.

Knowledge and practices of Parisian family physicians for the management of men who have sex with men in the era of HIV pre-exposure prophylaxis

INTRODUCTION

The optimal management of men who have sex with men (MSM) requires active involvement of family physicians (FP). We assessed knowledge and practices of Parisian FPs related to the management of MSM for sexually transmitted infections (STIs) and pre-exposure prophylaxis for HIV (PrEP).

METHOD

We conducted an observational prospective study between June 20 and July 31, 2017, with a sample of FPs practicing in Paris. The questionnaire posted via the Google Form website included 42 questions on sexual health management of MSM patients. A statistical analysis was then performed.

RESULTS

One hundred and four FPs took part in the study. The median age was 34 and 68% were women. Overall, 86.5% of FPs had already heard about PrEP, but only 36% of them were familiar with the indication for therapy and 77.9% of FPs declared to be willing to renew PrEP prescription. Overall, 89.4% of respondents declared to be willing to attend additional training on sexual health of MSM patients, including 73% on PrEP.

CONCLUSION

FPs have an important role in the management of MSM patients. They showed strong interest in PrEP despite limited knowledge of indications and methods of administration. They declared to be willing to attend additional training for further involvement.

Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis

BACKGROUND

Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV; however, its uptake remains modest. Given that there are fewer cost barriers to receiving PrEP within VHA than via commercial insurance, VHA represents an ideal setting in which to study other barriers that may impact patients seeking PrEP.

OBJECTIVE

We sought to understand potential barriers to obtaining PrEP within the Veterans Health Administration (VHA) through examination of documentation in electronic medical records.

DESIGN

Retrospective structured chart review, including chart abstractions of notes, referrals, and communications; content analysis of charts from a subsample of patients receiving PrEP in VHA.

PARTICIPANTS

One hundred sixty-one patients prescribed PrEP at 90 sites varying in PrEP prescribing rates.

APPROACH

We extracted descriptive information and conducted a qualitative analysis of all PrEP-relevant free-text notes including who initiated the PrEP conversation (patient vs. provider), time interval between request and prescription, reasons for denying PrEP, and patient responses to barriers.

KEY RESULTS

Patients initiated 94% of PrEP conversations and 35% of patients experienced delays receiving PrEP ranging from six weeks to 16 months. Over 70% of cases evidenced barriers to access. Barriers included provider knowledge gaps about PrEP, provider knowledge gaps about VHA systems related to PrEP, confusion or disagreement over clinic purview for PrEP, and provider attitudes or stigma associated with patients seeking PrEP.

CONCLUSIONS

Although PrEP is recommended for HIV prevention in high-risk persons, many PrEP-eligible individuals faced barriers to obtaining a prescription. Current practices place substantial responsibility on patients to request and advocate for this service, in contrast to many other preventive services. Understanding the prevalence and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission.

Health Care Provider Barriers to HIV Pre-Exposure Prophylaxis in the United States: A Systematic Review

Increasing prescription of pre-exposure prophylaxis (PrEP) is imperative to ending the HIV epidemic in the United States. The objective of this review was to identify health care provider barriers to PrEP implementation. A systematic review was conducted in February 2019 using PubMed to identify barriers to PrEP prescribing practices in the United States. Targeted search terms surrounding PrEP and providers resulted in 222 original studies, 28 of which were ultimately included in our review, with data collected between 2011 and 2018. Six themes were identified across reviewed studies: (i) a lack of PrEP knowledge, (ii) the presence of the Purview Paradox, which refers to discordance in beliefs between HIV specialists and primary care providers on who should prescribe PrEP, (iii) concerns about PrEP costs, (iv) concerns about behavioral and health consequences, (v) interpersonal stigma, and (vi) concerns about patient adherence. A majority of providers were lacking knowledge regarding PrEP, resulting in discomfort in prescribing PrEP, or limited awareness and understanding of PrEP clinical guidelines. Discrepant opinions were identified regarding whether PrEP was best managed within primary care or specialty clinics. Other barriers included concerns about cost, patient adherence, and follow-up maintenance care. Finally, concerns about risk compensation and discomfort discussing sexual activities with patients who would benefit most from PrEP were apparent. Additional work is needed to prepare providers to prescribe and manage patients on PrEP, optimize PrEP delivery, and reduce provider bias. Future research is needed to identify providers' attitudes and beliefs regarding innovations in PrEP dosing, task shifting, and novel strategies for PrEP care.

