Indications For Pre-exposure Prophylaxis Research Articles

P-519. Long-acting Injectable PrEP Uptake and Persistence in a Sexual Health Clinic

Abstract Background HIV pre-exposure prophylaxis (PrEP), a powerful tool for HIV prevention, has traditionally been taken as a daily oral medication. Long-acting injectable (LAI) cabotegravir is superior to daily oral PrEP for HIV prevention and was approved for use as LAI-PrEP in 2021. We aimed to evaluate the uptake of LAI-PrEP and six-month LAI-PrEP persistence in a sexual health clinic. Participant characteristics (N=36) LAI: Long acting injectable PrEP: Pre-exposure prophylaxis Methods In February 2023, an LAI-PrEP pilot was implemented in a county sexual health clinic serving a diverse patient population in a designated ending the HIV epidemic in the South. Through state funding, patients at risk of HIV through sexual transmission were eligible to receive initial doses of LAI-PrEP at no cost and same-day initiation was encouraged. We evaluated the first 12 months of implementation. The primary outcome was LAI-PrEP persistence at 6 months. Statistical analyses were performed (SPSS version 29) using chi-square test for categorical variables with a significance level of 0.05. LAI-PrEP – long-acting injectable pre-exposure prophylaxis Results During the 12-month period, 55 people initiated LAI-PrEP, with 36 eligible for the six-month PrEP persistence evaluation. This population was 83% men, 31% Black, 58% Hispanic/Latino, and the median age was 32 (range 20-58) years. 75% received oral PrEP previously. LAI-PrEP six-month persistence rate was 72% (26 of 36). Among the 10 people with LAI-PrEP discontinuation, 1 transitioned to oral PrEP, 2 no longer had an indication for PrEP (change in serodifferent relationship status), and 7 were lost to follow-up. LAI-PrEP persistence differed by race (46% Black vs 88% white, p=0.007) and sexual orientation (37% heterosexual, 89% gay, 67% bisexual, p=0.019). LAI-PrEP – long-acting injectable pre-exposure prophylaxis Conclusion In the first year of LAI-PrEP implementation, LAI-PrEP uptake was favorable in our clinic, especially among priority populations for HIV prevention. Loss to follow-up was the most common reason for discontinuation, but change in PrEP method or loss of PrEP indication accounted for 30% of discontinuations. Nevertheless, the differences in persistence rates suggest a need for targeted interventions to improve long-term adherence in minority and heterosexual groups. Addressing PrEP persistence in these populations is crucial for optimizing the impact of LAI-PrEP in communities with a high burden of new HIV infections. Disclosures All Authors: No reported disclosures

P-508. Opportunities for Prep Prescription At Two Urban Academic Healthcare Institutions

Abstract Background Pre-exposure prophylaxis (PrEP) use for HIV prevention remains unequal across groups vulnerable to HIV. Reasons for inequalities include both individual and healthcare level factors. We sought to understand opportunities for prescribing PrEP at two urban academic healthcare institutions in Chicago, Illinois. Methods We analyzed electronic medical record data from both institutions including persons >18 years of age with >1 negative HIV test between 1/1/2015-12/31/2021 who had indications for PrEP. Data included demographics, social history, medications, sexually transmitted infections (STI), and encounters. Indications for PrEP included STI with gonorrhea, chlamydia, and/or active syphilis infection or injection drug use (IDU). Eligible encounters were those within six months after an STI, or as long as IDU was documented. We categorized encounters as inpatient, emergency department (ED), primary care, infectious disease (ID), obstetrics and gynecology/women’s health (OBGYN) and other outpatient settings. Results In total, 9644 persons contributed 53031 encounters that resulted in 941 people with PrEP prescriptions. The two healthcare institutions had differing patient demographics, institution A had more 18-24 year olds (58.3% vs 31.3%), more African Americans (83.8% vs 27.9%), and more women (65.7% vs 46.3%). Institution B had more White (40.6% vs 7.1%) and Hispanic persons (14.0% vs 4.2%), and more men who have sex with men (MSM) (15.2% vs 3.3%). Institution A had more eligible encounters in the ED (30.8% vs 7.3%) as well as in infectious disease, inpatient, OBYGN, and primary care settings. Institution B had more eligible encounters in other outpatient settings (67.7% vs 18.7%). Institution B accounted for the majority of PrEP prescriptions (89.1%). Conclusion Institution A contained persons historically underrepresented in PrEP prescriptions, while institution B had more encounters in other outpatient settings where ]PrEP prescriptions commonly occur. These factors are likely to be responsible for our findings. Future work will examine associations between these factors and the likelihood of PrEP prescriptions in a combined as well as institution specific models. Disclosures Jessica Ridgway, MD, Gilead Sciences: Expert Testimony Moira McNulty, MD, Gilead Sciences, Inc.: Advisor/Consultant

