Pre-exposure Prophylaxis Prescription Research Articles

Tennessee Healthcare Provider Practices, Attitudes, and Knowledge Around HIV Pre-Exposure Prophylaxis.

Introduction/Objectives:Pre-exposure prophylaxis (PrEP) use in the southern United States is low despite its effectiveness in preventing HIV acquisition and high regional HIV prevalence. Our objectives were to assess PrEP knowledge, attitudes, and prescribing practices among Tennessee primary care providers.Methods:We developed an anonymous cross-sectional electronic survey from March to November 2019. Survey development was guided by the Capability, Opportunity, Motivation, and Behavior framework and refined through piloting and interviews. Participants included members of professional society and health center listservs licensed to practice in Tennessee. Respondents were excluded if they did not complete the question regarding PrEP prescription in the previous year or were not in a position to prescribe PrEP (e.g., hospital medicine). Metrics included PrEP prescription in the preceding year, PrEP knowledge scores (range 0-8), provider attitudes about PrEP, and provider and practice characteristics. Knowledge scores and categorical variables were compared across PrEP prescriber status with Wilcoxon rank-sum and Fisher’s exact tests, respectively.Results:Of 147 survey responses, 99 were included and 43 (43%) reported PrEP prescription in the preceding year. Compared with non-prescribers: prescribers had higher median PrEP knowledge scores (7.3 vs 5.6, P < .01), a higher proportion had self-reported patient PrEP inquiries (95% vs 21%, P < .01), and a higher proportion had self-reported good or excellent ability to take a sexual history (83% vs 58%, P = .01) and comfort taking a sexual history (92% vs 63%, P < .01) from men who have sex with men, a subgroup with high HIV risk. Most respondents felt obligated to provide PrEP (65%), and felt all primary care providers should provide PrEP (63%).Conclusion:PrEP provision is significantly associated with PrEP knowledge, patient PrEP inquiries, and provider sexual history taking ability and comfort. Future research should evaluate temporal relationships between these associations and PrEP prescription as potential routes to increase PrEP provision.

A Pharmacist-Led, Same-Day, HIV Pre-Exposure Prophylaxis Initiation Program to Increase PrEP Uptake and Decrease Time to PrEP Initiation.

Mississippi has one of the highest rates of HIV in the United States, but has low pre-exposure prophylaxis (PrEP) uptake, particularly among black men who have sex with men (MSM) and women. From November 2018 to May 2019, patients at high risk of HIV who tested negative for HIV at a nonclinical testing center in Jackson, Mississippi, were referred to an on-site clinical pharmacist for same-day PrEP initiation. The pharmacist evaluated patients for medical contraindications to PrEP, but no baseline labs were obtained. The pharmacist provided a PrEP prescription and scheduled a clinical appointment for patients within 6 weeks, at which time they were evaluated by a clinician and completed baseline labs. The pharmacist evaluated 69 patients for PrEP; 57% were MSM, 77% were black, and 65% were uninsured. All patients received a PrEP prescription; 83% received the prescription the same day and 97% received it within 5 days. Fifty-three (77%) of 69 clients filled the prescription; 87% of whom filled it within 1 week. Only 23 (43%) of 53 clients who filled their prescription attended their initial clinical appointment within 6 weeks of obtaining PrEP. There were no differences in PrEP initiation or retention by patient sex/gender. This pilot program suggests that an on-site pharmacist working in a nonclinical testing center in the southern United States can successfully initiate PrEP among predominately low-income black MSM. Future efforts should seek to better integrate laboratory testing into this demedicalized model of PrEP and to improve retention in care.

Australian interdisciplinary healthcare providers' perspectives on the effects of broader pre-exposure prophylaxis (PrEP) access on uptake and service delivery: a qualitative study.

