Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares.

STUDY OBJECTIVES: This study's objective was to evaluate the effect of nightmares (NMs) on attrition and symptom change following cognitive behavioral therapy for insomnia (CBT-I) treatment using data from a successful CBT-I randomized controlled trial delivered to participants with recent interpersonal violence exposure. METHODS: The study randomized 110 participants (107 women; mean age: 35.5 years) to CBT-I or to an attention-control group. Participants were assessed at 3 time periods: baseline, post-CBT-I (or attention control), and at time 3 (T3) post-cognitive processing therapy received by all participants. NM reports were extracted from the Fear of Sleep Inventory. Participants with weekly NMs were compared with those with fewer than weekly NMs on outcomes including attrition, insomnia, posttraumatic stress disorder, and depression. Change in NM frequency was examined. RESULTS: Participants with weekly NMs (55%) were significantly more likely to be lost to follow-up post-CBT-I (37%) compared with participants with infrequent NMs (15.6%) and were less likely to complete T3 (43%) than patients with less frequent NMs (62.5%). NMs were unrelated to differential treatment response in insomnia, depression, or posttraumatic stress disorder. Treatment with CBT-I was not associated with reduced NM frequency; however, change in sleep-onset latency from post-CBT-I to T3 predicted fewer NMs at T3. CONCLUSIONS: Weekly NMs were associated with attrition but not a reduced change in insomnia symptoms following CBT-I. NM symptoms did not change as a function of CBT-I, but change in sleep-onset latency predicted lower NM frequency. CBT-I trials should screen for NMs and consider augmenting CBT-I to specifically address NMs. CITATION: Hamilton NA, Russell JA, Youngren WA, et al. Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares. J Clin Sleep Med. 2023;19(11):1913-1921.

Procurement of patient medical records from multiple health care facilities for public health research: feasibility, challenges, and lessons learned.

Objectives: Studies that combine medical record and primary data are typically conducted in a small number of health care facilities (HCFs) covering a limited catchment area; however, depending on the study objectives, validity may be improved by recruiting a more expansive sample of patients receiving care across multiple HCFs. We evaluate the feasibility of a novel protocol to obtain patient medical records from multiple HCFs using a broad representative sampling frame. Materials and Methods: In a prospective cohort study on HIV pre-exposure prophylaxis utilization, primary data were collected from a representative sample of community-dwelling participants; voluntary authorization was obtained to access participants' medical records from the HCF at which they were receiving care. Medical record procurement procedures were documented for later analysis. Results: The cohort consisted of 460 participants receiving care from 122 HCFs; 81 participants were lost to follow-up resulting in 379 requests for medical records submitted to HCFs, and a total of 343 medical records were obtained (91% response rate). Less than 20% of the medical records received were in electronic form. On average, the cost of medical record acquisition was $120 USD per medical record. Conclusions: Obtaining medical record data on research participants receiving care across multiple HCFs was feasible, but time-consuming and resulted in appreciable missing data. Researchers combining primary data with medical record data should select a sampling and data collection approach that optimizes study validity while weighing the potential benefits (more representative sample; inclusion of HCF-level predictors) and drawbacks (cost, missing data) of obtaining medical records from multiple HCFs.

Depressive Symptoms Moderate the Association Between the Recent History of Alcohol Use Severity and Suicide Attempt History Among Adults in a Pretrial Jail Diversion Program.