Gay and Bisexual Men's Strategies to Maintain Daily Adherence to Their HIV Pre-exposure Prophylaxis (PrEP) Medication: Results from a Qualitative Study

Since FDA approval in 2012, HIV pre-exposure prophylaxis (PrEP) has been adopted by key populations, including gay and bisexual men (GBM), to reduce their HIV transmission risk. Given that PrEP is optimally effective when taken as prescribed, it is critical to understand the adherence strategies GBM use. We conducted one-on-one, semi-structured interviews with GBM taking PrEP in 2015-2016 (n = 103). Using thematic analysis, we identified six adherence strategies, with most participants (84.3%) utilizing multiple strategies to maintain adequate adherence: (1) integrating PrEP into part of a daily routine, (2) using a pillbox, (3) cognitive strategies/visual cues, (4) setting recurring smartphone alarms or reminders, (5) keeping medication on oneself at all times, and (6) partner or peer support for reminders and/or pill sharing. Overall, participants reported high PrEP adherence (M = 1.6 missed doses in the prior 30 days), though nearly all described missing at least one dose unintentionally in the past. Participants credited their high levels of adherence in part to the strategies they adopted. Providers working with GBM prescribed PrEP, especially patients reporting difficulties with adherence, might consider recommending any or all of the six strategies described in this study.

Current US Guidelines for Prescribing HIV Pre-exposure Prophylaxis (PrEP) Disqualify Many Women Who Are at Risk and Motivated to Use PrEP

BACKGROUND

US Centers for Disease Control and Prevention clinical guidelines for HIV pre-exposure prophylaxis (PrEP) are widely used to assess patients' PrEP eligibility. The guidelines include 2 versions of criteria-guidance summary criteria and recommended indications criteria-that diverge in a potentially critical way for heterosexually active women: Both require women's knowledge of their own risk behavior, but the recommended indications also require women's knowledge of their partners' HIV risk or recognition of a potentially asymptomatic sexually transmitted infection. This study examined women's PrEP eligibility according to these 2 different versions of criteria across risk and motivation categories.

SETTING/METHODS

HIV-negative women (n = 679) recently engaged in care at Connecticut Planned Parenthood centers were surveyed online in 2017. The survey assessed PrEP eligibility by both versions of Centers for Disease Control and Prevention criteria, HIV risk indicators, PrEP motivation indicators, and sociodemographic characteristics.

RESULTS

Participants were mostly non-Hispanic white (33.9%) or black (35.8%) and had low income (<$30,000/year; 58.3%). Overall, 82.3% were eligible for PrEP by guidance summary criteria vs. 1.5% by recommended indications criteria. Women disqualified by recommended indications criteria included those reporting condomless sex with HIV-positive or serostatus-unknown male partners (n = 27, 11.1% eligible); 1 or more recent sexually transmitted infection(s) (n = 53, 3.8% eligible); multiple sex partners (n = 168, 3.0% eligible); intended PrEP use (n = 211, 2.8% eligible); and high self-perceived risk (n = 5, 0.0% eligible).

CONCLUSION

Current guidelines disqualify many women who could benefit from PrEP and may lead to discrepant assessments of eligibility. Guideline reform is needed to improve clarity and increase women's PrEP access and consequent HIV protection.