P-957. Introducing PrEP to Primary Care: A Resident-Focused Initiative

Abstract Background Despite studies showing that HIV pre-exposure prophylaxis (PrEP) dramatically decreases risk of HIV acquisition, it is only currently prescribed to 30% of those who could benefit. The buy in of primary care providers (PCPs), who have an essential role as preventionists, is critical for the most successful reach; however, studies have shown that PCPs often do not feel knowledgeable about PrEP or may be uncomfortable discussing sexual activity or HIV. We hypothesized that dedicated PrEP training for PCPs in a resident clinic would increase prescribing habits. Methods At an Internal Medicine residency clinic with 73 trainees in New Orleans, LA, a pre-intervention survey was distributed to gauge baseline PrEP knowledge and comfort in discussing sexual practices, HIV status and risk factors. Following the training, residents attended a one-hour PrEP training. A post-training survey then assessed interest and intent to prescribe PrEP. We abstracted primary care clinic records to evaluate PrEP prescribing outcomes post-training, from October 2023 to April 2024. Results Forty-four residents completed the pre-training assessment. Most indicated non-routine discussions regarding sexual practices (37/44, 84.1%) and HIV risk assessments (41/44, 93.2%). Many trainees reported being not at all familiar with PrEP indications (40.9%), medications (45.5%), or monitoring (81.8%). Most (61.4%) had never discussed PrEP with clients. 53/73 (72.6%) residents attended the educational session, and 26/73 (35.6%) completed the post-training survey. All of the residents who completed both indicated that the training was informative, and 20/21 (95.2%) reported willingness to prescribe PrEP. In the six months post-training, we found that 11 clients were successfully initiated on PrEP. One client was diagnosed with HIV on intake labs, and 3 clients were found to have sexually transmitted infections, all of whom were treated or referred for treatment. Conclusion The results of this initiative’s pre-training surveys highlight a lack of routine sexual health and HIV risk assessments in a resident primary care clinic, as well as deficiencies in education regarding HIV PrEP. Following training, residents began prescribing PrEP, demonstrating promise for scaling such educational programs. PrEP Primary Care Pocket Card A pocket card adapted from the CDC PrEP TRAIN module was provided to trainees in the resident clinic. Contains information regarding medications available, contraindications, side effects, laboratory monitoring (on back side), ICD-10 code, etc. Disclosures Meredith E. Clement, MD, Gilead Sciences: Grant/Research Support|Viiv Pharmaceuticals: Advisor/Consultant

P-950. Pre-Exposure Prophylaxis Education for Internal Medicine Residents (PRIMER)

Abstract Background Pre-exposure prophylaxis (PrEP) for HIV is a safe and effective strategy for HIV prevention among high-risk patient groups. Despite consistent experimental and real-world data showing benefit, PrEP is underutilized. There is a dearth of non-specialized providers engaging in PrEP services. The purpose of this project is to increase knowledge and prescribing of PrEP among a cohort of internal medicine (IM) residents. Methods A 3 hour interactive education session was provided to the IM residents of the University of Connecticut Categorical Internal Medicine Residency. Baseline knowledge was assessed with a pre-training survey. This survey was repeated up within six months to assess for a change in PrEP knowledge and prescribing. Results The pre-intervention (pre) survey was completed by 39 IM residents. The post-intervention (post) survey was completed by 25 IM residents from the same cohort. 4 participants from the post group were excluded as they had not completed a pre survey. Similar proportions indicated PrEP awareness pre- and post-intervention 97.4% and 100%, respectively. There was a numeric increase in the proportion of respondents reporting knowledge of PrEP indications from 69.2% pre to 85.7% post. Similar proportions reported prescribing PrEP 15.4% pre and 14.3% post. Those who had prescribed PrEP reported providing it to only 1-5 patients. When assessing for paired differences among a sub-set of participants who had both pre- and post scores, general knowledge of PrEP significantly improved. General knowledge scores averaged 8.6% pre and 22.6% post (p-value 0.001). Of the five general knowledge questions – testing individual domains -- the mean differences between pre and post scores were: 0.6 (95% CI 0.3-1.0), 0.2 (0.04-0.4), 0.05 (-0.1-0.2), 0.2 (0.007-0.4), 0.05 (-0.05-0.1), and 0.3 (0.08-0.5), respectively. Indicating that in all but 2 domains the 95% confidence interval did not include 0. Conclusion Among a cohort of IM residents from a mid-sized, university-based program, general PrEP knowledge was low despite widespread awareness. Knowledge was improved following an educational session; however, prescribing did not increase. Other barriers besides knowledge likely impact the likelihood of generalists, and in particular learners, to prescribe PrEP. Disclosures All Authors: No reported disclosures