Background: Justice-involved individuals are at elevated risk for suicidal behavior; however, research examining risk for suicidal behavior in pretrial jail diversion programs (pretrial diversion) is limited. Aims: We aimed to test (1) associations between depressive symptoms and alcohol and drug use, and suicide attempt history (SAH), and (2) interactions between depressive symptoms and alcohol and drug use in relation to SAH among adults in an urban pretrial jail diversion program. Method: The design was cross-sectional, including self-report assessments and file reviews of historical information. Adults (N = 274; Mage = 33.72; 73.7% men; 52.6% non-Hispanic Black) completed assessments within two weeks of beginning the pretrial program. Results: Depressive symptoms were positively associated with SAH after adjusting for other covariates. The significant depressive symptoms by alcohol use interaction indicated that adults with low to average depressive symptoms evidenced a similar likelihood of SAH to those with high depressive symptoms when they also had elevated alcohol use scores. Limitations: We used cross-sectional self-report data. Conclusion: It may be important to conduct suicide risk assessments for justice-involved people who use alcohol even when depressive symptoms are low.

Measurement of primary care providers' suicide prevention skills following didactic education.

OBJECTIVE: Almost half of individuals who die by suicide have had contact with primary care (PC) services within 1 month of their death. PC providers must be able to assess and manage patients' suicidal ideation, intent, and behaviors. When didactic training is provided to providers, it is assumed that their requisite skills are well developed. The current study assessed observed skills following high-quality online didactics. METHOD: Medical residents and nurse practitioner (NP) trainees (n = 127) participated in online didactic training as part of their education program, followed by a standardized patient interaction conducted to assess demonstrated suicide prevention skills (i.e., assessment of risk factors, protective factors, suicidal ideation and behavior, safety planning). RESULTS: Participants demonstrated only about 50% of the possible total skills in most domains and were least competent in assessing potential risk for suicide. Regression analyses showed that residents were rated significantly higher than NPs on observed skills. Personal experience with suicide was not associated with any observed skills. Baseline knowledge scores were positively associated with some skills while elapsed days since completion of didactics were negatively associated with skills. CONCLUSIONS: Didactics were insufficient for building suicide-specific assessment skills among physicians and nurses in advanced training.

Subjective memory in adults over 50 years of age: associations with affective and physiological markers of emotion regulation.

OBJECTIVES: To examine associations among subjective memory reports, psychophysiological markers of emotion regulation, and cognitive performance in healthy adults over 50 years of age. METHOD: A cross-sectional laboratory study was conducted with healthy, community-dwelling, non-depressed adults (M age = 60.4 years, SD = 8.4). The Metamemory in Adulthood (MIA) questionnaire provided reports of subjective memory capacity and stability (versus decline) and anxiety about memory. Poorer emotion regulation was marked by greater negative affect (NA) and lower high frequency heart rate variability (HF-HRV) responses to a challenging working memory task. Regression models were used to identify associations between subjective memory and emotion regulation markers, and structural equation modeling was used to explore whether emotion regulation mediated associations between subjective memory and objective task performance. RESULTS: A total of 115 participants were included in the final sample. Subjective memory decline (indicated by lower scores on memory stability) was associated with lower HF-HRV response and worse working memory performance. Poorer subjective memory capacity and more anxiety about memory were both associated with greater negative affect in response to the working memory task. There was an indirect effect of subjective memory capacity on working memory performance through negative affect response. CONCLUSIONS: The findings here suggest that worse subjective memory may signal reduced capacity for emotion regulation. Along with known cognitive risks of depression and anxiety, more subtle emotion regulation difficulties may be involved in pathways of poor cognitive aging.

A Randomized Clinical Trial of Cognitive-Behavioral Therapy for Insomnia to Augment Posttraumatic Stress Disorder Treatment in Survivors of Interpersonal Violence.

