Brief Report: "I Didn't Really Have a Primary Care Provider Until I Got PrEP": Patients' Perspectives on HIV Preexposure Prophylaxis as a Gateway to Health Care

Lessons Learned From Engaging Healthcare Providers in Research on Implementation of HIV Preexposure Prophylaxis

BACKGROUND

Health care providers are critical for successful implementation of HIV preexposure prophylaxis (PrEP), but barriers to PrEP provision persist. Researchers must engage with providers to understand how to optimize PrEP delivery across settings. Yet researcher-provider collaborations can be challenging. To offer guidance on engaging providers in PrEP implementation research, we synthesized the experiences of researchers working with different types of providers on studies related to PrEP implementation that were funded as part of the US Ending the HIV Epidemic (EHE) initiative.

SETTING

Geographic areas designated as high priority by the EHE initiative.

METHODS

We defined providers broadly, including physicians, pharmacists, health educators, and peer navigators. Using thematic analysis from collaborative case reports by EHE study teams, we synthesized strategies, challenges, and successes related to provider engagement, with categorization into three stages of research: study development, recruitment, and data collection.

RESULTS

Among 17 research teams invited, 9 contributed. Findings suggested that extensive resources (eg, time, professional networks, financial, and nonfinancial incentives) are required to engage clinical and nonclinical providers across all stages of PrEP implementation research, with the most intensive strategies required for recruiting clinical providers who are not yet providing PrEP. However, when effective strategies are deployed, this investment of resources can yield rich insights into PrEP implementation.

CONCLUSIONS

The lessons learned by the investigators in our study can be applied to future EHE-funded projects, other HIV-prevention studies, and studies in other areas of health research to improve engagement of providers during all stages of the research process.

Long-Acting Injectable Pre-Exposure Prophylaxis Perceptions and Preferences Among Transgender and Nonbinary Young Adults in the United States

Long-acting injectable pre-exposure prophylaxis for HIV prevention (LAI-PrEP) was approved for use in the United States in 2021, yet little is known about perceptions of LAI-PrEP among transgender and nonbinary young adults, a group that faces substantial barriers to HIV prevention. We investigated US transgender and nonbinary young adults' perceptions of and attitudes toward LAI-PrEP and how perceived advantages and disadvantages of LAI-PrEP related to the PrEP continuum of care. We conducted semi-structured interviews with 31 transgender and nonbinary young adults who reported oral PrEP use or were PrEP-eligible. We analyzed responses using both a deductive RADaR approach, to identify LAI-PrEP perceptions relevant to the PrEP continuum of care, and an inductive thematic analysis to explore key themes. In this study, all PrEP-experienced and most PrEP-naïve participants indicated an interest in LAI-PrEP, citing advantages over daily oral medication (e.g., fewer adherence challenges). Three key themes emerged: (1) Some participants linked perceived advantages of LAI-PrEP to experiences with gender-affirming care (e.g., familiarity with needles via hormone use). (2) Participants weighed trade-offs and contextual factors that influenced their LAI-PrEP preferences (e.g., interest contingent on whether location for receiving injection was geographically accessible). (3) Participants envisaged alternative delivery methods that could enhance LAI-PrEP acceptability and uptake (e.g., home injection). HIV prevention programs should incorporate the insights of transgender and nonbinary young adults to ensure that emerging HIV prevention technologies are accessible and responsive to the needs and concerns of people of all gender modalities.

Unawareness of partner risk factors thwarts implementation of USPSTF recommendations for HIV pre-exposure prophylaxis in primary care

The United States Preventive Services Task Force recommends pre-exposure chemoprophylaxis for persons at high risk of HIV exposure. The optimal screening strategy for at-risk individuals in primary care is not known. We evaluated the strategy of universal screening and discussed challenges to the implementation of this recommendation in primary care. Around 430 of 500 (86%) screening surveys were completed. Mutual monogamy was common but monogamous partners with recent negative HIV testing were uncommon. Likewise, among heterosexually active men and women, inconsistent condom use was common. Such individuals would be on guideline for HIV pre-exposure prophylaxis (PrEP) if their partner was at risk for HIV exposure. None of these potentially at-risk individuals met the criteria for PrEP, but 13% lacked knowledge of their partners' sexual and behavioral risk factors, preventing a clear decision on whether PrEP should be used. Our screen identified no individuals who clearly met the guideline criteria for HIV PrEP. We conclude that universal screening for HIV PrEP in primary care is unlikely to be an efficient strategy; targeted screening is likely more appropriate. Moreover, the 2019 guidelines for heterosexually active men and women rely on information that is often unknown to the patient, which makes these guidelines difficult to implement. Future guidelines should address these problems.

