Search

Integrating pregnancy and HIV prevention services would make reproductive health care settings an optimal venue for the promotion and delivery of preexposure prophylaxis (PrEP) to cisgender women. However, these settings have been slow to adopt PrEP. Planned parenthood clinicians and leaders possess critical insight that can help accelerate PrEP implementation in reproductive health care settings and elements of the Consolidated Framework for Implementation Research (i.e., relative priority of the intervention to staff, implementation climate, available resources to implement the intervention, and staff access to knowledge and information about the intervention) can shed light on elements of Planned Parenthood's inner setting that can facilitate PrEP implementation. In this study, individual 60-min interviews were conducted with clinical care team members (n = 10), leadership team members (n = 6), and center managers (n = 2) to explore their perspectives on PrEP implementation and associated training needs. Transcripts were transcribed verbatim and thematically analyzed. Despite having variable PrEP knowledge, participants (100% women, 61% non-Hispanic White) expressed positive attitudes toward implementing PrEP. Barriers and facilitators toward providing PrEP were reported at the structural, provider, and patient levels. Participants desired PrEP training that incorporated culturally competent patient-provider communication. Although participants identified ways that Planned Parenthood uniquely enabled PrEP implementation, barriers must be overcome to optimize promotion and delivery of PrEP to cisgender women. [ABSTRACT FROM AUTHOR]

Background: Survivors of intimate partner violence are at elevated risk for HIV acquisition, yet there is limited research on the best strategies to optimize biomedical HIV prevention, such as pre-exposure prophylaxis among this population. Domestic violence agencies are critical collaborating partners and function as potential entry points into HIV prevention services for survivors; however, limited knowledge regarding HIV prevention has been an important barrier to advocate-led discussions. This study aimed to develop, implement, and evaluate an HIV prevention intervention for domestic violence advocates. Setting: A nonrandomized, group-based intervention with pre-intervention, immediate post-intervention, and 3-month post-intervention periods were conducted with multiple domestic violence agencies in Mississippi. Methods: Overall, 25 domestic violence advocates participated in the two-session intervention. Surveys were administered to assess pre-exposure prophylaxis knowledge, self-efficacy, subjective norms, and willingness to provide HIV prevention services to intimate partner violence survivors. Generalized estimating equations were conducted to assess change in behavioral outcomes over time. Results: Compared to pre-intervention, there were significant increases at immediate and 3-month post-intervention in advocates' intervention acceptability, pre-exposure prophylaxis knowledge, and self-efficacy to provide HIV prevention information, discuss pre-exposure prophylaxis eligibility criteria, assist pre-exposure prophylaxis-engaged clients, and initiate pre-exposure prophylaxis counseling. Conclusion: This group-based intervention enhanced domestic violence advocates' acceptability, pre-exposure prophylaxis knowledge, and self-efficacy to offer HIV care information, discuss pre-exposure prophylaxis eligibility, assist pre-exposure prophylaxis-engaged survivors, and initiate pre-exposure prophylaxis counseling with intimate partner violence survivors. Efforts should focus on training domestic violence advocates in HIV prevention care for survivors and also include these agencies in collaborative strategies to reduce HIV incidence. [ABSTRACT FROM AUTHOR]

Addressing women's low uptake of HIV pre-exposure prophylaxis (PrEP) requires improved understanding of their product preferences. Such preferences should be contextualized according to other aspects of their reproductive health, including their contraception practices. We investigated women's preferences across 10 PrEP modalities currently available or under study and examined associations between PrEP modality preferences and contraception practices. Heterosexually active women recently engaged in care at Connecticut Planned Parenthood centers (n = 563) completed an online survey. Participants were presented with images and descriptions of 10 PrEP modalities and asked to indicate their preference and specify their reasoning in an open-response format. Participants also reported prior and current use of 16 contraception modalities along with relationship, sexual health, and sociodemographic characteristics. The sample included women ages 18–45 (45.3% 25 or younger) who were predominantly non-Hispanic black (35.7%) or white (33.7%). All PrEP modalities presented were preferred by at least some women, with daily pills (24.9%), injections (24.3%), and invisible implants (14.9%) preferred most commonly. Across all modalities, associated reasoning often centered around ease of use and comfort. Coincidence with contraception modality was the third-most common reason underlying women's preferences. Women currently using the analogous contraception modality versus never having used it had higher odds of preferring PrEP daily pills [adjusted odds ratio (AOR) = 2.03], injections (AOR = 8.45), invisible implants (AOR = 11.63), and vaginal rings (AOR = 8.66). Diversification of available PrEP modalities and prioritization of those coinciding with popular contraception practices—especially daily pills, injections, and implants—could optimize PrEP acceptability, encourage PrEP uptake, and ultimately reduce HIV incidence among women. [ABSTRACT FROM AUTHOR]

