Dataset Information

HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis.

ABSTRACT: Although pre-exposure prophylaxis (PrEP) has been approved for primary HIV prevention for individuals aged 18 years or older since 2012, PrEP utilization has been suboptimal. To understand trends in PrEP provision from the health care providers' perspective, we systematically assessed each specific stage along the PrEP implementation cascade (i.e., awareness, willingness, consultation, and prescription) among health care professionals (HCPs) in the United States. Between June and December 2018, we conducted a systematic review of published studies on this topic. A total of 36 eligible studies were identified and included in the analyses. Random-effect models were employed to examine the pooled prevalence of each key stage along the cascade. Time trend and subgroup analyses were conducted. A thematic analysis was used to identify barriers and facilitators along the PrEP cascade. In this study, a total of 18,265 HCPs representing diverse demographics were included. The pooled prevalence of PrEP awareness was 68% [95% confidence interval (CI)?=?55-80%], willingness to prescribe PrEP was 66% (95% CI?=?54-77%), PrEP consultation was 37% (95% CI?=?25-51%), and prescription provision was 24% (95% CI?=?17-32%). Subgroup analyses revealed that PrEP provision among HCPs was lowest in the south, but has been improving annually nationwide. Infectious disease specialists [odds ratio (OR)?=?4.06, 95% CI?=?3.12-5.28; compared with primary care providers] and advanced practice registered nurses/physician assistants (OR?=?1.51, 95% CI?=?1.09-2.09; compared with physicians) had higher odds of prescribing PrEP. Barriers and facilitators regarding optimal PrEP implementation were embedded within individual, dyadic, social, and structural levels. This meta-analysis has comprehensively examined the trend and pattern of PrEP implementation among HCPs. To achieve optimal implementation of the PrEP cascade in the United States, tailored training and programs need to be provided to HCPs.

SUBMITTER: Zhang C

PROVIDER: S-EPMC6918849 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis.

Zhang Chen C McMahon James J Fiscella Kevin K Przybyla Sarahmona S Braksmajer Amy A LeBlanc Natalie N Liu Yu Y

AIDS patient care and STDs 20191201 12

Although pre-exposure prophylaxis (PrEP) has been approved for primary HIV prevention for individuals aged 18 years or older since 2012, PrEP utilization has been suboptimal. To understand trends in PrEP provision from the health care providers' perspective, we systematically assessed each specific stage along the PrEP implementation cascade (i.e., awareness, willingness, consultation, and prescription) among health care professionals (HCPs) in the United States. Between June and December 2018, ...[more]

PMID: 31821044

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Project description:BACKGROUND:Despite evidence supporting pre-exposure prophylaxis (PrEP) efficacy, there are concerns regarding the feasibility of widespread PrEP implementation among men who have sex with men (MSM). To inform the development of targeted PrEP delivery guidelines, sexual risk trajectories among HIV-negative MSM were characterized. METHODS:At semiannual visits from 2003 to 2011, HIV-negative MSM (N = 419) participating in the Multicenter AIDS Cohort Study provided data on sexual risk behaviors (SRBs) since their last visit. Based on their reported behaviors, participants were assigned a SRB score at each visit as follows: 0 = no insertive or receptive anal intercourse, 1 = no unprotected insertive or receptive anal intercourse, 2 = only unprotected insertive anal intercourse, 3 = unprotected receptive anal intercourse with 1 HIV-negative partner, 4 = condom serosorting, 5 = condom seropositioning, and 6 = no seroadaptive behaviors. Group-based trajectory modeling was used to examine SRB scores (<4 vs. ?4) and identify groups with distinct sexual risk trajectories. RESULTS:Three sexual risk trajectory groups were identified: low-risk (n = 264; 63.0%), moderate-risk (n = 96; 22.9%; mean duration of consecutive high-risk intervals ?1 year), and high-risk (n = 59; 14.1%; mean duration of consecutive high-risk intervals ?2 years). Compared to low-risk group membership, high-risk group membership was associated with younger age (in years) [adjusted odds ratio (AOR) = 0.92, 95% confidence interval (CI): 0.88 to 0.96], being White (AOR = 3.67, 95% CI: 1.48 to 9.11), earning an income ?$20,000 (AOR = 4.98, 95% CI: 2.13 to 11.64), distress/depression symptoms (Center for Epidemiologic Studies Depression Scale ? 16) (AOR = 2.36, 95% CI: 1.14 to 4.92), and substance use (AOR = 2.00, 95% CI: 1.01 to 3.97). CONCLUSIONS:Screening for the sociodemographic and behavioral factors described above may facilitate targeted PrEP delivery during high-risk periods among MSM.