Implementation Determinants of PrEP and Behavioral Health Treatment Referral among HIV Test Counselors.

Pre-exposure prophylaxis (PrEP), an effective biomedical prevention intervention, is not sufficiently reaching populations experiencing high HIV incidence. Behavioral health (BH) treatment addressing mental health and substance use similarly requires increased reach to HIV-affected populations. HIV testing is an opportunity to refer individuals to PrEP and BH treatment. This study, conducted in Miami-Dade County, FL, a domestic HIV epicenter, aimed to assess (1) self-reported rates at which HIV test counselors refer clients to PrEP and BH treatment, (2) barriers and facilitators to PrEP and BH treatment referral, and (3) the relationship between barriers and facilitators and test counselors' referral rates. Among 127 HIV test counselors, the average PrEP referral rate was 63.8% (SD = 41.5) of those potentially meeting PrEP indications. Insufficient time was associated with lower PrEP referral (OR: 0.64, 95% CI: 0.42-0.99, p = 0.023) and training in PrEP screening was associated with higher rates of PrEP referral (OR: 1.27, 95% CI: 0.98-1.64, p = 0.034). The average BH treatment referral rate was 52.7% (SD = 44.4) of clients who the counselor felt would potentially benefit from treatment. Counselors lacking knowledge of screening (OR: 0.4, 95% CI: 0.2-0.78, p = 0.004), referral procedures (OR: 0.45, 95% CI: 0.23-0.87, p = 0.008), or locations to refer clients (OR: 0.47, 95% CI: 0.25-0.86, p = 0.008), as well as those with higher caseloads (OR: 0.998, 95% CI: 0.997-0.999, p < 0.001) were less likely to refer for BH. Training in substance use screening (OR: 1.26, 95% CI: 0.96-1.64, p = 0.046) and referral (OR: 1.28, 95% CI: 0.99-1.66, p = 0.029) were associated with increased BH referral. Implementation strategies are needed to address key barriers to PrEP and BH referrals in HIV testing contexts.

The PrEP cascade in a sample of HIV-negative or unknown status adolescent and young adult transgender women in Peru.

Transgender women are a key population in the HIV epidemic globally, including in Peru. This cross-sectional epidemiological study characterized the pre-exposure prophylaxis (PrEP) cascade in adolescent and young adult transgender women in Peru to inform roll-out of early HIV prevention efforts. Between February-July 2022, a community-recruited sample of HIV-negative or status unknown young transgender women (n = 140) in Peru completed a socio-behavioral survey and biological testing for HIV and bacterial STIs. Logistic regression models estimated the association of sociodemographic, healthcare, and behavioral factors to PrEP indication and willingness. Median age was 22years (range = 16-24 years); 65.7% reported sex work and 28.6% homelessness. Overall, 45.7% had a PrEP indication based on past 6months HIV behavioral risk profiles. In a multivariable model, sex work (aRR = 2.27; 95% CI = 1.24-4.17) and homelessness (aRR = 1.27; 95% CI = 1.00-1.60) were associated with PrEP indication. More than one-third (38.6%) had never been HIV tested; 25.3% were tested >1 year ago. Only 34.3% heard of daily oral PrEP, 8.6% reported ever PrEP use, and 5.0% current PrEP use. Nearly half (49.3%) reported willingness to take daily oral PrEP. In a multivariable model, younger age was associated with increased willingness to use PrEP (aRR = 0.92; 95% CI = 0.87-0.98). Highest ranked PrEP preferences were a daily oral pill (35.7%), implant (32.1%), and injection by a provider (10.0%). PrEP indication and willingness were high in this sample, but HIV testing and PrEP uptake were low. Findings highlight opportunities for age-responsive and contextually-relevant interventions to increase HIV prevention among young transgender women in Peru.

