Pre-exposure Prophylaxis Barriers Research Articles

P-523. Impact of Tailored Education on Engagement in Sexual Health and HIV Prevention Services Among US Women

Abstract Background Women in the US are facing increasing barriers to sexual health services. This project aimed to enhance sexual health literacy and linkage to HIV prevention among US women. Methods From 6/2023-8/2023, six patient education sessions on sexual health and HIV prevention were held in women’s health clinics in California, Georgia, and Virginia. Surveys were given to participating patients and healthcare professionals (HCPs) before/after each session and one month later. Content was shared nationally through an online toolkit for HCPs and a public social media video. Results Among the 88 patients who attended a sexual health education session (mean age: 44 years; 60% Black, 83% previously tested for HIV), baseline awareness of pre-exposure prophylaxis (PrEP) (23%) and resources for HIV testing/prevention (63%) significantly increased to 71% (P < .001) and 84% (P = .002), respectively, after the sessions. More women felt confident in HIV prevention after the education than before (93% vs. 82%, P = .028). After education, all participating HCPs (n = 6) correctly identified that a woman’s HIV risk is nearly constant throughout life and that PrEP should be offered to anyone who asks for it, compared to 50% correctly answering each question at baseline (P = .181). When asked about patients’ barriers to HIV/STI testing, HCPs most frequently chose fear of judgment (50%), while patients reported cost concerns (27%) and test-related anxiety (26%). When asked what would make testing easier, learning about free or low-cost local testing centers was most frequently chosen by both patients (49%) and HCPs (67%). Discordances were observed regarding PrEP barriers. The top patient-reported barrier was insurance coverage/medication costs (48%), while HCPs perceived fear of side effects as the main barrier (67%). One month later, 73% (n = 19/26) of patients had gotten tested for HIV, and HCPs had discussed HIV screening/prevention with 94 women and helped 38 start PrEP. As of 1/2024, the online toolkit and social media video were accessed by 1,057 and 4,054 people, respectively. Conclusion This tailored educational initiative offered insights into women’s barriers to HIV screening and prevention, after which women’s participation in HIV testing and awareness of PrEP improved. Disclosures All Authors: No reported disclosures

Adaptation of a Theory-Based Mobile App to Improve Access to HIV Prevention Services for Transgender Women in Malaysia: Focus Group Study.

Globally, transgender women have been disproportionately affected by the HIV epidemic, including in Malaysia, where an estimated 11% of transgender women are living with HIV. Available interventions designed specifically to meet transgender women's needs for HIV prevention are limited. Mobile health, particularly smartphone mobile apps, is an innovative and cost-effective strategy for reaching transgender women and delivering interventions to reduce HIV vulnerability. This study aims to adapt a theory-based mobile health HIV prevention smartphone app, HealthMindr, to meet the unique needs of transgender women in Malaysia. We conducted theater testing of the HealthMindr app with transgender women and key stakeholders and explored barriers to transgender women's uptake of HIV pre-exposure prophylaxis (PrEP). From February to April 2022, a total of 6 focus group (FG) sessions were conducted with 29 participants: 4 FG sessions with transgender women (n=18, 62%) and 2 FG sessions with stakeholders (n=11, 38%) providing HIV prevention services to transgender women in Malaysia. Barriers to PrEP uptake and gender-affirming care services among transgender women in Malaysia were explored. Participants were then introduced to the HealthMindr app and provided a comprehensive tour of the app's features and functions. Participants provided feedback on the app and on how existing features should be adapted to meet the needs of transgender women, as well as any features that should be removed or added. Each FG was digitally recorded and transcribed. Transcripts were coded inductively using Dedoose software (version 9.0.54; SocioCultural Research Consultants, LLC) and analyzed to identify and interpret emerging themes. Six subthemes related to PrEP barriers were found: stigma and discrimination, limited PrEP knowledge, high PrEP cost, accessibility concerns, alternative prevention methods, and perceived adverse effects. Participants suggested several recommendations regarding the attributes and app features that would be the most useful for transgender women in Malaysia. Adaptation and refinement of the app were related to the attributes of the app (user interface, security, customizable colors, themes, and avatars), feedback, and requests for additional mobile app functional (appointment booking, e-consultation, e-pharmacy, medicine tracker, mood tracker, resources, and service site locator) and communication (peer support group, live chat, and discussion forum) features. The results reveal that multifaceted barriers hinder PrEP uptake and use among transgender women in Malaysia. The findings also provide detailed recommendations for successfully adapting the HealthMindr app to the context of Malaysian transgender women, with a potential solution for delivering tailored HIV prevention, including PrEP, and increasing accessibility to gender-affirming care services.