Exploring the Pre-exposure Prophylaxis (PrEP) Health Care Experiences Among Men Who Have Sex With Men (MSM) Who Live in Rural Areas of the Midwest

Most pre-exposure prophylaxis (PrEP) research samples men who have sex with men (MSM) who live in metropolitan cities. There is a limited understanding of the PrEP experiences among rural MSM. Thirty-four semi-structured interviews were conducted to explore the PrEP health care experiences among 34 rural Midwestern MSM. Of the 34 participants, 23 obtained PrEP from their non-primary care provider (PCP). Three themes were present: (1) PrEP is unavailable in rural areas, (2) PrEP is inaccessible in rural areas due to PCPs being unwilling to prescribe PrEP, and (3) PrEP services are unamicable in rural areas due to stigmatizing attitudes and behaviors of PCPs. It is important to address PrEP care continuum factors in all settings; however, these factors are often exacerbated in rural areas due to social determinants. Without further research and programming, organizational and social determinants may contribute to lower rates of PrEP outcomes in rural areas.

Developing a Scale to Measure Interprofessional Collaboration in HIV Prevention and Care: Implications for Research on Patient Access and Retention in the HIV Continuum of Care

To adapt and validate a scale for measuring interprofessional collaboration in HIV prevention and care (IPC-HIV), primary survey data were collected (2012-2017) from 577 HIV service providers in 60 organizations in New York, New Jersey, and Michigan. Cross-sectional training data were used to develop the IPC-HIV scale. The model was validated by fitting the five-factor confirmatory factor-analysis model to a 30-item set. The scale measures five domains with reliable alpha coefficients: Interdependence, Professional Activities, Flexibility, Collective Ownership, and Reflection on Process. Correlations between subscales were significant (p < .05). The strongest correlation was between Reflection on Process and Collective Ownership subscale scores. Mean scores ranged lfrom 4.070 to 4.880, with the highest score for Flexibility across all locations. IPC-HIV is valid and reliable among HIV-prevention and care workers, and is recommended for examining the effect of IPC on patient access to HIV testing and primary care.

HIV Preexposure Prophylaxis-The Role of Primary Care Clinicians in Ending the HIV Epidemic

A global human immunodeficiency virus (HIV) epidemic persists despite data to support multiple effective and safe tools that prevent HIV transmission and acquisition. Human immunodeficiency virus preexposure prophylaxis (PrEP) for HIV-uninfected at-risk populations using tenofovir disoproxil fumarate emtricitabine is highly effective, safe, and recently endorsed by the US Preventive Services Task Force (USPSTF) as a grade A recommendation. In this Special Communication, we summarize current guidelines and expert recommendations in a call for wider adoption of PrEP prescribing activities by frontline primary care clinicians. Key components include the ideal contexts in which PrEP may be prescribed, eligibility criteria, clinical considerations and pitfalls, laboratory monitoring, prescription practices, situations that may warrant expert consultation, and future directions. Given the broad scope, access, and point-of-entry status of primary clinicians in health systems, generalists will need to be at the center of any successful effort to leverage the power of, and destigmatize PrEP to end the HIV epidemic.

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.

HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis

Although pre-exposure prophylaxis (PrEP) has been approved for primary HIV prevention for individuals aged 18 years or older since 2012, PrEP utilization has been suboptimal. To understand trends in PrEP provision from the health care providers' perspective, we systematically assessed each specific stage along the PrEP implementation cascade (i.e., awareness, willingness, consultation, and prescription) among health care professionals (HCPs) in the United States. Between June and December 2018, we conducted a systematic review of published studies on this topic. A total of 36 eligible studies were identified and included in the analyses. Random-effect models were employed to examine the pooled prevalence of each key stage along the cascade. Time trend and subgroup analyses were conducted. A thematic analysis was used to identify barriers and facilitators along the PrEP cascade. In this study, a total of 18,265 HCPs representing diverse demographics were included. The pooled prevalence of PrEP awareness was 68% [95% confidence interval (CI) = 55-80%], willingness to prescribe PrEP was 66% (95% CI = 54-77%), PrEP consultation was 37% (95% CI = 25-51%), and prescription provision was 24% (95% CI = 17-32%). Subgroup analyses revealed that PrEP provision among HCPs was lowest in the south, but has been improving annually nationwide. Infectious disease specialists [odds ratio (OR) = 4.06, 95% CI = 3.12-5.28; compared with primary care providers] and advanced practice registered nurses/physician assistants (OR = 1.51, 95% CI = 1.09-2.09; compared with physicians) had higher odds of prescribing PrEP. Barriers and facilitators regarding optimal PrEP implementation were embedded within individual, dyadic, social, and structural levels. This meta-analysis has comprehensively examined the trend and pattern of PrEP implementation among HCPs. To achieve optimal implementation of the PrEP cascade in the United States, tailored training and programs need to be provided to HCPs.

