The need for a health equity framework in next-generation pre-exposure prophylaxis implementation.

Pre-exposure prophylaxis (PrEP) is highly effective for prevention of HIV transmission and plays an important role in efforts to end the HIV epidemic within the next decade. However, disparities in access to PrEP might be fuelling disparities in the burden of HIV in the USA. The advent of next-generation PrEP formulations that do not involve daily regimens (eg, long-acting cabotegravir) holds potential to facilitate medication adherence, but if the roll-out of these formulations does not consider disparities in access, HIV disparities might be further widened. On the basis of US epidemiological data and informed by the Theory of Fundamental Causes of Health Disparities, we propose an equity-promoting framework to guide the implementation of daily oral and next-generation PrEP. Multilevel efforts to bolster equity in PrEP care include generating demand for next-generation PrEP formulations among marginalised groups, expanding the availability of health services providing oral and next-generation PrEP, and addressing structural and financial barriers to HIV prevention care. The aim of these strategies is to realise the potential of next-generation PrEP to provide people at high risk with effective options to prevent HIV acquisition, thereby helping to reduce both overall HIV transmission and health disparities in the USA.

Readiness to Provide Oral and Injectable PrEP for Sexual and Gender Minority Youth Among Healthcare Providers and Clinics in the U.S. Northeast.

PURPOSE: To examine readiness to provide oral and injectable pre-exposure prophylaxis (PrEP) for sexual and gender minority youth (SGMY) and to explore decision-making for HIV prevention strategies (e.g., condom use, daily and event-driven oral PrEP, and injectable PrEP) among healthcare providers. METHODS: Between February and April 2022, we recruited 31 prescribing providers (M.Ds, D.Os, P.As, and N.Ps) practicing in primary care and specialized clinics in the U.S. Northeast for focus groups or individual interviews. Focus groups and interview transcripts were analyzed using thematic analysis. RESULTS: Most providers specialized in Pediatrics (42%) or Adolescent Medicine (23%) and 58% had previously prescribed PrEP. Main barriers to PrEP readiness were low PrEP knowledge, limited time for visits, and competing clinical priorities. Organizational factors such as routine HIV/STI testing, PrEP-specific electronic health records templates, and specialized staff (e.g., PrEP navigators) promoted PrEP readiness. Providers held positive attitudes toward injectable PrEP to promote adherence among SGMY, yet barriers to implementation of this modality were identified (e.g., patient anxiety about needles, additional staffing needs). Providers described event-driven oral PrEP as an option for SGMY with episodic HIV risk. Assurances of conditional confidentiality, including preventing disclosure of sensitive information through insurance forms, and shared decision-making facilitated conversations about HIV prevention with SGMY. DISCUSSION: Future PrEP implementation efforts for SGMY should consider combined efforts targeting provider knowledge about PrEP modalities (e.g., decision aids) and clinic organizational factors (e.g., routine HIV/STI testing, resources to assist providers and patients in navigating the multiple steps between prescription and adherence to PrEP).

Preferences Across Pre-Exposure Prophylaxis Modalities Among Young Men Who Have Sex with Men in the United States: A Latent Class Analysis Study.

Access to daily oral pre-exposure prophylaxis (PrEP) is suboptimal among young cisgender men who have sex with men (YMSM) in the United States. Next-generation modalities that do not involve daily oral regimens may mitigate some of the barriers to PrEP use. We identified latent classes of YMSM based on health care decision-making patterns and examined associations between latent classes and access to health care and PrEP modality preferences (i.e., daily and event-driven oral, rectal douches, broadly neutralizing antibodies, subcutaneous implants, and an injectable). Between October 2020 and June 2021, we administered an online survey to 737 YMSM. Latent class analysis (LCA) identified groups of YMSM based on communication with providers, stigma and mistrust in health care, and autonomy in sexual health decisions. Logistic regression examined associations between class membership and health care access, and exploded logit regression examined associations between class membership and ranked PrEP modality preferences. LCA identified three classes: shared decision-making (high communication with providers and high autonomy); provider-led decision-making (high communication and low autonomy); and patient-driven decision-making (low communication and high autonomy). Shared decision-making was associated with higher access to health care in comparison with the other classes. Across all classes, YMSM preferred daily oral PrEP over all next-generation PrEP modalities. Preferences for daily oral PrEP over next-generation PrEP modalities were particularly marked among the patient-driven decision-making class. Shared decision-making is associated with access to health care and HIV prevention and higher acceptability of next-generation PrEP modalities, and should be considered as part of future interventions to promote use of daily oral and next-generation PrEP.

