Background Pre-exposure prophylaxis is an HIV medication taken by an individual who is HIV-negative to prevent infection before exposure to the virus. Numerous clinical studies in various communities have shown high rates of effectiveness when pre-exposure prophylaxis is taken as prescribed. Since FDA (US Food and Drug Administration) approval of the first product for pre-exposure prophylaxis in 2012, uptake has been lower than the estimated 1.1 million US adults who could benefit from its use, with an estimated 70,394 individuals on pre-exposure prophylaxis in 2017. Of these, only 11% were Black and 13% were Hispanic despite Black and Hispanic individuals comprising two-thirds of individuals who could benefit, highlighting racial and ethnic disparities in pre-exposure prophylaxis uptake. Patient navigators have been shown to be effective in improving the linkage and retention in care outcomes of people living with HIV across the HIV treatment cascade and can be used throughout the pre-exposure prophylaxis care continuum to assist decision making and connect potential users to pre-exposure prophylaxis services. Objective PleasePrEPMe Chat was designed as a novel online strategy aimed at improving engagement in pre-exposure prophylaxis care services with pre-exposure prophylaxis–eligible populations in California via free HIV-prevention information and health care navigation services. Methods Visitors connected with navigators via online bilingual (English, Spanish) chat. During the chat, navigators helped locate pre-exposure prophylaxis services through the PleasePrEPMe provider directory, provided links to HIV-prevention resources, and supported uninsured, insured, and undocumented visitors with benefits navigation. Data such as date, time, type of encounter, visitor type, key demographics, discussion topics, insurance, and other relevant information were collected via a chat log and through the HealthEngage chat platform. Results From April 2017 to December 2019, PleasePrEPMe completed 2191 online chats. Mean interaction time was 16 minutes, with 68% of chats covering more than one topic. Conversation topics included health care navigation (1104/2191, 50.39%), provider identification (954/2191, 43.54%), pre-exposure prophylaxis information (773/2191, 35.28%), post-exposure prophylaxis information (318/2191, 14.91%), and the California Pre-Exposure Prophylaxis Assistance Program (232/2191, 10.59%). Referrals to pre-exposure prophylaxis– or non pre-exposure prophylaxis–related resources included directory updates, HIV testing and treatment, undetectable=untransmittable, reproductive health, sexually transmitted infections, and other prevention methods. A total of 368 chat visitors completed a voluntary satisfaction scale rating the quality and helpfulness of the service provided, producing a mean rating of 4.7 out of 5. Conclusions Online chat is a method for reaching people not already engaged in HIV-prevention services, supporting HIV-prevention decision making, and linking people seeking information online with in-person services. Additional research to evaluate online sexual health information services and understand how social determinants of health influence online engagement is needed to better understand how to reach priority populations not well served by current HIV-prevention services. International Registered Report Identifier (IRRID) RR1-10.2196/20187

BackgroundUNAIDS estimates global HIV investment needs in low- and middle-income countries (LMICs) at $26 billion per year in 2020. Yet international financing for HIV programs has stagnated amidst despite the increasing number of people requiring and accessing treatment. Despite increased efficiencies in HIV service delivery, evaluating programs for greater efficiencies remains necessary. While HIV budgets have been under scrutiny in recent years, indirect costs have not been quantified for any major global HIV program, but may constitute an additional avenue to identify program efficiencies. This analysis presents a method for estimating indirect costs in the President’s Emergency Plan for AIDS Relief (PEPFAR).MethodsUtilizing PEPFAR country operational plan (COP) funding data from 2007 to 2016 for international organizations (IOs) and universities and standard regulatory cost bases, we calculated modified total direct costs on which indirect cost rates may be applied by partner and funding agency. We then apply a series of plausible indirect cost rates (10%–36.28%) to develop a range for total indirect costs that have accrued over the period.FindingsOf $37.01 billion in total COP funding between 2007 and 2016, $22.24 billion (60.08%) was identifiably allocated to IOs ($17.95B) and universities ($4.29B). After excluding funding for sub-awards ($1.92B) and other expenses ($3.89B) to which indirect rates cannot be applied, $16.44B remained in combined direct and indirect costs. From this, we estimate that between $1.85B (8.30% of total international partner funding) and $4.34B (19.51%) has been spent on indirect costs from 2007–2016, including $157-$369 million in 2016.InterpretationTo our knowledge, this is the first analysis to quantify the indirect costs of major implementing partners of a global HIV funder. However, lack of transparency in the indirect cost rates of non-University international partners creates an opaque layer of programmatic costs. Given the current funding environment and evolution of HIV programming in PEPFAR countries, the findings motivate a re-examination of the current policies and the return on investment in indirect cost recovery across the PEPFAR program.

BACKGROUND Pre-exposure prophylaxis (PrEP) is an HIV medication taken by an HIV-negative individual to prevent infection before exposure to the virus. Numerous clinical studies in various communities have shown high rates of effectiveness when PrEP is taken as prescribed. Since FDA approval of the first product for PrEP in 2012, uptake has been lower than the estimated 1.1 million US adults who could benefit from its use, with an estimated 70,394 individuals on PrEP in 2017. Of these, only 11% are Black and 13% Hispanic, highlighting racial/ethnic disparities in PrEP uptake. Patient navigators have been shown to be effective in improving the linkage and retention in care outcomes of people living with HIV across the HIV treatment cascade, and can be used throughout the PrEP care continuum to assist decision making and connect potential users to PrEP services. OBJECTIVE PleasePrEPMe Chat is a novel online strategy to improve engagement in PrEP care services with PrEP-eligible populations through an online navigation platform. METHODS Visitors connected with navigators via online bilingual (English, Spanish) chat. During the chat, navigators helped locate PrEP services through the PleasePrEPMe provider directory, provided links to HIV-prevention resources, and supported uninsured, insured, and undocumented visitors with benefits navigation. RESULTS From launch to December 31, 2019, PleasePrEPMe completed 2,191 online chats. Average interaction time was 16 minutes, with chats often covering more than one topic (68%). Conversation topics included healthcare navigation (50%), provider identification (44%), PrEP information (35%), PEP information (15%), and the California PrEP Assistance Program (11%). Referrals to PrEP- or non-PrEP-related resources included: directory updates, HIV testing and treatment, undetectable = untransmittable or U=U, reproductive health, sexually transmitted infections, and other prevention methods. A total of 368 chat visitors completed a voluntary satisfaction scale rating the quality and helpfulness of the service provided, producing an average rating of 4.7 out of 5. CONCLUSIONS Online chat is a method for reaching people not already engaged in HIV-prevention services, supporting HIV-prevention decision making, and linking people seeking information online with in-person services. HIV-prevention conversations must necessarily include PrEP and PEP navigation to holistically serve the needs of visitors at all stages in the PrEP care continuum. Challenges around PrEP access include insurance and payment issues, confidentiality, and stigma. The nature of challenges seen in California may be different and not generalizable to states without Medicaid expansion or where the overall culture may be more politically conservative. Additional research evaluating online sexual health information services and understanding how social determinants of health influence online engagement are needed to better understand how to reach priority populations not well served by current HIV-prevention services.