Semistructured interviews, conducted before PBS listing (October 2016-April 2017), explored PrEP knowledge and prescription experiences of 51 multidisciplinary HCPs involved with the Queensland Pre-Exposure Prophylaxis Demonstration study. Thematic analysis revealed that participants viewed PrEP as a necessary HIV prevention option, but there was concern about confusing prevention messages and potential risk compensation. Clinical capacity, stigma, cultural norms, rural access and PrEP-associated costs were identified as barriers to access and uptake. Some of these barriers may be addressed by the PBS listing; nonetheless, there was strong specialist concern about the preparedness of general practitioners without sexual health experience to prescribe PrEP. Participants identified a need to educate all HCPs, implement multidisciplinary supply models and provide timely access to PrEP for vulnerable populations and those ineligible for Medicare (Australia's universal healthcare insurance system). Although PrEP listing on the PBS addressed structural barriers to access, this study highlights the role of nurses and other interdisciplinary healthcare workers in the provision of PrEP in addressing the sociocultural barriers that still affect the access of certain populations to HIV prevention measures. These findings will inform further professional training as PrEP is more widely accessed and requested outside specialist sexual health services. Future work is needed to ensure that the primary healthcare workforce is prepared to provide competent and safe access to PrEP across diverse locations and population groups.

Implementation of HIV Preexposure Prophylaxis in a Homeless Primary Care Setting at the Veterans Affairs.

Objective: Oral preexposure prophylaxis (PrEP) is highly effective in preventing HIV-1 acquisition, yet it is underutilized among at-risk populations. In this pilot quality improvement (QI) initiative, we sought to identify barriers to PrEP implementation and create interventions to improve access to PrEP in a primary care clinic for homeless veterans. Methods: The setting was a large homeless primary care clinic at the Veterans Affairs in an urban area with high HIV prevalence. A root cause analysis was performed to identify barriers to PrEP expansion in the primary care clinic. Targeted interventions to improve provider knowledge and patient access to PrEP were implemented by the QI team. Results: Root cause analysis revealed 3 primary barriers to PrEP expansion in the primary care clinic: institutional limitations for prescribing PrEP, inconsistent screening and recognition of eligible patients by clinic staff, and lack of clinic workflow processes to support PrEP prescription. A multidisciplinary focus group found low levels of PrEP awareness and knowledge, with only 22% of providers reporting comfort discussing PrEP with patients. This improved to 40% of providers following targeted clinic educational interventions. The QI team also developed a pathway for primary care providers to obtain institutional PrEP prescribing privileges and used work groups to develop clinic workflows and protocols for PrEP. At the end of the intervention, at least 50% of primary care providers in the clinic had initiated PrEP in a new patient. Conclusions: We describe a multidisciplinary QI model to implement PrEP within a primary care setting serving Veterans and persons experiencing homelessness. Our program successfully addressed provider knowledge deficits and improved primary care capacity to prescribe PrEP. The primary care clinic can be a viable and important clinical setting to improve access to PrEP for HIV prevention, especially for vulnerable populations.

Brief Report: Incidence of HIV in a Nationwide Cohort Receiving Pre-exposure Prophylaxis for HIV Prevention.

Cases of HIV, while infrequent, have been reported during tenofovir disoproxil fumarate/emtricitabine use as pre-exposure prophylaxis (PrEP). We describe the incidence of HIV and patterns of PrEP use within the Veterans Health Administration (VHA). We conducted a retrospective cohort study among persons initiating PrEP in the VHA between July 2012 and April 2016 using national VHA data. We defined time on PrEP and time at risk of HIV exposure as the total time from the first PrEP fill to exhaustion of supply of the final PrEP prescription. We identified incident cases of HIV infection after PrEP initiation based on laboratory data. Medication adherence measures and days without pills were calculated using pharmacy fill data. We used a chart review to determine patient-reported PrEP use around the time of diagnosis. We identified 825 unique patients initiating PrEP; they were 97% men and 67% white, with a mean age of 41 years. Six HIV infections were observed during the study period, yielding an HIV incidence of 0.8 (Poisson exact 95% confidence interval: 0.3 to 1.8) cases per 100 person-years. Two cases occurred during active PrEP use by self-report and perfect adherence based on fill data. Both were infected with viruses containing the M184V mutation. Four additional cases were diagnosed after self-reported discontinuation. HIV infection was rare in a nationwide cohort of PrEP users. Although most of the infections occurred during inconsistent PrEP use, infections during periods of high measured adherence were also observed. These findings highlight the importance of PrEP persistence during periods of risk.

