The rising incidence of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), among sexual and gender minorities (SGMs) remains a significant public health concern. As biomedical prevention strategies such as HIV preexposure prophylaxis (PrEP) and doxycycline postexposure prophylaxis (doxy-PEP) for bacterial STIs continue to emerge, expanding access beyond specialized infectious diseases and sexual health settings is critical. Primary care, given its broad reach and continuity of care, is well positioned to integrate STI and HIV prevention services and improve equitable access to these interventions. We used group concept mapping with distinct stakeholder groups, including SGM clients and primary care clinicians, to (1) identify client-perceived strategies that facilitate awareness, uptake, and persistence of PrEP and doxy-PEP in primary care; (2) identify clinician-perceived strategies that support these outcomes; and (3) determine shared priorities for integrating biomedical prevention into primary care practice. Six thematic clusters emerged, representing key domains for effectively increasing PrEP and doxy-PEP use in primary care. Across clusters, 49 strategies were rated highly on both importance and feasibility. Highly prioritized strategies emphasized nonjudgmental patient education during routine visits, increasing access to SGM-affirming clinicians, fostering welcoming clinical environments, and strengthening health professional education on both biomedical prevention and SGM-specific health needs. This study offers a stakeholder-informed framework to guide the integration of biomedical STI and HIV prevention into primary care. Future research should focus on the implementation, evaluation, and sustainability of these strategies to optimize prevention uptake and persistence in primary care settings.
Barriers to initiating and maintaining HIV care continue to impede efforts to "End the HIV Epidemic" in the United States, particularly among members of Black sexual and gender minoritized (BSGM) groups in the US South. Evidence-informed social network-based interventions may improve engagement in HIV care services among BSGM; however, understanding and addressing context-specific barriers and facilitators to HIV service use are critical for intervention effectiveness. We explored barriers to HIV care engagement to inform the adaptation of a social network strategy to increase participation in HIV prevention and care services in Charlotte, NC. We interviewed BSGM with HIV who were in treatment, local health department officials, clinicians, and community-based organization leaders and held four focus groups (FGs) with HIV public health services staff. Transcripts were iteratively coded and analyzed thematically. We identified two themes across all FGs and in-depth interviews (IDIs). Two additional themes were identified specifically from IDIs with BSGM. Across data sources, participants described multi-level stigma, competing priorities, and logistical hurdles that impede BSGM engagement in HIV care. BSGM with HIV indicated that supportive social networks enhanced HIV treatment adherence and described how their personal agency and self-efficacy evolved after receiving an HIV diagnosis. Interventions to improve HIV care engagement among BSGM with HIV must address inequities, leverage social support networks, and enhance self-efficacy.
In 2016, the World Health Organization recommended differentiated service delivery (DSD) as a client-centred approach to simplify HIV care in frequency and intensity, thus reducing the clinic visit burden on individuals and HIV programmes. We describe the scale of DSD implementation among HIV facilities in low- and middle-income countries (LMICs) in Latin America, Africa and the Asia-Pacific before the COVID-19 pandemic. We analysed facility-level survey data from HIV care facilities participating in the International epidemiology Databases to Evaluate AIDS consortium in 2019. We used descriptive statistics to summarise the availability of DSD, multi-month dispensing (MMD) and DSD for HIV treatment models. We explored factors associated with DSD implementation using multivariable models. We included 175 facilities in the Asia-Pacific (n = 30), Latin America (n = 8), Central Africa (n = 21), East Africa (n = 74), Southern Africa (n = 28) and West Africa (n = 14). Overall, 133 facilities (76%) reported implementing DSD. Of these, 91% offered DSD for HIV treatment, 61% for HIV testing and 59% for antiretroviral therapy (ART) initiation. The most common duration of ART refills for clinically stable clients was 3MMD, (70%), followed by monthly (14%) and 6MMD (10%). Facility-based individual models were the most frequently available DSD for the HIV treatment model (82%), followed by client-managed group models (60%). Out-of-facility individual models were available at 48% of facilities. Facility-based individual models were particularly common among facilities in East (92%) and Southern Africa (96%). Facilities in medium and high HIV prevalence countries, and those with 3MMD, were more likely to implement DSD. In 2019, DSD was available in most HIV care facilities globally but was not evenly implemented across regions and HIV services. Most offered facility-based DSD for HIV treatment models and 3MMD for clinically stable clients. Efforts to expand DSD for HIV testing and ART initiation and to offer longer MMD can improve long-term retention in care of people living with HIV in LMICs, while further alleviating the operational burden on healthcare services. These findings from the pre-COVID-19 era underline the need for strengthening DSD in HIV care, which remains at the centre of current efforts towards client-centred care.