Claims-Based Algorithm to Identify Pre-Exposure Prophylaxis Indications for Tenofovir Disoproxil Fumarate and Emtricitabine Prescriptions (2012-2014): Validation Study.

To monitor the use of tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) and related medicines for pre-exposure prophylaxis (PrEP) as HIV prevention using commercial pharmacy data, it is necessary to determine whether TDF/FTC prescriptions are used for PrEP or for some other clinical indication. This study aimed to validate an algorithm to distinguish the use of TDF/FTC for HIV prevention or infectious disease treatment. An algorithm was developed to identify whether TDF/FTC prescriptions were for PrEP or for other indications from large-scale administrative databases. The algorithm identifies TDF/FTC prescriptions and then excludes patients with International Classification of Diseases (ICD)-9 diagnostic codes, medications, or procedures that suggest indications other than for PrEP (eg, documentation of HIV infection, chronic hepatitis B, or use of TDF/FTC for postexposure prophylaxis). For evaluation, we collected data by clinician assessment of medical records for patients with TDF/FTC prescriptions and compared the assessed indication identified by the clinician review with the assessed indication identified by the algorithm. The algorithm was then applied and evaluated in a large, urban, community-based sexual health clinic. The PrEP algorithm demonstrated high sensitivity and moderate specificity (99.6% and 49.6%) in the electronic medical record database and high sensitivity and specificity (99% and 87%) in data from the urban community health clinic. The PrEP algorithm classified the indication for PrEP in most patients treated with TDF/FTC with sufficient accuracy to be useful for surveillance purposes. The methods described can serve as a basis for developing a robust and evolving case definition for antiretroviral prescriptions for HIV prevention purposes.

Associations of HIV pre-exposure prophylaxis (PrEP) indication, HIV risk perception and unwillingness to use PrEP among people who inject drugs in Baltimore, MD

BackgroundPerceived HIV risk may impact willingness to initiate PrEP among people who inject drugs (PWID). MethodsWe analyzed baseline data from PrEP eligible PWID in Baltimore, MD. Risk perception was assessed by PWID relative to the average risk of their age group categorized as: higher-than, lower-than, or about average. Participants were informed of PrEP for HIV prevention and asked about their willingness to use daily PrEP. Associations of PrEP indication (categorized as injection risk only vs any sexual risk), perceived HIV risk and non-willingness to use PrEP was assessed using generalized linear models. ResultsAmong 489 participants, 61 % were male, 66 % were Black and mean age was 46 years. One-third (35 %) of the participants were aware of PrEP and <1 % had used PrEP in the prior 30 days. Overall, 30 % of PWID reported lower-than-average perceived HIV risk and 18 % reported non-willingness to use PrEP. Participants with injection risk only were more likely (aOR: 2.75; 95 %CI: 1.60 – 4.73) to report having lower-than-average perceived HIV risk compared to those with any sexual risk. Participants with lower-than-average perceived risk were more likely to report non-willingness to use PrEP compared to those with higher perceived risk (adjusted PR: 1.91; 95 %CI: 1.18 – 3.10). ConclusionA considerable proportion of PWID eligible for PrEP reported having low risk of HIV acquisition despite being eligible for PrEP. Consistent and tailored PrEP messaging that addresses drug use HIV risk perception may be critical to increasing PrEP uptake among PWID.

Brief Report: Gaps in HIV Preexposure Prophylaxis Acceptance: Findings From an Outpatient HIV Testing Service in Italy.

