Exploring the heterogeneity of factors that may influence implementation of PrEP in family planning clinics: a latent profile analysis

Abstract

Background Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention. However, PrEP has not been widely integrated into family planning services, especially in the Southern US, and data suggest there may be significant implementation challenges in this setting. Because Title X clinics vary greatly in provider-, organizational-, and systems-level characteristics, there is likely variation in capacity to implement PrEP across clinics. Methods We conducted a survey from February to June 2018 among providers and administrators of non-PrEP-providing Title X-funded clinics across 18 southern states. Survey items were designed using the Consolidated Framework for Implementation Research (CFIR) to assess constructs relevant to PrEP implementation. To explore the heterogeneity of CFIR-related implementation determinants and identify distinct sub-groups of Title X clinics, a latent profile analysis was conducted using nine CFIR constructs: complexity, relative advantage, cost, attitudes, implementation climate, compatibility, leadership engagement, available resources, and cosmopolitanism. We then conducted a multi-level analysis (accounting for nesting of participants within clinics) to test whether group membership was associated with readiness for implementation of PrEP, controlling for key sociodemographic characteristics. Results Four hundred and fourteen healthcare providers/administrators from 227 non-PrEP-providing Title X clinics participated in the study. We identified six sub-groups of clinics that each had distinct patterns of PrEP implementation determinants. Clinic sub-groups included “Highest Capacity for Implementation”, “Favorable Conditions for Implementation”, “Mixed Implementation Context”, “Neutral Implementation Context”, “Incompatible Setting for Implementation”, and “Resource-Strained Setting”. Group membership was related to numerous provider-level (i.e., ability to prescribe medication) and clinic-level (i.e., provision of primary care) characteristics. In comparison to the “Neutral” group (which held neutral perceptions across the implementation determinants), the “Highest Capacity” and “Favorable Conditions” groups had significantly higher levels of implementation readiness, and the “Resource-Strained” group had a significantly lower level of implementation readiness. Conclusions Latent profile analyses can help researchers understand how implementation readiness varies across healthcare settings, promoting tailoring of implementation strategies to unique contexts.

Applying implementation science frameworks to identify factors that influence the intention of healthcare providers to offer PrEP care and advocate for PrEP in HIV clinics in Colombia: a cross-sectional study

“…Similar to the study of Piper et al in HCP from family planning clinics in the USA [ 10 ], we have found that the HCP’s positive perceptions on the need for PrEP favors both outcomes, offering and advocating for PrEP. We have previously reported that HCP’s perception on the high need for PrEP in the population they serve was explained by their awareness of the nondecreasing incidence of HIV in Colombia, problems with antiretroviral drug adherence, and the lack of sexual health education [ 14 ].…”

“…HCP who felt that PrEP was compatible with their practice, were more likely to have an intention to offer PrEP or advocate for PrEP, a finding consistent with a report of family planning clinics in the USA [ 10 ]. We explored this further in qualitative interviews and found that concerns on moral and religious values may hinder their willingness to offer PrEP [ 14 ].…”

“…We identified good construct validity and high reliability for most of the domains examined, and thus the scales and the items could be used to assess determinants of the intention of HCP and readiness for PrEP implementation in various settings. In the USA, similar CFIR-based scales have been found useful in the evaluation of the readiness of family planning clinics for PrEP implementation [ 10 ].…”

“…The CFIR posits that the adoption of any intervention or program requires an understanding of determinants at multiple levels and multilevel strategies. This is the case for the adoption of PrEP, where it is recognized that care and adoption should include identifying determinants at the individual (i.e., community members and providers), organizational (clinics, centers, community organizations), and contextual levels (i.e., policies, stigma, social inequities) [ 5 , 10 – 13 ].…”

“…Various studies have found relationships between the four domains of the CFIR analyzed here and PrEP adoption. For instance, Piper et al described that family planning clinics with higher readiness to implement PrEP had HCP who valued PrEP and HIV prevention, believed that PrEP was compatible with their patient population, perceived that PrEP was a low complexity intervention, and had leadership supporting that intervention [ 10 ]. Sullivan et al found that the perceptions of HCP about PrEP characteristics (e.g., effectiveness, relative advantage, simplicity), the lower capacity of the health system, the lack of policies for Medicaid expansion, and peers norms were important barriers for PrEP adoption [ 12 ].…”