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别女性中，85%的人 与异性接触有关的病例。黑人妇女受到的影响不成比例，占新移民的60%。 妇女感染艾滋病毒，尽管她们只占女性人口的14%。一致性避孕套 每日口服富马酸替诺福韦酯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针对妇女的循证干预措施，可降低她们感染艾滋病毒的风险 采集然而，只有1-6%的妇女谁可以受益于PrEP是规定它。 多因素的患者水平的PrEP吸收障碍包括可能不认为PrEP适合他们的女性， 大多数PrEP临床试验和营销策略都针对与男性发生性关系的男性。还有， 顺性别妇女可能不认为自己有感染艾滋病毒的风险。进一步加剧了不和谐 风险认知和实际风险之间的一个重要联系是，妇女往往不知道其男性伴侣的艾滋病毒血清状况， 艾滋病风险因素。提供者一级的障碍包括难以识别艾滋病毒高风险患者， 有性行为史和缺乏PrEP知识不幸的是，一个准确的艾滋病毒风险评估工具 对美国顺性别妇女来说不存在，而且可能永远不存在，因为美国妇女的艾滋病毒发病率是 我们迫切需要一种替代性的循证干预措施。我们计划填补这一空白 通过确定有效的干预和实施策略，以增加在ObGyn临床PrEP吸收 环境（妇女在此接受产前护理以及性健康和生殖健康服务）。由于TDF-FTC是 妇女一直表示更愿意在诊所接受艾滋病毒预防服务， 接受妇产科护理我们的多层次（患者和提供者层次）、多成分干预 包括EHR数据收集和使用多媒体工具的教育。我们的核心假设是 以相关和全面的方式向患者实时传达量身定制的艾滋病毒风险信息 妇产科医生可以增加关于艾滋病预防的对话。目标1A：确定最大值 有效的干预，并评估其在妇产科临床环境中的实施。1B：识别可修改的 与使用RE-AIM框架有效实施相关的背景因素。目标2：评价 多层次干预的成本效益、投资回报、预算影响和公平影响 的组成部分和实施战略。与我们的当地政府合作-以及一个由HRSA资助的 实施伙伴网站，我们希望展示一个可持续和可扩展的解决方案，以增加PrEP ObGyn提供者的咨询和患者的PrEP吸收。

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.