Health Care Providers’ Views on Clinic Infrastructure and Practice Models That May Facilitate HIV Preexposure Prophylaxis (PrEP) Prescribing: A Qualitative Meta-Synthesis

HIV (human immunodeficiency virus) preexposure prophylaxis (PrEP) is an effective biomedical HIV prevention tool. Increasing PrEP use among populations disproportionately affected by HIV is one of the key efforts in the United States’ Ending the HIV Epidemic (EHE) initiative and the HIV National Strategic Plan for the United States. Given that PrEP is available only through prescription, it is important to explore structural, organizational, or environmental factors that could facilitate or impede health care provider’s PrEP prescribing behavior. The purpose of this systematic review (PROSPERO [CRD: 42019138889]) is to identify qualitative studies that addressed this topic and conduct meta-synthesis using the thematic synthesis method to identify major themes on the characteristics of clinic infrastructure or clinic models that providers consider as facilitators of PrEP prescribing in the United States. Eighteen citations representing 15 studies were included in this review. Five overarching themes were identified: (1) routinized HIV risk assessment; (2) interdisciplinary/coordinated PrEP teams or services; (3) clinic capacity to provide essential PrEP-related services; (4) low out-of-pocket patient costs; and (5) access to the priority populations. Some of these themes are consistent with the recommendations of CDC’s PrEP clinical guidelines and the EHE initiative. More recent studies that include perspectives of diverse providers, timely analysis of these studies, and implementation research to assess strategies to address the current practice gaps are needed to further promote PrEP prescribing among providers in the United States.

Validation of HIV Risk Screening Tool To Identify Infected Adults And Adolescents >14 Years At Community Level

BackgroundThere are a number of risk factors being used to identify undiagnosed HIV infected adults. As the number of undiagnosed people gets lesser and lesser, it is important to know if existing risk factors and risk assessment tools are valid for use. In this study, we validate existing HIV risk assessment tools and see if they are worth using for HIV case finding among adults who remain undiagnosed. Methods The Tanzania and Zambia Population-Based HIV Impact Assessment (PHIA) household surveys were conducted during 2016. We used adult interview and HIV datasets to assess validity of different HIV risk assessment tools. We first included 12 risk factors (being divorced, separated or widowed (DSW); having an HIV+ spouse; having one of the following within 12 months of the survey: paid work, slept away from home for at least a month, had multiple sexual partners, paid for sex, had sexually transmitted infection (STI), being a tuberculosis (TB) suspect, being very sick for at least 3 months; had ever sold sex; diagnosed with cervical cancer; and had TB disease into a risk assessment tool and assessed its validity by comparing it against HIV test result. Sensitivity, specificity and predictive value of the tool were assessed against the HIV test result. A receiver operator characteristic (ROC) analysis was conducted to determine a suitable cut-off score in order to have a tool with better sensitivity, specificity, and PPV. ROC comparison statistics was used to statistically test equality between AUC (area under the curve) of the different scores. ROC comparison statistics was also used to determine which risk assessment tool was better compared to the tool that contained all risk factors. Results Of 14,820 study participants, 57.8% were men, and had a median age of 30 (IQR: 21-24). HIV prevalence was 2.3% (95% confidence interval (CI): 2.0-2.6). For the tool containing all risk factors, HIV prevalence was 1.0% when none of the risk factors were positive (Score 0) compared to 3.2% when at least one factor (Score ≥1) was present and 8.0% when ≥4 risk factors were present. Sensitivity, specificity, PPV, and NPV were 82.3% (78.6%-85.9%), 41.9% (41.1%-42.7%), 3.2% (2.8%-3.6%), and 99.0% (98.8%-99.3%), respectively. The use of a tool containing conventional risk factors (all except those related with working and sleeping away) was found to have higher AUC compared to the use of all risk factors (p value <0.001), with corresponding sensitivity, specificity, PPV, and NPV of 63.5% (58.9%-68.1%), 66.2% (65.5%-67.0%), 4.2% (3.6%-4.8%), and 98.7% (98.5%-98.9%), respectively. Conclusion Use of a screening tool containing conventional risk factors improved HIV testing yield compared to doing universal testing. Prioritizing people who fulfil multiple risk factors should be explored further to improve HIV testing yield.