[Care providers' knowledge and willingness to prescribe pre-exposure prophylaxis (PrEP) in Kinshasa, Democratic Republic of Congo (DRC)]

Introduction

la réduction de l'incidence de nouvelles infections liées au VIH est un objectif de santé publique. L’objectif de l’étude était d’évaluer la connaissance et volonté de prescrire la PrEP à Kinshasa.

Méthodes

il s’agit d’une étude transversale à visée analytique auprès des prestataires de soins de 4 structures de prise en charge de VIH/SIDA de la ville de Kinshasa d’avril à octobre 2017. Les analyses univariées et multivariées par régression logistique ont été effectuées pour identifier les facteurs associés à la connaissance et la volonté de prescrire la PrEP.

Résultats

quatre-vingt-cinq prestataires ont répondu à l’enquête. Moins du quart des prestataires connaissaient la PrEP avant l’enquête et la moitié avait la volonté de la prescrire. La barrière à cet acte évoquée était la résistance (83%). Les facteurs associés à la connaissance de la PrEP étaient la spécialité d’infectiologie et l’expertise en VIH. Les facteurs associés à la volonté de prescrire la PrEP étaient l’âge supérieur à 40 ans, la spécialité d’infectiologie et l’expertise en VIH.

Conclusion

la connaissance de la PrEP à Kinshasa était faible et seule la moitié des prestataires était disposée à la prescrire. Etre médecin infectiologue et expert en VIH était associé à la connaissance et la volonté de prescrire. Les futurs programmes d'éducation devraient renforcer la connaissance sur la PrEP et aborder les préoccupations identifiées dont les barrières à la prescription.

PrEP and sexual well-being: a qualitative study on PrEP, sexuality of MSM, and patient-provider relationships

Most new diagnoses of HIV in the United States are among men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is a medication that mitigates risk of HIV acquisition and requires regular STI testing and prescription refills with PrEP providers. Because PrEP care monitors sexual behavior, there is a need to understand how PrEP providers approach sexual health care for MSM patients. In this study, semi-structured qualitative interviews were conducted with 20 MSM in Atlanta, Georgia with current or past prescriptions for PrEP. Data were analyzed with thematic analysis using four major steps: (1) code and codebook development, (2) assigning codes to segments of interviews, (3) code-based and comparative analysis methods, and (4) developing thematic findings. Findings from interviews about changes in sexuality while using PrEP include decreased anxiety surrounding sex, increased feelings of control over personal health, and experiencing less stigma towards sexual partners with HIV. Participants indicated needs for tailored health advice based on individual sexual preferences, sexual health care free from stereotypical assumptions, and improved access to PrEP providers identifying as gay men or who practice in LGBT-friendly settings. Study findings support a call for a gain-frame approach to sexual health in PrEP care for MSM.

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.

Racial/ethnic and HIV risk category disparities in preexposure prophylaxis discontinuation among patients in publicly funded primary care clinics

OBJECTIVE

Dissemination of preexposure prophylaxis (PrEP) is a priority for reducing new HIV infections, especially among vulnerable populations. However, there are limited data available on PrEP discontinuation following initiation, an important component of the PrEP cascade.

DESIGN

Patients receiving PrEP within the San Francisco Department of Public Health Primary Care Clinics (SFPCC) are included in a PrEP registry if they received a PrEP prescription, were not receiving postexposure prophylaxis, and not known to be HIV-positive.

METHODS

We calculated PrEP discontinuation for patients initiating PrEP at any time from January 2012 to July 2017 and evaluated their association with demographic and risk variables using Cox regression analysis.