The postpartum period presents an opportunity to provide pre-exposure prophylaxis (PrEP) to cisgender women who may benefit. As patients rely on providers to provide PrEP education and frame relevance, barriers and facilitators to providers' initiating sexual health and HIV prevention discussions as a part of postpartum care must be identified to support implementation. Semi-structured interviews with 33 postpartum providers (10 residents, 6 advanced practice providers, 6 attendings, and 11 registered nurses) were conducted utilizing social cognitive theory as a framework. Providers expected that their postpartum patients would find HIV prevention discussions uncomfortable, not personally relevant, and/or stigmatizing. Providers identified normalization of PrEP discussions, universalization of PrEP discussions and tailoring conversations to meet their patients' needs as strategies to support comfort and confidence in discussing PrEP with their patients. Providers who believed that obstetrical care extended beyond an exclusive focus on pregnancy identified the postpartum context as an opportunity to provide PrEP education and other sexual health services. Providers identified environmental barriers, including frequent interruptions, language barriers, and lack of time for discussions. Nurses demonstrated receptivity to discussing PrEP, suggesting task shifting as a potential implementation strategy for integration of PrEP into postpartum care. Findings indicate that to support integration of PrEP into postpartum care, providers must be (1) educated on patient preferences surrounding sexual health discussions to align their expectations, (2) empowered with communication strategies that support normalization and tailoring of universally delivered PrEP education, and (3) supported in providing postpartum care that is comprehensive and includes education about HIV prevention.
This systematic review and meta-analysis aimed to assess health care providers' awareness, willingness, and key barriers in implementing HIV pre-exposure prophylaxis (PrEP). The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42024620671). A comprehensive search was conducted across major databases, and the eligible studies published between May 2014 and November 2024 were selected based on predefined inclusion and exclusion criteria. Participants were primarily health care providers involved in the adult PrEP care, with some studies also including providers caring for adolescents. A total of 23 cross-sectional studies comprising 6977 participants from various regions were included. The pooled awareness rate of health care providers regarding HIV PrEP was 89% (95% confidence interval [CI]: 85-93%), while their willingness to prescribe PrEP was 70% (95% CI: 65-75%). Providers with experience in caring for at least one HIV-positive patient (odds ratio [OR] = 1.35, 95% CI: 1.02-1.68) and those with greater knowledge (OR = 1.60, 95% CI: 1.06-2.14) demonstrated higher odds of prescribing PrEP. Despite the high level of awareness, the pooled willingness to prescribe PrEP was suboptimal, indicating limited adoption. The findings identify a small but critical group of less-aware providers who represent a key target for awareness and training initiatives. Barriers to PrEP implementation were identified at individual, community, and structural levels, including limited training, concerns about toxicity and resistance, discomfort with sexual health discussions, and low acceptance among both providers and patients. Targeted interventions addressing these barriers are essential to enhance PrEP uptake and optimize HIV prevention efforts globally.
In the antiretroviral therapy era, as people living with HIV (PWH) age, the decline of HIV-associated dementia has been accompanied by a growing burden of earlier Alzheimer-type pathology and other milder, heterogeneous cognitive impairments, underscoring the need for proactive detection and multidisciplinary management within routine HIV care. Yet, cognitive care remains largely absent, particularly in low- and middle-income countries (LMIC). We evaluated readiness to integrate a multidomain cognitive-rehabilitation program into tertiary HIV clinic in Malaysia and identified implementation determinants. We used a sequential mixed-methods design. An online Knowledge-Attitude-Practice survey was distributed to all infectious-disease physicians nationwide (N = 94). Qualitative data were generated through focus-group discussions with health care providers (HCPs) and in-depth interviews with PWH aged >40 years. Transcripts were analyzed thematically using the Consolidated Framework for Implementation Research (CFIR 2.0). Forty-nine physicians responded (52.4% response), median age was 44 years (inter-quartile range (IQR) 38-51), and 71.4% were female. While 71-82% demonstrated satisfactory knowledge and attitudes toward cognitive health, 88% reported poor practice; only 20.5% routinely screened older PWH. Thirty-three HCPs from multidisciplinary backgrounds participated in five focus groups, alongside 19 in-depth interviews with PWH. Three interlinked domains emerged: (1) knowledge-practice gap related to uncertainty around screening tools, referral pathways, and evidence applicability; (2) systemic barriers including time constraints, high caseloads, lack of guidelines, and workforce limitations; and (3) stigma affecting acceptability. Facilitators included strong patient motivation for brain health, allied health upskilling, physician-initiated referrals, and dedicated care coordination. Integration of multidisciplinary cognitive rehabilitation is hindered by modifiable structural deficits in knowledge translation, workforce organization, and guideline support. HIV-adapted screening algorithms, formalized referral processes, and task-shared coordinator roles could enable earlier cognitive interventions for older adults living with HIV in Malaysia and similar LMIC settings.