Next Generation Pre-Exposure Prophylaxis for Young Men who have Sex with Men: Lessons from System and Provider-level barriers to oral PrEP.

Next generation pre-exposure prophylaxis (PrEP) modalities that do not require daily regimens may address some of the barriers to daily oral PrEP among young men who have sex with men (YMSM). We conducted online semi-structured interviews with 30 YMSM to examine experiences and preferences related to HIV prevention care that may inform implementation of next generation PrEP. Barriers to PrEP care included initiating conversations about sexuality with providers; confidentiality concerns regarding disclosure of sexual practices and PrEP use to family; gaps in access to healthcare; and limited availability of affordable health services. Future implementation of next generation PrEP may benefit from providers addressing confidentiality concerns when discussing PrEP with YMSM; PrEP programs accounting for discontinuities in healthcare access among YMSM while strengthening access to affordable services; and collaborations between generalist providers and specialized clinics and providers to address providers' education needs, which may increase as next generation PrEP becomes available. We have linked affiliation 9 to author name "Katie B. Biello". Please check and confirm. Okay!

RESUMEN: Las modalidades de próxima generación de la profilaxis pre-exposición (PrEP) que no requieren un régimen diario pueden disminuir las barreras de tomar la PrEP oral diariamente por hombres jóvenes que tienen sexo con hombres (YMSM). Llevamos a cabo entrevistas semiestructuradas en línea con 30 YMSM para entender sus experiencias y preferencias relacionadas con el cuidado de la prevención del VIH que puedan informar la implementación de la próxima generación de la PrEP. Las barreras al cuidado de la PrEP incluyeron tender conversaciones sobre la sexualidad con proveedores médicos; las preocupaciones de confidencialidad al divulgar información sobre las relaciones sexuales y el uso de la PrEP con la familia; las brechas en el acceso al cuidado médico; y la disponibilidad limitada de servicios de salud accesibles. La futura implementación de la próxima generación de la PrEP se puede beneficiar de proveedores que hablan sobre las preocupaciones de confidencialidad al discutir la PrEP con YMSM; los programas de la PrEP que tienen en cuenta las discontinuidades en el acceso de salud por YMSM mientras que fortalezcan acceso a servicios accesibles; y las colaboraciones entre proveedores de atención primaria y proveedores especializados para entender las necesidades educativas de proveedores, que puedan aumentar cuando la próxima generación esté disponible.

Trends in risk behaviors and sexually transmitted infections among youth presenting to a sexually transmitted infection clinic in the United States, 2013-2017.

Background: Sexually transmitted infections (STIs) are increasing among adolescents and young adults (AYA) across the United States. However, data are scarce on trends in condom use, number of partners, and other STI risk factors among AYA. The present study evaluated associations between sexual behaviors and STI diagnoses over time among AYA. Methods: We evaluated linked encounters of AYA aged 13-26 attending an urban Northeast public STI clinic from 2013-2017. Demographics, risk behaviors, self-reported past year and lifetime STI, and STI diagnosis during clinic encounter (positive test for urine, oral, or anal chlamydia; urine, oral, or anal gonorrhea; urine trichomonas; HIV; and syphilis) were extracted from electronic health records. We estimated prevalence and performed trend analyses of the repeated cross-sectional data. Cochran-Armitage and Kruskal-Wallis trend test were conducted for categorical and continuous variables, respectively. Results: Among 3822 encounters, clinical STIs demonstrated statistically significant increases including chlamydia (+9%, p = 0.001), gonorrhea (+5%, p = 0.008), and syphilis (+3%, p = 0.006) all of which significantly increased over time, as did any STI (+10%, p < 0.001). HIV and trichomonas rates remained low and unchanged. Self-reported STI increased as well, both past year (+9%) and lifetime (+14%). Greater proportions of AYA reported multiple partners (+9%, p < 0.001), and condomless oral (+12%, p = 0.001) and vaginal/anal (+7%, p = 0.001) sex. Conclusion: Among AYA presenting to a STI clinic, the proportion who engaged in condomless sex and had multiple partners increased over a 5 year period, which corresponded to increased STI prevalence during this period. Preventions efforts for AYA should continue to emphasize the importance of condoms and partner selection.

Disclosure of male attraction to primary care clinicians by adolescent sexual minority males.