Clinical guidelines for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) developed by the US Centers for Disease Control and Prevention have been instrumental in the implementation of PrEP in medical practices throughout the country. However, the eligibility criteria contained within may inadvertently limit PrEP access for some patients. We describe the following key considerations and caveats related to these criteria: promotion of a selective vs universal approach to sexual health education involving PrEP; misalignment between criteria stated in the table and text boxes; problematic categorization and confounding of sexual orientation, gender identity, and risk behavior; underemphasis of network/community-level drivers of HIV transmission; oversimplification of serodiscordant risk; and lack of clarity surrounding the relevance of condoms to PrEP eligibility. We offer concrete recommendations to address the identified issues and strengthen future iterations of the guidelines, applying these recommendations in an alternative table of "criteria." [ABSTRACT FROM AUTHOR]

This study examines the effect of condom negotiation strategies on condom use and partner type and substance use before sex as moderators of strategy effectiveness. Women reported their daily sexual behavior during the last month. Withholding sex was more strongly associated with condom use when utilized with a non-casual sex partner. Directly requesting condom use was more strongly and using deceptive reasons to influence condom use was less strongly related to condom use during substance use. Results underscore the importance of understanding the contexts in which condom negotiation strategies are successful in order to improve HIV/sexually transmitted infection prevention efforts among women. [ABSTRACT FROM AUTHOR]

Efforts to identify and address social inequities in HIV pre-exposure prophylaxis (PrEP) access are urgently needed. We investigated early-adopting PrEP prescribers' beliefs about how stigma contributes to PrEP access disparities in health care and explored potential intervention strategies within the context of PrEP service delivery. US-based PrEP prescribers were recruited through professional networks and participant referrals. Qualitative interviews were conducted, transcribed, and thematically analyzed. Participants (n = 18) were primarily male (72%); white (39%) or Asian (33%); and heterosexual (56%). Most practiced in the Northeastern (67%) or Southern (22%) United States; were physicians (94%); and specialized in HIV/infectious disease (89%). Participants described multiple forms of structural and interpersonal stigma impeding PrEP access. The requirement that PrEP be prescribed was a perceived deterrent for populations with medical mistrust and/or low health literacy. Practice norms such as discussing PrEP only in response to patient requests were seen as favoring more privileged groups. When probed about personally held biases, age-related stereotypes were the most readily acknowledged, including assumptions about older adults being sexually inactive and uncomfortable discussing sex. Participants criticized providers who chose not to prescribe PrEP within their clinical practice, particularly those whose decision reflected personal values related to condomless sex or discomfort communicating about sex with their patients. Suggested solutions included standardizing PrEP service delivery across patients and increasing cultural competence training. These early insights from a select sample of early-adopting providers illuminate mechanisms through which stigma could compromise PrEP access for key populations and corresponding points of intervention within the health care system. [ABSTRACT FROM AUTHOR]