PrEP and sexual well-being: a qualitative study on PrEP, sexuality of MSM, and patient-provider relationships

ABSTRACTMost new diagnoses of HIV in the United States are among men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is a medication that mitigates risk of HIV acquisition and requires regular STI testing and prescription refills with PrEP providers. Because PrEP care monitors sexual behavior, there is a need to understand how PrEP providers approach sexual health care for MSM patients. In this study, semi-structured qualitative interviews were conducted with 20 MSM in Atlanta, Georgia with current or past prescriptions for PrEP. Data were analyzed with thematic analysis using four major steps: (1) code and codebook development, (2) assigning codes to segments of interviews, (3) code-based and comparative analysis methods, and (4) developing thematic findings. Findings from interviews about changes in sexuality while using PrEP include decreased anxiety surrounding sex, increased feelings of control over personal health, and experiencing less stigma towards sexual partners with HIV. Participants indicated needs for tailored health advice based on individual sexual preferences, sexual health care free from stereotypical assumptions, and improved access to PrEP providers identifying as gay men or who practice in LGBT-friendly settings. Study findings support a call for a gain-frame approach to sexual health in PrEP care for MSM.

Racial/ethnic and HIV risk category disparities in preexposure prophylaxis discontinuation among patients in publicly funded primary care clinics.

Dissemination of preexposure prophylaxis (PrEP) is a priority for reducing new HIV infections, especially among vulnerable populations. However, there are limited data available on PrEP discontinuation following initiation, an important component of the PrEP cascade. Patients receiving PrEP within the San Francisco Department of Public Health Primary Care Clinics (SFPCC) are included in a PrEP registry if they received a PrEP prescription, were not receiving postexposure prophylaxis, and not known to be HIV-positive. We calculated PrEP discontinuation for patients initiating PrEP at any time from January 2012 to July 2017 and evaluated their association with demographic and risk variables using Cox regression analysis. Overall, 348 patients received PrEP over the evaluation period. The majority (84%) were men, and the cohort was racially/ethnically diverse. The median duration of PrEP use was 8.3 months. In adjusted analysis, PrEP discontinuation was lower among older patients (aHR 0.89; 95% CI 0.80-0.99; P = 0.03); but higher among black patients (compared with white patients; aHR 1.87; 95% CI 1.27-2.74; P = 0.001), patients who inject drugs (aHR 4.80; 95% CI 2.66-8.67; P < 0.001), and transgender women who have sex with men (compared with MSM; aHR 1.94; 95% CI 1.36-2.77; P < 0.001). Age, racial/ethnic, and risk category disparities in PrEP discontinuation were identified among patients in a public health-funded primary care setting. Further efforts are needed to understand and address PrEP discontinuation among priority populations to maximize the preventive impact of PrEP, and reverse HIV-related disparities at a population level.

Health Care Provider Perspectives on Pre-exposure Prophylaxis: A Qualitative Study.

Although pre-exposure prophylaxis (PrEP) requires a prescription from a health care provider, we lack unanimity in guidelines for the identification of the ideal provider type to prescribe PrEP. The purpose of our study was to understand clinician perspectives on provider categories to determine who is best suited to prescribe this medication to HIV-uninfected patients. We conducted 28 in-depth interviews between September 2017 and January 2018 with current prescribers of PrEP. Qualitative findings indicated that providers were split on recommended PrEP prescriber type. Five themes emerged that centered on the explicit identification of the issue of opportunity for providers to educate their patients on PrEP and offer this medication to at-risk populations. To effectively maximize presentation for care and subsequently amplify uptake of PrEP, growing the base of providers who offer PrEP to eligible patients can provide a meaningful public health impact on reducing HIV incidence.

