Developing and Assessing the Feasibility of a Home-based Preexposure Prophylaxis Monitoring and Support Program

Siegler, Aaron J; Mayer, Kenneth H.; Liu, Albert Y.; Patel, Rupa; Ahlschlager, Lauren; Kraft, Colleen S.; Fish, Rossi; Wiatrek, Sarah; Sullivan, Patrick S.

doi:10.1093/cid/ciy529

Cited by 110 publications

(141 citation statements)

References 7 publications

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“…This heterogeneity in the reasons for discontinuing PrEP suggests that preventing inappropriate discontinuations will likely require diverse or multifaceted interventions. Interventions may include innovative forms of PrEP delivery to facilitate adherence to care plans, such as home‐based PrEP services ; pharmacist‐supported PrEP services; programmes to help patients maintain insurance coverage and access financial assistance resources for PrEP care, such as through the use of health system navigators; and strategies to increase access to mental healthcare or substance use treatment programmes. In addition, PrEP users who discontinue daily PrEP due to decreased frequency of sex might be more likely to use event‐driven PrEP without discontinuation , although CDC has not recommended non‐daily PrEP use .…”

Section: Discussionmentioning

confidence: 99%

“…This heterogeneity in the reasons for discontinuing PrEP suggests that preventing inappropriate discontinuations will likely require diverse or multifaceted interventions. Interventions may include innovative forms of PrEP delivery to facilitate adherence to care plans, such as home-based PrEP services [18,19]; pharmacist-supported PrEP services; [20] Includes non-adherence to clinical visits, laboratory monitoring and/or medications, or using medications other than as prescribed. b Includes expressed preference to discontinue PrEP and "experiencing stigma from romantic partners, sexual partners, and/or peers. "…”

Section: Discussionmentioning

confidence: 99%

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Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care

et al. 2019

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Introduction Discontinuations of HIV preexposure prophylaxis (Pr EP ) by at‐risk individuals could decrease the effectiveness of Pr EP . Our objective was to characterize patterns of, reasons for, and clinical outcomes associated with Pr EP discontinuations in primary care. Methods We conducted medical chart reviews for patients prescribed Pr EP during 2011 to 2014 at a Boston community health centre specializing in healthcare for sexual and gender minorities. Patients were followed through 2015. We characterized patients’ sociodemographics, relationship status, behavioural health conditions, patterns of and reasons for Pr EP discontinuations, and HIV seroconversions. Cox proportional hazards models were used to assess patient factors associated with Pr EP discontinuations. Results Of the 663 patients prescribed Pr EP , the median age was 33 years, 96% were men who have sex with men ( MSM ) and 73% were non‐Hispanic white; 40% were in committed relationships and 15% had HIV ‐infected partners. Patients either used Pr EP continuously (60%), had 1 or more discontinuations (36%), or did not initiate Pr EP (4%). Discontinuations were most often due to a decrease in HIV risk perception (33%), non‐adherence to care plans (16%), or insurance barriers (12%). Of the 7 (1.1%) Pr EP patients diagnosed with HIV , 1 was HIV ‐infected at baseline, 2 seroconverted while using Pr EP , and 4 seroconverted after discontinuations. In a multivariable model adjusted for race/ethnicity, relationship status, substance use disorders, and insurance status, those who were less than 30 years old ( aHR 2.0, 95% CI 1.4 to 2.9 for ages 18 to 24, aHR 2.2, 95% CI 1.6 to 3.1 for ages 25 to 29, vs. ages 30 to 39 years), who identified as transgender women ( aHR 2.0, 95% CI 1.2 to 3.4, vs. cisgender men), and who had mental health disorders ( aHR 1.2, 95% CI 1.1 to 1.4 for each additional disorder) were more likely to have discontinuations. Conclusions Discontinuations of Pr EP use among this American sample of predominately MSM were common, particularly among patients who were younger, identified as transgender women, or had behavioural health issues. As HIV ...

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Section: Discussionmentioning

confidence: 99%

“…This heterogeneity in the reasons for discontinuing PrEP suggests that preventing inappropriate discontinuations will likely require diverse or multifaceted interventions. Interventions may include innovative forms of PrEP delivery to facilitate adherence to care plans, such as home-based PrEP services [18,19]; pharmacist-supported PrEP services; [20] Includes non-adherence to clinical visits, laboratory monitoring and/or medications, or using medications other than as prescribed. b Includes expressed preference to discontinue PrEP and "experiencing stigma from romantic partners, sexual partners, and/or peers. "…”

Section: Discussionmentioning

confidence: 99%

Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care

et al. 2019

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“…Even when co‐pay assistance is available, the time, transportation needs and costs of care required for ongoing PrEP prescriptions is burdensome for many PrEP users. Pharmacy‐/ telehealth‐delivered PrEP, and express visit systems, in which an initial triage is performed on computer tablets to allow stable PrEP users to defer in‐person medical provider visits, are potential solutions that deserve additional study [35‐37]. The recently‐passed California bill‐159, which allows pharmacists to dispense 60 days of PrEP without prescription, is likely to support uptake [37].…”