Validation of HIV Risk Screening Tool to Identify Infected Adults and Adolescents >14 years at Community Level

Background There are a number of risk factors being used to identify undiagnosed HIV infected adults. As the number of undiagnosed people gets lesser and lesser, it is important to know if existing risk factors and risk assessment tools are valid for use. In this study, we validate existing HIV risk assessment tools and see if they are worth using for HIV case finding among adults who remain undiagnosed. Methods The Tanzania and Zambia Population-Based HIV Impact Assessment (PHIA) household surveys were conducted during 2016. We used adult interview and HIV datasets to assess validity of different HIV risk assessment tools. We first included 12 risk factors (being divorced, separated or widowed (DSW); having an HIV+ spouse; having one of the following within 12 months of the survey: paid work, slept away from home for at least a month, had multiple sexual partners, paid for sex, had sexually transmitted infection (STI), being a tuberculosis (TB) suspect, being very sick for at least 3 months; had ever sold sex; diagnosed with cervical cancer; and had TB disease into a risk assessment tool and assessed its validity by comparing it against HIV test result. Sensitivity, specificity and predictive value of the tool were assessed against the HIV test result. A receiver operator characteristic (ROC) analysis was conducted to determine a suitable cut-off score in order to have a tool with better sensitivity, specificity, and PPV. ROC comparison statistics was used to statistically test equality between AUC (area under the curve) of the different scores. ROC comparison statistics was also used to determine which risk assessment tool was better compared to the tool that contained all risk factors. Results Of 14,820 study participants, 57.8% were men, and had a median age of 30 (IQR: 21-24). HIV prevalence was 2.3% (95% confidence interval (CI): 2.0-2.6). For the tool containing all risk factors, HIV prevalence was 1.0% when none of the risk factors were positive (Score 0) compared to 3.2% when at least one factor (Score ≥1) was present and 8.0% when ≥4 risk factors were present. Sensitivity, specificity, PPV, and NPV were 82.3% (78.6%-85.9%), 41.9% (41.1%-42.7%), 3.2% (2.8%-3.6%), and 99.0% (98.8%-99.3%), respectively. The use of a tool containing conventional risk factors (all except those related with working and sleeping away) was found to have higher AUC compared to the use of all risk factors (p value <0.001), with corresponding sensitivity, specificity, PPV, and NPV of 63.5% (58.9%-68.1%), 66.2% (65.5%-67.0%), 4.2% (3.6%-4.8%), and 98.7% (98.5%-98.9%), respectively. Conclusion Use of a screening tool containing conventional risk factors improved HIV testing yield compared to doing universal testing. Prioritizing people who fulfil multiple risk factors should be explored further to improve HIV testing yield.

Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis: Implications for Medical Student Training

There is growing evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition. However, in the United States, approximately only 4% of people who could benefit from PrEP are currently receiving it, and it is estimated only 1 in 5 physicians has ever prescribed PrEP. We conducted a scoping review to gain an understanding of physician-identified barriers to PrEP provision. Four overarching barriers presented in the literature: Purview Paradox, Patient Financial Constraints, Risk Compensation, and Concern for ART Resistance. Considering the physician-identified barriers, we make recommendations for how physicians and students may work to increase PrEP knowledge and competence along each stage of the PrEP cascade. We recommend adopting HIV risk assessment as a standard of care, improving physician ability to identify PrEP candidates, improving physician interest and ability in encouraging PrEP uptake, and increasing utilization of continuous care management to ensure retention and adherence to PrEP.