HIV prescriptions on the frontlines: Primary care providers' use of antiretrovirals for prevention in the Southeast United States, 2017

HIV disproportionately affects persons in Southeast United States. Primary care providers (PCPs) are vital for HIV prevention. Data are limited about their prescribing of antiretrovirals (ARVs) for prevention, including non-occupational post-exposure prophylaxis (nPEP), pre-exposure prophylaxis (PrEP), and antiretroviral therapy (ART). We examined these practices to assess gaps. During April–August 2017, we conducted an online survey of PCPs in Atlanta, Baltimore, Baton Rouge, Miami, New Orleans, and Washington, DC to assess HIV-related knowledge, attitudes and practices. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were used to estimate correlates of nPEP, PrEP and ART prescribing practices. Adjusting for MSA and specialty, the weighted sample (n = 820, 29.6% adjusted response rate) comprised 60.2% white and 59.4% females. PCPs reported ever prescribing nPEP (31.0%), PrEP (18.1%), and ART (27.2%). Prescribing nPEP was associated with nPEP familiarity (aPR = 2.63, 95% CI 1.59, 4.35) and prescribing PrEP (aPR = 3.57, 95% CI 2.78, 4.55). Prescribing PrEP was associated with PrEP familiarity (aPR = 4.35, 95% CI 2.63, 7.14), prescribing nPEP (aPR = 5.00, 95% CI 2.00, 12.50), and providing care for persons with HIV (aPR = 1.56, 95% CI 1.06, 2.27). Prescribing ART was associated with nPEP familiarity (aPR = 1.89, 95% CI 1.27, 2.78) and practicing in outpatient public practice versus hospital-based facilities (aPR = 2.14 95% CI 1.51, 3.04), and inversely associated with collaborations involving specialists (aPR = 0.60, 95% CI 0.42, 0.86). A minority of PCPs surveyed from the Southeast report ever prescribing ARVs for prevention. Future efforts should include enhancing HIV care coordination and developing strategies to increase use of biomedical tools.

1276. Changes in Primary Care Pre-exposure Prophylaxis prescribing in a Large Healthcare System after the Implementation of an HIV Screening Alert and Educational Intervention

BackgroundThe number of providers that prescribe pre-exposure prophylaxis (PrEP) for HIV remains low. Primary care providers (PCPs) are less knowledgeable than HIV providers (HIVPs) with regards to PrEP: fewer PCPs had heard of PrEP (76% vs. 98%), knew about prescribing PrEP (28% vs. 76%), or ever had prescribed it (17% vs. 64%). PCPs limited knowledge about PrEP and questions about insurance coverage were identified as barriers to prescribing PrEP. Additional information on changes in prescribing PrEP in primary care within a large healthcare system is limited.Methods12 practices were part of a systemwide implementation of an HIV screening Electronic Medical Record (EMR) alert in October 2017 for patients ages 18–64. The 12 primary care practices were also included as part of an educational intervention regarding HIV prevention presented in the first quarter of 2018. As part of the educational intervention, information on prescribing PrEP was included along with resources for linkage-to-care and insurance coverage. The number of PrEP prescriptions were summarized for all 12 practices one year prior to the EMR alert and one-year post-EMR alert. Paired T-test statistics were used to test the number of patients prescribed PrEP by each practice pre- and post-EMR alert. The same analysis was conducted one-year pre- and post- the educational intervention.ResultsAcross the 12 practices, 62 PrEP prescriptions were written one year prior to the implementation of the EMR alert (M=5.2, SD=7.3) and 88 post-EMR alert (M=7.3, SD=6.4), a 42% increase (P = 0.02). There were no differences in PrEP prescriptions one-year pre- and post- the educational intervention (n = 69).ConclusionWhile the number of PrEP prescriptions written showed significant increase after the implementation of the EMR alert, the overall number of prescriptions in primary care are still relatively low. While there has been national attention to increase PrEP prescribing through initiatives with local health departments, efforts to increase PrEP uptake require additional interventions above and beyond education interventions to increase the knowledge, comfort, and skills of providers to prescribe PrEP.Disclosures All authors: No reported disclosures.