Population-level effectiveness of pre-exposure prophylaxis for HIV prevention among men who have sex with men in Montréal (Canada): a modelling study of surveillance and survey data.

HIV pre-exposure prophylaxis (PrEP) has been recommended and partly subsidized in Québec, Canada, since 2013. We evaluated the population-level impact of PrEP on HIV transmission among men who have sex with men (MSM) in Montréal, Québec's largest city, over 2013-2021. We used an agent-based mathematical model of sexual HIV transmission to estimate the fraction of HIV acquisitions averted by PrEP compared to a counterfactual scenario without PrEP. The model was calibrated to local MSM survey, surveillance, and cohort data and accounted for COVID-19 pandemic impacts on sexual activity, HIV prevention, and care. PrEP was modelled from 2013 onwards, assuming 86% individual-level effectiveness. The PrEP eligibility criteria were: any anal sex unprotected by condoms (past 6 months) and either multiple partnerships (past 6 months) or multiple uses of post-exposure prophylaxis (lifetime). To assess potential optimization strategies, we modelled hypothetical scenarios prioritizing PrEP to MSM with high sexual activity (≥11 anal sex partners annually) or aged ⩽45 years, increasing coverage to levels achieved in Vancouver, Canada (where PrEP is free-of-charge), and improving retention. Over 2013-2021, the estimated annual HIV incidence decreased from 0.4 (90% credible interval [CrI]: 0.3-0.6) to 0.2 (90% CrI: 0.1-0.2) per 100 person-years. PrEP coverage among HIV-negative MSM remained low until 2015 (<1%). Afterwards, coverage increased to a maximum of 10% of all HIV-negative MSM, or about 16% of the 62% PrEP-eligible HIV-negative MSM in 2020. Over 2015-2021, PrEP averted an estimated 20% (90% CrI: 11%-30%) of cumulative HIV acquisitions. The hypothetical scenarios modelled showed that, at the same coverage level, prioritizing PrEP to high sexual activity MSM could have averted 30% (90% CrI: 19%-42%) of HIV acquisitions from 2015-2021. Even larger impacts could have resulted from higher coverage. Under the provincial eligibility criteria, reaching 10% coverage among HIV-negative MSM in 2015 and 30% in 2019, like attained in Vancouver, could have averted up to 63% (90% CrI: 54%-70%) of HIV acquisitions from 2015 to 2021. PrEP reduced population-level HIV transmission among Montréal MSM. However, our study suggests missed prevention opportunities and adds support for public policies that reduce PrEP barriers, financial or otherwise, to MSM at risk of HIV acquisition.

A Principal Investigator as a PrEP-Using Peer Change Agent for HIV Prevention among Black Gay and Bisexual Men: An Autoethnography.

HIV pre-exposure prophylaxis (PrEP) use remains suboptimal among Black gay and bisexual men (GBM). Multilevel factors such as medication costs, intersectional stigma, patient-clinician communication, medical mistrust, side effect concerns, and low perceived HIV risk (PHR) are well-established PrEP initiation barriers for this group. Peer change agents (PCAs) are culturally congruent interventionists who can circumvent multilevel PrEP barriers among Black GBM. I led an intervention as a PrEP-using PCA to improve PHR and PrEP willingness among 69 Black GBM from 2019-2022 and conducted an autoethnography to better understand multilevel barriers and identify the personal/professional challenges of being an in-group HIV interventionist serving Black SMM. Findings provide novel perspectives regarding PrEP barriers, the role of cultural homophily in behavior change interventions, and how interpersonal dynamics can impact staff fatigue, protocol fidelity, and research participation. Recommendations to prepare and support culturally congruent research staff are also provided.

