Hybrid implementation-effectiveness study to optimize HIV testing and PrEP in a southern jail (HOTSPOT)

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PROJECT SUMMARY Over half of all new HIV infections in the US in 2017 occurred in 48 high-incidence counties and rural states known as HIV “hotspots”, indicating a need to intensify HIV prevention efforts in these regions. Preexposure prophylaxis (PrEP) can reduce new HIV infections by 99%, but PrEP use is limited in hotspots in the South where HIV incidence is highest. The criminal justice system is a prime location to engage persons in PrEP, as many people who pass through jails and prisons have risk factors for acquiring HIV. Implementing PrEP in jails in particular, where medically underserved Black and Latinx populations are over-represented, can have a high public health impact given rapid turnover back to the community. Because virtually no jails in the South offer PrEP due to resource constraints and competing priorities, there is a critical need for strategies to implement PrEP in this setting. Our central hypothesis is that a rigorously-developed PrEP implementation strategy can improve linkage to community PrEP care for persons released from southern jails. The objective of this proposal is to develop, implement and evaluate a multicomponent PrEP implementation strategy for the Dallas County Jail, the 8th largest jail in the nation and located in an HIV hotspot. We will leverage our robust partnerships with stakeholders in the jail, public health department, and community as we follow a well- established EPIS (exploration, preparation, implementation, sustainment) framework. The implementation strategy will include locally-adapted, evidence-based tools for identifying candidates for PrEP, engaging them in shared decision-making about PrEP, and navigating them to PrEP care at community reentry. We will rigorously evaluate our implementation strategy using a type 3 effectiveness-implementation hybrid study, which prioritizes implementation outcomes while also collecting clinical outcomes. Our specific aims are to: 1) Assess facilitators and barriers to PrEP evaluations in jail and linkage to PrEP at jail release; 2) Refine a multicomponent PrEP implementation strategy for the Dallas County Jail; and 3) Implement and evaluate the PrEP implementation strategy. We will use mixed-methods to evaluate implementation processes (feasibility, acceptability, penetration and sustainment) and clinical outcomes for PrEP evaluations and linkage, and an interrupted time series to measure changes in HIV/STI testing and diagnoses. Our study team includes experts in HIV, PrEP, implementation science, qualitative research, and clinical care for incarcerated populations. This project is significant in its potential to impact HIV incidence in a highly affected population in an HIV hotspot. The work is innovative in using implementation science to improve PrEP for incarcerated populations and is directly responsive to NOT-MH-20-024, “Implementation Science to Advance the United States HIV Prevention and Treatment Goals.” Our strategy is scalable and with guidance from Dissemination Consultants, can serve as a model for future public health initiatives in other criminal justice settings, directing PrEP in a patient- centered manner to those most likely to benefit in order to maximize impact on HIV incidence.