1284. Pre-exposure Prophylaxis (PrEP) for HIV in Vermont: an Assessment of Prescribing in a Uniquely Rural State

BackgroundIn the United States and Vermont, men who have sex with men (MSM) make up the majority of new human immunodeficiency virus (HIV) infections every year. Despite HIV prevention campaigns and approval of antiviral therapy for pharmacologic HIV pre-exposure prophylaxis (PrEP), HIV cases in Vermont—a predominantly rural state—are on the rise. The primary objective of this study was to assess prescribing practices and barriers surrounding PrEP for adult MSM in Vermont.MethodsA web-based healthcare provider survey was deployed electronically over a 10 week period in 2019 to a convenience sample of licensed primary care, sexual health, and infectious disease providers in Vermont. Questions were designed to target factors thought to influence PrEP prescribing, with a focus on prescribing behaviors and perceived barriers.ResultsAn estimated 500 providers received the survey. There were 137 survey respondents, 106 (77%) were physicians, primarily in internal medicine. Though only 47 (34%) providers had experience prescribing PrEP to MSM patients, over 89% identified as willing to prescribe PrEP to high-risk groups. Among PrEP prescribers, screening frequency for HIV and bacterial sexually transmitted infections (STIs) while on PrEP fell below the current guideline recommendations at 72% and 53%, respectively. Less than 70% of providers routinely obtain sexual history for male patients. Among providers willing to prescribe PrEP, concern regarding medication toxicity was the only statistically significant barrier (χ 2 = 5.5, P = 0.02). Concerns regarding risk compensation behavior and lack of knowledge or experience regarding prescribing PrEP also demonstrated an association with provider willingness to prescribe PrEP, however did not reach statistical significance.ConclusionThe majority of Vermont providers sampled are willing to prescribe PrEP, suggesting there is great opportunity to increase prescribing and use, potentially having an impact on reducing HIV transmission among MSM in the state. Provider education targeted toward guidelines for STI and HIV screening on therapy, obtaining sexual histories, and minimal toxicity risk may serve to increase prescribing of PrEP among Vermont providers.Disclosures All authors: No reported disclosures.

1286. Healthcare Provider Attitudes and Knowledge Around Pre-Exposure Prophylaxis (PrEP) for the Prevention of HIV-Infection in Tennessee

BackgroundDaily pre-exposure prophylaxis (PrEP) is very effective at preventing HIV acquisition. PrEP use in the southern United States is low despite high regional HIV prevalence. Prior surveys of primary care providers (PCPs) regarding PrEP occurred before recent guideline updates, were not constructed using a theoretical behavioral framework and validated, or did not focus on the South.MethodsWe conducted a cross-sectional survey of Tennessee (TN) PCPs from March-April 2019 to assess PrEP knowledge, attitudes, and prescribing practices. Survey development was guided by the COM-B framework (capability, opportunity, motivation and behavior) and validated by pilot testing and cognitive interviews. Knowledge scores were calculated as +1 point for each correct option and 0 points for each incorrect option (maximum score=8). Wilcoxon rank-sum tests were used to compare scores, and Fisher’s exact tests were used to compare categorical variables, between PrEP prescribers and nonprescribers.ResultsAmong 69 respondents, 39% (n = 27) had prescribed PrEP. There were no differences in beliefs about PrEP or sense of obligation to prescribe PrEP between prescribers and nonprescribers. Patient inquiry about PrEP was significantly associated with prescription (P < 0.001); 100% of prescribers had ≥1 patient ask about PrEP in the past year vs. 29% of nonprescribers. Prescribers’ median PrEP knowledge scores were higher than nonprescribers’ (Figure 1). Prescribers had higher self-reported ability to take sexual histories for MSM and heterosexual male patients than nonprescribers (P = 0.007, P = 0.007), and higher self-reported comfort with taking sexual histories for MSM, heterosexual male, and heterosexual female patients (P = 0.061, P = 0.005, P = 0.026, respectively). Nonprescribers frequently cited a need for training in PrEP contraindications and eligibility, cost of PrEP, and administrative burden as barriers to provision.ConclusionLess than half of TN PCPs we surveyed prescribed PrEP despite similar senses of obligation and PrEP-related beliefs between prescribers and nonprescribers. Future interventions to improve PrEP provision among PCPs in TN should target PrEP knowledge, ability and comfort with sexual history taking, and patient awareness of and ability to inquire about PrEP. Disclosures All authors: No reported disclosures.