Risk assessment and identification of HIV infection among men who have sex with men: a cross-sectional study in Southwest China

ObjectivesThe HIV epidemic is around 7%–20% among men who have sex with men (MSM) in Southwest China. The low HIV-testing rate highlights the need for tools to identify high-risk MSM in resource-limited regions. Our aim was, therefore, to evaluate the HIV RISK Assessment Tool for HIV prediction and to characterise the primary infection among MSM in Southwest China.DesignA cross-sectional survey was conducted in Guizhou province between January and December 2018. Participants were recruited from gay communities, among whom the HIV RISK Assessment Tool was evaluated. Logistic regression was used to analyse items associated with HIV and the area under the curve (AUC) of the receiver operating curve was calculated to quantify discrimination performance.Participants1330 MSM participants, of which 83 (6.2%) tested as HIV positive.ResultsA higher composite score of the tool (adjusted OR (aOR) 9.33, 95% CI 4.57 to 19.05) was independently associated with HIV infection. Items positively associated with HIV infection included having 2–5 same sex partners (aOR 2.43, 95% CI 1.28 to 4.64), always (aOR 5.93, 95% CI 1.59 to 22.13) or sometimes (aOR 4.25, 95% CI 2.09 to 8.64) having unprotected anal intercourse, taking both insertive and receptive sex roles (aOR 4.95, 95% CI 2.57 to 9.53) or only the receptive sex role (aOR 2.26, 95% CI 1.21 to 4.24). The tool showed an optimal discrimination ability (AUC=0.827), with a specificity of 0.747 and sensitivity of 0.785. Five MSM were identified with primary infection and had similar sexual risk behaviors as HIV-positive participants.ConclusionsThe HIV RISK Assessment Tool showed an overall good performance in predicting HIV risk among MSM in Guizhou province where the prevalence is still severe. This tool also demonstrated a potential to identify primary infection and is worth being promoted in resource-limited regions.

Understanding the association between caregiver sex and HIV infection among orphans and vulnerable children in Tanzania: Learning from the USAID Kizazi Kipya Project

Background Tanzania has met only 50.1% of the 90% target for diagnosing HIV in children. Context-specific strategies are necessary to find the hidden children for HIV testing. This study assesses the association between caregiver sex and HIV status of orphans and vulnerable children (OVC). Methods Data originate from the community-based, USAID-funded Kizazi Kipya Project, which works towards increasing OVC’s and their caregivers’ uptake of HIV/AIDS and other social services in Tanzania. Included in this study are 39,578 OVC ages 0–19 years who the project served during January-March 2017 in 18 regions of Tanzania and who voluntarily reported their HIV status. Data analysis involved multi-level logistic regression, with OVC HIV status as the outcome and caregiver’s sex the main independent variable. Results Three-quarters (74.3%) of the OVC included in the study had female caregivers, and their overall HIV prevalence was 7.1%. The prevalence was significantly higher (p<0.001) among OVC with male caregivers (7.8%) than among OVC with female caregivers (6.8%), and indeed, multivariate analysis showed that OVC with male caregivers were significantly 40% more likely to be HIV-positive than those with female caregivers (OR=1.40, 95% CI 1.08–1.83). This effect was the strongest among 0–4 year-olds (OR=4.02, 95% CI 1.61–10.03), declined to 1.72 among 5–9 year-olds (OR=1.72, 95% CI 1.02–2.93), and lost significance for children over age 9 years. This effect was adjusted for OVC sex and nutritional status; caregiver marital status, education level, and HIV status; family’s place of residence, size, wealth quintile, and health insurance ownership; and co-residence of multiple OVC. Conclusion OVC in Tanzania with male caregivers have a 40% higher likelihood of being HIVpositive than those with female caregivers. HIV risk assessment activities should target OVC with male caregivers, as well as OVC who have malnutrition, HIV-positive caregivers, or caregivers who do not disclose their HIV status to community volunteers. Further, younger HIV-positive OVC are more likely to live in rural areas, while older HIV-positive OVC are more likely to live in urban areas. These factors should be integrated in HIV risk assessment algorithms to enhance HIV testing yields and pediatric case-finding in the OVC population in Tanzania.