Life and Disability Insurance for People with or at Risk of HIV: Aligning Policy with Evidence

Antiretroviral medications have substantially improved life expectancy for people with HIV. These medications are also highly effective in preventing HIV acquisition in people who do not have HIV, a strategy known as HIV preexposure prophylaxis (PrEP). Despite these advances, some life and disability insurers continue to deny or limit coverage for people with HIV, and some have even refused to cover people who are using PrEP to protect themselves. These policies unfairly deny people with HIV, PrEP users, and their families the peace of mind and financial protection that can come with life and disability insurance coverage. This article summarizes the current evidence on HIV treatment and prevention, arguing that underwriting decisions by life and disability insurers should not be made based on HIV status or use of PrEP.

Uptake and Persistent Use of HIV Preexposure Prophylaxis Among Key Populations: Results From Ukraine's Scaled National Preexposure Prophylaxis Program

BACKGROUND

Ukraine has implemented ambitious HIV-prevention programs since 1999 and began offering preexposure prophylaxis (PrEP) in 2017. Little is known about PrEP uptake and persistence in this setting.

SETTING

We analyzed data from 40 facilities providing PrEP in 11 oblasts (regions) of Ukraine between October 2020 and February 2022.

METHODS

We estimated the time between PrEP visits and conducted Kaplan-Meier analyses to estimate retention on PrEP stratified by sex, age, and key populations (KPs): men who have sex with men (MSM), people who inject drugs (PWID), sex workers (SW), discordant couples, and others vulnerable to HIV acquisition (DC/other). We used Cox regression to estimate the risk of PrEP discontinuation by KP group and sex, adjusting for age.

RESULTS

Overall, 2033 clients initiated PrEP across regions; the majority (51%) were DC/other, 22% were MSM, 22% were PWID, and 5% were SW. The overall 3-month persistence was 52.3% (95% confidence interval [CI]: 49.9% to 54.8%) and was lowest among MSM (46.7%; 95% CI: 41.9% to 52.2%) and SW (25.9%; 95% CI: 18.2% to 36.9%) (P < 0.05 for differences by KP group). After adjusting for age, PrEP discontinuation was not statistically significantly different across groups, although female PWID tended to have the lowest discontinuation risk (adjusted hazard ratio [aHR] 0.59; 95% CI: 0.31 to 1.11) while male SW tended to have the highest risk (aHR 1.87, 95% CI: 0.57 to 6.11) compared with females in the DC/other group.

CONCLUSION

Three-month PrEP persistence was low across KP groups, especially in SW. Further research examining the barriers and enablers of persistence by KPs is needed.

Need for informed providers: exploring LA-PrEP access in focus groups with PrEP-indicated communities in Baltimore, Maryland

BACKGROUND

The approval of long-acting pre-exposure prophylaxis PrEP (LA-PrEP) in the United States brings opportunities to overcome barriers of oral PrEP, particularly among sexual and gender minority communities who bear a higher HIV burden. Little is known about real-time decision-making among potential PrEP users of LA-PrEP post-licensure.

METHODS

We held focus group discussions with people assigned male at birth who have sex with men in Baltimore, Maryland to explore decision-making, values, and priorities surrounding PrEP usage. A sexual and gender minority-affirming health center that provides PrEP services supported recruitment. Discussions included a pile-sorting activity and were audio-recorded. Recordings were transcribed and analyzed iteratively, combining an inductive and deductive approach.

RESULTS

We held five focus groups from Jan-June 2023 with 23 participants (21 cisgender men who have sex with men, two transgender women who have sex with men; mean age 37). Among participants, 21 were on oral PrEP, one was on injectable PrEP, and one had never taken PrEP. Most had never heard about LA-PrEP. When making decisions about PrEP, participants particularly valued efficacy in preventing HIV, side effects, feeling a sense of security, and ease of use. Perceptions varied between whether oral or injectable PrEP was more convenient, but participants valued the new opportunity for a choice in modality. Factors influencing PrEP access included cost, individual awareness, provider awareness, and level of comfort in a healthcare environment. Participants emphasized how few providers are informed about PrEP, placing the burden of being informed about PrEP on them. Comfort and trust in a provider superseded proximity as considerations for if and where to access PrEP.

CONCLUSIONS

There is still low awareness about LA-PrEP among sexual and gender minority communities; thus, healthcare providers have a critical role in influencing access to LA-PrEP. Despite this, providers are still vastly underinformed about PrEP and underprepared to support clients in contextualized ways. Clients are more likely to engage in care with affirming providers who offer non-judgmental conversations about sex and life experiences. Provider education in the United States is urgently needed to better support clients in choosing a PrEP modality that is right for them and supporting adherence for effective HIV prevention.