Project description:PurposeHIV pre-exposure prophylaxis (PrEP) is highly efficacious, and yet most individuals indicated for it are not currently using it. To provide guidance for health policymakers, researchers, and community advocates, we developed county-level PrEP use estimates and assessed locality and policy associations.MethodsUsing data from a national aggregator, we applied a validated crosswalk procedure to generate county-level estimates of PrEP users in 2018. A multilevel Poisson regression explored associations between PrEP use and (1) state policy variables of Medicaid expansion and state Drug Assistance Programs (PrEP-DAPs) and (2) county-level characteristics from the U.S. Census Bureau. Outcomes were PrEP per population (prevalence) and PrEP-to-need ratio (PnR), defined as the ratio of PrEP users per new HIV diagnosis. Higher levels of PrEP prevalence or PnR indicate more PrEP users relative to the total population or estimated need, respectively.ResultsOur 2018 county-level data set included a total of 188,546 PrEP users in the United States. Nationally, PrEP prevalence was 70.3/100,000 population and PnR was 4.9. In an adjusted model, counties with a 5% higher proportion of black residents had 5% lower PnR (rate ratio (RR): 0.95, 95% confidence interval (CI): 0.93, 0.96). Similarly, counties with higher concentration of residents uninsured or living in poverty had lower PnR. Relative to states without Medicaid expansion or PrEP-DAPs, states with only one of those programs had 25% higher PrEP prevalence (RR: 1.25, 95% CI: 1.09, 1.45), and states with both programs had 99% higher PrEP prevalence (RR: 1.99, 95% CI: 1.60, 2.48). There was a significant linear trend across the three policy groups, and similar findings for the relation between PnR and the policy groups.ConclusionsIn a data set comprising approximately 80% of PrEP users in the United States, we found that Medicaid expansion and PrEP-DAPs were associated with higher PrEP use in states that adopted those policies, after controlling for potential confounders. Future research should identify which components of PrEP support programs have the most success and how to best promote PrEP among groups most impacted by the epidemic. States should support the admirable health decisions of their residents to get on PrEP by implementing policies that facilitate access.

Project description:Pre-exposure prophylaxis (PrEP) has emerged as a promising strategy for preventing the transmission of HIV. Although only one formulation is currently approved for PrEP, research into both new compounds and new delivery systems for PrEP regimens offer intriguing challenges from the perspective of pharmacokinetic and pharmacodynamic modeling. This review aims to provide an overview the current modeling landscape for HIV PrEP, focused on PK/PD and QSP models relating to antiretroviral agents. Both current PrEP treatments and new compounds that show promise as PrEP agents are highlighted, as well as models of uncommon administration routes, predictions based on models of mechanism of action and viral dynamics, and issues related to adherence to therapy. The spread of human immunodeficiency virus (HIV) remains one of the foremost global health concerns. In the absence of a vaccine, other prophylactic strategies have been developed to prevent HIV transmission. One approach, known as pre-exposure prophylaxis (PrEP), allows HIV-negative individuals who are at high risk of exposure to the virus, be it through an HIV-positive sexual partner or through the shared use of drug injection equipment, to substantially reduce the risk of developing an HIV infection. PrEP is a relatively recent approach to combating the HIV epidemic, with the only currently approved treatment being Truvada, a daily oral antiretroviral (ARV) therapy initially indicated in the treatment of active HIV-1 infections, but approved for HIV PrEP in 2012. Although PrEP therapy has consistently demonstrated high efficacy in preventing HIV infection, this efficacy is dependent on patient adherence to the prescribed treatment regimen. This can present a significant problem in low- and middle-income countries, which may lack the infrastructure to provide sufficient access to PrEP medication to maintain daily dosing regimens. Furthermore, while the conventional approach has generally been to advocate for continuous administration akin to regimens used for viral suppression in infected patients, there has been some discussion of whether a better treatment paradigm might be to push for PrEP therapy primarily during those known periods of heightened exposure risk, while relying on post-exposure prophylaxis regimens to prevent infection after unanticipated exposures during low-risk periods. These considerations have led to a push for the development of long-duration and on-demand PrEP formulations, including subdermal and subcutaneous implants, slow-release intramuscular depot injections, vaginal and rectal antimicrobial gels, and intravaginal rings and dissolving films. PrEP therapy is a quickly evolving field, with a variety of antiretroviral compounds and formulations under investigation. This review aims to report on notable drugs and formulations from a pharmacokinetic/pharmacodynamic (PK/PD) modeling perspective. Given the nature of PrEP as a preventive therapy designed for long-term use, clinical trials for PrEP therapies can last for months or even years, particularly in the case of long-duration formulations. Furthermore, in contrast to antiretroviral trials in infected patients, pharmacodynamic endpoints in PrEP therapies are difficult to quantify, as the primary endpoint for efficacy is generally the rate of seroconversion. Computational modeling approaches offer flexible and powerful tools to provide insight into drug behavior in clinical settings, and can ultimately reduce the time, expense, and patient burden incurred in the development of PrEP therapies.

Dataset Information

HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis.

Publications

HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis.

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