RESULTS

Overall, 348 patients received PrEP over the evaluation period. The majority (84%) were men, and the cohort was racially/ethnically diverse. The median duration of PrEP use was 8.3 months. In adjusted analysis, PrEP discontinuation was lower among older patients (aHR 0.89; 95% CI 0.80-0.99; P = 0.03); but higher among black patients (compared with white patients; aHR 1.87; 95% CI 1.27-2.74; P = 0.001), patients who inject drugs (aHR 4.80; 95% CI 2.66-8.67; P < 0.001), and transgender women who have sex with men (compared with MSM; aHR 1.94; 95% CI 1.36-2.77; P < 0.001).

CONCLUSION

Age, racial/ethnic, and risk category disparities in PrEP discontinuation were identified among patients in a public health-funded primary care setting. Further efforts are needed to understand and address PrEP discontinuation among priority populations to maximize the preventive impact of PrEP, and reverse HIV-related disparities at a population level.

Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama

Limited studies to date assess barriers to and facilitators of PrEP uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. We examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama. Participants were 32 years old on average, 66% Black, 66% gay or lesbian, 70% male, and 66% single. Perceived barriers to PrEP access included: lack of PrEP awareness and advertisement; sexuality-related stigma; time and resource constraints; and concerns about the adequacy and technical quality of PrEP services. Perceived facilitators to PrEP access were: PrEP-related information gathering and sharing; increased dialogue and visibility around PrEP; social, programmatic, and clinical support; and, lastly, self-preservation; personal motivation; and treatment self-efficacy. Results point to opportunities to address complex barriers to equitable PrEP access using multilevel and multimodal solutions.

Attitudes and referral practices for pre-exposure prophylaxis (PrEP) among HIV rapid testers and case managers in Philadelphia: A mixed methods study

Objective

Adoption of pre-exposure prophylaxis (PrEP) to prevent HIV infection has been slow. The purpose of this study was to evaluate knowledge, attitudes and referral practices for PrEP among non-prescribing providers, who may play key role.

Methods

We performed a cross-sectional survey on PrEP knowledge, attitudes, and referral practices among 66 non-prescribing HIV prevention providers (1st August to 31st December, 2016), in Philadelphia, followed by qualitative interviews with 12 of them (5th April to 10th May, 2017).

Results

Participants had a mean age of 36 years, with 62% females. Majority were HIV case managers and rapid testers. For half of the respondents, PrEP eligibility screening was part of rapid HIV testing at their organization, 40% never had PrEP training and only 27% indicated personally screening clients for eligibility. Qualitative data revealed that participants held positive attitudes about PrEP and perceived organizational support, but had concerns about potential negative impacts and barriers to routine HIV screening.

Conclusion

Results highlight the importance of training non-prescribing HIV prevention providers about PrEP, addressing their concerns, and incorporating PrEP screening and referral into routine HIV testing.

Location of Pre-exposure Prophylaxis Services Across New York City Neighborhoods: Do Neighborhood Socio-demographic Characteristics and HIV Incidence Matter?

Despite an increasing pre-exposure prophylaxis (PrEP) use among populations at highest risk of HIV acquisition, comprehensive and easy access to PrEP is limited among racial/ethnic minorities and low-income populations. The present study analyzed the geographic distribution of PrEP providers and the relationship between their location, neighborhood characteristics, and HIV incidence using spatial analytic methods. PrEP provider density, socio-demographics, healthcare availability, and HIV incidence data were collected by ZIP-code tabulation area in New York City (NYC). Neighborhood socio-demographic measures of race/ethnicity, income, insurance coverage, or same-sex couple household, were not associated with PrEP provider density, after adjusting for spatial autocorrelation, and PrEP providers were located in high HIV incidence neighborhoods (P < 0.01). These findings validate the need for ongoing policy interventions (e.g. public health detailing) vis-à-vis PrEP provider locations in NYC and inform the design of future PrEP implementation strategies, such as public health campaigns and navigation assistance for low-cost insurance.

