Primary Care and Pre-exposure Prophylaxis Services in Publicly Funded Family Planning Clinics in the Southern United States

Abstract

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is underutilized by US women. Cost and resource concerns are barriers to PrEP delivery in settings that see men. Family planning clinics may be ideal PrEP delivery settings for women, but as they are not uniform in their clinical services, cost and resource concerns may vary. OBJECTIVE: We examined factors that influence perceptions of costs and resources related to PrEP delivery in Title X-funded family planning clinics in Southern states, which overlaps with high HIV-burden areas. DESIGN: We conducted a web-based survey among a convenience sample of clinicians and administrators of Title X clinics across 18 Southern states (DHHS regions III, IV, VI). We compared cost-and resource-related survey items and other clinic-and county-level variables between clinics by whether their clinics also provided other primary care services. We analyzed interviews for cost and resource themes. PARTICIPANTS: Title X clinic staff in the South. KEY RESULTS: Among 283 unique clinics, a greater proportion of clinics that also provided primary care currently provided PrEP compared with those that did not provide primary care (27.8% vs. 18.3%, p = 0.06), but this difference was not statistically significant. Among 414 respondents in clinics that were not providing PrEP, those in clinics with primary care services were more likely to respond that they had the necessary financial resources (p < 0.01) and staffing (p < 0.01) for PrEP implementation compared to those without primary care services. In interviews, respondents differed on concerns about costs of labs and staffing based on whether their clinic had concomitant primary care services or not. CONCLUSIONS: Among publicly funded Southern family planning clinics, current PrEP provision was higher among clinics with concomitant primary care. Among clinics not providing PrEP, those with concomitant primary care services have lower perceived cost and resource barriers and therefore may be optimal for expanding PrEP among women.

Tennessee Pharmacists’ Opinions on Barriers and Facilitators to Initiate PrEP: A Qualitative Study

“…This financial obstacle was corroborated by another study that surveyed clinicians and prescribers in various clinics across the South [17]. They found that prescribers were hesitant to prescribe PrEP due to the perception of PrEP costs and insurance coverage, especially outside of primary care clinics [17].…”

“…For some of the participants, men who have sex with men (MSM), when users are adherent to PrEP in McKenney's study, the authors attributed the low uptake of PrEP in the U.S. due to the financial burden [16]. This financial obstacle was corroborated by another study that surveyed clinicians and prescribers in various clinics across the South [17]. They found that prescribers were hesitant to prescribe PrEP due to the perception of PrEP costs and insurance coverage, especially outside of primary care clinics [17].…”

Provision of HIV preexposure prophylaxis to female patients seeking family planning services in the United States

“…Provider and staff knowledge and confidence about PrEP delivery in a family planning setting increased with specific trainings on this topic, but few staff reported having been trained about PrEP screening and delivery [9,22,[37][38][39]. In one study, despite promising results at a 3-month time point, comfort with screening for PrEP eligibility, and physician comfort with prescribing PrEP Provider-level barriers to PrEP care included competing clinical priorities such as time constraints, sensitivity to the emotional needs of patients seeking abortion, and the importance of addressing the patient's primary reason for the visit rather than HIV prevention, insurance-related issues, lack of on-site psychosocial support for risk reduction and adherence counseling, and lack of education materials for patients [2,9].…”

“…With nearly 1 million patients a year seeking induced abortion and 1.5 million people attending Title X family planning clinics in 2020 [15,16], and over 90% of women aged 15-44 who had one sexual encounter used some form of effective contraception such as birth control pills, injectable methods, contraceptive patches, or intrauterine devices in their lifetimes [17], this is a way to reach many women. Although family planning clinics offer a unique opportunity for women to receive counseling and PrEP prescriptions [9,13,18,19], implementation barriers include limited knowledge among family planning providers regarding PrEP, worries regarding cost of PrEP, and insurance policies in regards to PrEP [13,[20][21][22].…”

Provider Perspectives on Factors Affecting the PrEP Care Continuum Among Black Cisgender Women in the Midwest United States: Applying the Consolidated Framework for Implementation Research

“…Sales et al applied CFIR to study PrEP implementation in family planning clinics in the Southern United States through an online quantitative survey. 22,23 The CFIR framework is useful to identify and categorize barriers and facilitators that influence implementation outcomes; in this case, Sales et al 23 highlight that outer (availability of resources) and inner setting characteristics (supportive climate of HIV prevention practices and supportive leadership) rather than individual characteristics (knowledge) were the most salient factors associated with readiness to provide PrEP in family planning settings in the Southern United States. Identifying CFIR characteristics that affect PrEP implementation outcomes is vital to improving uptake and persistence among Black cisgender women.…”