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Camfield C, Evans YN, Kumbhakar RG. HIV preexposure prophylaxis in adolescents and young adults: an update. Curr Opin Pediatr 2024:00008480-990000000-00178. [PMID: 38655797 DOI: 10.1097/mop.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW This review provides an update of evidence for HIV preexposure prophylaxis (PrEP), including efficacy and safety of newly available medications. It discusses barriers to care that are unique to adolescents and young adults as well as interventions that may help increase uptake, adherence, and retention in care. RECENT FINDINGS Tenofovir alafenamide-emtricitabine and cabotegravir are both newly approved medications for the prevention of HIV and are well tolerated and effective for adolescents. These medications, along with tenofovir disoproxil-emtricitabine, offer a variety of PrEP options to choose from. SUMMARY Adolescents and young adults have many options when it comes to HIV prevention, but barriers persist in terms of uptake and adherence to PrEP and retention in care. Technology-based interventions, provider education, navigation support, and multiple access options are all tools to help increase PrEP use in young people.
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Affiliation(s)
- Caitlin Camfield
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington & Seattle Children's Hospital
| | - Yolanda N Evans
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington & Seattle Children's Hospital, Seattle, Washington, USA
| | - Raaka G Kumbhakar
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington
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Sinno J, Daroya E, Wells A, Hull M, Lachowsky NJ, Tan DHS, Grace D. "To do so in a patient-centred way is not particularly lucrative": The effects of neoliberal health care on PrEP implementation and delivery. Soc Sci Med 2024; 347:116749. [PMID: 38492264 DOI: 10.1016/j.socscimed.2024.116749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/11/2024] [Accepted: 03/01/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention used by HIV-negative people to prevent HIV acquisition. Despite increased use of PrEP worldwide, several barriers to PrEP implementation have resulted in insufficient uptake, inadequate adherence, and frequent discontinuation. Our objective was to interrogate the social, political, and economic conditions shaping PrEP implementation and delivery among gay, bisexual, queer and other men who have sex with men (GBQM) in Ontario, Canada. METHODS Six focus groups and three interviews with 20 stakeholders in Ontario (e.g., healthcare professionals, clinicians, community-based organization staff, and government staff) were conducted between July and October 2021. Participants were asked about the personal, workplace, and structural factors shaping PrEP delivery strategies for GBQM. Transcripts were analyzed using reflexive thematic analysis informed by the political economy of PrEP and employed a critique of neoliberalism. RESULTS Participants critiqued the problematic arrangements of the current healthcare system in Canada. Neoliberal governmentality and policies have resulted in inequitable PrEP care by establishing funding structures prioritizing profit and requiring patients and providers to function as individual entrepreneurs. Consequently, healthcare disparities are compounded for marginalized peoples who lack the resources and capacity to navigate existing healthcare systems. Participants identified several pathways to improve the implementation of PrEP, including greater institutional and governmental supports for PrEP and healthcare, leveraging communities and collaboration, and moving beyond risk-based health frameworks. CONCLUSION Socio-political-economic changes reflecting post-neoliberal principles are needed to overcome existing barriers to PrEP care, and sexual and reproductive healthcare more broadly.