INTRODUCTION: Individuals exposed to interpersonal violence (IPV) commonly develop posttraumatic stress disorder (PTSD) with co-occurring depression and insomnia. Standard PTSD interventions such as cognitive processing therapy (CPT) do not typically lead to remission or improved insomnia. Cognitive behavioral therapy for insomnia (CBTi) improves insomnia in individuals with PTSD, but PTSD severity remains elevated. OBJECTIVE: To determine whether sequential treatment of insomnia and PTSD is superior to treatment of only PTSD. METHODS: In a 20-week trial, 110 participants exposed to IPV who had PTSD, depression and insomnia were randomized to CBTi followed by CPT or to attention control followed by CPT. Primary outcomes following CBTi (or control) were the 6-week change in score on the Insomnia Severity Index (ISI), the Clinician-Administered PTSD Scale (CAPS), and the Hamilton Rating Scale for Depression (HAM-D). Primary outcomes following CPT were the 20-week change in scores. RESULTS: At 6 weeks, the CBTi condition had greater reductions in ISI, HAM-D, and CAPS scores than the attention control condition. At 20 weeks, participants in the CBTi+CPT condition had greater reductions in ISI, HAM-D, and CAPS scores compared to control+CPT. Effects were larger for insomnia and for depression than for PTSD. Similar patterns were observed with respect to clinical response and remission. A tipping point sensitivity analyses supported the plausibility of the findings. CONCLUSIONS: The sequential delivery of CBTi and CPT had plausible, significant effects on insomnia, depression, and PTSD compared to CPT alone. The effects for PTSD symptoms were moderate and clinically meaningful.

Ecological and Syndemic Predictors of Drug Use During Sex and Transactional Sex among U.S. Black Men Who Have Sex with Men: A Secondary Data Analysis from the HPTN 061 Study.

Threats to sexual health among U.S. Black men who have sex with men (MSM) may manifest in a context of social adverse experiences. Situational sex is one such context, which we characterize as sexual behaviors driven either by a desire to cultivate a specific sexual experience or attributable to social vulnerability. Two characterizations of situational sex explored in this study were drug use during sex and transactional sex. Guided by ecological and syndemic frameworks, we conducted a secondary data analysis of social conditions and sexual behaviors among a prospective cohort of Black MSM from the HIV Prevention Trial Network (HPTN) 061 study. Using structural equation modeling, this analysis examined the indirect effect of syndemic factors (substance use, depression, violence exposure) in the relationship between ecological constructs (anti-Black/homophobic stigma, childhood violence, and economic vulnerability) and situational sex (drug use during sex, transactional sex). Model fit indices, CFI (.870) and SRMR (.091), demonstrated reasonable fit. Significant indirect effects emerged via substance use for economic vulnerability (indirect effect = .181, 95% CI [.078, .294]) and anti-Black/homophobic violence and stigma (indirect effect = .061, 95% CI [.008, .121]) on drug use during sex; as well as on transactional sex (economic vulnerability indirect effect = .059, 95% CI [.018, .121] and anti-Black/homophobic stigma and violence indirect effect = .020, 95% CI [.003, .051]). Findings implicate the need for social and fiscal intervention to address upstream, ecological, and syndemic factors that influence inherent vulnerability of situational sex and overall threats to sexual health among Black MSM.

Brief Video-Based Suicide Prevention Training for Primary Care.

BACKGROUND AND OBJECTIVES: One-third of individuals who die by suicide had primary care contact in the preceding month. Primary care trainees need engaging and effective suicide prevention training that can be delivered within tight time and resource constraints. However, training is currently scarce and its effectiveness unknown. The objective of this study was to assess learner engagement, learning, self-efficacy, and perceived ability to transfer training to practice from brief video-based modules centered around visual concept mapping of suicide prevention practices. METHODS: We assigned 127 primary care trainees 21 brief instructional videos to watch. We analyzed engagement by monitoring the proportion of learners who began each video and the proportion of the video watched. We assessed knowledge and self-efficacy pre- and posttraining. Learners provided feedback on satisfaction with modules and ability to transfer training to practice. RESULTS: Engagement was high, with most learners watching most of each video (mean=83.2%). Increase in knowledge was large (t(131 df)=19.91, P<.001). Confidence in ability to manage suicide risk rose significantly (t(131 df)=16.31, P<.001). Perception of ability to transfer training to practice was moderate. Satisfaction with modules was high. Feedback asked for patient scenarios and practical skills examples. CONCLUSIONS: This training successfully engaged primary health care trainees in suicide prevention education. Training transfer will be improved by adding skill demonstrations, a suicide attempt survivor perspective, and a memorable framework to assist implementation of knowledge. A new iteration incorporating these improvements is under evaluation. Variants for other health care settings are under development.