Gender inequities place women at an increased risk for HIV acquisition, and this association may particularly disenfranchize young pregnant women. Intimate partner violence (IPV) and food insecurity may contribute to gender differences in power, thereby influencing HIV disparities between women and men. Factors influencing gender disparities in HIV are unique and country-specific within sub-Saharan Africa, yet these factors are understudied among women in Liberia. This paper sought to examine the unique contributions and intersections of intimate partner violence (IPV) and food insecurity with HIV-related risk factors among young pregnant women in Liberia. Between March 2016 and August 2016, cross-sectional data collected from 195 women aged 18-30, residing in Monrovia, Liberia who were receiving prenatal services were used to examine the independent and interaction effects of IPV and food insecurity on HIV-related risk factors (i.e., sexual partner concurrency, economically-motivated relationships). IPV (31.3%) and food insecurity (47.7%) were prevalent. Young women who experience IPV are more likely to report food insecurity (p < 0.05). Young women who experienced IPV and food insecurity were more likely to start a new relationship for economic support (ps < 0.05). Young women who experience IPV and food insecurity were more likely to report engaging in transactional sex (ps < 0.05). There were no significant interaction effects between IPV and food insecurity (ps > 0.05). IPV and food insecurity each uniquely heighten young Liberian women’s vulnerability to HIV. Intervention and policy efforts are need to promote and empower women’s sexual health through integrated sexual and reproductive health services, and reduce IPV and food insecurity among pregnant Liberian women. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Despite healthcare providers’ growing awareness of pre‐exposure prophylaxis (PrEP), prescription rates remain low. PrEP is an efficacious HIV prevention strategy recommended for use with condoms but still protective in their absence. Concern about the impact of PrEP on condom use and other risk behaviour is, nonetheless, among the barriers to prescription commonly reported. To understand the implications of this concern for PrEP access, we examined how medical students’ willingness to prescribe PrEP varied by patients’ condom use and partnering practices. We also assessed the perceived acceptability of various reasons for condom discontinuation with PrEP. Methods: An online survey was distributed to 854 medical students in the Northeastern US in 2015. Participants (n = 111) were surveyed about their willingness to prescribe PrEP for each of six male patients who systematically differed in their reported condom use (sustained use, sustained nonuse, or discontinuation with PrEP) and partnering practices (single male partner with untreated HIV or multiple male partners of unknown HIV status). Participants also reported perceived acceptability of four reasons for condom discontinuation: pleasure, sexual functioning, intimacy, and conception. Results: Willingness to prescribe PrEP was inconsistent with patient risk: When the patient used condoms and planned to sustain condom use, most participants were willing to prescribe PrEP – 93% if the patient had a single partner and 86% if the patient had multiple partners. Fewer were willing to prescribe if the patient did not use condoms and planned to sustain nonuse (53% and 45%, respectively) or used condoms but planned to discontinue use (27% and 28%). Significantly fewer participants were willing to prescribe for a patient with multiple partners versus a single partner when the patient reported sustained condom use or sustained condom nonuse. The number of participants who were willing to prescribe was similarly low for a patient with multiple partners versus a single partner when the patient reported that he planned to discontinue condom use. More participants accepted a patient discontinuing condoms for conception (69%) than for intimacy (23%), pleasure (14%), or sexual functioning (13%). Conclusion: Medical students’ clinical judgments were misaligned with patient risk and suggest misconceptions or personal values may undermine provision of optimal HIV prevention services. [ABSTRACT FROM AUTHOR]

Despite the demonstrated effectiveness of HIV pre-exposure prophylaxis (PrEP) and evidence that most PrEP users do not engage in risk compensation (i.e., increased risk behavior due to a perceived decrease in HIV susceptibility), some healthcare providers report patient risk compensation to be a deterrent to prescribing PrEP. Overcoming this barrier is essential to supporting PrEP access and uptake among people at risk for HIV. To inform such efforts, this qualitative study explored PrEP-related risk compensation attitudes among providers with firsthand experience prescribing PrEP. US-based PrEP providers ( n = 18), most of whom were HIV specialists, were recruited through direct outreach and referral from colleagues and other participants. Individual 90-min semistructured interviews were conducted by phone or in person from September 2014 through February 2015, transcribed, and thematically analyzed. Three attitudinal themes emerged: (1) providers' role is to support patients in making informed decisions, (2) risk behavior while taking PrEP does not fully offset PrEP's protective benefit (i.e., PrEP confers net protection, even with added behavioral risk), and (3) PrEP-related risk compensation is unduly stigmatized within and beyond the healthcare community. Participants were critical of other healthcare providers' negative judgment of patients and reluctance to prescribe PrEP due to anticipated risk compensation. Several providers also acknowledged an evolution in their thinking from initial ambivalence toward greater acceptance of PrEP and PrEP-related behavior change. PrEP providers' insights about risk compensation may help to address unsubstantiated concerns about PrEP-related risk compensation and challenge the acceptability of withholding PrEP on these grounds. [ABSTRACT FROM AUTHOR]

