Understanding the role of nurse practitioners, physician assistants and other nursing staff in HIV pre-exposure prophylaxis care in the United States: a systematic review and meta-analysis

Unlocking the potential of primary healthcare nurse practitioners globally: A concept analysis of their added value

BACKGROUND

Primary healthcare nurse practitioners (PHCNPs) are expanding globally to meet rising healthcare demands. Despite positive outcomes, their added value remains underexplored.

PURPOSE

To clarify and refine the added value PHCNPs bring.

METHODS

Building on a previous concept analysis of the added value of nurse practitioners, we analyzed 37 systematic reviews focusing on PHCNPs' roles across various settings, using Rodgers' evolutionary approach.

FINDINGS

Attributes include PHCNPs' skills and competencies, activities, positive outcomes, and professional autonomy. Antecedents involve PHCNP characteristics and structural and institutional factors, while consequences highlight improved patient outcomes, satisfaction, professional dynamics, and system efficiency.

DISCUSSION

Understanding PHCNPs' added value is crucial for policy development, role implementation, and healthcare optimization. Clear regulatory frameworks and supportive policies are needed to maximize their impact.

CONCLUSION

This analysis provides and updates the conceptual definition of PHCNPs' added value, offering insights for policy, education, and research to support their critical role in healthcare.

Understanding the PrEP Care Continuum for Adults: Health Care Providers' Perspectives on Barriers, Facilitators, and Missed Opportunities

Pre-exposure prophylaxis (PrEP) is an effective strategy in reducing HIV transmission, yet its uptake remains suboptimal. Health care providers play a vital role in facilitating PrEP access and care. This qualitative study explores health care providers' perspectives on the oral PrEP care continuum for adults, emphasizing barriers, facilitators, and missed opportunities in PrEP implementation. Drawing on interviews with 18 primary care providers in New York State, our research investigates multi-level factors influencing PrEP awareness, initiation, and management. Findings reveal significant barriers at the patient level, such as low awareness, stigma, and misconceptions about HIV risk. Provider-level challenges include knowledge gaps, discomfort in discussing sexual health, and logistical constraints. Structural factors such as insufficient infrastructure and high costs impede consistent PrEP management. Facilitators identified include proactive provider-patient communication, educational resources, and workflow integration strategies. Subgroup analyses highlight variations in attitudes based on provider demographics and experience. Younger and female providers are more proactive in discussing PrEP, while older and male providers often perceive it as less relevant. Nurses emphasize patient education and trust-building, contrasting with physicians' focus on logistical challenges. Providers experienced in prescribing PrEP view it as a valuable prevention tool, while nonprescribers report hesitancy and limited familiarity. Discrepancies in patient-perceived versus actual HIV risk, as well as provider assumptions about patient candidacy for PrEP, underscore the need for routine, stigma-free discussions about HIV prevention. This study emphasizes the importance of targeted provider training, system-level support, and inclusive policies to enhance PrEP uptake. Addressing these barriers and leveraging facilitators can advance public health efforts, fostering equitable and effective HIV prevention strategies.

Lenacapavir to prevent HIV infection: current prices versus estimated costs of production

BACKGROUND

Despite improvements in treatment and oral pre-exposure prophylaxis (PrEP) access, 1.3 million people acquired HIV in 2022. Six-monthly lenacapavir PrEP could benefit tens of millions of people at high risk of infection. However, prices are currently up to $44 819 per person per year (pppy).

OBJECTIVES

We projected minimum lenacapavir pricing based on generic mass production and a Cost-Plus (Cost+) model.

METHODS

Current active pharmaceutical ingredient (API) and key starting materials (KSMs) costs were obtained from export databases. The routes of synthesis (ROS) were analysed to project a cost of goods (COGs). Formulation, vials and profit margin costs were included using standardized algorithms and Cost+ pricing. We estimated prices with scale-up to supply 1 million then 10 million treatment-years, comparing this with national list prices.

RESULTS

The lenacapavir API is currently exported from India for $64 480/kg on 1 kg scale. Based on the ROS and KSMs, API COGs of $25 000/kg and $10 000/kg are achievable for a committed demand of 1 million (2 million tonnes/annum of API) and 10 million treatment-years, respectively. Including formulation steps, injectable lenacapavir could be mass produced for approximately $94 pppy for 1 million and $41 for 10 million treatment-years, if voluntary licences are in place and competition between generic suppliers substantially improves. Greater scale-up with improvements in manufacturers' ROS could reduce prices further. Currently lenacapavir costs $25 395-44 819 pppy.

