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Merle JL, Benbow N, Li DH, Zapata JP, Queiroz A, Zamantakis A, McKay V, Keiser B, Villamar JA, Mustanski B, Smith JD. Improving Delivery and Use of HIV Pre-Exposure Prophylaxis in the US: A Systematic Review of Implementation Strategies and Adjunctive Interventions. AIDS Behav 2024:10.1007/s10461-024-04331-0. [PMID: 38564136 DOI: 10.1007/s10461-024-04331-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 04/04/2024]
Abstract
Implementation of pre-exposure prophylaxis (PrEP) to prevent HIV transmission is suboptimal in the United States. To date, the literature has focused on identifying determinants of PrEP use, with a lesser focus on developing and testing change methods to improve PrEP implementation. Moreover, the change methods available for improving the uptake and sustained use of PrEP have not been systematically categorized. To summarize the state of the literature, we conducted a systematic review of the implementation strategies used to improve PrEP implementation among delivery systems and providers, as well as the adjunctive interventions used to improve the uptake and persistent adherence to PrEP among patients. Between November 2020 and January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer reviewed articles. We identified 44 change methods (18 implementation strategies and 26 adjunctive interventions) across a variety of clinical and community-based service settings. We coded implementation strategies and adjunctive interventions in accordance with established taxonomies and reporting guidelines. Most studies focused on improving patient adherence to PrEP and most conducted pilot trials. Just over one-third of included studies demonstrated a positive effect on outcomes. In order to end the human immunodeficiency virus (HIV) epidemic in the U.S., future, large scale HIV prevention research is needed that develops and evaluates implementation strategies and adjunctive interventions for target populations disproportionately affected by HIV.
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Affiliation(s)
- James L Merle
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Nanette Benbow
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Seattle, WA, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Dennis H Li
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Seattle, WA, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Juan P Zapata
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Artur Queiroz
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Alithia Zamantakis
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
| | - Virginia McKay
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Brennan Keiser
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Juan A Villamar
- Public Health and Epidemiology Unit, Westat, Rockville, MD, USA
| | - Brian Mustanski
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Seattle, WA, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Seattle, WA, USA
- Department of Infectious Diseases, Northwestern University, Seattle, WA, USA
- Medical Social Sciences Department, Northwestern University, Seattle, WA, USA
| | - Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
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Mckay V, Zamantakis A, Pachicano AM, Merle J, Purrier M, Swan M, Li D, Mustanski B, Smith JD, Hirschhorn L, Benbow N. Establishing Evidence Criteria for Implementation Strategies: A Delphi Study for HIV Services. RESEARCH SQUARE 2024:rs.3.rs-3979631. [PMID: 38464091 PMCID: PMC10925451 DOI: 10.21203/rs.3.rs-3979631/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND There are no criteria specifically for evaluating the quality of implementation research and recommend implementation strategies likely to have impact to practitioners. We describe the development and application of the Best Practices Rubric, a set of criteria to evaluate the evidence supporting implementation strategies, in the context of HIV. METHODS We developed the Best Practices Rubric from 2022-2023 in three phases. (1) We purposively selected and recruited by email participants representing a mix of expertise in HIV service delivery, quality improvement, and implementation science. We developed a draft rubric and criteria based on a literature review and key informant interviews. (2) The rubric was then informed and revised through two e-Delphi rounds using a survey delivered online through Qualtrics. The first and second round Delphi surveys consisted of 71 and 52 open and close-ended questions, respectively, asking participants to evaluate, confirm, and make suggestions on different aspects of the rubric. After each survey round, data were analyzed and synthesized as appropriate, and the rubric and criteria were revised. (3) We then applied the rubric to a set of research studies assessing 18 implementation strategies designed to promote the adoption and uptake of pre-exposure prophylaxis, an HIV prevention medication, to assess reliable application of the rubric and criteria. RESULTS Our initial literature review yielded existing rubrics and criteria for evaluating intervention-level evidence. For a strategy-level rubric, additions emerged from interviews, for example, a need to consider the context and specification of strategies. Revisions were made after both Delphi rounds resulting in the confirmation of five evaluation domains - research design, implementation outcomes, limitations and rigor, strategy specification, and equity - and four evidence levels - best practice, promising practice, more evidence needed, and harmful practices. For most domains, criteria were specified at each evidence level. After an initial pilot round to develop an application process and provide training, we achieved 98% reliability when applying the criteria to 18 implementation strategies. CONCLUSIONS We developed a rubric to evaluate the evidence supporting implementation strategies for HIV services. Although the rubric is specific to HIV, this tool is adaptable for evaluating strategies in other health areas.