The aim of this study is to assess the acceptability of HIV preexposure prophylaxis (PrEP) among individuals eligible for prophylaxis. Retrospective study of individuals receiving their first HIV test at the Infectious Diseases Unit of IRCCS San Raffaele Scientific Institute, Milan, Italy. People (1) who received their first HIV test (baseline date) between January 2018 (availability of PrEP in Italy) and December 2023 (data lock) and (2) with an indication for PrEP based on condomless sex were included; those already on PrEP were excluded. Individuals with a negative HIV test result were offered PrEP counseling and prescription according to guidelines. Characteristics of people who accepted or declined HIV PrEP were compared using Mann-Whitney or χ 2 tests, as appropriate. A total of 2627 people were tested for HIV: 175 (6.6%) were diagnosed with HIV. Of the 2452 people with negative HIV test results, 2165 (88.3%) were men; median age was 34.3 years (interquartile range = 28.7-42.4). Sexually transmitted infections were detected in 478 of 2452 (19.5%) people, most commonly gonorrhea (206/2452, 8.4%). Overall, 982 of 2452 (40.0%) people accepted PrEP, including only 3 women. Nonacceptance was higher among women ( P < 0.001) and non-White ( P < 0.001). Of those who did not accept PrEP, 260 (17.7%) were diagnosed with at least 1 sexually transmitted infection at the time of HIV testing. Low PrEP acceptance was observed, particularly among women and people of non-White origin. Nonacceptance of PrEP was also observed among individuals diagnosed with an sexually transmitted infection.

Design and Proof of Concept of a Web-Based Questionnaire to Identify Patients at Risk for HIV and HCV Infection.

Despite remarkable improvement in the human immunodeficiency virus (HIV) and hepatitis C virus (HCV) care continuum, the rate of late diagnosis of HIV and HCV in high-income countries remains unacceptably high. Testing relies mainly on primary care physicians' identification of risk factors. We aimed to adapt an analogic to an online questionnaire to help HIV and HCV screening and perform a pilot study to assess its accuracy and acceptability. We used the Delphi method to adapt a previously validated analogical questionnaire to a user-friendly online tool. It aimed to identify participants who should be screened for HIV or HCV and those who should be referred for pre-exposure prophylaxis (PrEP). We then designed a proof-of-concept pilot study from July to October 2022 to test its feasibility and suitability for use on a larger scale and to assess its accuracy in identifying patients at risk for HIV or HCV or with indication for PrEP. The final questionnaire consisted of 37 questions. A total of 142 participants provided informed consent, and 102 completed the questionnaire: 41 random patients recruited at the primary care level, 10 participants recently diagnosed with HIV, 20 participants with HIV on follow-up, 21 participants from the PrEP program, and 10 patients diagnosed with HCV. The tool adequately indicated the need for testing in more than 98% of participants with confirmed HIV/HCV infections or in the PrEP program. Furthermore, it adequately assessed PrEP referral in 94% of participants already on PrEP or with known HIV infection. Participants were highly satisfied with the tool, and 98% of them recommended its use. A self-administered web-based tool to identify patients who should be tested for HIV or HCV or referred to PrEP could simplify patient selection and help reduce late diagnosis.

Examining HIV pre-exposure prophylaxis (PrEP) acceptability among rural people who inject drugs: predictors of PrEP interest among syringe service program clients

ABSTRACT Rural communities in the US have increasing HIV burden tied to injection drug use, yet engagement in pre-exposure prophylaxis (PrEP) care has been low among people who inject drugs (PWID). Syringe service programs (SSPs) are widely implemented in Kentucky’s Appalachian region, presenting an important opportunity to scale PrEP services. This paper examines PrEP awareness, interest and preferences among PWID attending community-based SSPs in Appalachia. Eighty participants were enrolled from two SSP locations. Eligibility included: ≥ 18 years old, current injection drug use and SSP use, and an indication for PrEP as defined by CDC guidelines. Participants completed a structured baseline interview. Predictors of PrEP awareness, interest and formulation preferences were examined. 38.8% reported baseline awareness of PrEP, 50% expressed high interest in PrEP, and 48.1%reported a preference for injectable PrEP. Significant bivariate predictors of PrEP interest included: current worry about health, higher perceived HIV risk, higher community HIV stigma, and higher enacted substance use stigma in the past year; in the adjusted model, enacted substance use stigma remained significant. Findings demonstrate substantial interest in PrEP among rural PWID. Intrapersonal and social determinant factors were associated with PrEP interest, which suggests the importance of multi-level intervention targets to increase PrEP uptake.

Low Self-Perceived Need for PrEP and Behavioral Indications of MSM Who Recently Refused Daily PrEP: A Mixed Methods Study in Three U.S. Cities.