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Affiliation(s)
- Jad Sinno
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Emerich Daroya
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Alex Wells
- School of Public Health and Social Policy, University of Victoria, Victoria, Canada
| | - Mark Hull
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Nathan J Lachowsky
- School of Public Health and Social Policy, University of Victoria, Victoria, Canada
| | - Darrell H S Tan
- St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Daniel Grace
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Spadacio C, Santos LAD, Sorrentino IDS, Gomes R, Castellanos MEP, Zucchi EM, Grangeiro A, Couto MT. Methodological issues in qualitative research on HIV prevention: an integrative review. CAD SAUDE PUBLICA 2023; 39:e00033123. [PMID: 38055543 DOI: 10.1590/0102-311xen033123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 10/06/2023] [Indexed: 12/08/2023] Open
Abstract
In view of the growing concern about the use of qualitative approach in health research, this article aims to analyze how the qualitative theoretical-methodological framework of HIV prevention is presented in empirical research. We conducted an integrative literature review with the following guiding questions: "How is the qualitative theoretical-methodological framework expressed in empirical research on HIV prevention?"; "What are the limits and potentials of the qualitative methodological designs employed?". In the qualitative methodological discussion, five dimensions guided the methodological course and the presentation of findings, from the analysis of the characterization of qualitative studies to the contextualization of the studies and the methodological approaches used, highlighting the use of semi-structured interviews with thematic content analysis. We also examined social categories and analytical references, drawing attention to the plurality of these theoretical-conceptual references and to the authors' polyphony, and identified the limits and potentials of qualitative research. This study focuses on a scientific topic that is related to a wide variety of social groups and analyzes how they are affected by it, examining issues related to social inequality and other analytical possibilities surrounding HIV prevention, and providing resources for a comprehensive methodological discussion. Hence, avoiding the risk of conducting qualitative research based on checklists that limit inventiveness and openness to different designs and forms of execution and analysis is as pivotal as ensuring that the research is consistent and detailed in publications.
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Affiliation(s)
| | | | | | - Romeu Gomes
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
- Hospital Sírio-Libanês, São Paulo, Brasil
| | | | - Eliana Miura Zucchi
- Programa de Pós-graduação em Saúde Coletiva, Universidade Católica de Santos, Santos, Brasil
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Valente PK, Rusley JC, Operario D, Biello KB. Readiness to Provide Oral and Injectable PrEP for Sexual and Gender Minority Youth Among Healthcare Providers and Clinics in the U.S. Northeast. J Adolesc Health 2023; 72:722-729. [PMID: 36604205 PMCID: PMC10121770 DOI: 10.1016/j.jadohealth.2022.11.246] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/19/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To examine readiness to provide oral and injectable pre-exposure prophylaxis (PrEP) for sexual and gender minority youth (SGMY) and to explore decision-making for HIV prevention strategies (e.g., condom use, daily and event-driven oral PrEP, and injectable PrEP) among healthcare providers. METHODS Between February and April 2022, we recruited 31 prescribing providers (M.Ds, D.Os, P.As, and N.Ps) practicing in primary care and specialized clinics in the U.S. Northeast for focus groups or individual interviews. Focus groups and interview transcripts were analyzed using thematic analysis. RESULTS Most providers specialized in Pediatrics (42%) or Adolescent Medicine (23%) and 58% had previously prescribed PrEP. Main barriers to PrEP readiness were low PrEP knowledge, limited time for visits, and competing clinical priorities. Organizational factors such as routine HIV/STI testing, PrEP-specific electronic health records templates, and specialized staff (e.g., PrEP navigators) promoted PrEP readiness. Providers held positive attitudes toward injectable PrEP to promote adherence among SGMY, yet barriers to implementation of this modality were identified (e.g., patient anxiety about needles, additional staffing needs). Providers described event-driven oral PrEP as an option for SGMY with episodic HIV risk. Assurances of conditional confidentiality, including preventing disclosure of sensitive information through insurance forms, and shared decision-making facilitated conversations about HIV prevention with SGMY. DISCUSSION Future PrEP implementation efforts for SGMY should consider combined efforts targeting provider knowledge about PrEP modalities (e.g., decision aids) and clinic organizational factors (e.g., routine HIV/STI testing, resources to assist providers and patients in navigating the multiple steps between prescription and adherence to PrEP).