Social and structural factors associated with interest in HIV preexposure prophylaxis among Black women in the United States

In a nationwide sample of cisgender Black women in the US, we assessed the associations between social and structural factors and interest in using HIV preexposure prophylaxis (PrEP). Among 315 respondents, 62.2% were interested in PrEP if it were provided for free. Positive social norms surrounding PrEP, including injunctive norms (perceived social acceptability of PrEP use) and descriptive norms (perceived commonality of PrEP use), were positively associated with interest in using PrEP. Concerns about HIV infection, recently visiting a health care provider, and comfort discussing PrEP with a provider were also positively associated with interest in using PrEP. Anticipating PrEP disapproval from others was negatively associated with interest in PrEP. Although PrEP can promote autonomy and personal discretion, Black women's PrEP-related decisions occur in a complex social environment. Black women may benefit from interventions to promote positive norms and attitudes surrounding PrEP at the community level and empower them in discussions with their providers about PrEP.

HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis

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.

Needs and Opportunities for Anal Cancer Prevention in Patients Engaged With PrEP Care: Development of Conceptual Model

INTRODUCTION

Populations at risk for HIV infection-including gay, bisexual, and other men who have sex with men (GBM) and transgender/gender diverse people (TGD)-are at disproportionate risk for anal cancer. Most anal cancers are caused by human papillomavirus (HPV) and are preventable with HPV vaccination and screening. Engaging at-risk populations who are already receiving HIV preventive care (eg, pre-exposure prophylaxis [PrEP]) may be an effective implementation strategy. The purpose of this study was to (1) identify the information, motivation, and behavioral skills that influence decisions about anal cancer prevention and to (2) describe the healthcare utilization patterns among PrEP users that impact their engagement in anal cancer prevention.

METHODS

Using purposive sampling in the United States, we ensured diverse representation among PrEP users aged 18 to 45 across gender and ethnoracial identities. Recruitment sources included primary healthcare clinics, social media, and community venues. Semi-structured interviews were recorded, transcribed, and coded using structural, pattern, and theoretical approaches.

RESULTS

Participants (N = 36) were mostly cisgender gay ethnoracial minority men. We identified 29 unique codes that were nested within 3 categories: individual decision-making, healthcare utilization patterns, and healthcare system influences. Participants commonly lacked essential information about HPV and anal cancer, often holding misconceptions about risks and prevention. Motivation for anal cancer prevention was driven by healthcare interactions and perceived risks, while fragmented healthcare and reliance on telemedicine were potential barriers. Many participants used telehealth services to access PrEP, described it as convenience, cost-effective, and liked the lack of provider interaction. Some participants used telehealth for PrEP and did not have a primary care provider. The importance of access to LGBTQ+-affirmative healthcare services was highlighted.

CONCLUSIONS

Integrating patient education and prevention services into ongoing PrEP management can enhance the reach and equity of anal cancer prevention. Our model underscores critical areas of misinformation, necessary systems-level changes, and unmet needs.

Optimizing HIV PrEP Persistence: Does Your Pharmacy Matter?

Persistence to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is integral to preventing new HIV infections. Previous studies have shown real-world PrEP persistence is low and insight is needed into PrEP delivery strategies that improve persistence. This single-center, retrospective, cohort study measured persistence in patients filling PrEP through an integrated health-system specialty pharmacy (HSSP) compared to those filling at external pharmacies. The Kaplan-Meier estimates for persistence probability at 6, 12, and 18 months were 0.87 (95% CI 0.79-0.95), 0.75 (95% CI 0.66-0.86), and 0.64 (95% CI 0.53-0.76) for the HSSP cohort compared to 0.65 (95% CI 0.51-0.83), 0.41 (95% CI 0.28-0.62), and 0.32 (95% CI 0.2-0.53), respectively, for the non-HSSP cohort (log-rank p < 0.001, [Formula: see text] = 11.2). Cox PH modeling showed that patients using a non-HSSP were 2.7 times more likely to be non-persistent than HSSP patients (HR 2.7, 95% CI 1.6-4.7, p < 0.001, [Formula: see text] = 12.61), demonstrating patients were better maintained on PrEP therapy when their prescriptions were filled with the HSSP.

