Document Type

Dissertation

Date of Degree

Spring 2021

Primary Advisor

Paige McDonald, EdD

Keywords

Pre-Exposure Prophylaxis, Men who Have Sex with Men, Transgender Persons, Demonstration Project, Mixed Methods, Implementation Science

DOI

https://doi.org/10.4079/THS2021.01

Abstract

Men who have sex with men (MSM) and transgender persons of color experience disproportionate, multi-level HIV risks. Pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy; however, access to PrEP has been limited among this population. PrEP demonstration projects that target MSM and transgender persons and test the implementation of PrEP in real-world settings are underway. However, PrEP demonstration projects specific to MSM and transgender persons of color are limited and most demonstration projects do not consider the impact of the implementation process or organization contextual characteristics on PrEP outcomes. The Improve Measurable Participation and Access to Care and Treatment District of Columbia, Maryland, and Virginia (IMPACT DMV) demonstration project was created in response to the high rates of HIV, AIDS, and STIs among MSM and transgender persons of color in the DC, Maryland, Virginia region aimed to provide equitable access to HIV prevention, care and treatment, and support services for those populations. Using a mixed-methods case study design, this study sought to describe PrEP screening and PrEP need in the overall project, understand how the project was implemented at the clinic level with respect to PrEP screening and determination of PrEP need, and describe how the varying contexts and implementation strategies of the clinics impacted PrEP screening and PrEP need in the overall project.

An implementation science framework guided the study’s exploration of PrEP screening and determination of PrEP need. Quantitative data was collected via archival records collected by the project on patients receiving PrEP services from clinics funded by the project. Qualitative data were collected through document review, interviews, and focus groups. Purposeful and snowball sampling were used to identify interview and focus group participants. Descriptive and inferential statistics were used to analyze the quantitative data, and Creswell’s spiral method was used to analyze the qualitative data.

To aid the clinic staff in screening for PrEP, the project created an intake form that contained questions meant to assess a patient’s or client’s risk for HIV and developed a Coalition meant to provide education and updates to partners in the project. Of the 5043 HIV-negative MSM and transgender persons of color enrolled in the project 3803 (75%) were screened for PrEP. Persons not screened for PrEP (n=594) were significantly more likely to have an annual income under $16K (49% vs. 37%, p=.0264) compared to persons screened for PrEP (Table 4). Persons screened for PrEP (n=337) were significantly more likely to have no health insurance (50% vs. 43%, p=.0054) and to be single (77% vs. 72%, p=.0419) compared to persons not screened for PrEP. After adjusting for demographics and site of care, those screened for PrEP had a decreased odds of having an annual income under 16K (aOR 0.512; 0.328-0.800) compared to those not screened (Table 5). The project leadership loosely defined PrEP need as a patient meeting the eligibility criteria outlined in the CDCs clinical practice guidelines as well as having an interest in PrEP. As of March 2019, 3271 (86%) persons were deemed eligible for PrEP of 3803 persons screened for PrEP. Persons deemed eligible for PrEP were significantly more likely to lack insurance (51% vs. 49%, p=.0004) compared to those not deemed eligible for PrEP (Table 6). Those not deemed eligible for PrEP were significantly more likely to identify as male (89% vs. 78%, p=.0355) compared to those deemed eligible. After adjusting for demographics and site of care, those deemed eligible for PrEP had a decreased odds of identifying as male (aOR=.333; .113-.980) compared those deemed not eligible for PrEP (Table 7). Staff at 9 of the 10 clinics funded by the project provided information related to their mission and vision, their staff and patient populations, their motivations for joining the project, their implementation of the project with respect to PrEP screening and determination of PrEP need; and perceived barriers and facilitators at multiple levels to PrEP screening and determination of PrEP need. There was variation between the project leadership and the clinic and among the clinics. The clinics varied most notably in their organizational contexts, specifically their organizational characteristics (i.e., age, type, location, size), their networks and communication (i.e., degree of collaboration within and among clinics), and their cultures (i.e., the priority populations at the center of their mission and vision). While there was often overlap between the barriers and facilitators identified by project leadership and the clinic staff, there were also differences between the barriers and facilitators identified by project leadership and clinic staff and among clinics based on type and size. The barriers to PrEP screening and determination of PrEP need identified by project leadership and clinic staff may partially explain the screening and need gaps reflected in the project’s PrEP continuum and the continuums for most clinics. In terms of the degrees of adaptation within the project, most clinics made little to no adaptations to the project’s recommended processes for PrEP screening or determining PrEP need.

Key recommendations resulting from this study include: 1) Expansion of PrEP indications for MSM in clinical practice guidelines; (2) Conduct of PrEP clinical trials among transgender persons; 3) Inclusion of an HIV risk assessment and PrEP indications for transgender persons in clinical practice guidelines; 4) Standardization and optimization of data collection with the IMPACT DMV demonstration project; 5) Addressing barriers to PrEP screening and determination of PrEP need within the IMPACT DMV demonstration project; (6) Provision of additional technical assistance and capacity-building, and individualized targets, and; 7) Increased engagement of transgender men in the IMPACT DMV demonstration project.

Comments

©2021 by Brittany Wilbourn. All rights reserved.

Open Access

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