Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men

Abstract

Data indicate that diffusion of pre-exposure prophylaxis (PrEP) programs for HIV prevention is increasing in the United States; however, persistent disparities in PrEP access remain. Earlier waves of PrEP implementation focused on development (2012)(2013)(2014)(2015) and diffusion (2016)(2017)(2018). To reduce disparities, the next wave of PrEP implementation should focus on integration; that is, the assimilation of PrEP service as an integral part of HIV prevention, sexual health, and primary care. This review analyzes PrEP implementation literature in the context of three ''next-wave'' challenges: increasing patient demand, enhancing provider investment and competency, and improving health systems capacity. Our review revealed five activities we consider critical to successful next-wave PrEP implementation efforts: (1) redefining PrEP eligibility assessment, (2) de-emphasizing risk perception as a strategy to increase demand, (3) rejecting risk compensation arguments, (4) altering guidelines to make PrEP follow-up less onerous, and (5) focusing directly on strategies to reduce the cost of PrEP medication. This article ends with a case study of a research-practice partnership designed to instantiate new approaches to integrative implementation efforts.

“A Good Habit”: Telehealth PrEP Users Find Benefit in Quarterly Monitoring Requirements

“…Researchers are beginning to consider whether reducing the number of health-care tasks patients must navigate to secure PrEP would benefit the patient (ie, reducing the required clinic visits and/or laboratory monitoring from 4 times per year to 2). 28,29 However, our findings illustrate that, in the context of receiving PrEP through a telehealth service, some PrEP users see monitoring as a secondary benefit and as another method of preventing STIs. Careful consideration should precede any decision to reduce the frequency of required laboratories while on PrEP-particularly since at least some men are making decisions about sexual practices based on the notion that PrEP users are being tested 4 times per year.…”

Health Care Provider Barriers to HIV Pre-Exposure Prophylaxis in the United States: A Systematic Review

“…They are also uniquely situated to educate patients on the risks and benefits of PrEP and have the ability to reach a large number of high-risk individuals. Two prior reviews have highlighted the substantial breadth of research on barriers to PrEP use among populations with higher rates of HIV, 19,20 and two other reviews have incorporated health care provider barriers to PrEP service delivery, 21,22 but a comprehensive and systematic review on provider-level barriers to PrEP prescription was needed.…”

Give PrEP a chance: moving on from the “risk compensation” concept

“…More precisely, they explained that the main reason for not implementing this bio‐behavioural intervention (BI) was lack of information regarding “people's own responsibility to use a condom, the relevance of being free of fear of HIV infection when having sex, and the relative importance of preventing HIV versus a possible rise in other sexually transmitted diseases because of reduced condom use” . This quote makes explicit important points that have overshadowed PrEP and other BI: moral judgements on sex and HIV prevention as a means of controlling sex .…”