The presence of chlamydia, gonorrhea, or syphilis infection is a significant risk factor for HIV acquisition and transmission and disproportionately impacts men who have sex with men (MSM) and transgender women. While HIV preexposure prophylaxis (PrEP) reduces HIV risk, its use may influence sexual behaviors, potentially increasing sexually transmitted infection (STI) exposure. Conversely, PrEP users are often more engaged in care, regularly screened and treated for STIs, and may access other prevention tools such as doxycycline postexposure prophylaxis. Studies on the relationship between PrEP use and STIs have shown mixed results. This cross-sectional analysis included 392 participants (381 cisgender MSM; 11 transgender women) enrolled in the US-based Multicenter AIDS Cohort Study/WIHS Combined Cohort Study between 2021 and 2024 who were sexually active in the year prior to STI testing and HIV negative at their most recent study visit. We assessed whether bacterial STI positivity (i.e., laboratory-confirmed chlamydia and gonorrhea at the urethral, pharyngeal, and/or rectal sites and/or current/past syphilis infection) differed by current PrEP use (yes/no). Multi-variable logistic regression models included sociodemographic and behavioral covariates that were associated with bacterial STI positivity at p < 0.05, with the most parsimonious models selected based on the lowest Akaike Information Criterion. Overall, 32.7% reported current PrEP use. Syphilis was the most prevalent STI (6.8%), followed by chlamydia (3.2%) and gonorrhea (2.1%); 11.7% of PrEP users tested positive for at least one STI, compared with 6.1% of non-PrEP users. Among PrEP users, 37.9% reported stopping or decreasing condom use, and 31.6% reported an increased number of sex partners after initiating PrEP. In both bivariate and multi-variable models, PrEP use was associated with higher odds of gonorrhea positivity (adjusted odds ratio = 4.70, 95% confidence interval [CI]: 1.10-20.04, p = 0.037) and greater odds of being positive for at least one STI (crude odds ratio = 1.94, 95% CI: 1.06-3.90, p = 0.041). No significant differences were observed for chlamydia and syphilis by PrEP use status. Overall, these findings suggest that current PrEP users (vs. non-PrEP users) have an increased odds of bacterial STI positivity, particularly gonorrhea, in a diverse, multi-city cohort of HIV negative, sexually active MSM and transgender women in the United States PrEP remains highly effective in preventing HIV, and our results underscore the importance of integrated sexual health services that support ongoing STI screening and prevention alongside PrEP use among sexual and gender minorities.
Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy for adolescents and young adults (AYAs, ages 14-26). PrEP uptake among AYAs remains low. Barriers to uptake include provider discomfort discussing sexuality, challenges engaging parents in sexual health conversations, and low perceived HIV risk. To address these gaps, we aimed to develop a toolkit to enhance AYA-serving primary care providers' (PCPs) comfort and confidence in discussing and prescribing PrEP. The Consolidated Framework for Implementation Research informed our approach. Four focus groups with youth-serving PCPs across three clinics in a Northeastern US city were held in April and May 2024. PCPs included residents (n = 10), attending physicians (n = 11), nurse practitioners (n = 2), and a physician assistant (n = 1). Debrief summaries were created following each focus group and analyzed. We used a rapid qualitative process, guided by an a priori codebook and reflexive thematic analysis. PCPs emphasized that the toolkit should be easy to access, interactive, and provide practical, age-appropriate prescribing information. They identified outer-setting factors such as the role of parents in AYAs' health care, sexual health education in schools, and uncertainty around laws that impact PrEP provision to minors. Within the clinical setting, providers noted that limited time often hindered sexual health discussions. Individually, PCPs reported moderate comfort with PrEP and were motivated to prescribe PrEP when AYAs expressed interest. Findings informed the development of a PrEP toolkit tailored for AYA-serving PCPs and future implementation tailored for AYA-serving PCPs. This approach may help expand access and address persistent barriers to PrEP uptake among AYAs.