1275. Factors Associated with Patient-Provider Discussions about Preexposure Prophylaxis Among Young Men Who Have Sex with Men in Washington, DC

BackgroundThe CDC estimates that 1.2 million people in the United States are eligible for HIV pre-exposure prophylaxis (PrEP). However, only about 120,000 people have received PrEP prescriptions through 2017. Healthcare providers’ (HCP) willingness to engage patients in discussions regarding sexual health, including PrEP, is integral to increasing PrEP uptake in the United States. Our objective was to identify factors associated with patients having discussions about PrEP with their HCP.MethodsMen who have sex with men (MSM) aged 16–25 in the Washington, DC metro area recruited from the community completed a web-based survey in 2016 about their perceptions of and experiences with PrEP. We used multivariable logistic regression to calculate adjusted odds ratios (aOR) for associations between sociodemographic characteristics (including: age, race/ethnicity, insurance, student/employment status, education, income, living arrangements, social support, depressive symptoms) and patient-provider discussions, including willingness to have or ever having a discussion about PrEP.ResultsAmong 239 MSM, 51% were Black, 25% were White, and 16% were Hispanic. 154 participants (65%) were willing to ask a HCP about PrEP without their HCP bringing it up. 159 participants (67%) reported that a HCP had never talked to them about PrEP, although 100 of the 159 (63%) expressed interest in discussing PrEP with a HCP. Participants aged <21 were less willing to ask a HCP about PrEP (aOR: 0.49, 95% CI 0.28–0.85) and insured participants were more willing to ask their HCP about PrEP (aOR: 3.64, 95% CI 1.42–9.33). In multivariable analyses, no sociodemographic characteristics were associated with having talked to a HCP about PrEP, and among those who had never talked to a HCP about PrEP, no characteristics were associated with wanting to do so.ConclusionThere is a need to increase PrEP uptake in populations at high risk for HIV exposure. While MSM >21 and those with health insurance were more willing to ask their HCP about PrEP, there were no other differences across multiple demographic groups. Our study suggests that a wide PrEP engagement strategy that encourages HCPs to address PrEP with their patients regardless of their demographics would be beneficial to increase PrEP uptake. Disclosures All authors: No reported disclosures.

Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers.

Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP's preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs' PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers ("all trained") (42%) or having an onsite PrEP specialist ("on-site specialist") (43%). Only 15% preferred referring patients out of the practice to a specialist ("refer out"). Compared to those who preferred to "refer out," participants who preferred the "all trained" model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the "refer out" or on-site specialist" models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.

High Rates of PrEP Eligibility but Low Rates of PrEP Access Among a National Sample of Transmasculine Individuals

Transmasculine individuals have been largely ignored in HIV prevention research, and there is a lack of data regarding this population's eligibility for and utilization of HIV pre-exposure prophylaxis (PrEP). National online survey conducted in the United States. Between May and July 2017, we surveyed 1808 transmasculine individuals (aged 18-60 years; 30% people of color and/or Latinx), asking questions about sexual behavior and receipt of sexual health care, including PrEP. We examined the number of individuals who would meet eligibility criteria for PrEP and then used log-linked Poisson regression with robust variance estimation to examine predictors of PrEP eligibility. Almost one-quarter of the sample (n = 439; 24.3%) met one or more criterion for PrEP eligibility. PrEP eligibility did not differ by age, race/ethnicity, education, or binary gender identity. PrEP eligibility was lower among heterosexual-identified and higher income participants, and was higher among participants who were in open relationships and reported substance use. Among PrEP-eligible individuals, 64.9% had received an HIV test in the past year, 33.9% had received PrEP information from a provider, and 10.9% (n = 48) had received a PrEP prescription. PrEP-eligible individuals who had received a PrEP prescription were more likely to have a binary gender identity, identify as gay, and be taking testosterone. A substantial proportion of transmasculine individuals meet PrEP eligibility criteria, but few are receiving adequate PrEP services. Enhanced efforts should be made by providers, programs, and systems to assess HIV-related risk in transmasculine patients and engage them in comprehensive sexual health care.

Using a student-led, community-specific training module to increase PrEP uptake amongst at-risk populations: results from an exploratory pilot implementation

ABSTRACTHIV incidence continues to be a significant global and domestic public health concern. Pre-exposure prophylaxis (PrEP) is safe and effective in preventing HIV. PrEP uptake in the populations at risk for HIV has been slow and unequal. One reason for this is low levels of provider knowledge about PrEP. Prior training initiatives have focused exclusively on prescribers, which overlooks a substantial number of professionals who interact with patients. A novel method of training was designed and implemented by an interprofessional student team. The training module was purposely designed with community specificity about the patients at the highest risk for new HIV infections. Assessment of this training initiative occurred by query of electronic medical records to determine changes in the number of prescriptions for PrEP following the training intervention. Results indicate this student-led initiative was effective in providing education about PrEP, which translated to changes in PrEP prescription.

