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

项目摘要 加强与暴露前预防的联系和使用暴露前预防对结束艾滋病毒在非洲的流行至关重要。 United States（US）.尽管PrEP具有很高的疗效，但只有不到20%的PrEP合格人群接受了 处方和接受方面的差距暴露了区域和种族差异。2018年，美南占 超过一半的新艾滋病毒诊断，但只有三分之一的PrEP用户。北卡罗来纳州（NC）的PrEP使用 同样滞后，年轻的性和性别少数群体（YSGM）的吸收率最低， 该州近三分之二的感染病例在艾滋病毒感染率最高的北卡罗来纳州各县中 在诊断中，四个是农村地区，九个是中小城市地区。NC的艾滋病毒流行 性传播感染（STI）也经常集中在农村地区， 地区尽管事件性传播感染和艾滋病毒的行为风险重叠，在NC，PrEP仅在少数情况下提供，主要是 城市卫生部下属的性病诊所。农村地区缺乏健全的医疗基础设施， 和持续交叉的耻辱YSGM的颜色，提出了独特的挑战，艾滋病毒和性病预防。 利用HD附属STI诊所作为PrEP的入口是利用STI服务的理想机会 遭遇和解决YSGM的PrEP访问的差异。利用现有诊所的PrEP途径 基础设施，以识别潜在的PrEP用户，调整服务，以改善诊所的限制，并定制PrEP 针对特定客户需求的参与工具是一项引人注目的战略，可以改善PrEP的获取、采用和 在农村NC。这种将PrEP和STI服务联系起来的多层次干预措施解决了政策上的障碍， 诊所、提供者和用户级别。该战略通过诊所培训建立能力和信心; 将患者移交给导航器，以链接到财务支持;并使用基于证据的数字健康 平台，将用户与同伴教育者，PrEP资源和远程医疗提供者联系起来。总体 目标是将YSGM的偶发性STI服务与方便，持续的PrEP联系起来 护理NC这一目标将在四个方面实现。在目标1中，研究人员进行了一项随机试验， 在八个农村和城市周边的卫生署附属性病诊所，将YSGM纳入上述干预措施，或 根据入组临床组分配进行控制。主要结果是在3个月内的PrEP吸收 诊所访问。在目标2中，调查人员进行成本效益分析，包括预算影响分析， 检查每个新PrEP启动的成本。如果满足预定义的去/不去标准，目标3将通过进行 关键利益相关者使用干预映射框架并通过以下信息完善干预措施： 效率成果和成本杠杆。最后，在目标4中，精细干预措施将扩大到所有八个方面， 诊所检查对PrEP吸收的影响，并最终确定成本估算。如果成功增加PrEP的使用， 对于增加PrEP摄取和避免HIV感染具有成本效益，这种干预措施可以适用于其他 在美国，该项目已扩大到北卡罗来纳州和其他农村及城郊地区的性病诊所。

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.