Section: Discussionmentioning

confidence: 99%

Missed opportunities to prevent HIV infections among pre‐exposure prophylaxis users: a population‐based mixed methods study, San Francisco, United States

et al. 2020

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Introduction Pre‐exposure prophylaxis (PrEP) is highly effective, although PrEP adherence and persistence has been variable during real world implementation. Little is known about missed opportunities to enhance PrEP adherence among individuals who later HIV seroconverted after using PrEP. The goal of this analysis was to identify all HIV infections among individuals who had accessed PrEP in an integrated health system in San Francisco, and to identify potentially intervenable factors that could have prevented HIV infection through in‐depth interviews with people who HIV seroconverted after using PrEP. Methods We identified individuals who initiated PrEP in an integrated safety‐net public health system and performed in‐depth chart review to determine person‐time on and after stopping PrEP over six years. We identified all PrEP seroconversions using the Centers for Disease Control and Prevention’s Enhanced HIV/AIDS Reporting System and then calculated HIV incidence while using PrEP and during gaps in use. We then performed in‐depth interviews with those who seroconverted. Results Overall, 986 initiated PrEP across the San Francisco Department of Public Health from July 2012 to November 2018. Data were gathered from 895 person‐years on PrEP and 953 after stopping PrEP. The HIV incidence was 7.5‐fold higher after stopping PrEP compared to while on PrEP (95% CI 1 to 336). Of the eight individuals who HIV seroconverted; only one was taking PrEP at the time of seroconversion but was using on‐demand PrEP inconsistently. All eight agreed to qualitative interviews. Major barriers to PrEP persistence included substance use, mental health and housing loss; difficulty accessing PrEP due to cost, insurance, and the cost and time of medical visits; difficulty weighing PrEP’s benefit versus self‐perceived risk; and entering a primary partnership. The individual who developed HIV using on‐demand PrEP reported confusion about the dosing regimen and which sexual encounters required accompanying PrEP dosing. Conclusions HIV incidence during gaps in PrEP use was nearly eight‐fold higher than while on PrEP in this large cohort in San Francisco. Many individuals who stop PrEP remain at risk of HIV, and participants reported that proactive outreach could potentially have prevented HIV infections. Individuals using non‐daily PrEP may require additional education and support in the United States.

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“…Universal education pertaining to PrEP is especially important given consistently low knowledge and awareness about PrEP reported among women (5). Other potential adaptations to PrEP, that could help overcome barriers, include pharmacy-based PrEP services (which could be useful for clinics that have a pharmacy on-site) (46), telemedicine (47), and at-home PrEP services (48).…”

Section: Discussionmentioning

confidence: 99%

Exploring the Heterogeneity of Factors that may Influence Implementation of PrEP in Family Planning Clinics: A Latent Profile Analysis

Piper

Haardörfer

Escoffery

et al. 2020

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Background: Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention. However, PrEP has not been widely integrated into family planning services, especially in the Southern U.S., and data suggest there may be significant implementation challenges in this setting. Because Title X clinics vary greatly in provider-, organizational-, and systems-level characteristics, there is likely variation in capacity to implement PrEP across clinics. Methods: We conducted a survey from February-June 2018 among providers and administrators of non-PrEP providing Title X-funded clinics across 18 southern states. Survey items were designed using the Consolidated Framework for Implementation Research (CFIR) to assess constructs relevant to PrEP implementation. To explore the heterogeneity of CFIR-related determinants and identify distinct sub-groups of Title X clinics, a latent profile analysis was conducted using nine CFIR constructs: complexity, relative advantage, cost, attitudes, implementation climate, compatibility, leadership engagement, available resources, and cosmopolitanism. We then conducted a multi-level analysis (accounting for nesting of participants within clinics) to test whether group membership was associated with readiness for implementation of PrEP, controlling for key sociodemographic characteristics. Results: 414 healthcare providers/administrators from 227 non-PrEP providing Title X clinics participated in the study. We identified six sub-groups of clinics that each had distinct patterns of perceptions across the CFIR-related determinants. Clinic sub-groups included: “High Capacity”, “Optimistic”, “Advantageous”, “Moderate”, “Incompatible”, and “Resource Constrained”. Group membership was related to numerous provider-level (i.e., ability to prescribe medication), clinic-level (i.e., provision of primary care), and community-level characteristics (i.e., county-level HIV prevalence). In comparison to the “Moderate” group (which held neutral perceptions across the CFIR constructs), the “High Capacity” and “Optimistic” groups had significantly higher levels of implementation readiness; and the “Resource Constrained group had a significantly lower level of implementation readiness.Conclusions: Latent profile analyses can help researchers understand how context-specific implementation determinants vary across individuals and settings (such as clinics), allowing implementation planning to be tailored to the specific needs of each segment of the population.

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Developing and Assessing the Feasibility of a Home-based Preexposure Prophylaxis Monitoring and Support Program

Cited by 110 publications

References 7 publications

Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care

Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care

Missed opportunities to prevent HIV infections among pre‐exposure prophylaxis users: a population‐based mixed methods study, San Francisco, United States

Exploring the Heterogeneity of Factors that may Influence Implementation of PrEP in Family Planning Clinics: A Latent Profile Analysis

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