Medical Providers and Harm Reduction Views on Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs.

Despite high pre-exposure prophylaxis (PrEP) acceptability among people who inject drugs (PWID) and PrEP providers, PrEP uptake is low and little is known about how to promote PrEP among PWID. This qualitative study with providers in North Carolina explored views on PrEP delivery approaches for PWID. Interviewers conducted semistructured interviews with 10 PrEP providers and 10 harm reduction (HR) providers. Interviews were transcribed and analyzed. Many participants expressed acceptability for providing PrEP referrals at syringe exchange sites, stationing PrEP providers at syringe exchange sites to provide PrEP prescriptions, and providing standing orders for PrEP at syringe exchange sites. Barriers were identified, including low PrEP awareness and limited resources. Many advocated for co-location of HR and PrEP services and scaled-up outreach services. PrEP providers emphasized maintenance of clinical requirements, while HR providers emphasized flexibility when treating PWID. Promoting PrEP uptake and adherence among PWID likely requires integration of HR and PrEP services.

The PrEP You Want: A Web-Based Survey of Online Cross-Border Shopping for HIV Prophylaxis Medications.

BackgroundIn response to the high cost of HIV pre-exposure prophylaxis (PrEP) medications in Canada, community organizations have created internet-based guides detailing how to legally order generic medications online and travel to collect them in the United States. However, little is known about the patients following these guides.ObjectiveOur primary objective was to measure the proportion of Ontario gay, bisexual, and other men who have sex with men (GBMSM) accessing these online guides who intended to use the border-crossing approach. Our secondary objectives were to explore their demographic characteristics, their completion of the steps in the border-crossing approach, and the barriers they perceived.MethodsBetween July 20, 2017, and May 18, 2018, we administered two online surveys of GBMSM accessing an online border-crossing guide posted by a gay men’s health organization in Ontario. Participants completed an open baseline survey posted on the border-crossing guide’s Web page and a follow-up survey 3 months later. The data were analyzed using descriptive statistics. We used multivariable logistic regression to identify characteristics associated with the intention to use the border-crossing approach.ResultsMost of the 141 participants were young (median age 23, interquartile range 22-25 years) and black (79.4%; 112/141) GBMSM who had completed a college or an undergraduate degree (62.4%; 88/141). In addition, 19.9% (28/141) of them reported a total family income less than Can $30,000 and another 53.9% (76/141) reported income between Can $30,000 and Can $60,000. 54.6% (76/141) paid for medications entirely out of pocket. Most participants indicated that they were likely to complete a border-crossing approach: 80.1% (113/141) at baseline and 79.1% (87/110) at follow-up. The characteristics associated with the intention to use the approach included being black (adjusted odds ratio [aOR] 5.73, 95% CI 2.06-16.61), paying for medications out of pocket (aOR 5.18, 95% CI 1.82-17.04), and having a provider who was thought to be willing to prescribe PrEP (aOR 4.42, 95% CI 1.63-12.41). Comparing baseline and follow-up for the 110 participants who completed both surveys, 65.4% (72/110) and 80.0% (88/110) had discussed PrEP with a health care provider, 18.1% (20/110) and 25.4% (28/110) had obtained a PrEP prescription, and 8.2% (9/110) and 5.5% (6/110) had ordered medications to that mailbox, whereas only 1.0% (1/110) and 0.0% (0/110) had crossed the border to collect them at baseline and follow-up, respectively. Reported barriers included perceived concerns about the approach’s legality (56.0%; 79/141), the security of personal health information (39.0%; 55/141), and the safety of online vendors (38.3%; 54/141).ConclusionsDespite high interest in pursuing an online border-crossing approach to get PrEP medications, such an approach may not be a viable option for PrEP scale-up among interested GBMSM because of logistical challenges and perceptions of safety and legitimacy.