CONCLUSIONS

Lenacapavir could be mass produced for <$100 pppy at launch. Voluntary licensing and multiple suppliers are required to achieve these low prices. This mechanism is already in place for other antiretrovirals. To date, Gilead has not agreed lenacapavir voluntary licences with the Medicines Patent Pool.

Ameliorating Racial Disparities in HIV Prevention via a Nurse-Led, AI-Enhanced Program for Pre-Exposure Prophylaxis Utilization Among Black Cisgender Women: Protocol for a Mixed Methods Study

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is a critical biomedical strategy to prevent HIV transmission among cisgender women. Despite its proven effectiveness, Black cisgender women remain significantly underrepresented throughout the PrEP care continuum, facing barriers such as limited access to care, medical mistrust, and intersectional racial or HIV stigma. Addressing these disparities is vital to improving HIV prevention outcomes within this community. On the other hand, nurse practitioners (NPs) play a pivotal role in PrEP utilization but are underrepresented due to a lack of awareness, a lack of human resources, and insufficient support. Equipped with the rapid evolution of artificial intelligence (AI) and advanced large language models, chatbots effectively facilitate health care communication and linkage to care in various domains, including HIV prevention and PrEP care.

OBJECTIVE

Our study harnesses NPs' holistic care capabilities and the power of AI through natural language processing algorithms, providing targeted, patient-centered facilitation for PrEP care. Our overarching goal is to create a nurse-led, stakeholder-inclusive, and AI-powered program to facilitate PrEP utilization among Black cisgender women, ultimately enhancing HIV prevention efforts in this vulnerable group in 3 phases. This project aims to mitigate health disparities and advance innovative, technology-based solutions.

METHODS

The study uses a mixed methods design involving semistructured interviews with key stakeholders, including 50 PrEP-eligible Black women, 10 NPs, and a community advisory board representing various socioeconomic backgrounds. The AI-powered chatbot is developed using HumanX technology and SmartBot360's Health Insurance Portability and Accountability Act-compliant framework to ensure data privacy and security. The study spans 18 months and consists of 3 phases: exploration, development, and evaluation.

RESULTS

As of May 2024, the institutional review board protocol for phase 1 has been approved. We plan to start recruitment for Black cisgender women and NPs in September 2024, with the aim to collect information to understand their preferences regarding chatbot development. While institutional review board approval for phases 2 and 3 is still in progress, we have made significant strides in networking for participant recruitment. We plan to conduct data collection soon, and further updates on the recruitment and data collection progress will be provided as the study advances.

CONCLUSIONS

The AI-powered chatbot offers a novel approach to improving PrEP care utilization among Black cisgender women, with opportunities to reduce barriers to care and facilitate a stigma-free environment. However, challenges remain regarding health equity and the digital divide, emphasizing the need for culturally competent design and robust data privacy protocols. The implications of this study extend beyond PrEP care, presenting a scalable model that can address broader health disparities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/59975.

A global perspective of advanced practice nursing research: A review of systematic reviews

INTRODUCTION

The World Health Organization (WHO) called for the expansion of all nursing roles, including advanced practice nurses (APNs), nurse practitioners (NPs) and clinical nurse specialists (CNSs). A clearer understanding of the impact of these roles will inform global priorities for advanced practice nursing education, research, and policy.

OBJECTIVE

To identify gaps in advanced practice nursing research globally.

MATERIALS AND METHODS

A review of systematic reviews was conducted. We searched CINAHL, Embase, Global Health, Healthstar, PubMed, Medline, Cochrane Library, DARE, Joanna Briggs Institute EBP, and Web of Science from January 2011 onwards, with no restrictions on jurisdiction or language. Grey literature and hand searches of reference lists were undertaken. Review quality was assessed using the Critical Appraisal Skills Program (CASP). Study selection, data extraction and CASP assessments were done independently by two reviewers. We extracted study characteristics, country and outcome data. Data were summarized using narrative synthesis.

RESULTS

We screened 5840 articles and retained 117 systematic reviews, representing 38 countries. Most CASP criteria were met. However, study selection by two reviewers was done inconsistently and language and geographical restrictions were applied. We found highly consistent evidence that APN, NP and CNS care was equal or superior to the comparator (e.g., physicians) for 29 indicator categories across a wide range of clinical settings, patient populations and acuity levels. Mixed findings were noted for quality of life, consultations, costs, emergency room visits, and health care service delivery where some studies favoured the control groups. No indicator consistently favoured the control group. There is emerging research related to Artificial Intelligence (AI).