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Watson DL, Listerud L, Drab RA, Lin WY, Momplaisir FM, Bauermeister JA. HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis. J Int AIDS Soc 2024; 27:e26211. [PMID: 38332521 PMCID: PMC10853582 DOI: 10.1002/jia2.26211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/16/2024] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION Current implementation efforts have failed to achieve equitable HIV pre-exposure prophylaxis (PrEP) provision for transgender and gender-diverse (trans) populations. We conducted a choice-based conjoint analysis to measure preferences for key attributes of hypothetical PrEP delivery programmes among a diverse online sample predominantly comprised of transmasculine and nonbinary individuals in the United States. METHODS Between April 2022 and June 2022, a national online survey with an embedded conjoint analysis experiment was conducted among 304 trans individuals aged ≥18 years in the United States to assess five PrEP programme attributes: out-of-pocket cost; dispensing venue; frequency of visits for PrEP-related care; travel time to PrEP provider; and ability to bundle PrEP-related care with gender-affirming hormone therapy services. Participants responded to five questions, each of which presented two PrEP programme scenarios and one opt-out option per question and selected their preferred programme in each question. We used hierarchical Bayes estimation and multinomial logistic regression to measure part-worth utility scores for the total sample and by respondents' PrEP status. RESULTS The median age was 24 years (range 18-56); 75% were assigned female sex at birth; 54% identified as transmasculine; 32% as nonbinary; 14% as transfeminine. Out-of-pocket cost had the highest attribute importance score (44.3%), followed by the ability to bundle with gender-affirming hormone therapy services (18.7%). Minimal cost-sharing ($0 out-of-pocket cost) most positively influenced the attribute importance of cost (average conjoint part-worth utility coefficient of 2.5 [95% CI 2.4-2.6]). PrEP-experienced respondents preferred PrEP delivery in primary care settings (relative utility score 4.7); however, PrEP-naïve respondents preferred pharmacies (relative utility score 5.1). CONCLUSIONS Participants preferred programmes that offered PrEP services without cost-sharing and bundled with gender-affirming hormone therapy services. Bolstering federal regulations to cover PrEP services and prioritizing programmes to expand low-barrier PrEP provision are critical to achieving equitable PrEP provision. Community-engaged implementation research conducted by and in close collaboration with trans community stakeholders and researchers are needed to streamline the design of patient-centred PrEP programmes and develop implementation strategies that are salient to the diverse sexual health needs of trans patients.
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Affiliation(s)
- Dovie L. Watson
- Department of Medicine (Infectious Diseases)University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Louis Listerud
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ryan A. Drab
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Willey Y. Lin
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Florence Marie Momplaisir
- Department of Medicine (Infectious Diseases)University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - José A. Bauermeister
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Andrzejewski J, Pines HA, Morris S, Burke L, Bolan R, Sevelius J, Moore DJ, Blumenthal J. Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:133. [PMID: 38397624 PMCID: PMC10888369 DOI: 10.3390/ijerph21020133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 02/25/2024]
Abstract
Transgender women (TW) face inequities in HIV and unique barriers to PrEP, an effective biomedical intervention to prevent HIV acquisition. To improve PrEP retention among TW, we examined factors related to retention using a two-phase, sequential explanatory mixed methods approach. In Phase I, we used data from a trial of 170 TW who were provided oral PrEP to examine predictors of 24-week retention. In Phase II, we conducted 15 in-depth interviews with PrEP-experienced TW and used thematic analysis to explain Phase I findings. In Phase I, more participants who were not retained at 24 weeks reported sex work engagement (18% versus 7%) and substantial/severe drug use (18% versus 8%). In Phase II, participants reported drug use as a barrier to PrEP, often in the context of sex work, and we identified two subcategories of sex work. TW engaged in "non-survival sex work" had little difficulty staying on PrEP, while those engaged in "survival sex work" struggled to stay on PrEP. In Phase I, fewer participants not retained at 24 weeks reported gender-affirming hormone therapy (GAHT) use (56% versus 71%). In Phase II, participants prioritized medical gender affirmation services over PrEP but also described the bidirectional benefits of accessing GAHT and PrEP. TW who engaged in "survival sex work" experience barriers to PrEP retention (e.g., unstable housing, drug use) and may require additional support to stay in PrEP care.