Initial Session Effects of Brief Cognitive Behavioral Therapy for Insomnia: A Secondary Analysis of A Small Randomized Pilot Trial.

Objective/Background: While cognitive-behavioral therapy for insomnia (CBT-I) is typically delivered over six-eight sessions, the field has introduced ever briefer versions. We examined session by session effects on both insomnia and depression outcomes in a brief, four-session version of CBT-I.Participants: This is a secondary analysis of data drawn from participants randomized to brief cognitive behavioral therapy for insomnia (bCBTi) in a pilot clinical trial. All participants (n = 19) were veterans enrolled in primary care who screened positive for insomnia and co-occurring PTSD and/or depression.Methods: Participants received four, weekly, individual sessions of bCBTi during which they provided self-report data on insomnia, depression, and sleep parameters over the preceding week. Baseline and follow-up assessments were also collected.Results: Changes in insomnia and depression severity between baseline and the beginning of session one were non-significant. Statistically significant decreases were observed, however, for insomnia severity between sessions one to two (g = -.65) and sessions two to three (g = -.59). This pattern was mirrored for depression severity with significant decreases between sessions one and two (g = -.65) and sessions two to three (g = -.68). However, there was little change for either outcome from session three to session four (insomnia g = -.16; depression g = -.14).Conclusions: This session by session analyses of bCBTi revealed that the majority of the treatment effect occurred over the first two sessions. Findings suggest that even brief interventions addressing insomnia may have a positive impact on both insomnia and co-occurring depression.

Demonstrated health care cost savings for women: findings from a community health worker intervention designed to address depression and unmet social needs.

To evaluate the impact of a community health worker intervention (CHW) (referred to as Personalized Support for Progress (PSP)) on all-cause health care utilization and cost of care compared with Enhanced Screening and Referral (ESR) among women with depression. A total of 223 patients (111 in PSP and 112 in ESR randomly assigned) from three women's health clinics with elevated depressive symptoms were enrolled in the study. Their electronic health records were queried to extract all-cause health care encounters along with the corresponding billing information 12 months before and after the intervention, as well as during the first 4-month intervention period. The health care encounters were then grouped into three mutually exclusive categories: high-cost (> US$1000 per encounter), medium-cost (US$201-$999), and low-cost (≤ US$200). A difference-in-difference analysis of mean total charge per patient between PSP and ESR was used to assess cost differences between treatment groups. The results suggest the PSP group was associated with a higher total cost of care at the baseline; taking this baseline difference into account, the PSP group was associated with lower mean total charge amounts (p = 0.008) as well as a reduction in the frequency of high-cost encounters (p < 0.001) relative to the ESR group during the post-intervention period. Patient-centered interventions that address unmet social needs in a high-cost population via CHW may be a cost-effective approach to improve quality of care and patient outcomes.

Implementing a New Tool to Predict the Risk of Intimate Partner Violence in Rural China.

Most of current scales for assessing intimate partner violence (IPV) were developed for Western populations. The Chinese Risk Assessment Tool for Victims (CRAT-V) was a new scale evaluating the risk of IPV, which was developed based on Chinese populations in the context of Chinese culture. To determine whether the CRAT-V could add further value to research involving IPV and violence against women in rural China, we sought to implement the CRAT-V and to explore its factor structure among a rural population in the mainland of China. This study included women from rural Sichuan Province of China, who aged 16 years and older, had been living locally for at least 2 years, and reported that they were married or in a relationship in the preceding year. A total of 670 participants completed the CRAT-V during the field survey. We utilized exploratory factor analysis to validate the fact structure of CRAT-V. The Cronbach's alpha of the CRAT-V was 0.90, indicating good reliability. The CRAT-V reported that 45.07% (302/670) of participants were in risk of IPV, and the risk was higher in women who were 16 to 29 years old, having 7 years and higher education, and living in stem families. The CRAT-V fit a 5-factor model including healthy relationship, jealous feeling, jealous reaction, stressful living condition, and sexual abuse. Our findings provided support for using the CRAT-V as a culturally sensitive measure to predict the risk of experiencing IPV in China, and lend insights into factors that may contribute to timely IPV prevention and intervention.