Expanding Knowledge About Implementation of Pre-exposure Prophylaxis (PrEP): A Methodological Review

Methodological limitations in PrEP implementation studies may explain why PrEP implementation is lagging. This methodological review provides a description and critique of the methods used to identify barriers to PrEP implementation in the United States (2007-18). For each selected article, we provide: (1) research questions; (2) measures; (3) design; (4) sample (size and type); and (5) theoretical orientation. Among 79 articles which identified knowledge, attitudes, and behavioral and social/structural barriers to PrEP implementation, 51 (65%) were quantitative; 25 (32%) qualitative; and 3 (4%) were mixed-methods; overall, just one-half described a conceptual approach. About two-thirds of articles were conducted with patients and one-third with healthcare providers. Our review reveals a paucity of longitudinal, mixed-methods, and ethnographic/observational research and guiding theoretical frameworks; thus, the applicability of results are limited. We recommend that interventions aimed at PrEP implementation address barriers situated at multiple ecological domains, and thus improve PrEP access, uptake, and adherence.

Factors Associated With Discussions of Human Immunodeficiency Virus Pre-Exposure Prophylaxis in Men Who Have Sex With Men

Background: Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (Truvada) is highly effective at preventing human immunodeficiency virus (HIV) transmission in high-risk populations, including in men who have sex with men (MSM). In 2019, the US Preventive Services Task Force released an A recommendation to offer PrEP to persons at high risk of HIV acquisition. Despite the demonstrated efficacy of PrEP, areas with high HIV incidence, such as Louisiana, have historically had low PrEP prescription rates. The objective of this study was to determine the factors associated with whether providers in the Ochsner Health System (OHS) discussed PrEP with HIV-negative MSM patients. Methods: Investigators extracted electronic medical record data on all HIV-negative MSM patients who had at least one outpatient visit at OHS between July 1, 2012 and July 1, 2016 and manually reviewed a random sample of 115 charts. Results: Subjects were predominantly Caucasian (75.7%) with a mean age of 37.6 years. A PrEP discussion was documented for 34 (29.6%) patients. Multivariate modeling showed that having a PrEP discussion was associated with 3 factors: being assigned to a primary care provider known to specialize in MSM care (odds ratio [OR] 5.05, 95% confidence interval [CI] 1.81-14.10; P=0.002), having a documented history (positive or negative) of sexually transmitted infection vs no documentation (OR 5.41, 95% CI 1.80-16.23; P=0.003), and having documentation of condom use (consistent or inconsistent) vs no documentation (OR 3.32, 95% CI 1.27-8.74; P=0.015). Conclusion: Despite evidence that PrEP significantly reduces sexual transmission of HIV in MSM, PrEP discussions with MSM across OHS were undesirably low. Additional resources need to be aimed at increasing PrEP uptake and should focus on providing skills-based training and education in PrEP and MSM care to healthcare providers. With increased knowledge of and familiarity with PrEP prescribing guidelines, more providers will be better equipped to identify at-risk patients and to discuss prevention options such as PrEP.

Response Rates of Medical Providers to Internet Surveys Regarding Their Adoption of Preexposure Prophylaxis for HIV: Methodological Implications

In 2016 to 2017, we surveyed primary care providers (PCPs) in upper Manhattan and the South Bronx, New York, on their knowledge, attitudes, and practices surrounding preexposure prophylaxis (PrEP) for HIV. Despite efforts to promote survey response, we were only able to obtain a meager response rate, limiting our ability to interpret results. In this short communication, we examine our survey’s methodology, as well as the methods used by other similar studies, in order to suggest how certain strategies appear to influence PCP response to PrEP surveys. Administering the survey in a variety of modes, sampling from a professional organization’s listserv, promoting the survey topic’s relevance to potential participants, and offering monetary incentives to each survey respondent all appear to be promising strategies for increasing response rates in PrEP provider surveys.

Human Immunodeficiency Virus/Sexually Transmitted Infection Counseling and Testing Services Received by Gay and Bisexual Men Using Preexposure Prophylaxis at Their Last PrEP Care Visit

BACKGROUND

Preexposure prophylaxis (PrEP) reduces risk of human immunodeficiency virus infection for many gay and bisexual men (GBM); however, bacterial sexually transmitted infections associated with decreasing condom use among users is of concern. Center for Disease Control and Prevention's guidelines for PrEP use recommend bacterial sexually transmitted infection screening every 6 months. We sought to investigate comprehensive PrEP care, defined as: (1) discussion of sexual behavior, (2) blood sample, (3) urine sample, (4) rectal sample (rectal swab), and (5) throat sample (throat swab), provided at the user's last PrEP appointment.