CONCLUSION

There is a large body of advanced practice nursing research globally, but several WHO regions are underrepresented. Identified research gaps include AI, interprofessional team functioning, workload, and patients and families as partners in healthcare.

PROSPERO REGISTRATION NUMBER

CRD42021278532.

Perspectives on Injectable HIV Pre-Exposure Prophylaxis: A Qualitative Study of Health Care Providers in the United States

The introduction of injectable HIV pre-exposure prophylaxis (PrEP) has the potential to significantly change the biomedical HIV prevention landscape. However, effective implementation will require health care providers to adopt, prescribe, and administer injectable PrEP within clinical settings. This study qualitatively examined challenges and benefit of injectable PrEP implementation from the perspective of health care providers. From April to August 2022, we conducted 19 in-depth interviews with current PrEP-prescribing health care providers in New York State, including 3 physician assistants, 5 physicians, and 11 nurse practitioners. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed to report semantic-level themes regarding injectable PrEP implementation. More than half of participants (61%) were aware of injectable PrEP; only 21% had experience prescribing it. Qualitative findings highlighted five themes. Three themes represented implementation challenges, including speculative concerns about side effects, appointment compliance, and practical and logistical considerations. The remaining two themes described benefits of injectable PrEP relative to oral PrEP, which included greater convenience and enhanced privacy. Findings from this qualitative study make significant applied contributions to the sparse knowledge on health care provider perspectives of injectable PrEP post-US Food and Drug Administration approval and their concerns and considerations regarding implementation in real-world clinical settings.

Identifying indicators sensitive to primary healthcare nurse practitioner practice: A review of systematic reviews

AIM

To identify indicators sensitive to the practice of primary healthcare nurse practitioners (PHCNPs).

MATERIALS AND METHODS

A review of systematic reviews was undertaken to identify indicators sensitive to PHCNP practice. Published and grey literature was searched from January 1, 2010 to December 2, 2022. Titles/abstracts (n = 4251) and full texts (n = 365) were screened independently by two reviewers, with a third acting as a tie-breaker. Reference lists of relevant publications were reviewed. Risk of bias was examined independently by two reviewers using AMSTAR-2. Data were extracted by one reviewer and verified by a second reviewer to describe study characteristics, indicators, and results. Indicators were recoded into categories. Findings were summarized using narrative synthesis.

RESULTS

Forty-four systematic reviews were retained including 271 indicators that were recoded into 26 indicator categories at the patient, provider and health system levels. Nineteen reviews were assessed to be at low risk of bias. Patient indicator categories included activities of daily living, adaptation to health conditions, clinical conditions, diagnosis, education-patient, mortality, patient adherence, quality of life, satisfaction, and signs and symptoms. Provider indicator categories included adherence to best practice-providers, education-providers, illness prevention, interprofessional team functioning, and prescribing. Health system indicator categories included access to care, consultations, costs, emergency room visits, healthcare service delivery, hospitalizations, length of stay, patient safety, quality of care, scope of practice, and wait times.

DISCUSSION

Equal to improved care for almost all indicators was found consistently for the PHCNP group. Very few indicators favoured the control group. No indicator was identified for high/low fidelity simulation, cultural safety and cultural sensitivity with people in vulnerable situations or Indigenous Peoples.

CONCLUSION

This review of systematic reviews identified patient, provider and health system indicators sensitive to PHCNP practice. The findings help clarify how PHCNPs contribute to care outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020198182.

Implementation of a bundle to improve HIV testing during hospitalization for people who inject drugs

Background

Increased HIV testing is essential to ending the HIV epidemic. People who inject drugs (PWID) are among the highest risk for HIV infection. Previous research at Tufts Medical Center identified low HIV testing rates in hospitalized PWID. Our research team aimed to identify and overcome barriers to inpatient HIV screening of PWID using implementation science methods.

Methods

Stakeholders were engaged to gather perspectives on barriers and facilitators of HIV testing. A PWID care bundle was developed and implemented, which included (1) HIV screening; (2) hepatitis A, B, and C testing and vaccination; (3) medications for opioid use disorder; and (4) naloxone prescription. Strategies from all nine Expert Recommendations for Implementing Change (ERIC) clusters guided the implementation plan. Stakeholder feedback was gathered throughout implementation, and implementation outcomes of acceptability and feasibility were assessed.