To evaluate the proportion of gay, bisexual, and other men who have sex with men (GBMSM) with ongoing high-risk sexual practices not engaged in care, and to assess linkage to and retention in care following a community-based intervention. A two-phase study was conducted (January-June 2023) in a sex-on-premises venue in Spain. Community-based screening for HIV and hepatitis C virus (HCV) was offered, followed by a fast-track referral intervention. Individuals with reactive results were linked to specialized care. Individuals with negative results not engaged in care were referred to pre-exposure prophylaxis or sexually transmitted infections (STI) screening programs. Outcomes: (i) Primary: proportion of participants requiring care who were not engaged in routine sexual health services; (ii) Secondary: linkage to and retention in care at 6 months. Of 614 individuals invited, 405 (66%) participated. At baseline, 226 participants (56%) were not engaged in HIV or PrEP follow-up. One (0.3%) previously undiagnosed HIV infection was identified. One (0.2%) HCV infection was detected. Among 165 HIV-negative GBMSM residing in Andalusia who were not engaged in care, 148 (89.7%) were either not linked to sexual health services or not retained in PrEP care, including 63 (42.6%) who fulfilled PrEP criteria. In conclusion, a substantial proportion of GBMSM with ongoing high-risk sexual practices were not engaged in sexual health services. While few HIV and HCV infections were identified, linkage to and retention in PrEP and STI prevention services were limited, with losses before or shortly after first contact, underscoring persistent gaps in the prevention cascade among GBMSM.
Preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) continue to be underutilized among transgender people despite elevated HIV incidence in this population. Many transgender individuals report that their gender-affirming care (GAC) is their highest health care priority, and an increasing number seek this care via telehealth. We sought to understand clinician perspectives and needs regarding integrating HIV PrEP and HIV PEP into GAC in a telehealth model. We conducted semi-structured interviews with clinicians who self-identified as providing gender-affirming care via telehealth. We used the transdisciplinary approach to evidence-based practice to inform our interview guide and codebook and used thematic analysis to analyze the resulting data. Among our 20 participants interviewed in December 2023 and January 2024, there was enthusiasm to offer trans patients biomedical HIV prevention within GAC. Participants were most comfortable managing oral PrEP. Identified barriers include lab work cadence and issues getting medication to patients (especially the drugs for HIV PEP). PrEP navigators, patient self-advocacy, and trusting patient-clinician relationships were identified as facilitators of co-location. A clinician's ability to offer a transgender patient both GAC and PrEP/HIV PEP in the same telehealth visit is a promising strategy to tackle the disproportionate incidence of HIV among trans people. Trusting clinical relationships facilitated by the provision of GAC can be utilized to more accurately assess HIV risk and more effectively offer PrEP and HIV PEP.
Rapid start of antiretroviral therapy (ART) has been recommended by the World Health Organization since 2017 and is an important approach toward optimizing HIV care. Our objective was to understand the experiences of people with HIV (PWH) undergoing rapid start and to synthesize lessons learned to improve our program. This mixed-methods study recruited newly diagnosed patients establishing care at an urban safety-net clinic in Dallas, TX, between 2021 and 2022. Eligible PWH were ART-naïve and diagnosed with HIV within 12 months prior to the rapid start visit. Participants completed baseline and follow-up surveys 3-12 months after enrollment. A subset of participants completed semi-structured interviews to capture their experiences with HIV and elucidate barriers and facilitators to rapid start. Interviews were evaluated using thematic analysis. Qualitative and quantitative findings were integrated to develop best practices. In total, 199 participants (35.5 ± 11.6 years; 73.9% men; 39.7% Black; 48.7% Hispanic; 38.2% heterosexual risk transmission of HIV) participated in the study. Completed surveys and interviews (n = 20) centered around five themes: (1) social and emotional needs, (2) patient-centered approach, (3) cultural competence, (4) structural navigation, and (5) longitudinal support. Key elements of a rapid start program include evaluating and fostering support networks; emphasizing patient-centered care like tailored education on HIV; acknowledging distinctive cultural values and behaviors of the patients; improving structural factors, including support for insurance issues; and strengthening longitudinal support past the rapid start visit. Such lessons can serve as a blueprint for other practices, particularly in the US South, looking to establish or strengthen rapid start programs.