Pre-exposure prophylaxis (PrEP) reduces sexual risk for HIV transmission by 99% when used appropriately, but remains underutilized among gay, bisexual, and other men who have sex with men (MSM). In this mixed-method study, we describe reasons for PrEP refusal associated with low self-perceived need for PrEP among MSM who recently declined daily oral PrEP when offered by a provider. Data are from a quantitative behavioral survey of MSM (N = 93) living in Atlanta, Chicago, and Raleigh-Durham, who also either responded to an in-depth interview (n = 51) or participated in one of 12 focus groups (n = 42). Themes of low self-perceived need for PrEP were: low self-perceived risk for HIV acquisition (33% of respondents); confidence in remaining HIV-negative (35%); using condoms (81%); limiting number of partners and choosing partners carefully (48%); asking partners about their HIV status before having sex (45%); engaging in safer sexual positions or oral sex (28%); being in a monogamous relationship or exclusivity with one partner (26%); and regular HIV testing (18%). Low self-perceived risk for HIV acquisition and high confidence in other prevention strategies were important factors related to low self-perceived need in MSM refusing daily oral PrEP when offered. Providers should continue to discuss the benefits of PrEP as a safe and highly effective option for HIV prevention.

Missed Opportunities for HIV Prevention in a Large County Safety Net Health System.

HIV pre-exposure prophylaxis (PrEP) is effective at reducing HIV transmission. However, PrEP uptake is low for racial and ethnic minorities and women, especially in the Southern US Health care clinicians should be prepared to identify all patients eligible for PrEP, provide counseling, and prescribe PrEP. Retrospective analysis of persons newly diagnosed with HIV was conducted at a large public health system from January 2015 to June 2021. Interactions with the health system in the 5 years preceding HIV diagnosis were analyzed, and missed opportunities for HIV prevention interventions, including PrEP and condom use counseling, were identified. We identified 454 patients with a new HIV diagnosis with previous health system interactions. 166(36.6%) had at least 1 identifiable indication for PrEP: 42(9.3%) bacterial STI, 63(13.9%) inconsistent condom use, or 82(18%) injection drug use before HIV diagnosis. Only 7(1.5%) of patients were counseled on PrEP. Most patients (308; 67.8%) had no documented condom use history in the EHR before diagnosis, a surrogate marker for obtaining a sexual history. Patients who exclusively interacted with the emergency care setting did not receive PrEP education and were less likely to receive condom use counseling. Missed opportunities to offer HIV prevention before diagnosis were common among patients newly diagnosed with HIV. Most patients did not have sexual history documented in the chart before their HIV diagnosis. Educational interventions are needed to ensure that clinicians are prepared to identify those eligible and discuss the benefits of PrEP.

PrEP Discontinuation In A US National Cohort Of Sexual And Gender Minority Populations, 2017-22.

In the US, sexual and gender minority populations are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a key prevention method, but its effectiveness relies on consistent usage. Our four-year national cohort study explored PrEP discontinuation among sexual and gender minority people who initiated PrEP. We found a high annual rate of discontinuation (35-40percent) after PrEP initiation. Multivariable analysis with 6,410 person-years identified housing instability and prior history of PrEP discontinuation as predictors of discontinuation. Conversely, older age, clinical indication for PrEP, and having health insurance were associated with ongoing PrEP use. To promote sustained PrEP use, strategies should focus on supporting those at high risk for discontinuation, such as younger people, those without stable housing or health insurance, and prior PrEP discontinuers.

HIV Risk and Interest in Preexposure Prophylaxis in Justice-Involved Persons.

Preexposure prophylaxis (PrEP) is underused in persons who use drugs and justice-involved persons. In an ongoing randomized controlled trial in 4 US locations comparing patient navigation versus mobile health unit on time to initiation of HIV medication or PrEP for justice-involved persons who use stimulants or opioids and who are at risk for or living with HIV, we assessed HIV risk factors, perceived HIV risk, and interest in PrEP. Participants without HIV (n = 195) were 77% men, 65% White, 23% Black, and 26% Hispanic; 73% reported a recent history of condomless sex, mainly with partners of unknown HIV status. Of 34% (67/195) reporting injection drug use, 43% reported sharing equipment. Despite risk factors, many persons reported their risk for acquiring HIV as low (47%) or no (43%) risk, although 51/93 (55%) with PrEP indications reported interest in PrEP. Justice-involved persons who use drugs underestimated their HIV risk and might benefit from increased PrEP education efforts.

