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      Decentralizing PrEP delivery: Implementation and dissemination strategies to increase PrEP uptake among MSM in Toronto, Canada

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          Abstract

          Pre-exposure prophylaxis (PrEP) is traditionally prescribed by HIV specialist physicians. Given finite specialist resources, there is a need to scale up PrEP delivery by decentralizing services via other healthcare professionals. We aimed to assess the feasibility of delivering PrEP to men who have sex with men (MSM) through primary care physicians and sexual health clinic nurses. We piloted a multi-component, implementation and dissemination research program to increase provision of PrEP through primary care physicians and sexual health clinic nurses in Toronto, Canada. Community-based organizations (CBOs) provided prospective participants with information cards that contained links to an online module on engaging providers in a conversation about PrEP. In our patient-initiated continuing medical education (PICME) strategy, participants saw their family doctors and gave them the card, which also contained a link to a Continuing Medical Education module. In the nurse-led strategy, participants visited one of two participating clinics to obtain PrEP. We administered an optional online questionnaire to patients and providers at baseline and six months. CBOs distributed 3043 cards. At least 339 men accessed the online module and 196 completed baseline questionnaires. Most (55%) intended to visit nurses while 21% intended to consult their physicians. Among 45 men completing follow-up questionnaires at 6 months, 31% reported bringing cards to their physicians and obtaining PrEP through them; sexual health clinics delivered PrEP to 244 patients. Participants who went through the PICME approach reported no changes in relationships with their providers. Nurses showed fidelity to PrEP prescribing guidelines. Nurse-led PrEP and patient-initiated continuing medical education (PICME) for primary care physicians are feasible strategies to increase PrEP uptake. Nurse-led PrEP delivery was preferred by most patients.

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          Most cited references32

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          HIV providers' perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study.

          Oral pre-exposure prophylaxis (PrEP) can reduce HIV incidence among at-risk persons. However, for PrEP to have an impact in decreasing HIV incidence, clinicians will need to be willing to prescribe PrEP. HIV specialists are experienced in using antiretroviral medications, and could readily provide PrEP, but may not care for HIV-uninfected patients. Six focus groups with 39 Boston area HIV care providers were conducted (May-June 2012) to assess perceived barriers and facilitators to prescribing PrEP. Participants articulated logistical and theoretical barriers, such as concerns about PrEP effectiveness in real-world settings, potential unintended consequences (e.g., risk disinhibition and medication toxicity), and a belief that PrEP provision would be more feasible in primary care clinics. They identified several facilitators to prescribing PrEP, including patient motivation and normative guidelines. Overall, participants reported limited prescribing intentions. Without interventions to address HIV providers' concerns, implementation of PrEP in HIV clinics may be limited.
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            Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection.

            There is little evidence to support the widely accepted assertion that better physician-patient relationships result in higher rates of adherence with recommended therapies. To determine whether and which aspects of a better physician-patient relationship are associated with higher rates of adherence with antiretroviral therapies for persons with HIV infection. Cross-sectional analysis. Twenty-two outpatient HIV practices in a metropolitan area. Five hundred fifty-four patients with HIV infection taking antiretroviral medications. We measured adherence using a 4-item self-report scale (alpha= 0.75). We measured core aspects of physician-patient relationships using 6 previously tested scales (general communication, HIV-specific information, participatory decision making, overall satisfaction, willingness to recommend physician, and physician trust; alpha > 0.70 for all) and 1 new scale, adherence dialogue (alpha= 0.92). For adherence dialogue, patients rated their physician at understanding and solving problems with antiretroviral therapy regimens. Mean patient age was 42 years, 15% were female, 73% were white, and 57% reported gay or bisexual sexual contact as their primary HIV risk factor. In multivariable models that accounted for the clustering of patients within physicians' practices, 6 of the 7 physician-patient relationship quality variables were significantly (P < .05) associated with adherence. In all 7 models worse adherence was independently associated (P < .05) with lower age, not believing in the importance of antiretroviral therapy, and worse mental health. This study showed that multiple, mutable dimensions of the physician-patient relationship were associated with medication adherence in persons with HIV infection, suggesting that physician-patient relationship quality is a potentially important point of intervention to improve patients' medication adherence. In addition, our data suggest that it is critical to investigate and incorporate patients' belief systems about antiretroviral therapy into adherence discussions, and to identify and treat mental disorders.
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              PrEP Awareness, Familiarity, Comfort, and Prescribing Experience among US Primary Care Providers and HIV Specialists.