In the United States, youth are disproportionately affected by HIV and have poorer health outcomes than adults. Health care transition (HCT) from pediatric/adolescent- to adult-oriented HIV care is associated with disruptions to youths' care retention, medication adherence, and viral suppression. However, no evidence-based interventions exist to improve HIV-related HCT outcomes. Accordingly, our team designed and implemented the iTransition intervention to support youth and providers in navigating HIV-related HCT. We conducted a pilot trial of iTransition in two cities in the United States with four participant groups: (1) historical control group (n = 21), (2) youth intervention group (n = 33), (3) provider intervention group (n = 17), and (4) Transition Champions (i.e., staff members from each participating pediatric/adolescent and adult clinic designated to support iTransition implementation; n = 7). Analyses examined acceptability, feasibility, and preliminary efficacy. Youth, providers, and Transition Champions, who completed the assessments, generally assessed the feasibility and acceptability of the iTransition app and provider console favorably. Linkage to adult HIV care (defined as one adult HIV care appointment) was significantly higher in the youth intervention group, where 81.8% were linked compared with 47.6% in the historical control group (χ2= 6.96, p = 0.008). Rates of care linkage were not significantly different between app users and non-users (χ2 = 1.09, p = 0.30). Notably, overall use of the app and the provider console was low. This study suggests that iTransition could serve as an important tool to support HCT for youth living with HIV in the United States; however, further work is needed to optimize implementation and improve uptake.
Structural inequities significantly shape disparities across the HIV care continuum, yet few validated tools exist to quantify HIV-specific structural vulnerability at the population level in the United States. This study introduces and validates the HIV-Specific Social and Structural Determinants of Health Index (HIV-SSDI), a multi-dimensional, state-level index designed to capture structural disadvantage relevant to HIV prevention and care. Using publicly available state-level index (2008-2023) spanning nine structural domains, we developed the HIV-SSDI through exploratory factor analysis with three extraction methods: principal component analysis, maximum likelihood, and minimum residual. We constructed HIV-SSDI scores based on normalized factor loadings and evaluated their associations with HIV care continuum outcomes, using cross-sectional and longitudinal linear regression models. Three consistent latent factors emerged across methods: (1) socioeconomic and health care disadvantage, (2) HIV service infrastructure and urban density, and (3) structural/legal context. Higher HIV-SSDI scores were significantly associated with HIV prevalence, mortality, preexposure prophylaxis (PrEP) use, and testing rates but not with linkage to care or viral suppression. Longitudinally, the strength of association between SSDI and diagnosis rates declined between 2008 and 2022, while SSDI associations with PrEP use and PrEP-to-Need-Ratio increased sharply from 2012 to 2023. These trends were robust across factor extraction methods and model specifications. The HIV-SSDI is a validated, multi-dimensional metric that captures structural disadvantage relevant to HIV vulnerability and prevention. Its growing association with prevention outcomes over time supports its utility as a policy-relevant tool for identifying high-need states, guiding equitable resource allocation, and monitoring progress toward HIV-related health equity.
Substance use adversely affects engagement in HIV care, adherence to medication, and HIV viral suppression. This review assessed the scope of US interventions designed to promote positive outcomes along the HIV care continuum for people with HIV who have substance use disorder (SUD) or at-risk substance use. A literature search identified 27 interventions published in peer-reviewed articles found on PubMed and PsycINFO databases between January 1, 2019, and December 31, 2023. Common strategies to improve HIV care continuum outcomes included support for HIV medication adherence, motivational interviewing, medications to treat SUD, contingency management, cognitive-behavioral skills building, patient navigation, mindfulness practice, and low-barrier entry to care. Contingency management (offering financial or material incentives for attaining desired outcomes) alone or combined with other strategies was most consistently associated with positive HIV outcomes, but more research is needed to understand how these outcomes can be sustained. Few intervention studies addressed or measured linkage to care (12%) or retention in care (15%), despite a clear need to better engage this population. Further innovation is needed to improve HIV engagement and retention among people with SUD or at-risk substance use.
