Active-Offer Nurse-Led PrEP (PrEP-RN) Referrals: Analysis of Uptake Rates and Reasons for Declining

Abstract

While pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy, its uptake is limited. To address barriers, we piloted a nurse-led PrEP clinic in an STI clinic and had public health nurses refer patients during STI follow-up. We recorded the number of PrEP offers and declines and clinic uptake. We conducted a thematic analysis of patients' responses from nursing notes written at the time patients declined PrEP. From August 6, 2018 to August 5, 2019, nurses offered a PrEP referral to 261 patients who met our criteria; only 47.5% accepted. Qualitative analysis identified four themes: (1) perceptions of risk, (2) lack of interest, (3) inability to manage, and (4) concerns about PrEP. Our patients did not feel sufficiently at-risk for HIV to use PrEP and maintained that PrEP was for a reckless "other". This analysis sheds light on how assumptions about risk affect PrEP uptake, particularly among those at-risk for HIV.

PrEP your team! Clinician initiation of HIV pre-exposure prophylaxis discussion at sexually transmissible infection testing and diagnosis in gay and bisexual men

“…In this audit, there was minimal documentation of reasons for declining PrEP; however, reasons that GBM might say no to PrEP have been explored in recent studies and include lack of self-perceived ongoing HIV risk, needing time to consider PrEP, concerns about managing PrEP (cost and logistics) and concerns about harm (stigma and toxicities). 5 Our audit findings are echoed in an Australian cohort where 68% of GBM meeting eligibility criteria for PrEP did not commence PrEP, whereby younger men, those with less social engagement with other gay men or without additional risks such as chemsex or group sex were less likely to accept PrEP. 6 Quality improvement continues to be a fundamental tool to optimise clinical care, with this audit prompting system changes and ongoing audit to optimise PrEP discussion and documentation.…”

Community Legal Systems: Targeting PrEP and HIV Education to Decrease Risk of HIV Transmission

“…After educational intervention, only about a third (34.2%) indicated intent to use PrEP and only 36% accepted free, on-site HIV testing. The disconnect between self-reported risks and recognition of risk has been documented in other studies of HIV-negative individuals but is not universal [36,[38][39][40]. This study examined a range of factors thought to be predictive of intent to use PrEP, such as access to medical insurance, HIV knowledge, age, and race.…”

“…It is potentially related to the fact that the south is home to 58% of the black U.S. population and the low acceptance of PrEP by this population [ 32 , 37 ]. Among some populations, while counter-intuitive, an individual-level perceived HIV risk is not associated with a willingness to use PrEP [ 36 , 38 , 39 ]. On the other hand, individuals living in an area with a high area-level HIV risk are more likely to use PrEP [ 36 ].…”

“…Generally, high endorsement of PrEP stigma is associated with less HIV knowledge, less willingness to use PrEP, and less perceived PrEP effectiveness [ 27 ]. Specifically, stigma beliefs that stereotype others (e.g., PrEP is for promiscuous people) are linked to less PrEP use in some populations [ 39 , 45 ]. Other factors associated with acceptance of PrEP may also co-occur with an individual’s risk level.…”

Nurse-led PrEP-RN clinic: a prospective cohort study exploring task-Shifting HIV prevention to public health nurses

“…(Results about why people decline PrEP are published elsewhere. 28 ) Two interesting points on this matter were, first, that those who continued PrEP continued using it, and, second, that age demonstrated a trend toward significance. One reason why this might have occurred is that those who continue PrEP could simply agree with this intervention and thus continue PrEP because it aligns with their worldviews.…”