METHODS

The PrEP-using GBM in New York City (n = 104) were asked about their last PrEP care visit. We examined associations of demographics (age, race/ethnicity, and education), recent number of condomless anal sex events, time on PrEP, and health care provider type on receiving comprehensive care at last visit using fully adjusted binary logistic regression.

RESULTS

At their last visit, nearly all men (94%) gave blood for testing, 88% provided a urine sample, and 77% discussed sexual behavior with their provider. However, only 51% reported having a rectal swab, and 48% an oral swab. Only 32% of men received comprehensive PrEP care at their last PrEP visit. Odds of receiving comprehensive care were significantly higher among younger men, men with a bachelor's degree or more education, and those who reported more condomless anal sex.

CONCLUSIONS

Less than one third of GBM received comprehensive human immunodeficiency virus/sexually transmitted infection counseling and testing at their last visit. These findings indicate further efforts are needed to prepare health care providers for prescribing and managing patients on PrEP.

Evolving Toward Shared HIV Care Using the Champlain BASE eConsult Service

Background. Electronic consultation (eConsultation) is a potential strategy to improve access to specialist expertise and facilitate collaborative care models. The Champlain BASE eConsult service allows for asynchronous communication between primary care providers (PCP) and specialists on a secure, web-based system. HIV experts accessible include HIV physician specialists, HIV pharmacists, and social workers with expertise in HIV. Objective. This study aims to describe the use, value, and utility of this eConsultation service in the care of people living with HIV and to characterize the common question types and clinical topics asked by PCPs. Methods. We analyzed the data from eConsults sent to the HIV specialty group in Ontario’s Champlain Local Health Integration Network between February 2015 and December 2017. Usage data and close-out survey responses were analyzed using descriptive statistics, eConsults were classified using a predefined list of validated taxonomy, and a thematic analysis was performed on the consultation logs to identify common clinical themes. Results. Among the 46 eConsults, the most common question type related to drug treatment (58.7%, n = 27) and management (19.6%, n = 9). The main clinical themes involved the care of significant complexities in people living with HIV, such as comorbidities and drug interactions, and suggestions of coordinated patient care. As well, eConsult was used for advice regarding pre-exposure prophylaxis for HIV-negative patients at risk of HIV infection. PCPs highly valued the eConsult service (average rating 4.8/5). Conclusion. Overall, this study demonstrates that eConsult provides an efficient and valuable service to PCPs caring for patients living with or at risk for HIV by improving access to HIV specialists and facilitating the delivery of team-based comprehensive care.

US Guideline Criteria for Human Immunodeficiency Virus Preexposure Prophylaxis: Clinical Considerations and Caveats

Clinical guidelines for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) developed by the US Centers for Disease Control and Prevention have been instrumental in the implementation of PrEP in medical practices throughout the country. However, the eligibility criteria contained within may inadvertently limit PrEP access for some patients. We describe the following key considerations and caveats related to these criteria: promotion of a selective vs universal approach to sexual health education involving PrEP; misalignment between criteria stated in the table and text boxes; problematic categorization and confounding of sexual orientation, gender identity, and risk behavior; underemphasis of network/community-level drivers of HIV transmission; oversimplification of serodiscordant risk; and lack of clarity surrounding the relevance of condoms to PrEP eligibility. We offer concrete recommendations to address the identified issues and strengthen future iterations of the guidelines, applying these recommendations in an alternative table of "criteria."

Acceptability and feasibility of a pharmacist-led HIV pre-exposure prophylaxis (PrEP) program in the Midwestern United States

Background

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) substantially reduces the risk of HIV acquisition, yet significant barriers exist to its prescription and use. Incorporating pharmacists in the PrEP care process may help increase access to PrEP services.