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Affiliation(s)
- Pablo K Valente
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island; Department of Allied Health Sciences, University of Connecticut, Waterbury, Connecticut.
| | - Jack C Rusley
- Division of Adolescent Medicine, Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island; Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Katie B Biello
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island; Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island; The Fenway Institute, Fenway Health, Boston, Massachusetts
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Valente PK, Operario D, Rusley J, Bauermeister JA, Biello KB. The need for a health equity framework in next-generation pre-exposure prophylaxis implementation. Lancet HIV 2023; 10:e266-e268. [PMID: 36848924 DOI: 10.1016/s2352-3018(23)00009-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/19/2022] [Accepted: 01/11/2023] [Indexed: 03/01/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is highly effective for prevention of HIV transmission and plays an important role in efforts to end the HIV epidemic within the next decade. However, disparities in access to PrEP might be fuelling disparities in the burden of HIV in the USA. The advent of next-generation PrEP formulations that do not involve daily regimens (eg, long-acting cabotegravir) holds potential to facilitate medication adherence, but if the roll-out of these formulations does not consider disparities in access, HIV disparities might be further widened. On the basis of US epidemiological data and informed by the Theory of Fundamental Causes of Health Disparities, we propose an equity-promoting framework to guide the implementation of daily oral and next-generation PrEP. Multilevel efforts to bolster equity in PrEP care include generating demand for next-generation PrEP formulations among marginalised groups, expanding the availability of health services providing oral and next-generation PrEP, and addressing structural and financial barriers to HIV prevention care. The aim of these strategies is to realise the potential of next-generation PrEP to provide people at high risk with effective options to prevent HIV acquisition, thereby helping to reduce both overall HIV transmission and health disparities in the USA.
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Affiliation(s)
- Pablo K Valente
- Department of Allied Health Sciences, University of Connecticut, Waterbury, CT, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.
| | - Don Operario
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jack Rusley
- Division of Adolescent Medicine, Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - José A Bauermeister
- Department of Family and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Katie B Biello
- Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; The Fenway Institute, Fenway Health, Boston, MA, USA
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Pickel J, Fiks AG, Karavite D, Maleki P, Beidas RS, Dowshen N, Petsis D, Gross R, Wood SM. Provider perspectives on clinical decision support to improve HIV prevention in pediatric primary care: a multiple methods study. Implement Sci Commun 2023; 4:18. [PMID: 36810099 DOI: 10.1186/s43058-023-00394-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/25/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Clinical decision support (CDS) is a promising intervention for improving uptake of HIV testing and pre-exposure prophylaxis (PrEP). However, little is known regarding provider perspectives on acceptability, appropriateness, and feasibility of CDS for HIV prevention in pediatric primary care, a key implementation setting. METHODS This was a cross-sectional multiple methods study utilizing surveys and in-depth interviews with pediatricians to assess acceptability, appropriateness, and feasibility of CDS for HIV prevention, as well as to identify contextual barriers and facilitators to CDS. Qualitative analysis utilized work domain analysis and a deductive coding approach grounded in the Consolidated Framework of Implementation Research. Quantitative and qualitative data were merged to develop an Implementation Research Logic Model to conceptualize implementation determinants, strategies, mechanisms, and outcomes of potential CDS use. RESULTS Participants (n = 26) were primarily white (92%), female (88%), and physicians (73%). Using CDS to improve HIV testing and PrEP delivery was perceived as highly acceptable (median score 5), IQR [4-5]), appropriate (5, IQR [4-5]), and feasible (4, IQR [3.75-4.75]) using a 5-point Likert scale. Providers identified confidentiality and time constraints as two key barriers to HIV prevention care spanning every workflow step. With respect to desired CDS features, providers sought interventions that were integrated into the primary care workflow, standardized to promote universal testing yet adaptable to the level of a patient's HIV risk, and addressed providers' knowledge gaps and bolstered self-efficacy in providing HIV prevention services. CONCLUSIONS This multiple methods study indicates that clinical decision support in the pediatric primary care setting may be an acceptable, feasible, and appropriate intervention for improving the reach and equitable delivery of HIV screening and PrEP services. Design considerations for CDS in this setting should include deploying CDS interventions early in the visit workflow and prioritizing standardized but flexible designs.