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Affiliation(s)
- Jack Andrzejewski
- San Diego Joint Doctoral Program in Public Health, San Diego State University—University of California San Diego, San Diego, CA 92093, USA
| | - Heather A. Pines
- School of Public Health, San Diego State University, San Diego, CA 92182, USA;
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA 92093, USA
- Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA; (S.M.); (L.B.); (J.B.)
| | - Sheldon Morris
- Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA; (S.M.); (L.B.); (J.B.)
| | - Leah Burke
- Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA; (S.M.); (L.B.); (J.B.)
| | | | - Jae Sevelius
- Department of Psychiatry, Columbia University, New York, NY 10032, USA;
| | - David J. Moore
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093, USA;
| | - Jill Blumenthal
- Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA; (S.M.); (L.B.); (J.B.)
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Mustanski B, Queiroz A, Merle JL, Zamantakis A, Zapata JP, Li DH, Benbow N, Pyra M, Smith JD. A Systematic Review of Implementation Research on Determinants and Strategies of Effective HIV Interventions for Men Who Have Sex with Men in the United States. Annu Rev Psychol 2024; 75:55-85. [PMID: 37722749 PMCID: PMC10872355 DOI: 10.1146/annurev-psych-032620-035725] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Men who have sex with men (MSM) are disproportionately affected by HIV, accounting for two-thirds of HIV cases in the United States despite representing ∼5% of the adult population. Delivery and use of existing and highly effective HIV prevention and treatment strategies remain suboptimal among MSM. To summarize the state of the science, we systematically review implementation determinants and strategies of HIV-related health interventions using implementation science frameworks. Research on implementation barriers has focused predominantly on characteristics of individual recipients (e.g., ethnicity, age, drug use) and less so on deliverers (e.g., nurses, physicians), with little focus on system-level factors. Similarly, most strategies target recipients to influence their uptake and adherence, rather than improving and supporting implementation systems. HIV implementation research is burgeoning; future research is needed to broaden the examination of barriers at the provider and system levels, as well as expand knowledge on how to match strategies to barriers-particularly to address stigma. Collaboration and coordination among federal, state, and local public health agencies; community-based organizations; health care providers; and scientists are important for successful implementation of HIV-related health innovations.
