Improving HIV Prevention Services among Socioeconomically Disadvantaged Cis-gender Women

摘要 在美国，近五分之一的新艾滋病毒感染发生在顺性女性中，85%的 被归因于异性接触的病例。黑人女性受到的影响不成比例，占新增人口的60% 妇女中的艾滋病毒感染，尽管她们只占女性人口的14%。一致的避孕套 使用，每日口服富马酸替诺福韦300 mg-恩曲他滨200 mg(TDF-FTC)作为暴露前预防 (PREP)和男性伴侣艾滋病毒检测是妇女降低感染艾滋病毒风险的循证干预措施 收购。然而，在可以从PrEP中受益的女性中，只有1%-6%的人开了这种药。PrEP吸收的障碍是 多因素。患者层面的PrEP吸收障碍包括可能认为PrEP不适合他们的女性，因为 大多数PrEP临床试验和营销策略都是针对与男性发生性行为的男性。另外， 顺性别女性可能不会认为自己有感染艾滋病毒的风险。进一步加剧了这种不和谐 在风险认知和实际风险之间，女性往往不知道她们男性伴侣的艾滋病毒血清状态 和艾滋病毒风险因素。提供者层面的障碍包括难以识别艾滋病毒高危患者、不适 性史服用，缺乏PrEP知识。不幸的是，一种准确的艾滋病毒风险评估工具 美国顺性别女性不存在，也可能永远不存在，因为美国女性的艾滋病毒发病率是 太低了，不能开发。迫切需要另一种以证据为基础的干预。我们计划填补这一空白 通过确定有效的干预和实施策略来增加妇产科临床对PrEP的摄取 环境(妇女接受产前护理、性健康和生殖健康服务)。由于TDF-FTC是 获得批准后，女性一直表示更倾向于在诊所接受艾滋病毒预防服务 在那里他们接受妇产科护理。我们的多层次(患者和提供者级别)、多组件干预 包括使用多媒体工具收集电子病历数据和进行教育。我们的中心假设是 以相关和全面的方式实时向患者传达量身定做的艾滋病毒风险信息 OBGYN提供者可以增加关于艾滋病毒预防的对话。目标1A：确定最多 有效干预并评估其在妇产科临床环境中的实施情况。1B：确定可修改的 与使用RE-AIM框架有效执行有关的背景因素。目标2：评估 多层次干预的成本效益、投资回报、预算影响和股权影响 组件和实施策略。与我们的当地政府合作--以及一个由HRSA资助的 实施合作伙伴站点，我们希望展示一种可持续且可扩展的解决方案，以提高PrEP OBGYN提供者的咨询和患者的PrEP摄取。

ABSTRACT Nearly one out of five new HIV infections in the United States occurs among cisgender women, with 85% of cases attributed to heterosexual contact. Black women are disproportionately affected, comprising 60% of new HIV infections among women, although they comprise only 14% of the female population. Consistent condom use, daily oral tenofovir disoproxil fumarate 300mg-emtricitabine 200mg (TDF-FTC) as pre-exposure prophylaxis (PrEP), and male partner HIV testing are evidence-based interventions for women to reduce their risk of HIV acquisition. Yet, only 1-6% of women who could benefit from PrEP are prescribed it. Barriers to PrEP uptake are multifactorial. Patient-level barriers to PrEP uptake include women who may not think PrEP is for them, given that the majority of PrEP clinical trials and marketing strategies have targeted men who have sex with men. Also, cisgender women may not perceive themselves as being at risk for HIV. Further exacerbating the discordance between risk perception and actual risk is that women tend to be unaware of their male partners' HIV serostatus and HIV risk factors. Provider-level barriers include difficulty identifying patients at high risk for HIV, discomfort with sexual history taking, and lack of PrEP knowledge. Unfortunately, an accurate HIV risk assessment tool does not exist for U.S. cisgender women and may not ever exist because the HIV incidence in U.S. women is too low to develop it. An alternative evidence-based intervention is desperately needed. We plan to fill this gap by identifying an effective intervention and implementation strategy to increase PrEP uptake in an ObGyn clinical setting (where women receive prenatal care and sexual and reproductive health services). Since TDF-FTC was approved, women have consistently expressed a preference for receiving HIV prevention services in clinics where they receive ObGyn care. Our multi-level (patient and provider-level), multi-component intervention includes EHR data collection and education using multi-media tools. Our central hypothesis is that communicating tailored HIV risk messaging in real-time in a relatable and comprehensive manner to patients and ObGyn providers can increase conversations about HIV prevention. Aim 1A: To determine the most effective intervention and evaluate its implementation in an ObGyn clinical setting. 1B: To identify modifiable contextual factors associated with effective implementation using the RE-AIM framework. Aim 2: To evaluate the cost-effectiveness, return on investment, budget impact, and equity impact of the multi-level intervention components and the implementation strategy. In collaboration with our local government- and a HRSA-funded implementing partner sites, we hope to demonstrate a sustainable and scalable solution to increasing PrEP counseling by ObGyn providers and PrEP uptake by patients.