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Newman PA, Tepjan S, Fongkaew K, Akkakanjanasupar P, de Lind van Wijngaarden JW, Chonwanarat N. Multilevel Factors Impacting PrEP Engagement Among Young Gay Men and Young Transgender Women in Thailand: A Qualitative Analysis. J Int Assoc Provid AIDS Care 2023; 22:23259582231188221. [PMID: 37461326 DOI: 10.1177/23259582231188221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Half of new HIV infections in Thailand are among young people, the majority of whom are young gay and other men who have sex with men (YMSM) and young transgender women (YTGW). Amid low pre-exposure prophylaxis (PrEP) coverage, we explored practice-based factors that impact PrEP engagement among YMSM and YTGW. In 2018, we conducted 4 focus group discussions with 20 YMSM and 5 YTGW, and 22 in-depth interviews (5 in 2022) with healthcare providers (HCPs), community-based organization (CBO)/nongovernmental organization (NGO) staff, and peer educators. The inclusion of PrEP in universal healthcare coverage, including YMSM and YTGW, is a substantial facilitator of PrEP use; however, systemic barriers at microsocial (lack of communication about PrEP from HCPs, teachers, parents), mesosocial (healthcare-service fragmentation, lack of PrEP-competent HCPs), and macrosocial levels (annual quotas on free HIV-testing, HIV- and sexual-stigma) constrain and disincentivize adolescents' engagement with PrEP. National scale-up of youth-friendly and LGBT-affirmative CBO/NGO clinics, HCP training, and tailored programs to support adolescents' adherence may promote PrEP engagement among YMSM and YTGW in Thailand.
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Affiliation(s)
- Peter A Newman
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | | | - Kangwan Fongkaew
- Faculty of Humanities and Social Sciences, Burapha University, Chonburi, Thailand
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Valente PK, Bauermeister JA, Lin WY, Silva DTD, Hightow-Weidman L, Drab R, Mayer KH, Operario D, Rusley J, Biello KB. Preferences Across Pre-Exposure Prophylaxis Modalities Among Young Men Who Have Sex with Men in the United States: A Latent Class Analysis Study. AIDS Patient Care STDS 2022; 36:431-442. [PMID: 36367995 PMCID: PMC9910107 DOI: 10.1089/apc.2022.0111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Access to daily oral pre-exposure prophylaxis (PrEP) is suboptimal among young cisgender men who have sex with men (YMSM) in the United States. Next-generation modalities that do not involve daily oral regimens may mitigate some of the barriers to PrEP use. We identified latent classes of YMSM based on health care decision-making patterns and examined associations between latent classes and access to health care and PrEP modality preferences (i.e., daily and event-driven oral, rectal douches, broadly neutralizing antibodies, subcutaneous implants, and an injectable). Between October 2020 and June 2021, we administered an online survey to 737 YMSM. Latent class analysis (LCA) identified groups of YMSM based on communication with providers, stigma and mistrust in health care, and autonomy in sexual health decisions. Logistic regression examined associations between class membership and health care access, and exploded logit regression examined associations between class membership and ranked PrEP modality preferences. LCA identified three classes: shared decision-making (high communication with providers and high autonomy); provider-led decision-making (high communication and low autonomy); and patient-driven decision-making (low communication and high autonomy). Shared decision-making was associated with higher access to health care in comparison with the other classes. Across all classes, YMSM preferred daily oral PrEP over all next-generation PrEP modalities. Preferences for daily oral PrEP over next-generation PrEP modalities were particularly marked among the patient-driven decision-making class. Shared decision-making is associated with access to health care and HIV prevention and higher acceptability of next-generation PrEP modalities, and should be considered as part of future interventions to promote use of daily oral and next-generation PrEP.
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Affiliation(s)
- Pablo K. Valente
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | | | - Willey Y. Lin
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Teixeira Da Silva
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Hightow-Weidman
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ryan Drab
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Don Operario
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Jack Rusley
- School of Public Health, Brown University, Providence, Rhode Island, USA
- Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Katie B. Biello
- School of Public Health, Brown University, Providence, Rhode Island, USA
- Fenway Institute, Fenway Health, Boston, Massachusetts, USA
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