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Affiliation(s)
- Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Third Coast Center for AIDS Research, Chicago, Illinois, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Artur Queiroz
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - James L Merle
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Alithia Zamantakis
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Juan Pablo Zapata
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dennis H Li
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
- Third Coast Center for AIDS Research, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nanette Benbow
- Third Coast Center for AIDS Research, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Maria Pyra
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA;
| | - Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
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Sila J, Wagner AD, Abuna F, Dettinger JC, Odhiambo B, Ngumbau N, Oketch G, Sifuna E, Gómez L, Hicks S, John-Stewart G, Kinuthia J. An implementation strategy package (video education, HIV self-testing, and co-location) improves PrEP implementation for pregnant women in antenatal care clinics in western Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1205503. [PMID: 38045529 PMCID: PMC10690761 DOI: 10.3389/frph.2023.1205503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/20/2023] [Indexed: 12/05/2023] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization and the Kenyan Ministry of Health for HIV prevention in pregnancy and postpartum for women at risk for HIV. Integration of PrEP into antenatal care is promising, but delivery gaps exist in the face of healthcare provider shortages in resource-limited settings. Methods Between May and November 2021, we conducted a difference-in-differences study (3 months pre-intervention data collection and 3 months post-intervention data collection) analyzing four intervention facilities, where the strategies were implemented, and four comparison facilities, where no strategies were implemented. We tested a combination of three implementation strategies-video-based PrEP information in the waiting bay, HIV self-testing, and dispensing of PrEP in the antenatal care rooms-to improve PrEP delivery. We compared absolute changes in the proportion of antenatal attendees screened for PrEP (PrEP penetration), the proportion receiving all PrEP-specific steps in a visit (HIV testing, risk screening, and PrEP counseling) (PrEP fidelity), and client PrEP knowledge, client satisfaction, and waiting time and service time (a priori outcomes); post hoc, we compared the proportion offered PrEP (PrEP offer) and completing HIV testing. We measured provider perceptions of the acceptability and appropriateness of the implementation strategies. Results We observed significant improvements in PrEP penetration, PrEP offer, satisfaction, and knowledge (p < 0.05) and improvements in fidelity that trended towards significance (p = 0.057). PrEP penetration increased 5 percentage points (p = 0.008), PrEP fidelity increased 8 percentage points (p = 0.057), and PrEP offer increased 4 percentage points (p = 0.003) in intervention vs. comparison facilities. Client PrEP knowledge increased by 1.7 out of 6 total points (p < 0.001) and client satisfaction increased by 0.7 out of 24 total points (p = 0.003) in intervention vs. comparison facilities. We observed no changes in service time (0.09-min decrease; p = 0.435) and a small increase in waiting time (0.33-min increase; p = 0.005). HIV testing among those eligible did not change (1.5 percentage point decrease, p = 0.800). Providers felt the implementation strategies were acceptable and appropriate (median acceptability: 20/20; median appropriateness: 19.5/20). However, absolute levels of each step of the PrEP cascade remained suboptimal. Conclusions An implementation strategy package with video information, HIV self-testing, and co-location of medication dispensing enhanced PrEP delivery across several implementation outcomes and client satisfaction, while not substantially increasing wait time or decreasing provider-client contact time. Clinical trial registration ClinicalTrials.gov , identifier, NCT04712994.
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Affiliation(s)
- Joseph Sila
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Ben Odhiambo
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Nancy Ngumbau
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Oketch
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Enock Sifuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Departments of Pediatrics & Medicine, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
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Camila-Bolívar M, Gomez-Peñaloza SA, Camargo-Plazas P, Peralta-Ardila MDP, Mueses-Marín HF, Alvarado-Llano B, Martínez-Cajas JL. Barriers and facilitators to HIV pre-exposure prophylaxis uptake among transgender women in Colombia: A qualitative analysis using the COM-B model. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001395. [PMID: 37756283 PMCID: PMC10529613 DOI: 10.1371/journal.pgph.0001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
Abstract
Transgender women [TGW] in Colombia are disproportionately affected by HIV due to their low sociodemographic conditions, varied risk behaviours, difficulty accessing health services, and discrimination. Offering pre-exposure prophylaxis [PrEP] as part of a combination of prevention strategies is an appropriate option for this population to reduce their risk of HIV infection. However, little is known about how to implement a PrEP program for TGW in Colombia. Between June and October 2020, we conducted individual interviews with 16 TGW from four different cities in Colombia. The interviews assessed contextual influences, knowledge, skills, perceptions, and beliefs. We used qualitative thematic analysis to identify themes and the Capability, Opportunity, Motivation, and Behavior framework to further delineate barriers and possible interventions. After delineating the main themes across the three subdomains of the model, nine barriers were identified: one related to capability, knowledge, and perception of PrEP; six related to opportunity, which includes, family relations, sexual work environment, stable partner relations, interactions with healthcare workers, health service provision, and community interactions and opportunities; and two related to motivation, mental health, and concerns about medication side effects. Mapping barriers with interventions generated the following intervention functions: education, training, enablement, and environmental structure; and the following policy functions: communication/marketing, legislation, and changes in service provision. Examples of possible interventions are presented and discussed.