Insomnia, Posttraumatic Stress Disorder Symptoms, and Danger: Their Impact on Victims' Return to Court for Orders of Protection.

The linkages between intimate partner violence (IPV), posttraumatic stress disorder (PTSD), and insomnia have been the subject of inquiry. This study is the first to explore the associations between clinical-level insomnia, PTSD symptoms, danger, and victim socio-demographics, and whether IPV victims pursue permanent orders of protection (OPs). Data for this secondary analysis were collected through surveys, interviews, and reviews of court records on 112 women who resided in upstate New York. Women initiated actions to obtain OPs from the Domestic Violence Intensive Intervention Court (DVIIC), from 2007 to 2008. The following factors were analyzed to determine their impact on whether a woman returned to court: (a) age, (b) race, (c) employment status, (d) perceived danger, (e) PTSD symptoms, and (f) clinical-level insomnia. This study finds that the following factors significantly relate to return to court: race, clinical-level insomnia and perceived danger, clinical-level insomnia and PTSD symptoms, and severe danger level. However, in the final multivariate logistic regression, only race emerged as a predictor of whether a woman returned to court. Specifically, women of color were a third less likely to return to court than White women. These results have significant implications for future research and clinical intervention.

Pre-exposure Prophylaxis Use Among Men Who Have Sex with Men Experiencing Partner Violence.

Intimate partner violence (IPV) significantly increases HIV risk among MSM. Pre-exposure prophylaxis (PrEP) may provide MSM experiencing IPV an option for self-protection from HIV without requiring condom negotiation or compromising safety. This study examined relationships among various forms of IPV (physical, emotional, monitoring, controlling, and forced sex) and PrEP use among 863 MSM participating in a cross-sectional, internet-based survey. Participants reported IPV rates during the prior 6 months that were consistent with prior research (physical violence, 23.3%; emotional violence, 36.3%; monitoring, 45.1%; controlling, 25.3%; forced sex, 20.0%). Forced sex and emotional IPV were negatively associated with PrEP use in our sample; in contrast, controlling was positively associated with PrEP use. We suggest clinical IPV screenings among MSM seeking PrEP, as well as PrEP-focused interventions that explicitly address IPV.

A Comparative Effectiveness Trial of Two Patient-Centered Interventions for Women with Unmet Social Needs: Personalized Support for Progress and Enhanced Screening and Referral.

Background: Despite recent widespread acceptance that unmet social needs are critically relevant to health, limited guidance exists about how best to address them in the context of women's health care delivery. We aimed to evaluate two interventions: enhanced screening and referral (ESR), a screening intervention with facilitated referral and follow-up calls, and personalized support for progress (PSP), a community health worker intervention tailored to women's priorities. Materials and Methods: Women >18 years were screened for presence of elevated depressive symptoms in three women's health clinics serving primarily Medicaid-eligible patients. If eligible and interested, we enrolled and randomized women to ESR or PSP. Pre- and postintervention assessments were conducted. Primary outcomes were satisfaction, depression, and quality of life (QOL). Planned analyses of subgroup differences were also explored. Results: A total of 235 participants were randomized; 54% identified as African American, 19% as White, and 15% as Latina. Participant mean age was 30 years; 77% reported annual incomes below US $20,000/year; and 30% were pregnant at enrollment. Participants in both arms found the interventions satisfactory and improved for depression (p < 0.001). There were no differences between groups for the primary outcomes. Subgroups reporting greater improvement in QOL in PSP compared with ESR included participants who at baseline reported anxiety (p = 0.05), lack of access to depression treatment (p = 0.02), pain (p = 0.04), and intimate partner violence (p = 0.02). Conclusions: Clinics serving women with unmet social needs may benefit from offering PSP or ESR. Distinguishing how best to use these interventions in practice is the next step.