Co-delivery of HIV pre-exposure prophylaxis (PrEP) and HIV testing among publicly insured adolescents and young adults (AYA) receiving medication for opioid use disorder (MOUD)

BackgroundLow rates of HIV pre-exposure prophylaxis (PrEP) prescribing contribute to the disproportionate burden of HIV in the United States. Among adolescent and young adults (AYA) with opioid use disorder, HIV testing and PrEP co-prescription rates are poorly characterized. MethodsWe performed a retrospective analysis involving deidentified data from Philadelphia’s Medicaid beneficiaries ages 16–29 years who were prescribed medication for opioid use disorder (MOUD) from 2015 to 2020 and continuously Medicaid-enrolled for ≥6 months prior to that prescription. After identifying the presence of a qualifying diagnosis signifying a PrEP indication, we examined the outcome of appropriate PrEP co-prescriptions and HIV testing using generalized estimating equations (GEE) modeling. ResultsWe identified 795 AYA Medicaid beneficiaries with 1269 qualified treatment episodes. We calculated a PrEP prescribing rate of 29.47 per 1000 person-years among AYA receiving MOUD. The HIV testing rate was 63.47 per 1000 person-years among AYA receiving MOUD. GEE modeling revealed that individuals receiving methadone were more likely (aOR=2.62, 95% CI=1.06–6.49) to receive HIV testing within 6 months after a PrEP-qualifying diagnosis compared to those receiving other MOUD medications. Those who only saw outpatient behavioral health providers were less likely (aOR=0.48, 95% CI=0.24–0.99) to have received an HIV test within 6 months after the PrEP-qualifying diagnosis compared to those receiving inpatient behavioral health services. ConclusionsCo-prescription of PrEP and HIV testing among AYA receiving MOUD was rare in this large urban publicly insured population. Interventions are needed to increase HIV prevention services for this key population of AYA at risk for HIV infection.

Identifying Key Factors to PrEP Initiation and Persistence Among YMSM Through Focus Groups and Surveys in Two High-Priority Settings.

Cisgender men are diagnosed with HIV at a rate four times greater than cisgender women, with 71% of infections attributed to male-male sexual contact. Despite expanding accessibility, pre-exposure prophylaxis (PrEP) for HIV prevention is initiated by only 30% of people with PrEP indications. Five focus groups with 42 young men who have sex with men from New York and Alabama were conducted to identify key factors to PrEP initiation and persistence. Thirty focus group participants completed a survey on demographics, PrEP choices and health care attitudes. Findings suggest provider competency significantly influences PrEP use due to stigmatization in medical settings. Participants noted benefits of PrEP including HIV protection and sexual empowerment, yet barriers like cost and side effects were prevalent. Our findings outline barriers and facilitators to PrEP use among young men who have sex with men in two high priority settings that will inform PrEP care updates in participating clinics.

Age-related factors associated with intention to initiate pre-exposure prophylaxis among cisgender women in Washington D.C.

Pre-exposure prophylaxis (PrEP) utilization among cisgender women (subsequently 'women') is low across age groups, relative to their risk of HIV acquisition. We hypothesize that age-related differences in psychosocial factors also influence women's intention to initiate oral PrEP in Washington, D.C. A secondary analysis of a cross-sectional survey data was performed to evaluate factors influencing intention to initiate oral PrEP among women seen at a family planning and a sexual health clinic. A bivariate analysis was performed to identify differences by age group in demographic characteristics, indications for PrEP, and attitudes toward PrEP; we then performed additional bivariate analysis to assess these variables in relation to PrEP intention. Across age groups, perceived risk of HIV acquisition was not significantly different and was not associated with intention to initiate PrEP. Awareness of and attitude toward PrEP, injunctive norms, descriptive norms, and self-efficacy were not different across age, however there were significant age-associated differences in relation to PrEP intention. Specifically, among 18-24-year-olds, intention to start PrEP was associated with support from provider (p = 0.03), main sexual partner (p < 0.01), and peers (p < 0.01). For women 25-34 years old, having multiple sexual partners (p = 0.03) and support from casual sexual partners (p = 0.03) was also important. Among women 35-44 years old, prior awareness of PrEP (p = 0.02) and their children's support of PrEP uptake (p < 0.01) were associated with intention to initiate PrEP. Among 45-55 year-old women intention to initiate PrEP was positively associated with engaging in casual sex (p = 0.03) and negatively associated with stigma (p < 0.01). Overall, there were more similarities than differences in factors influencing intention to initiate PrEP across age groups. Observed differences offer an opportunity to tailor PrEP delivery and HIV prevention interventions to increase awareness and uptake for cisgender women.