New HIV treatment modalities, including long-acting injectable antiretroviral therapy (LAI-ART), increase the range of options available to people with HIV (PWH). As new treatments become available, it is important to understand how PWH perceive these new options and the role of providers in informing patients about them. We explored the perspectives of gay, bisexual, and other men who have sex with men with HIV (MWH) on new HIV treatment modalities and provider communication about these modalities. Semi-structured interviews were conducted with a total of 18 MWH from the US (n = 9) and Australia (n = 9), who were recruited in partnership with two community organizations. Participants identified as gay, cisgender men aged 29-66 years (Median = 54). All reported taking oral ART and having an undetectable viral load. Two main themes were identified: (1) Long-acting injectables are not as simple as daily pills, and (2) Providers should inform patients about new HIV treatments. Most MWH perceived LAI-ART to be more complex compared with their current oral treatment regimen because of frequent clinic visits to receive injections, discomfort with needles, and concerns about missed doses and side effects. MWH believed providers should inform all patients about new treatments and were less likely to do so if they did not have a relationship with their patients, were not satisfied with patients' current treatment, or were limited on time. Standardizing patient education about new treatments and broadening information channels may enhance informed decision-making among PWH, including those most likely to benefit from new modalities.
The New York City "Data-to-Suppression" (D2S) initiative was launched to improve HIV viral suppression among Ryan White HIV/AIDS Program Part A (RWPA) clients through a combination of surveillance-based, client-level reporting and capacity-building activities with RWPA housing and behavioral health service providers. This study qualitatively examines provider perspectives on its implementation. Drawing from 8 RWPA-funded agencies participating in D2S, we conducted semistructured interviews with 24 purposively sampled providers from 8 RWPA-funded agencies participating in D2S, including patient navigators engaged in D2S outreach, patient navigator supervisors, and administrators. Interviews were conducted between August and November 2022. The interviews explored four topics: (1) D2S workflow and benefits, (2) implementation facilitators, (3) implementation barriers, and (4) areas for improvement. Providers reported that D2S was easy to implement and identified clients in need of additional support. Suggestions for improvement included issuing more timely reports, adding more detailed data to reports, and focusing the intervention on agencies where behavioral health and housing program staff do not already have access to clients' HIV care and viral suppression status. Providers described barriers such as organizational capacity constraints (e.g., hiring and retaining staffing levels) and clients' difficulty with maintaining viral suppression due to competing needs. Qualitative feedback from the providers responsible for delivering an intervention is critical to identifying refinements that could strengthen engagement in intervention implementation and thus critical to achieving and sustaining the intended impact.
The Rio Grande Valley (RGV) comprises counties with some of the highest prevalence of HIV in Texas. The predominantly Latino population also faces socioeconomic challenges, including high poverty rates, low health literacy, and transiency, contributing to increased risk of advanced HIV disease. AHORA was a real-world mixed-methods study evaluating viral control and immune reconstitution in a Latino population with advanced HIV disease, who were enrolled in a rapid start treatment program with bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) at two clinics in the RGV. To explore reasons for late diagnosis and experiences of rapid antiretroviral therapy (ART) initiation, document analysis and 27 in-depth semi-structured interviews were conducted with 18 individuals receiving treatment and 9 clinic staff. Median time to an HIV-1 RNA level <200 copies/mL was 5.3 weeks, with 90.5% (19/21) achieving this by Week 24. There were statistically significant differences in mean HIV-1 RNA levels, CD4% and CD4 counts between baseline and Week 24. Strategies to maximize ART engagement were grounded in person-centered care and included regular appointment reminders and transportation assistance. Common barriers to accessing care included limited HIV knowledge and financial constraints. These were addressed through education and financial support, including the provision of treatment samples at no cost, independent of insurance status. The AHORA study effectively showcases the benefits of rapid B/F/TAF initiation for individuals with advanced HIV in the RGV, facilitating early viral suppression and improved health outcomes. It also emphasizes the critical role of person-centered care and tailored support services in overcoming health care access barriers.