Pre-Exposure Prophylaxis Barriers, Facilitators and Unmet Need Among Rural People Who Inject Drugs: A Qualitative Examination of Syringe Service Program Client Perspectives.

BackgroundPeople who inject drugs (PWID) are at high risk for HIV infection, yet in rural areas PWID are understudied with respect to prevention strategies. Kentucky is notable for heavy rural HIV burden and increasing rates of new HIV diagnoses attributable to injection drug use. Despite high need and the strong evidence for Pre-Exposure Prophylaxis (PrEP) as a gold-standard biomedical HIV prevention tool, scale up has been limited among PWID in Kentucky and elsewhere. This paper explores individual, environmental, and structural barriers and facilitators of PrEP care from the perspective of PWID in rural Kentucky.MethodsData are drawn from an ongoing NIH-funded study designed to adapt and integrate a PrEP initiation intervention for high-risk PWID at point of care in two rural syringe service programs (SSPs) in southeastern Kentucky. As part of this initiative, a qualitative study guided by PRISM (Practical, Robust, Implementation, and Sustainability Model) was undertaken to gather SSP client perspectives on intervention needs related to PrEP, competing needs related to substance use disorder, as well as tangible supports for and barriers to PrEP uptake. Recruitment and interviews were conducted during September-November 2021 with 26 SSP clients, 13 from each of the two SSP sites. A semi-structured guide explored injection behaviors, SSP use, knowledge of PrEP, perceived barriers to PrEP, as well as aspects of the risk environment (e.g., housing instability, community stigma) that may impact PrEP uptake. Interviews were digitally recorded, transcribed verbatim and verified by project staff. A detailed coding scheme was developed and applied by independent coders using NVivo. Coded transcripts were synthesized to identify salient themes in the data using the principles of thematic analysis All study procedures were approved by the University IRB.ResultsParticipants were 96% white, 42% female, with a median age of 41 years (range 21–62); all reported injection use within the past month. Overall, we found low PrEP awareness among this sample, yet interest in PrEP was high, with several indicating PrEP is urgently needed. Clients reported overwhelmingly positive experiences at the SSPs, considering them trusted and safe locations to receive health services, and were enthusiastic about the integration of co-located PrEP services. Lack of basic HIV and PrEP knowledge and health literacy were in evidence, which contributed to common misperceptions about personal risk for HIV. Situational risks related to substance use disorder, particularly in the context of withdrawal symptoms and craving, often lead to heightened HIV injection and sexual risk behaviors. Stigma related to substance use and HIV arose as a concern for PrEP uptake, with several participants reflecting that privacy issues would impact their preferences for education, prescribing and monitoring of PrEP. Noted tangible barriers included inconsistent access to phone service and transportation. Primary supports included high levels of insurance coverage, consistent pharmacy access, and histories with successful medication management for other health conditions.ConclusionsDrawing on the critical perspectives of people with substance use disorder, our findings provide important and actionable information on individual and environmental barriers and facilitators of PrEP uptake among rural PWID at high risk for HIV infection. These data will drive the adaptation and implementation of a client-centered approach to integrated PrEP care within rurally located SSP settings to address unmet needs for PrEP care.

Unsupervised Machine Learning to Detect and Characterize Barriers to Pre-exposure Prophylaxis Therapy: Multiplatform Social Media Study.