PrEP initiation and adherence among Black cisgender women in Mississippi: The role of HIV and PrEP stigma and social support.

Stigma and lack of social support are barriers to HIV prevention, especially among cisgender Black women in the United States. While HIV pre-exposure prophylaxis (PrEP) can decrease HIV transmission, PrEP initiation and adherence remains low among Black women, especially in the U.S. South. The purpose of this study was to characterize experiences with stigma and social support among PrEP-naïve and PrEP-experienced Black cisgender women in Mississippi. Qualitative study in which semi-structured interviews and focus groups were conducted. We purposively recruited PrEP-naïve cisgender Black women who met PrEP indications to participate in focus groups and all PrEP-experienced cisgender Black women at a sexual health clinic in Jackson, Mississippi to participate in one-on-one semi-structured interviews. Inductive thematic analysis was used to analyze focus group and interview transcripts. A total of 37 PrEP-naïve Black cisgender women participated across 6 focus groups and 8 PrEP-experienced cisgender Black women completed semi-structured interviews. Four themes were identified: (1) the intersection of gendered racism, discrimination, and HIV stigma, (2) enacted and anticipated PrEP stigma, (3) stigma mitigation strategies and PrEP adherence, and (4) social support's role in PrEP initiation and adherence. PrEP-naïve and -experienced Black women discussed the negative consequence that sexual stigmatization and gendered racism has on HIV testing. PrEP-naïve Black women discussed how HIV stigma decreases PrEP initiation. Conversely, PrEP-experienced Black women were able to identify strategies they utilized to mitigate stigma. PrEP-experienced Black women discussed how differing levels of social support impact their PrEP use. Improving social support and stigma mitigation strategies could help improve PrEP initiation and adherence among cisgender Black women at-risk of acquiring HIV in the U.S. South. Educating communities on PrEP, and training providers on stigma-mitigating strategies when serving Black women in the U.S. South who are seeking HIV prevention is paramount.

PrEP initiation and discontinuation among transgender women in the United States: a longitudinal, mixed methods cohort study.

Transgender women in the United States experience high HIV incidence and suboptimal Pre-exposure prophylaxis (PrEP) engagement. We sought to estimate PrEP initiation and discontinuation rates and characterize PrEP discontinuation experiences among a prospective cohort of transgender women. Using a sequential, explanatory, mixed-methods design, 1312 transgender women at risk for HIV acquisition were enrolled from March 2018 to August 2020 and followed through July 2022 (median follow-up 24 months; interquartile range 15-36). Cox regression models assessed predictors of initiation and discontinuation. In-depth interviews were conducted among 18 participants, including life history calendars to explore key events and experiences surrounding discontinuations. Qualitative and quantitative data were integrated to generate typologies of discontinuation, inform meta-inferences and facilitate the interpretation of findings. 21.8% (n = 286) of participants reported taking PrEP at one or more study visits while under observation. We observed 139 PrEP initiations over 2127 person-years (6.5 initiations/100 person-years, 95% CI: 5.5-7.7). Predictors of initiation included identifying as Black and PrEP indication. The rate of initiation among those who were PrEP-indicated was 9.6 initiations/100 person-years (132/1372 person-years; 95% CI: 8.1-11.4). We observed 138 PrEP discontinuations over 368 person-years (37.5 discontinuations/100 person-years, 95% CI: 31.7-44.3). Predictors of discontinuation included high school education or less and initiating PrEP for the first time while under observation. Four discontinuation typologies emerged: (1) seroconversion following discontinuation; (2) ongoing HIV acquisition risk following discontinuation; (3) reassessment of HIV/STI prevention strategy following discontinuation; and (4) dynamic PrEP use coinciding with changes in HIV acquisition risk. PrEP initiation rates were low and discontinuation rates were high. Complex motivations to stop using PrEP did not consistently correspond with HIV acquisition risk reduction. Evidence-based interventions to increase PrEP persistence among transgender women with ongoing acquisition risk and provide HIV prevention support for those who discontinue PrEP are necessary to reduce HIV incidence in this population.