              HIV pre-exposure prophylaxis (PrEP) was FDA approved in 2012, but uptake remains low. To characterize what would facilitate health care providers' increased PrEP prescribing, we conducted a 10-city, online survey of 525 primary care providers (PCPs) and HIV providers (HIVPs) to assess awareness, knowledge, and experience with prescribing PrEP; and, comfort with and barriers to PrEP-related activities. Fewer PCPs than HIVPs had heard of PrEP (76 vs 98%), felt familiar with prescribing PrEP (28 vs. 76%), or had prescribed it (17 vs. 64%). PCPs were less comfortable than HIVPs with PrEP-related activities such as discussing sexual activities (75 vs. 94%), testing for acute HIV (83 vs. 98%), or delivering a new HIV diagnosis (80 vs. 95%). PCPs most frequently identified limited knowledge about PrEP and concerns about insurance coverage as prescribing barriers. PCPs and HIVPs differ in needs that will facilitate their PrEP prescribing. Efforts to increase PrEP uptake will require interventions to increase the knowledge, comfort, and skills of providers to prescribe PrEP.
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                Author and article information

                Contributors
                Role: Data curationRole: Formal analysisRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: MethodologyRole: ResourcesRole: Writing – review & editing
                Role: MethodologyRole: ResourcesRole: Writing – review & editing
                Role: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: MethodologyRole: ResourcesRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: ResourcesRole: Writing – review & editing
                Role: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                18 March 2021
                2021
                : 16
                : 3
                : e0248626
                Affiliations
                [1 ] Ontario Institute for Studies in Education, University of Toronto, Toronto, Ontario, Canada
                [2 ] Division of Infectious Diseases, St. Michael’s Hospital, Toronto, Ontario, Canada
                [3 ] Department of Medicine, University of Toronto, Toronto, Ontario, Canada
                [4 ] Casey House, Toronto, Ontario, Canada
                [5 ] Maple Leaf Medical Clinic, Toronto, Ontario, Canada
                [6 ] Toronto Public Health, Toronto, Ontario, Canada
                [7 ] Centre for Disease Control, University of British Columbia, Vancouver, British Columbia, Canada
                [8 ] Women’s College Hospital, Toronto, Ontario, Canada
                [9 ] MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
                [10 ] Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
                [11 ] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
                [12 ] Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
                [13 ] Division of General Internal Medicine, University of Toronto, Toronto, Ontario, Canada
                [14 ] AIDS Committee of Toronto, Toronto, Ontario, Canada
                [15 ] Division of Infectious Diseases, Toronto General Hospital, Toronto, Ontario, Canada
                University of Arkansas for Medical Sciences, UNITED STATES
                Author notes

                Competing Interests: The authors have read the journal’s policy, and the authors of this study have the following competing interests to declare: DHST’s institution has received investigator-driven grants from Gilead Sciences, Abbvie and Viiv Healthcare, and DHST has served as a Site Principal Investigator for clinical trials sponsored by Glaxo Smith Kline, all outside the submitted work. DCK has been a consultant for Merck, Gilead Sciences and Viiv Healthcare, all outside of the submitted work. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare. All other authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0003-1727-7340
                https://orcid.org/0000-0002-3069-2875
                Article
                PONE-D-20-24619
                10.1371/journal.pone.0248626
                7971529
                33735209
                88d363f8-4e6b-401a-bfed-14a00fe41b7a
                © 2021 Charest et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 3 September 2020
                : 2 March 2021
                Page count
                Figures: 1, Tables: 2, Pages: 13
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;
                Award ID: HIM 145368
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100002879, Canadian HIV Trials Network, Canadian Institutes of Health Research;
                Award ID: CTN 303
                Award Recipient :
                Funded by: Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario
                Award ID: 16-004
                Award Recipient :
                This work was supported by the Canadian Institutes of Health Research (grant number HIM 145368 to DHST, SM and DCK), the CIHR Canadian HIV Trials Network (grant number CTN 303 to DHST, SM and DCK) and the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario (grant number 16-004 to DHST, SM and DCK). MS was supported by a Postdoctoral Fellowship from the CIHR Canadian HIV Trials Network, and DHST, SM and IIB were supported by a New Investigator Award from the Canadian Institutes of Health Research and Ontario HIV Treatment Network during the conduct of this work. DHST is currently supported by a Tier 2 Canada Research Chair in HIV prevention and STI research. DG was supported by his Canada Research Chair in Sexual and Gender Minority Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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                Data are available in Dryad: 10.5061/dryad.tx95x69x5.

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