Optimizing access to HIV pre-exposure prophylaxis (PrEP), an evidence-based HIV prevention resource, requires expanding healthcare providers’ adoption of PrEP into clinical practice. This qualitative study explored PrEP providers’ firsthand experiences relative to six commonly-cited barriers to prescription—financial coverage, implementation logistics, eligibility determination, adherence concerns, side effects, and anticipated behavior change (risk compensation)—as well as their recommendations for training PrEP-inexperienced providers. U.S.-based PrEP providers were recruited via direct outreach and referral from colleagues and other participants (2014–2015). One-on-one interviews were conducted in person or by phone, transcribed, and analyzed. The sample (n = 18) primarily practiced in the Northeastern (67%) or Southern (22%) U.S. Nearly all (94%) were medical doctors (MDs), most of whom self-identified as infectious disease specialists. Prior experience prescribing PrEP ranged from 2 to 325 patients. Overall, providers reported favorable experiences with PrEP implementation and indicated that commonly anticipated problems were minimal or manageable. PrEP was covered via insurance or other programs for most patients; however, pre-authorization requirements, laboratory/service provision costs, and high deductibles sometimes presented challenges. Various models of PrEP care and coordination with other providers were utilized, with several providers highlighting the value of clinical staff support. Eligibility was determined through joint decision-making with patients; CDC guidelines were commonly referenced but not considered absolute. Patient adherence was variable, with particularly strong adherence noted among patients who had actively sought PrEP (self-referred). Providers observed minimal adverse effects or increases in risk behavior. However, they identified several barriers with respect to accessing and engaging PrEP candidates. Providers offered a wide range of suggestions regarding content, strategy, and logistics surrounding PrEP training, highlighting sexual history-taking and sexual minority competence as areas to prioritize. These insights from early-adopting PrEP providers may facilitate adoption of PrEP into clinical practice by PrEP-inexperienced providers, thereby improving access for individuals at risk for HIV. [ABSTRACT FROM AUTHOR]

Objectives. Racial/ethnic disparities in heterosexual transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STls) have been hypothesized to be related to the high rate of incarceration and the shortage of men in black communities. This study tested associations of having multiple sex partners with these factors. Methods. Racial/ethnic-specific Census data on the sex ratio and the male incarceration rate were categorized into tertiles and matched with individual data from the National Health and Nutrition Examination Survey 1999-2004 by county of residence for non-Hispanic black, non-Hispanic white, and Mexican American participants. We used logistic regression analyses to examine whether these factors were associated with having multiple opposite-sex partners in the past year. Results. Sex ratios and incarceration rates varied greatly by race/ethnicity; however, we observed significant associations within each racial/ethnic group. Non-Hispanic black men in counties with a greater shortage of males (adjusted odds ratio [AOR] = 1.9; 95% confidence interval [Cl] 1.1, 3.5) and a greater number of incarcerated males (AOR=1.6; 95% Cl 1.1, 2.3) in the non-Hispanic black population had significantly greater odds of having two or more partners. Those in two low sex-ratio categories (AOR=2.4; 95% Cl 1.0, 5.8 and AOR=4.1; 95% Cl 1.6, 10.0) and one high incarceration-rate category (AOR=2.1; 95% Cl 1 .2, 3.6) had significantly greater odds of having five or more partners. Conclusion. Sex ratios and incarceration rates were associated with the number of opposite-sex partners in some groups. Because the risk of HIV/STI transmission depends, in part, on the number of partners, it is important to determine the causal relationships among these associations to help better understand racial/ethnic HIV/STI disparities and improve prevention programs and interventions. [ABSTRACT FROM AUTHOR]