Results

PWID overall felt comfortable with HIV testing being offered while hospitalized. Clinicians cited that the main barriers to HIV testing were discomfort and confusion around consenting requirements. Many resident physicians surveyed reported that, at times, they forgot HIV testing for PWID. Overall, though, resident physicians felt that the PWID bundle was useful and did not distract from other patient care responsibilities.

Conclusions

Engagement of key stakeholders to increase HIV testing in an inpatient setting led to the implementation of a PWID bundle, which was feasible and acceptable. Bundling evidence-informed care elements for inpatient PWID should be investigated further.

Challenges to meeting the HIV care needs of older adults in the rural South

People living with HIV in rural parts of the Southern United States face poor outcomes along the HIV care continuum. Additionally, over half of people with diagnosed HIV are age 50 and older. Older adults living with HIV in the rural South often have complex health and social needs associated with HIV, aging, and the rural environment. Research is needed to understand what support organizations and clinics need in providing care to this population. This qualitative study examines the challenges health and social service providers face in caring for older patients living with HIV. In 2020-2021, we interviewed 27 key informants who work in organizations that provide care to older adults with HIV in the seven states with high rural HIV burden: Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina. Our findings highlight how racism and poverty; culture, politics, and religion; and a lack of healthcare infrastructure collectively shape access to HIV care for older adults in the South. Rural health and social service providers need structural-level changes to improve their care and services.

Implementation of a Standardized National HIV Curriculum in a Primary Care Nurse Practitioner Program

BACKGROUND

Although efforts have been made to improve and integrate an HIV curriculum in schools of nursing, little has been done to standardize the integration of competencies related to HIV care in primary care nurse practitioner (NP) programs.

PURPOSE

The purpose of this study was to understand the effect of integrating the 6 core competencies from the National HIV Curriculum (NHC) on NP students' perceived knowledge about HIV care.

METHOD

This was a quasi-experimental study with a pre/posttest design that measured NP students' self-perceived knowledge of the 6 core competencies from the NHC.

RESULTS

A total of 375 student NHC training sessions were implemented across 5 semesters (fall 2019 through fall 2021 academic years). In each of the 3 courses that integrated the NHC, there were statistically significant increases in student knowledge from pre- to posttest for each of the 6 competencies.

CONCLUSION

This project supports using a standardized HIV curriculum as part of primary care NP curricula.

Telemedicine Experience for PrEP Care among PrEP-Eligible Women and Their Primary Care Providers during the First Year of the COVID-19 Pandemic in the United States

(1) Background: During the two-year-long siege from the COVID-19 pandemic, a significant proportion of doctor visits transitioned from in-person to virtual. Scare evidence is available to assess the quality of patient-provider communication via the platform of telemedicine, especially for PrEP care within primary care settings. (2) Methods: Participants included 18 primary care providers and 29 PrEP-eligible women. Through content analysis and thematic analysis, facilitators and barriers embedded at different levels of telemedicine were identified and assessed. (3) Results: Women and providers reported pros and cons regarding their telemedicine experiences during the initial wave of COVID-19. Both groups of participants agreed that telemedicine visits were more convenient, efficient, and comfortable than in-person visits. However, without face-to-face interactions, some women felt less empathy, caring, and connected with their providers during virtual visits. Health providers expressed concerns with telemedicine, including patients’ privacy, lack of intimacy between patients and providers, and delayed lab work. (4) Conclusions: Our data indicate multi-level factors may affect telemedicine experience among PrEP-eligible women and health providers. Participants expressed concerns that may further entrench these long-existing health disparities in healthcare. Proactive efforts from policymakers, health professionals, researchers, and stakeholders are urgently required to tackle identified barriers and to pave the way for the new infrastructure that ensures health equity in society.

Nurse practitioner model of care for the initiation of pre-exposure prophylaxis: A case series study

AIM

The purpose of this study was to create and implement a nurse practitioner model of care in the initiation of a pre-exposure prophylaxis (PrEP) protocol with African American men who have sex with men (MSM).

DESIGN

A case series design was used to implement the protocol for a nurse practitioner PrEP-based model of care.

METHODS

The participatory, evidence-based, patient-focus process (PEPPA) framework and the American Association of Colleges of Nursing (AACN) Doctoral Essentials for Advanced Practice were aligned to guide the development, implementation, and evaluation of this advanced practice role in an urban medical clinic.

