Meet me where I am: A multilevel strategy to increase PrEP uptake and persistence among young sexual and gender minority men in rural NC

项目总结 加强与暴露前预防的联系和吸收(PrEP)对于结束艾滋病毒在 美国(美国)。尽管PrEP的疗效很高，但只有不到20%的符合PrEP条件的人接受了 处方和吸食方面的差距暴露了地区和种族差异。2018年，美国南部占到了 所有新诊断的艾滋病毒患者中有一半以上，但只有三分之一的PrEP使用者。北卡罗来纳州(北卡罗来纳州)的Prep使用 同样滞后，在年轻的性和性别少数群体(YSGM)中接受率最低，他们 该州近三分之二的事件感染。北卡罗来纳州艾滋病感染率最高的县 确诊病例中，4例为农村地区，9例为中小城市地区。北卡罗来纳州的艾滋病毒流行 随着性传播感染(STI)的上升而蓬勃发展，性传播感染通常也集中在农村地区 区域。尽管事件性传播感染和艾滋病毒的行为风险重叠，但在NC，PrEP只在少数情况下提供，主要是 城市卫生部门(HD)附属的性传播感染诊所。农村地区缺乏强大的医疗基础设施， 对于YSGM的颜色和持久的交叉污名，对艾滋病毒和性传播感染的预防提出了独特的挑战。 利用HD附属的STI诊所作为PrEP的入口，是充分利用STI服务的理想机会 在YSGM的PrEP接入方面遇到和解决差距。利用现有诊所实现PrEP的途径 确定潜在PrEP用户的基础设施，调整服务以改善临床限制，并定制PrEP 针对特定客户需求的接洽工具是一项引人注目的战略，可改善PrEP的访问、吸收和 坚持在农村北卡罗来纳州。这种将PrEP和STI服务联系起来的多层次干预，解决了政策上的障碍， 诊所、提供者和用户级别。该战略通过临床培训建立能力和信心；促进 将患者移交给导航员以链接到财务支持；并使用基于证据的数字健康 平台，将用户连接到同行教育者、PrEP资源和远程医疗提供者。最重要的是 目标是将YSGM的间歇性性传播感染服务接触与方便、持续的PrEP联系起来 北卡罗来纳州的护理。这一目标将通过四个目标来实现。在目标1中，研究人员进行了随机试验 在8个农村和城市周边的HD附属STI诊所，让YSGM参加上述干预或 对照研究以入选临床分组为基础。主要结果是PrEP在3个月内被摄取 去诊所就诊。在目标2中，调查员进行了成本效益分析，包括预算影响分析， 检查每个新的PrEP启动的成本。如果满足预定义的通过/不通过标准，则目标3将通过参与 主要利益相关者使用干预地图框架改进干预措施，并由 成效、结果和成本杠杆。最后，在目标4中，精细化干预将扩大到所有八个 诊所检查对PrEP摄取的影响并最终确定成本估计。如果在增加PrEP使用率方面取得成功，并且 在增加PrEP摄入量和避免艾滋病毒感染方面具有成本效益，这种干预措施可以适用于其他 并在北卡罗来纳州和美国其他农村和城市周边地区扩大到性传播感染诊所。

PROJECT SUMMARY Improved linkage to and uptake of pre-exposure prophylaxis (PrEP) is critical to end the HIV epidemic in the United States (US). Despite PrEP’s high efficacy, less than 20% of PrEP-eligible people have received a prescription and gaps in uptake expose regional and racial disparities. In 2018, the US South accounted for more than half of all new HIV diagnoses but only one-third of PrEP users. PrEP use in North Carolina (NC) similarly lags, with uptake lowest among young sexual and gender minority populations (YSGM) who account for nearly two-thirds of the state’s incident infections. Among NC counties with the highest rate of HIV diagnoses, four have rural designation and nine are small or medium metropolitan areas. NC’s HIV epidemic thrives alongside rising sexually transmitted infections (STI), which are also frequently concentrated in rural areas. Despite behavioral risk overlap of incident STIs and HIV, in NC, PrEP is only offered at a few, primarily urban health department (HD) affiliated STI clinics. The lack of robust healthcare infrastructure in rural areas, and persistent intersecting stigmas for YSGM of color, present unique challenges for HIV and STI prevention. Leveraging HD-affiliated STI clinics as an on-ramp to PrEP is an ideal opportunity to capitalize on STI service encounters and address disparities in YSGM’s PrEP access. A pathway to PrEP that utilizes existing clinic infrastructure to identify potential PrEP users, adapts services to ameliorate clinic constraints, and tailors PrEP engagement tools to specific client needs is a compelling strategy to improve PrEP access, uptake, and persistence in rural NC. This multilevel intervention to link PrEP and STI services, addresses barriers at policy, clinic, provider, and user levels. The strategy builds capacity and confidence via clinic training; facilitates patient handoff to navigators for linkage to financial support; and uses an evidence-based digital health platform, connecting users to peer educators, PrEP resources, and telehealth providers. The overarching objective is to parlay YSGM’s episodic STI service encounters into linkage to convenient, continuous PrEP care in NC. This objective will be accomplished in four aims. In Aim 1, investigators conduct a randomized trial at eight rural and peri-urban HD-affiliated STI clinics, enrolling YSGM into the above-described intervention or control based on enrolling clinic group assignment. The primary outcome is PrEP uptake within 3 months of clinic visit. In Aim 2, investigators conduct a cost-effectiveness analysis, including a budget impact analysis, examining cost per new PrEP initiation. If pre-defined go/no-go criteria are met, Aim 3 will proceed by engaging key stakeholders to refine the intervention, using an Intervention Mapping framework and informed by effectiveness outcomes and cost levers. Finally, in Aim 4, the refined intervention will be expanded to all eight clinics to examine impact on PrEP uptake and finalize cost estimates. If successful at increasing PrEP use and cost effective for increasing PrEP uptake and averting HIV infections, this intervention can be adapted for other populations and scaled up to STI clinics across NC and other rural and peri-urban areas in the US.