Prioritising the values of potential users to promote uptake of HIV pre-exposure prophylaxis

Benefits of pre-exposure prophylaxis (PrEP) extend beyond HIV risk reduction. Users report a range of physical, emotional, and social effects, including reduced anxiety, increased intimacy, and greater sexual satisfaction. For some people, these benefits are the primary motivation for using PrEP. To successfully engage in shared decision making about HIV prevention methods, clinicians need to be able to discuss all potential risks and benefits of PrEP. These risks and benefits include not only those related to HIV risk reduction and other clinical outcomes, but also those related to experiences and relationships that people value. However, national and international clinical resources on the provision of PrEP do not include user-reported outcomes that are values-based or reflect positive effects on personal, social, or sexual wellbeing. To better integrate the values of potential users into discussions about PrEP, clinician training programmes and clinical guidelines need to be guided by community-driven frameworks and expanded to include user-reported outcomes of PrEP use, including beneficial effects. Achieving PrEP uptake and equity goals will require an approach to PrEP provision that centres the values and desired experiences of potential users, particularly those from populations with the greatest unmet need for PrEP.

The future of HIV pre-exposure prophylaxis adherence: reducing barriers and increasing opportunities

The effectiveness of HIV pre-exposure prophylaxis (PrEP) hinges on adherence, which has been restricted by multifaceted barriers. Uptake of PrEP has been impeded by poor access resulting from high costs, provider uncertainty, discrimination, stigma, and poor understanding within the health-care community and the public of who can benefit from PrEP. Other important barriers to adherence and persistence over time relate to individuals (eg, depression) and their community, partners, and family (eg, poor support), and their effects vary substantially with each person, population, and setting. Despite these challenges, key opportunities for improving PrEP adherence exist, including novel delivery systems, tailored individual interventions, mobile health and digital health interventions, and long-acting formulations. Objective monitoring strategies will help to improve adherence interventions and alignment of PrEP use with the need for HIV prevention (ie, prevention-effective adherence). The future of PrEP adherence lies in person-centred approaches to service delivery that meet the needs of individuals while creating supportive environments and facilitating health-care access and delivery.

Correlates of Mpox Vaccination among Sexual Minority Men in the United States: Sexual Behavior, Substance Use, and Main Partner Relationships

Sexual minority men (SMM) have accounted for the majority of infections during the 2022 outbreak of the orthopox virus known as mpox (previously "monkeypox") in the US. This study examined correlates of mpox vaccination. Between July 28 and September 22, 2022, adult cisgender SMM (n = 2,620) not previously diagnosed with mpox responded to recruitment advertisements on social networking applications and completed an online survey. Of these, 730 (27.9%) received at least one vaccine dose. Logistic regression indicated sex with a casual partner was positively associated with vaccination. Stimulant drug use was negatively associated with vaccination; meanwhile, the use of ecstasy, ketamine, gamma-hydroxybutyrate (GHB) or psychedelics was positively associated with vaccination. Among partnered SMM, non-monogamous sexual agreements, relationship length of ≥2 years, and relationship functioning were positively associated with vaccination. Even at low levels of relationship functioning, SMM in non-monogamous relationships of ≥2 years were more likely to be vaccinated than single SMM. At very high levels of relationship functioning, partnered SMM were more likely to be vaccinated than single SMM regardless of sexual agreement or relationship length. Findings are discussed in relation to prior research on HIV, other STI prevention, and theories of dyadic functioning and health in this population.

Determining the screening frequency for sexually transmitted infections for people who use HIV pre-exposure prophylaxis: a systematic review and meta-analysis

OBJECTIVES

Although the World Health Organization recommends 'frequent' screening of sexually transmitted infections (STI) for people who use pre-exposure prophylaxis for HIV, there is no evidence for optimal frequency.

METHODS

We searched five databases and used random-effects meta-analysis to calculate pooled estimates of STI test positivity. We narratively synthesized data on secondary outcomes, including adherence to recommended STI screening frequency and changes in STI epidemiology.

RESULTS

Of 7477 studies, we included 38 for the meta-analysis and 11 for secondary outcomes. With 2-3 monthly STI screening, the pooled positivity was 0.20 (95% confidence interval [CI]: 0.15-0.25) for chlamydia, 0.17 (95% CI: 0.12-0.22) for gonorrhea, and 0.07 (95% CI: 0.05-0.08) for syphilis. For chlamydia and gonorrhea, the positivity was approximately 50% and 75% lower, respectively, in studies that screened 4-6 monthly vs 2-3 monthly. There was no significant difference in the positivity for syphilis in studies that screened 4-6 monthly compared to 2-3 monthly. Adherence of clients to recommended screening frequency varied significantly (39-94%) depending on population and country. Modeling studies suggest more frequent STI screening could reduce incidence.

CONCLUSION

Although more frequent STI screening could reduce delayed diagnoses and incidence, there remain significant knowledge gaps regarding the optimal STI screening frequency.