Association of Medical Mistrust and Poor Communication with HIV-Related Health Outcomes and Psychosocial Wellbeing Among Heterosexual Men Living with HIV.

Studies have suggested that effective patient-provider relationships may reduce health disparities and foster engagement across the HIV care continuum among people living with HIV/AIDS. However, no studies have explored specific mechanisms between medical mistrust/poor communication and HIV-related/psychosocial health outcomes among HIV-positive men of color who have sex with women (MCSW) in the United States. From 2011 to 2012, the research team recruited 317 eligible participants in New York City. Using validated explanatory and predictive modeling strategies, we explored the associations between mistrust/poor communication and HIV-related/psychosocial health outcomes among this group. Subgroup analyses were further conducted to assess the different effects of non-Hispanic black and Hispanic men. A total of 313 males (204 black, 93 Hispanic, and 16 others) reported that valid responses were included in the current analysis. In the explanatory models, both mistrust and poor communication were negatively associated with various HIV-related and psychosocial outcomes among this group of HIV-positive MCSW. In the predictive models, predictors of mistrust for the overall sample and the black subsample were nearly the same. On the contrary, predictors of poor communication were substantially different when comparing black and Hispanic HIV-positive MCSW. Our findings confirm that patient-provider relationship quality is associated with poor HIV-related and psychosocial outcomes in black and Hispanic MCSW. A different set of multi-level predictors are associated with mistrust and poor communication comparing black and Hispanic MCSW. We call for interventions addressing patient-provider relationship quality that are tailored differently for black and Hispanic men.

Brief CBT for insomnia delivered in primary care to patients endorsing suicidal ideation: a proof-of-concept randomized clinical trial.

Insomnia co-occurs frequently with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD); all three conditions are prevalent among primary care patients and associated with suicidal ideation (SI). The purpose of the article was to test the effects of a brief cognitive behavioral therapy for insomnia (bCBTi) and the feasibility of delivering it to primary care patients with SI and insomnia in addition to either MDD and/or PTSD. Fifty-four patients were randomized to receive either bCBTi or treatment-as-usual for MDD and/or PTSD. The primary outcome was SI intensity as measured by the Columbia-Suicide Severity Rating Scale; secondary clinical outcomes were measured by the Insomnia Severity Index, Patient Health Questionnaire for depression, and PTSD Symptom Checklist. Effect sizes controlling for baseline values and sample size were calculated for each clinical outcome comparing pre-post differences between the two conditions with Hedge's g. The effect size of bCBTi on SI intensity was small (0.26). Effects were large on insomnia (1.91) and depression (1.16) with no effect for PTSD. There was a marginally significant (p = .069) effect of insomnia severity mediating the intervention's effect on SI. Findings from this proof-of-concept trial support the feasibility of delivering bCBTi in primary care and its capacity to improve mood and sleep in patients endorsing SI. The results do not support bCBTi as a stand-alone intervention to reduce SI, but this or other insomnia interventions may be considered as components of suicide prevention strategies.

Suicidal ideation among recently returned veterans and its relationship to insomnia and depression.