Delivering HIV testing and pre-exposure prophylaxis (PrEP) in community pharmacies can expand access to HIV services for populations with limited access to care. However, few pharmacies in the United States have successfully implemented these services. We investigated implementation barriers and facilitators of pharmacy-based HIV testing and PrEP initiation in Philadelphia, an Ending the HIV Epidemic priority jurisdiction with high rates of HIV and bacterial STIs, located in a state with relatively restrictive laws governing pharmacy scope of practice. Using a sequential, exploratory mixed-methods study design, we conducted 15 in-depth interviews with pharmacists and key implementing partners, followed by an online survey of pharmacists, pharmacy students, and technicians (n = 59). Interviews and surveys were analyzed using the Consolidated Framework for Implementation Research. Data were collected from October 31, 2023, to October 17, 2024. Interviewees representing three pharmacy sites had initiated HIV testing, but no sites had yet successfully implemented pharmacy-based PrEP. The primary barriers to delivering HIV testing were based on inner setting barriers (existing work burden, overly complex protocols). Legal restrictions and reimbursement concerns were the primary barriers to implementing pharmacy-based PrEP. Participants described potential solutions and mitigating strategies to these barriers, such as collaborative practice agreements and developing standing orders with medical providers, integration with telePrEP models, streamlined blueprints and protocols, and practice-based champions. Survey respondents indicated high levels of acceptability but lower levels of perceived implementation feasibility. To optimize implementation sustainability and success, implementation strategies need to adequately address legal barriers and reimbursement concerns and be integrated into the pharmacy workflow.
Over 7000 youth ages 13-24 are diagnosed annually with HIV-1 in the United States despite the 2018 approval of oral pre-exposure prophylaxis (PrEP) for adolescents, highlighting the need for more research on provider prescribing practices in pediatric populations. Prior research chiefly focuses on patient barriers to accessing PrEP, and thus, our study explored provider barriers. From August to December of 2023, we conducted a survey of medical providers in pediatrics, family medicine (FM), and internal medicine (IM)/pediatrics. A 5-point Likert scale (0-4) assessed comfort in providing adolescent sexual health care and potential barriers to PrEP prescription, including discussions around sexual activity, gender identity, sexual orientation, sexually transmitted infections, and PrEP. In total, 158 responses were received. FM providers were more familiar with PrEP (3.4 to 1.5, 76.4% difference) and with prescribing PrEP (3.4-0.7, 131.2%) than pediatric providers. Logistic regression analysis found that FM providers were 32 times more likely to prescribe PrEP than pediatric providers. Pediatric providers were 3.4 times more likely than FM providers to identify barriers to PrEP prescription, notably "lack of time to counsel on risk reduction", "lack of capacity for follow-up", "lack of knowledge," and "lack of comfort" and non-prescribers were 2.7 times more likely than prior prescribers to identify barriers, notably "lack of knowledge" and "lack of comfort". This study highlights the crucial need for educational interventions for pediatric providers around PrEP provision, but also adolescent sexual health care more widely.
High HIV incidence in the US South disproportionately affects adolescents, young adults, and Black women. Using a community-engaged approach and intervention mapping, we developed PrEP-Pro, an intervention to support family medicine physician-trainees to elicit a sexual history from and provide pre-exposure prophylaxis (PrEP) to adolescents, with special emphasis on engaging with Black adolescent girls and young women (AGYW). Intervention content includes PrEP curricula, adaptations to the Centers for Disease Control and Prevention (CDC)'s sexual history tool, and a PrEP Champion training program. Two community advisory boards (CABs)-one consisting of PrEP Champions and physicians, the other of AGYW-and two focus group discussions with physicians (N = 7) informed intervention content. We pretested PrEP-Pro at two sites over 3 months and assessed acceptability, appropriateness, feasibility. The provider CAB advised multiple training strategies: (1) locally informed sexual history videos; (2) HIV epidemiology review; (3) quick-reference badge and pocket cards on PrEP and eliciting sexual histories; (4) didactic, case-based content; (5) web-based content. The AGYW CAB informed development of (6) a sexual history screener and (7) clinic posters emphasizing confidentiality for adolescent clients. Across two family medicine residency programs, eight physicians participated in the 3-month pretest of the intervention. Acceptability (mean = 4.16/5 [standard deviation (SD) = 1.36]), appropriateness (4.16/5 [1.36]), and feasibility (4.19/5 [1.37]) were high. Six physician interviews informed adaptations including fostering a community of practice, increased case-based learning, and quick-reference card content modifications. We combined theory-driven and evidence-informed components to adapt and pilot PrEP-Pro to support physicians in discussing PrEP with adolescents. The adapted intervention was piloted across clinics to inform a future trial.