Use of electronic health record data and machine learning to identify candidates for HIV pre-exposure prophylaxis: a modelling study

The limitations of existing HIV risk prediction tools are a barrier to implementation of pre-exposure prophylaxis (PrEP). We developed and validated an HIV prediction model to identify potential PrEP candidates in a large health-care system. Our study population was HIV-uninfected adult members of Kaiser Permanente Northern California, a large integrated health-care system, who were not yet using PrEP and had at least 2 years of previous health plan enrolment with at least one outpatient visit from Jan 1, 2007, to Dec 31, 2017. Using 81 electronic health record (EHR) variables, we applied least absolute shrinkage and selection operator (LASSO) regression to predict incident HIV diagnosis within 3 years on a subset of patients who entered the cohort in 2007-14 (development dataset), assessing ten-fold cross-validated area under the receiver operating characteristic curve (AUC) and 95% CIs. We compared the full model to simpler models including only men who have sex with men (MSM) status and sexually transmitted infection (STI) positivity, testing, and treatment. Models were validated prospectively with data from an independent set of patients who entered the cohort in 2015-17. We computed predicted probabilities of incident HIV diagnosis within 3 years (risk scores), categorised as low risk (<0·05%), moderate risk (0·05% to <0·20%), high risk (0·20% to <1·0%), and very high risk (≥1·0%), for all patients in the validation dataset. Of 3 750 664 patients in 2007-17 (3 143 963 in the development dataset and 606 701 in the validation dataset), there were 784 incident HIV cases within 3 years of baseline. The LASSO procedure retained 44 predictors in the full model, with an AUC of 0·86 (95% CI 0·85-0·87) for incident HIV cases in 2007-14. Model performance remained high in the validation dataset (AUC 0·84, 0·80-0·89). The full model outperformed simpler models including only MSM status and STI positivity. For the full model, flagging 13 463 (2·2%) patients with high or very high HIV risk scores in the validation dataset identified 32 (38·6%) of the 83 incident HIV cases, including 32 (46·4%) of 69 male cases and none of the 14 female cases. The full model had equivalent sensitivity by race whereas simpler models identified fewer black than white HIV cases. Prediction models using EHR data can identify patients at high risk of HIV acquisition who could benefit from PrEP. Future studies should optimise EHR-based HIV risk prediction tools and evaluate their effect on prescription of PrEP. Kaiser Permanente Community Benefit Research Program and the US National Institutes of Health.

Enhancing HIV Pre-exposure Prophylaxis Practices via an Educational Intervention.

Pre-exposure prophylaxis (PrEP) for HIV involves using antiretroviral drugs to prevent individuals at high risk from acquiring HIV infection. Most practicing primary care providers believe PrEP to be safe and effective, but less than half have prescribed or referred for PrEP. Attitudes and prescribing patterns among house officers have not been well described previously. Can an educational intervention enhance HIV PrEP practices among internal medicine house officers? This study relied on a pretest/posttest design. All categorical trainees at a medium-sized internal medicine program were offered a baseline survey to assess their knowledge on PrEP. This was followed by a PrEP-focused educational intervention and a postintervention survey. Likert scales captured perceptions regarding safety, effectiveness, barriers, factors that would promote PrEP use, potential side effects, impact on risk-taking behavior, and provider comfort level in assessing behavioral risks and in PrEP prescribing. Data were analyzed using descriptive statistics, Wilcoxon signed rank test, and the Kruskal-Wallis test. Significance was accepted for P < 0.05. Forty-eight (100%) trainees participated in the educational session, 45 (94%) in a preintervention survey, and 36 (75%) in a postintervention survey. Before PrEP training, 22% of respondents were unaware of PrEP, 78% believed PrEP was effective, 66% believed PrEP was safe, 62% had fair or poor awareness of side effects; 18% of residents had referred for or prescribed PrEP, and 31% believed they were likely to prescribe PrEP in the next 6 months. After the intervention, 94% of trainees believed PrEP was effective (P < 0.001), 92% believed PrEP was safe (P < 0.001), and two-thirds believed they were likely to prescribe PrEP in the next 6 months. Brief, focused training on HIV prevention promotes awareness, acceptance, and likelihood of prescribing PrEP by internal medicine trainees.