Introduction: Adolescent sexual minority males (ASMM) experience higher rates of HIV and other sexually transmitted infections (STIs) relative to their heterosexual peers. Primary care clinicians (PCCs) are well positioned to discuss sexual health and STI prevention with adolescent males; however, ASMM report they are rarely asked about their sexual health, especially with respect to attraction and identity. This study sought to determine variables associated with disclosure of male attraction ("being out") to a PCC. Methods: ASMM (N=206; 14 to 17 years in the United States) completed an online sexual health survey in 2017. We assessed socio-demographics, sexuality, being out to a guardian, and being out to a PCC, and calculated proportions and associations among the variables using univariable (Fisher exact) and multivariable (Firth logistic regression) analyses. Results: Only 20% (n=41) of ASMM were out to their PCC even though 53% (n=109) were out to a parent or guardian. ASMM who were out to a parent or guardian were seven times more likely to be out to their PCC (adjusted odds ratio = 6.69, 95% confidential interval 2.69 to 16.60). No other variables were associated with being out to a PCC. Conclusions: Among ASMM, the only predictor of outness to a PCC in this study was outness to a parent or guardian, yet only half were out to a parent or guardian. Policy Implications: PCCs should proactively and routinely inquire about sexual health and screen adolescent males for same sex attraction and sexual minority identity in order to provide optimal health care.

Improvement of Electronic Health Record Integrated Transition Planning Tools in Primary Care.

INTRODUCTION: The transition from pediatric to adult care is under-studied in primary care. Electronic health record-integrated transition planning tools (ETPTs) can facilitate the transition. We tested whether ETPTs and clinician reminders increase the frequency of transition discussions during adolescent well-visits. METHODS: In an academic adolescent medicine primary care practice serving a predominantly African American, Medicaid-insured population, we developed 4 ETPTs-readiness assessment, plan template, information handout, and diagnosis code. We used Plan-Do-Study-Act quality improvement cycles to implement ETPTs and measure outcomes. Each cycle added a new layer of clinician support: (1) ETPT training, (2) visual reminders, (3) incentives, and (4) daily reminders. The primary outcome was the proportion of well-visits in which "any ETPT use" occurred. We collected data via chart review and used run charts and regression analyses with multiple comparisons to detect differences between cycles. Clinicians-provided feedback was elicited. RESULTS: Any ETPT use increased from 0% to 45% between baseline and cycle 4. The odds of any ETPT use was ten times larger in cycle 4 compared to cycle 1 (odds ratio 10.09, 95% confidence interval 2.29-44.44, P = 0.002) and 22 times larger in cycle 4 than cycle 2 (odds ratio 21.99, 95% confidence interval 3.96-122.00, P < 0.001). Clinicians identified time constraints and lack of sociocultural relevance as barriers to uptake. CONCLUSIONS: Daily reminders combined with training and visual reminders were effective in increasing the use of ETPTs in primary care. Future interventions should adapt existing transition tools to the needs of target populations and create regular reminders to facilitate uptake.

Sexual Orientation and Suicide Attempt Disparities Among US Adolescents: 2009-2017.

BACKGROUND: Sexual minority adolescents face mental health disparities relative to heterosexual adolescents. We evaluated temporal changes in US adolescent reported sexual orientation and suicide attempts by sexual orientation. METHODS: We used Youth Risk Behavioral Surveillance data from 6 states that collected data on sexual orientation identity and 4 states that collected data on sex of sexual contacts continuously between 2009 and 2017. We estimated odds ratios using logistic regression models to evaluate changes in reported sexual orientation identity, sex of consensual sexual contacts, and suicide attempts over time and calculated marginal effects (MEs). RESULTS: The proportion of adolescents reporting minority sexual orientation identity nearly doubled, from 7.3% in 2009 to 14.3% in 2017 (ME: 0.8 percentage points [pp] per year; 95% confidence interval [CI]: 0.6 to 0.9 pp). The proportion of adolescents reporting any same-sex sexual contact increased by 70%, from 7.7% in 2009 to 13.1% in 2017 (ME: 0.6 pp per year; 95% CI: 0.4 to 0.8 pp). Although suicide attempts declined among students identifying as sexual minorities (ME: -0.8 pp per year; 95% CI: -1.4 to -0.2 pp), these students remained >3 times more likely to attempt suicide relative to heterosexual students in 2017. Sexual minority adolescents accounted for an increasing proportion of all adolescent suicide attempts. CONCLUSIONS: The proportion of adolescents reporting sexual minority identity and same-sex sexual contacts increased between 2009 and 2017. Disparities in suicide attempts persist. Developing and implementing approaches to reducing sexual minority youth suicide is critically important.