Among racial and ethnic minority groups, the risk of HIV infection is an ongoing public health challenge. Pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV when taken as prescribed. However, there is a need to understand the experiences, attitudes, and barriers of PrEP for racial and ethnic minority populations and sexual minority groups. This infodemiology study aimed to leverage big data and unsupervised machine learning to identify, characterize, and elucidate experiences and attitudes regarding perceived barriers associated with the uptake and adherence to PrEP therapy. This study also specifically examined shared experiences from racial or ethnic populations and sexual minority groups. The study used data mining approaches to collect posts from popular social media platforms such as Twitter, YouTube, Tumblr, Instagram, and Reddit. Posts were selected by filtering for keywords associated with PrEP, HIV, and approved PrEP therapies. We analyzed data using unsupervised machine learning, followed by manual annotation using a deductive coding approach to characterize PrEP and other HIV prevention-related themes discussed by users. We collected 522,430 posts over a 60-day period, including 408,637 (78.22%) tweets, 13,768 (2.63%) YouTube comments, 8728 (1.67%) Tumblr posts, 88,177 (16.88%) Instagram posts, and 3120 (0.6%) Reddit posts. After applying unsupervised machine learning and content analysis, 785 posts were identified that specifically related to barriers to PrEP, and they were grouped into three major thematic domains: provider level (13/785, 1.7%), patient level (570/785, 72.6%), and community level (166/785, 21.1%). The main barriers identified in these categories included those associated with knowledge (lack of knowledge about PrEP), access issues (lack of insurance coverage, no prescription, and impact of COVID-19 pandemic), and adherence (subjective reasons for why users terminated PrEP or decided not to start PrEP, such as side effects, alternative HIV prevention measures, and social stigma). Among the 785 PrEP posts, we identified 320 (40.8%) posts where users self-identified as racial or ethnic minority or as a sexual minority group with their specific PrEP barriers and concerns. Both objective and subjective reasons were identified as barriers reported by social media users when initiating, accessing, and adhering to PrEP. Though ample evidence supports PrEP as an effective HIV prevention strategy, user-generated posts nevertheless provide insights into what barriers are preventing people from broader adoption of PrEP, including topics that are specific to 2 different groups of sexual minority groups and racial and ethnic minority populations. Results have the potential to inform future health promotion and regulatory science approaches that can reach these HIV and AIDS communities that may benefit from PrEP.

Who is using PrEP on-demand? Factors associated with PrEP use modality among Black and Hispanic/Latino emerging adults.

Pre-exposure prophylaxis (PrEP) is a highly efficacious HIV prevention medication, yet Black and Hispanic/Latino sexual minority men's and gender diverse individuals' (SMMGD) PrEP use is limited due to factors such as PrEP barriers and anticipated PrEP stigma. Although most individuals who use PrEP take it as a daily regimen, there is evidence that many SMMGD are interested in using "on-demand" (also known as event-driven or intermittent or 2-1-1) PrEP. We used stepwise multinomial logistic regression to explore factors associated with on-demand, daily, and no PrEP use among 820 Black and Hispanic/Latino SMMGD ages 18-29 in the United States. We found that greater reported PrEP barriers were associated with higher odds of using PrEP on-demand or not using PrEP compared to daily PrEP use. More past 3-month sex partners and greater comfort telling others about PrEP use were associated with lower odds of on-demand compared to daily PrEP use. In addition, compared to daily PrEP use, more past 3-month sex partners, greater comfort telling others about PrEP use, and higher anticipated PrEP stigma were associated with lower odds of no current PrEP use compared to daily PrEP use. Findings may inform clinical practices and interventions to promote PrEP uptake and adherence.

Expanding the Pie-Differentiated PrEP Delivery Models to Improve PrEP Uptake in the San Francisco Bay Area.

Background:Pre-exposure prophylaxis (PrEP) uptake among trans people to date has been low. Recommendations implemented in San Francisco to offer PrEP with feminizing hormones have not led to improvement of PrEP uptake in trans communities. New delivery models may be needed. The aim of this study was to examine whether a PrEP-only clinic was more likely to serve trans people at highest risk of HIV than trans-affirming primary care clinics.Methods:Participants were recruited between 2017 and 2019 as part of a PrEP demonstration project in the San Francisco Bay Area. Survey data including sociodemographics, HIV-related risk behavior, barriers to PrEP, and self-reported PrEP adherence were collected at baseline, 3 months, and 6 months for all participants. Bivariable Poisson regression models were used to examine differences between participants in the primary care clinics and PrEP-only clinic delivered to participants.Results:Baseline survey data were collected from 153 participants. Those with a higher number of sexual partners were significantly more likely to use the PrEP-only clinic rather than the primary care clinics. Participants with higher perceived HIV risk and those who engaged in sex work were also more likely to use the PrEP-only clinic compared with the primary care clinic. Medical mistrust was higher at baseline among participants of the PrEP-only clinic. PrEP adherence was not significantly different by delivery model. Few participants identified PrEP barriers, such as interactions with feminizing hormones, to be determinants of PrEP uptake.Conclusions:A PrEP-only delivery model could improve PrEP uptake and may better meet the needs of trans people who could most benefit from PrEP.