Is caregiver sex associated with HIV infection among orphans and vulnerable children in Tanzania? Learning from the USAID Kizazi Kipya Project

Background Tanzania has met only 50.1% of the 90% target for diagnosing HIV in children. Context-specific strategies are necessary to find the hidden children for HIV testing. This study assesses the association between caregiver sex and HIV status of orphans and vulnerable children (OVC). Methods Data originate from the community-based, USAID-funded Kizazi Kipya Project, which works towards increasing OVC’s and their caregivers’ uptake of HIV/AIDS and other social services in Tanzania. Included in this study are 39,578 OVC ages 0–19 years who the project served during January-March 2017 in 18 regions of Tanzania and who voluntarily reported their HIV status. Data analysis involved multi-level logistic regression, with OVC HIV status as the outcome and caregiver’s sex the main independent variable. Results Three-quarters (74.3%) of the OVC included in the study had female caregivers, and their overall HIV prevalence was 7.1%. The prevalence was significantly higher (p<0.001) among OVC with male caregivers (7.8%) than among OVC with female caregivers (6.8%), and indeed, multivariate analysis showed that OVC with male caregivers were significantly 40% more likely to be HIV-positive than those with female caregivers (OR=1.40, 95% CI 1.08–1.83). This effect was the strongest among 0–4 year-olds (OR=4.02, 95% CI 1.61–10.03), declined to 1.72 among 5–9 year-olds (OR=1.72, 95% CI 1.02–2.93), and lost significance for children over age 9 years. This effect was adjusted for OVC sex and nutritional status; caregiver marital status, education level, and HIV status; family’s place of residence, size, wealth quintile, and health insurance ownership; and co-residence of multiple OVC. Conclusion OVC in Tanzania with male caregivers have a 40% higher likelihood of being HIVpositive than those with female caregivers. HIV risk assessment activities should target OVC with male caregivers, as well as OVC who have malnutrition, HIV-positive caregivers, or caregivers who do not disclose their HIV status to community volunteers. Further, younger HIV-positive OVC are more likely to live in rural areas, while older HIV-positive OVC are more likely to live in urban areas. These factors should be integrated in HIV risk assessment algorithms to enhance HIV testing yields and pediatric case-finding in the OVC population in Tanzania.

2525. Understanding PrEP in Female Adolescents: A Parent/Adolescent Dyad Perspective

Background Adolescents aged 13–24 years account for 23% of HIV diagnoses in the Atlanta Metropolitan Area, indicating the need for new prevention strategies. Pre-Exposure Prophylaxis (PrEP), recently approved for adolescent use, is effective in HIV prevention and is often marketed to young men who have sex with men (MSM); however, problems with access, scalability and waning adherence have limited its use in this population and more broadly. A 2016 CDC HIV surveillance report showed 19.2% of new HIV diagnoses were attributed to heterosexual transmission in women aged 13–24, relative to 0% in their heterosexual male counterparts, and 5.4% in same-aged MSM. This study assesses parent and female adolescent knowledge on HIV risk and PrEP perception to inform potential implementation strategies. Methods PrEP acceptability and barrier surveys were administered to 102 adolescent-parent dyads attending an adolescent clinic and emergency room in Atlanta, Georgia. Eight female adolescent-parent pairs were randomly selected to participate in in-depth phone interviews. Responses were analyzed using computer-assisted thematic analyses. Results Of the 8 female adolescent participants (mean age = 18.9 years), all were African American, and 1 was sexually active. Of the 8 parent participants (mean age = 44.1 years), all were female and African American. None of the participants had ever used PrEP. Analysis indicated that both parents and adolescent females had poor HIV risk assessment and knowledge, as well as barriers to PrEP usage including concerns about side effects, cost, and desire for alternative PrEP delivery methods and/or schedules. Finally, adolescent females expressed reliance on self-efficacy to be able to discuss HIV protection methods with their partner. Conclusion Female adolescents use unreliable methods to ensure HIV prevention, and with poor HIV knowledge, are at risk of transmission. Thus, PrEP may be a viable option for adolescent females at high risk for infection. PrEP implementation strategies in adolescents needs to consider HIV risk assessment, PrEP education, potential options for alternative dosing and delivery, and continued implementation work, focused beyond just the young MSM community. Disclosures All authors: No reported disclosures.