Methods

Our pharmacist-led PrEP program (P-PrEP) included pharmacists from a university-based HIV clinic, a community pharmacy, and 2 community-based clinics. Through a collaborative practice agreement, pharmacists conducted PrEP visits with potential candidates for PrEP, according to the recommended Centers for Disease Control and Prevention guidelines, and authorized emtricitabine-tenofovir disoproxil fumarate prescriptions. Demographics and retention in care over 12 months were summarized, and participant satisfaction and pharmacist acceptability with the P-PrEP program were assessed by Likert-scale questionnaires.

Results

Sixty patients enrolled in the P-PrEP program between January and June 2017 completing 139 visits. The mean age was 34 years (range, 20–61 years), and 88% identified as men who have sex with men, 91.7% were men, 83.3% were white, 80% were commercially insured, and 89.8% had completed some college education or higher. Participant retention at 3, 6, 9, and 12 months was 73%, 58%, 43%, and 28%, respectively. To date, no participant has seroconverted. One hundred percent of the participants who completed the patient satisfaction questionnaire would recommend the P-PrEP program. Pharmacists reported feeling comfortable performing point-of-care testing and rarely reported feeling uncomfortable during PrEP visits (3 occasions, 2.2%) or experiencing workflow disruption (1 occasion, 0.7%).

Conclusions

Implementation of a pharmacist-led PrEP program is feasible and associated with high rates of patient satisfaction and pharmacist acceptability.

Health Care Facility Characteristics are Associated with Variation in Human Immunodeficiency Virus Pre-exposure Prophylaxis Initiation in Veteran's Health Administration

To quantify health care facility-level variation in pre-exposure prophylaxis (PrEP) use in the Veteran's Health Administration (VHA); to identify facility characteristics associated with PrEP use. Retrospective analysis of the health care facility-level rate of PrEP initiation in VHA through June 30, 2017. Standardized PrEP initiation rates were used to rank facilities. Characteristics of facilities, prescribers, and PrEP recipients were examined within quartiles. Multiple linear regression was used to identify associations between facility characteristics and PrEP use. We identified 1600 PrEP recipients. Mean PrEP initiation rate was 20.0/100,000 (SD 22.8), ranging from 3.0/100,000 (SD 2.0) in the lowest quartile to 48.1/100,000 (SD 29.1) in the highest. PrEP prescribing was positively associated with proportions of urban dwellers and individuals < 45, tertiary care status, and location. Variability in PrEP uptake across a national health care system highlights opportunities to expand access in non-tertiary care facilities and underserved areas.

A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV is effective, yet many providers continue to lack knowledge and comfort in providing this intervention. It remains unclear whether internal medicine (IM) residents receive appropriate training in PrEP care and if this affects their future practices.

OBJECTIVE

We sought to evaluate the relationship between current IM residents' prior PrEP training and knowledge, comfort, and practice regarding the provision of PrEP.

DESIGN AND PARTICIPANTS

We created an online survey to assess IM residents' knowledge, attitudes, and behaviors related to PrEP. The survey was distributed among five IM programs across the USA.

KEY RESULTS

We had a 35% response rate. Of 229 respondents, 96% (n = 220) had heard of PrEP but only 25% (n = 51) had received prior training and 11% (n = 24) had prescribed PrEP. Compared with those without, those with prior training reported good to excellent knowledge scores regarding PrEP (80% versus 33%, p < 0.001), more frequent prescribing (28% versus 7%, p = 0.001), and higher comfort levels with evaluating risk for HIV, educating patients, and monitoring aspects of PrEP (75% versus 26%, 56% versus 16%, and 47% versus 8%, respectively; all p values < 0.0001). While only 25% (n = 51) had received prior training, 75% (n = 103) of respondents reported that training all providers at their continuity clinic sites would improve implementation.

CONCLUSIONS

We found that prior training was associated with higher levels of self-reported PrEP knowledge, comfort, and prescribing behaviors. Given the significant need for PrEP, IM residents should be trained to achieve adequate knowledge and comfort levels to prescribe it. This study demonstrates that providing appropriate PrEP training for IM residents may lead to an increase in the pool of graduating IM residents prescribing PrEP.