HIV Pre-Exposure Prophylaxis Prevention Awareness, Willingness, and Perceived Barriers among People Who Inject Drugs in Los Angeles and San Francisco, CA, 2016–2018

Background Pre-exposure prophylaxis (PrEP) for HIV prevention is indicated for people who inject drugs (PWID), yet most studies do not focus on PWID. This study examines factors associated with PrEP awareness and willingness, and identifies perceived barriers to PrEP among PWID. Methods: PWID were interviewed in Los Angeles and San Francisco, CA from 2016 to 2018. We analyzed data from self-reported HIV-negative participants who had injected drugs within the past 6 months (n = 469). Questions on PrEP included awareness, willingness, barriers, and uptake. Multiple logistic regression models of factors associated with awareness of, and willingness to, take PrEP were developed. Descriptive statistics on perceived PrEP barriers are reported. Results: Among HIV-negative PWID, 40% were aware of PrEP, 59% reported willingness to take PrEP, and 2% were currently taking PrEP. In multivariable analysis, PrEP awareness was associated with study site and sexual minority status, higher educational attainment, and HIV testing in the last 6 months. Willingness to take PrEP was associated with self-reported risk (paying sex partner in the last 6 months, sharing drug paraphernalia, and being injected by another PWID) and perceived HIV risk. The most common perceived barriers to PrEP were copays, concerns about increased HIV or sexually transmitted risk with PrEP, and concerns about reduction of medication efficacy without daily use. Conclusion: PrEP awareness among PWID remains inadequate. Willingness to take PrEP was moderate and was most desired by PWID who engaged in high-risk behaviors. Interventions to increase PrEP awareness and willingness, and to facilitate PrEP uptake among PWID are needed.

PrEP Knowledge and Attitudes Among Adults Attending Public Health Clinics in Southern Arizona.

HIV pre-exposure prophylaxis (PrEP) is underutilized among Hispanics, women, and low-income individuals. To better understand PrEP barriers in this population, questionnaires were administered to 500 patients attending public health clinics in southern Arizona which provide family planning and sexually transmitted infections care. Sixty-three percent believed that they had no risk of HIV infection. When asked "Before today, did you know that there was a pill that can prevent HIV infection?" 80% of persons answered no. Among women, 88% answered no to this question. As expected, individuals with a higher perceived HIV risk (OR 1.76) or one HIV risk factor (OR 5.85) had a higher probability of knowledge. Among survey participants 87% would take a daily pill, 91% would visit a health-care provider every 3 months, and 92% would have laboratory testing every 3 months. Fifty-four percent would not be afraid or embarrassed if friends or family knew they were taking PrEP. Seventy-two percent would take PrEP despite temporary nausea. Sixty-two percent would pay ≥ $40 every 3 months for PrEP. Lack of knowledge, rather than patient attitudes, is the more important barrier to wider utilization of PrEP among individuals, especially women, attending public health clinics in Southern Arizona. Future efforts need to focus on education and access to PrEP in underserved populations including women and Hispanics.

Development of a 10-Item Tool to Identify Advanced Practice Nurse Readiness to Prescribe Pre-exposure Prophylaxis.

Pre-exposure prophylaxis (PrEP), a biomedical tool to prevent the acquisition of HIV, reduces the risk of HIV in high-risk individuals by more than 90%. An online questionnaire was fielded from March 2017 to May 2017 to a random sample of licensed advanced practice nurses (APNs) from the U.S. state of Indiana. Discriminant function analysis was performed to reveal willingness to prescribe PrEP. Two discriminant functions were identified: Sexual Risk Assessment (r = .686), PrEP Barriers (r = .587), Evidence-Based Practice Implementation (r = .545), Community Awareness (r = .446), Perceived Risk (r = .356), and Organizational Climate (r = .346) were loaded on the first function, whereas PrEP Skills (r = .837) was loaded on the second function. The results suggest APN's willingness to learn and knowledge about PrEP-influenced implementation. Findings demonstrated that readiness to prescribe PrEP by APNs in Indiana could be predicted with a high level of certainty using identified variables.