RESULTS

Seven African American HIV-negative MSM who received treatment under the nurse practitioner PrEP-based model of care had increased PrEP knowledge and medication adherence and did not contract a sexually transmitted infection.

CONCLUSIONS

New models of care can be created to meet the Getting to Zero HIV initiative of reducing rates of HIV infections with MSM.

Determinants of Implementation for HIV Pre-exposure Prophylaxis Based on an Updated Consolidated Framework for Implementation Research: A Systematic Review

BACKGROUND

Delivery and use of HIV pre-exposure prophylaxis (PrEP) are suboptimal in the United States. Previous reviews of barriers and facilitators have not used an implementation science lens, limiting comprehensiveness and the link to implementation strategies. To summarize the state of the science, we systematically reviewed determinants of PrEP implementation using the updated Consolidated Framework for Implementation Research (CFIR 2.0).

SETTING

PrEP-eligible communities and delivery settings in the United States.

METHODS

In January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer-reviewed articles related to HIV/AIDS, interventions, implementation, and determinants or strategies. We identified 286 primary research articles published after 1999 about US-based PrEP implementation. Team members extracted discrete "mentioned" and "measured" determinants, coding each by setting, population, valence, measurement, and CFIR 2.0 construct.

RESULTS

We identified 1776 mentioned and 1952 measured determinants from 254 to 239 articles, respectively. Two-thirds of measured determinants were of PrEP use by patients as opposed to delivery by providers. Articles contained few determinants in the inner setting or process domains (ie, related to the delivery context), even among studies of specific settings. Determinants across priority populations also focused on individual patients and providers rather than structural or logistical factors.

CONCLUSION

Our findings suggest substantial knowledge in the literature about general patient-level barriers to PrEP use and thus limited need for additional universal studies. Instead, future research should prioritize identifying determinants, especially facilitators, unique to understudied populations and focus on structural and logistical features within current and promising settings (eg, pharmacies) that support integration of PrEP into clinical practice.

Scaling up preexposure prophylaxis to maximize HIV prevention impact

PURPOSE OF REVIEW

Ten years since the first regulatory approval of oral HIV preexposure prophylaxis (PrEP), this review summarizes PrEP uptake, the role of ambitious PrEP targets, emerging evidence of impact on the HIV epidemic and innovative approaches to increasing PrEP uptake.

RECENT FINDINGS

PrEP uptake among people at risk of HIV has been slow, but has accelerated in recent years, particularly in gay and bisexual men in a limited number of high-income settings and recently in heterosexuals at risk of HIV in sub-Saharan Africa. However, UNAIDS 2020 PrEP targets and HIV prevention targets were missed by large margins. Although UNAIDS testing and treatment targets have galvanised public health action, in contras, PrEP targets have been lower profile and insufficiently ambitious. Parts of the USA, Australia and the UK with high PrEP coverage have demonstrated striking reductions in HIV infection at the population level, as PrEP is introduced at scale. Scaling up PrEP uptake will require innovations in PrEP promotion, simplified models of care, improved adherence interventions, improved choice in the form of longer-acting PrEP and interventions to ensure that all those who can benefit from PrEP can access it.

SUMMARY

PrEP is a revolutionary HIV prevention tool, which if ambitiously scaled up could drive HIV transmission towards elimination. Highly publicized and ambitious PrEP targets could help drive this.

Scaling up access to HIV pre-exposure prophylaxis (PrEP): should nurses do the job?

Task sharing has been one of the most important enabling policies supporting the global expansion of access to HIV testing and treatment. The WHO public health approach, which relies on delivery of antiretroviral therapy (ART) by nurses, has enabled a trebling of the number of people receiving ART during the past decade. WHO recognises that HIV pre-exposure prophylaxis (PrEP) can also be provided by nurses; however, many countries still do not have policies in place that support nurse provision of PrEP. In sub-Saharan Africa, most countries allow nurses to prescribe ART, but only a few countries have policies in place that allow nurses to prescribe PrEP. Nurse-led PrEP delivery is particularly low in the Asia-Pacific region, which has some of the world's fastest growing epidemics. Even in many high-income countries, PrEP scale-up has been limited because policies often require medical doctors or specialists to prescribe. Service providers in many countries are coming to realise that scaling up access to PrEP cannot be achieved by medical doctors alone, and nurse-led PrEP delivery can help to lay the groundwork for supporting uptake of other HIV prevention approaches that will become available in the future. Countries with policies that authorise nurses to prescribe ART could be early adopters and help to pave the way for wider adoption of nurse-led PrEP delivery.