Suicide is a significant public health problem associated with numerous health factors such as insomnia. Suicidal ideation is common among veterans, who often present with multiple comorbidities. The present study examined direct and indirect relationships among suicidal ideation, insomnia, depression, and alcohol use. U.S. veterans (n = 850) recently separated from military service completed phone-based interviews covering multiple domains. Tests of indirect effects and bias-corrected confidence intervals were used to conduct a cross-sectional analysis of baseline data from a larger parent study examining relationships among the latent variables of suicidal ideation, insomnia, alcohol use, and depression. In this analysis insomnia did not have direct associations with suicidal ideation (Β = 0.06, t = 0.29, p = .772) or alcohol use (Β = 0.07, t = 1.73, p = .084). Insomnia severity was, however, significantly and positively related to depression severity (Β = 0.58, t = 21.70, p < .001). Additionally, more severe depression was associated with greater intensity of suicidal ideation (Β = 0.59, t = 3.64, p < .001). Notably, insomnia's indirect effect on suicidal ideation was driven by depression. In this sample of returning veterans, insomnia appears to indirectly impact suicidal ideation through its relationship with depression. This finding suggests the potential utility of addressing insomnia as part of an overall approach to reducing depressive symptomatology and indirectly, suicidal ideation.

A randomized controlled trial of suicide prevention training for primary care providers: a study protocol.

BACKGROUND: Suicide is a national public health crisis and a critical patient safety issue. It is the 10th leading cause of death overall and the second leading cause of death among adolescents and young adults (15-34 years old). Research shows 80% of youth who died by suicide saw their primary care provider within the year of their death. It is imperative that primary care providers develop the knowledge and skills to talk with patients about distress and suicidal thoughts, and to assess and respond in the context of the ongoing patient - primary care provider relationship. METHODS: This study examines the effectiveness of simulation on suicide prevention training for providers-in-training by comparing two conditions: 1) a control group that receives online teaching on suicide prevention in primary care via brief online videos and 2) an experimental group that includes the same online teaching videos plus two standardized patient (SP) interactions (face-to-face and telehealth, presentation randomized). All SP interactions are video-recorded. The primary analysis is a comparison of the two groups' suicide prevention skills using an SP "test case" at 6-month follow-up. DISCUSSION: The primary research question examines the impact of practice (through SP simulation) over and above online teaching alone on suicide prevention skills demonstrated at follow-up. We will assess moderators of outcomes, differences among SP simulations (i.e., face-to-face vs. telehealth modalities), and whether the experimental group's suicide prevention skills improve over the three SP experiences. TRIAL REGISTRATION: The study was registered on Clinical Trials Registry ( clinicaltrials.gov ) on December 14, 2016. The Trial Registration Number is NCT02996344 .

Advancing the case for nurse practitioner-based models to accelerate scale-up of HIV pre-exposure prophylaxis.

AIMS: To explore the factors that position nurse practitioners (NPs) to lead the implementation of HIV pre-exposure prophylaxis. BACKGROUND: The HIV epidemic represents a global health crisis. Reducing new HIV infections is a public health priority, especially for Black and Latino men who have sex with men (MSM). When taken as directed, co-formulated emtricitabine and tenofovir have over 95% efficacy in preventing HIV; however, substantial gaps remain between those who would benefit from pre-exposure prophylaxis (PrEP) and current PrEP prescribing practices. DESIGN: This is a position paper that draws on concurrent assessments of research literature and advanced practice nursing frameworks. METHOD: The arguments in this paper are grounded in the current literature on HIV PrEP implementation and evidence of the added value of nurse-based models in promoting health outcomes. The American Association of Colleges of Nursing's advanced nursing practice competencies were also included as a source of data for identifying and cross-referencing NP assets that align with HIV PrEP care continuum outcomes. CONCLUSIONS: There are four main evidence-based arguments that can be used to advance policy-level and practice-level changes that harness the assets of nurse practitioners in accelerating the scale-up of HIV PrEP. RELEVANCE TO CLINICAL PRACTICE: Global public health goals for HIV prevention cannot be achieved without the broader adoption of PrEP as a prevention practice among healthcare providers. NPs are the best hope for closing this gap in access for the populations that are most vulnerable to HIV infection.