Risky sexual behavior can lead to pregnancy, sexually transmitted diseases (STDs), and human immunodeficiency virus (HIV). Our study of 300 adolescent females takes an integrative approach by incorporating these multiple outcomes to assess the influence of risk perceptions on sexual behavior by (1) identifying subgroups of perceived susceptibility to pregnancy, STDs, and HIV using cluster analysis and (2) comparing subgroups on demographics, sexual history, sexual risk behavior over time, and subsequent STD acquisition. Results demonstrated five perceived susceptibility clusters (no susceptibility; high HIV; high pregnancy; high STD; and high multisusceptibility) that differed in three important ways: demographic and sexual history profiles, current sexual risk behavior, and subsequent STDs. Young women in the no susceptibility cluster had the lowest sexual risk and those in the high multisusceptibility cluster had the highest sexual risk and the highest number of subsequent STDs. There were no significant changes in sexual risk over time, regardless of cluster. © 2005 Wiley Periodicals, Inc. J Comm Psychol 33: 313–331, 2005. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: US Centers for Disease Control and Prevention clinical guidelines for HIV pre-exposure prophylaxis (PrEP) are widely used to assess patients' PrEP eligibility. The guidelines include 2 versions of criteria—guidance summary criteria and recommended indications criteria—that diverge in a potentially critical way for heterosexually active women: Both require women's knowledge of their own risk behavior, but the recommended indications also require women's knowledge of their partners' HIV risk or recognition of a potentially asymptomatic sexually transmitted infection. This study examined women's PrEP eligibility according to these 2 different versions of criteria across risk and motivation categories. Setting/Methods: HIV-negative women (n = 679) recently engaged in care at Connecticut Planned Parenthood centers were surveyed online in 2017. The survey assessed PrEP eligibility by both versions of Centers for Disease Control and Prevention criteria, HIV risk indicators, PrEP motivation indicators, and sociodemographic characteristics. Results: Participants were mostly non-Hispanic white (33.9%) or black (35.8%) and had low income (<$30,000/year; 58.3%). Overall, 82.3% were eligible for PrEP by guidance summary criteria vs. 1.5% by recommended indications criteria. Women disqualified by recommended indications criteria included those reporting condomless sex with HIV-positive or serostatus-unknown male partners (n = 27, 11.1% eligible); 1 or more recent sexually transmitted infection(s) (n = 53, 3.8% eligible); multiple sex partners (n = 168, 3.0% eligible); intended PrEP use (n = 211, 2.8% eligible); and high self-perceived risk (n = 5, 0.0% eligible). Conclusion: Current guidelines disqualify many women who could benefit from PrEP and may lead to discrepant assessments of eligibility. Guideline reform is needed to improve clarity and increase women's PrEP access and consequent HIV protection. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: In the United States, women represent less than 5% of all pre-exposure prophylaxis (PrEP) users. Social networks may promote and/or inhibit women's PrEP awareness, which could influence PrEP intentions. Furthermore, women experiencing intimate partner violence (IPV) may have smaller, less supportive networks, which could deter or have no impact on PrEP care engagement. This study examined associations between network characteristics and women's PrEP awareness, interest, uptake, and perceived candidacy and analyzed IPV as an effect modifier. Setting/Methods: From 2017 to 2018, data were collected from a prospective cohort study of 218 PrEP-eligible women with (n = 94) and without (n = 124) IPV experiences in Connecticut. Women completed surveys on demographics, IPV, social networks, and PrEP care continuum outcomes. Results: Adjusted analyses showed that PrEP awareness related to having more PrEP-aware alters. PrEP intentions related to having more alters with favorable opinions of women's potential PrEP use and a smaller network size. Viewing oneself as an appropriate PrEP candidate related to having more PrEP-aware alters and more alters with favorable opinions of women's potential PrEP use. IPV modified associations between network characteristics and PrEP care. Having members who were aware of and/or used PrEP was positively associated with PrEP care engagement for women without IPV experiences but had either no effect or the opposite effect for women experiencing IPV. Conclusion: Improving PrEP attitudes might improve its utilization among women. Social network interventions might be one way to increase PrEP uptake among many US women but may not be as effective for women experiencing IPV. [ABSTRACT FROM AUTHOR]