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

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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.