"PrEP Gives the Woman the Control": Healthcare Worker Perspectives on Using pre-Exposure Prophylaxis (PrEP) During Pregnancy and Postpartum in Kenya.

Background: Pregnant and postpartum women in high HIV prevalent regions are at increased HIV risk. Oral pre-exposure prophylaxis (PrEP) can decrease HIV incidence reducing infant HIV infections. Understanding healthcare worker (HCW) beliefs about PrEP prior to national roll-out is critical to supporting PrEP scale-up. Methods: We conducted 45 semi-structured interviews among a range of HCW cadres with and without PrEP provision experience purposively recruited from four clinics in Kenya to compare their views on prescribing PrEP during pregnancy and postpartum. Interviews were analysed using a conventional content analysis approach to identify key influences on PrEP acceptability and feasibility. Results: All HCWs perceived PrEP as an acceptable and feasible HIV prevention strategy for pregnant and postpartum women. They believed PrEP meets women's needs as an on-demand, female-controlled prevention strategy that empowers women to take control of their HIV risk. HCWs highlighted their role in PrEP delivery success while acknowledging how their knowledge gaps, concerns and perceived PrEP implementation challenges may hinder optimal PrEP delivery. Conclusion: HCWs supported PrEP provision to pregnant and postpartum women. However, counseling tools to address risk perceptions in this population and strategies to reduce HCW knowledge gaps, concerns and perceived implementation barriers are required.

Pharmacogenomics in diverse practice settings: implementation beyond major metropolitan areas.

AIM: The limited formal study of the clinical feasibility of implementing pharmacogenomic tests has thus far focused on providers at large medical centers in urban areas. Our research focuses on small metropolitan, rural and tribal practice settings. MATERIALS & METHODS: We interviewed 17 healthcare providers in western Montana regarding pharmacogenomic testing. RESULTS: Participants were optimistic about the potential of pharmacogenomic tests, but noted unique barriers in small and rural settings including cost, adherence, patient acceptability and testing timeframe. Participants in tribal settings identified heightened sensitivity to genetics and need for community leadership approval as additional considerations. CONCLUSION: Implementation differences in small metropolitan, rural and tribal communities may affect pharmacogenomic test adoption and utilization, potentially impacting many patients. Original submitted 3 September 2014; Revision submitted 3 December 2014.

Factors that influence mammography use among older American Indian and Alaska Native women.

INTRODUCTION: American Indian and Alaska Native (AIAN) women have relatively high breast cancer mortality rates despite the availability of free or low-cost screening. PURPOSE: This qualitative study explored issues that influence the participation of older AIAN women in mammography screening through tribally directed National Breast and Cervical Cancer Early Detection Programs (NBCCEDPs). METHODS: We interviewed staff (n = 12) representing five tribal NBCCEDPs and conducted four focus groups with AIAN women ages 50 to 80 years (n = 33). RESULTS: Our analysis identified four main areas of factors that predispose, enable, or reinforce decisions around mammography: financial issues and personal investments, program characteristics including direct services and education, access issues such as transportation, and comfort zone topics that include cultural or community-wide norms regarding cancer prevention. CONCLUSION: This study has implications for nurse education and training on delivering effective mammography services and preventive cancer outreach and education programs in AIAN communities.

Essential elements of personalized medicine.

OBJECTIVES: Genomic information has been promoted as the basis for "personalized" health care. We considered the benefits provided by genomic testing in context of the concept of personalized medicine. MATERIALS AND METHODS: We evaluated current and potential uses of genomic testing in health care, using prostate cancer as an example, and considered their implications for individualizing or otherwise improving health care. RESULTS AND CONCLUSIONS: Personalized medicine is most accurately seen as a comprehensive effort to tailor health care to the individual, spanning multiple dimensions. While genomic tests will offer many potential opportunities to improve the delivery of care, including the potential for genomic research to offer opportunities to improve prostate cancer screening and treatment, such advances do not in themselves constitute a paradigm shift in the delivery of health care. Rather, personalized medicine is based on a partnership between clinician and patient that utilizes shared decision making to determine the best health care options among the available choices, weighing the patient's personal values and preferences together with clinical findings. This approach is particularly important for difficult clinical decisions involving uncertainty and trade-offs, such as those involved in prostate cancer screening and management. The delivery of personalized medicine also requires adequate health care access and assurance that basic health needs have been met. Substantial research investment will be needed to identify how genomic tests can contribute to this effort.