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Affiliation(s)
- Maria Camila-Bolívar
- Department of Public Health and Epidemiology, Pontificia Universidad Javeriana Cali, Cali, Colombia
- Corporación de Lucha Contra el Sida, Cali, Colombia
| | | | | | | | | | | | - Jorge L. Martínez-Cajas
- Division of Infectious Diseases, Department of Medicine, Queens University, Kingston, Ontario, Canada
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Zamudio-Haas S, Koester K, Venegas L, Salinas A, Herrera C, Gutierrez-Mock L, Welborn L, Deutsch MB, Sevelius J. "Entre Nosotras:" a qualitative study of a peer-led PrEP project for transgender latinas. BMC Health Serv Res 2023; 23:1013. [PMID: 37730598 PMCID: PMC10510224 DOI: 10.1186/s12913-023-09707-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/15/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Uptake of HIV pre-exposure prophylaxis (PrEP) remains low among transgender people as compared to other subgroups, despite high rates of HIV acquisition. In California, Latinx people comprise 40% of the population and Latina transgender women experience some of the highest burden of HIV of any subgroup, indicating a critical need for appropriate services. With funding from the California HIV/AIDS Research Programs, this academic-community partnership developed, implemented, and evaluated a PrEP project that co-located HIV services with gender affirming care in a Federally Qualified Heath Center (FQHC). Trans and Latinx staff led intervention adaptation and activities. METHODS This paper engages qualitative methods to describe how a PrEP demonstration project- Triunfo- successfully engaged Spanish-speaking transgender Latinas in services. We conducted 13 in-depth interviews with project participants and five interviews with providers and clinic staff. Interviews were conducted in Spanish or English. We conducted six months of ethnographic observation of intervention activities and recorded field notes. We conducted thematic analysis. RESULTS Beneficial elements of the intervention centered around three intertwined themes: creating trusted space, providing comprehensive patient navigation, and offering social support "entre nosotras" ("between us women/girls"). The combination of these factors contributed to the intervention's success supporting participants to initiate and persist on PrEP, many of whom had previously never received healthcare. Participants shared past experiences with transphobia and concerns around discrimination in a healthcare setting. Developing trust proved foundational to making participants feel welcome and "en casa/ at home" in the healthcare setting, which began from the moment participants entered the clinic and continued throughout their interactions with staff and providers. A gender affirming, bilingual clinician and peer health educators (PHE) played a critical part in intervention development, participant recruitment, and patient navigation. CONCLUSIONS Our research adds nuance to the existing literature on peer support services and navigation by profiling the multifaced roles that PHE served for participants. PHE proved instrumental to empowering participants to overcome structural and other barriers to healthcare, successfully engaging a group who previously avoided healthcare in clinical settings.
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Affiliation(s)
- Sophia Zamudio-Haas
- Department of Medicine, University of California, 550 16th Street, 3rd Floor, CA, 94158, San Francisco, USA.
| | - Kim Koester
- Department of Medicine, University of California, 550 16th Street, 3rd Floor, CA, 94158, San Francisco, USA
| | - Luz Venegas
- Department of Medicine, University of California, 550 16th Street, 3rd Floor, CA, 94158, San Francisco, USA
| | - Ariana Salinas
- Department of Medicine, University of California, 550 16th Street, 3rd Floor, CA, 94158, San Francisco, USA
| | - Cinthya Herrera
- Department of Medicine, University of California, 550 16th Street, 3rd Floor, CA, 94158, San Francisco, USA
| | - Luis Gutierrez-Mock
- Department of Medicine, University of California, 550 16th Street, 3rd Floor, CA, 94158, San Francisco, USA
| | - Layla Welborn
- La Clinica de La Raza, 3451 East 12th Street, CA, 94601, Oakland, USA
| | - Madeline B Deutsch
- Department of Medicine, University of California, 550 16th Street, 3rd Floor, CA, 94158, San Francisco, USA
| | - Jae Sevelius
- Department of Medicine, University of California, 550 16th Street, 3rd Floor, CA, 94158, San Francisco, USA
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