Situational Analysis of PrEP
Summary of themes in primary care providers (PCPs) and staff in sexual health clinics (SHC)
Theme 1: Perception of PrEP
Most participants shared positive beleifs about PrEP, they felt PrEP is an important medication that can help keep individuals stay healthy and safe. However, one SHC manager expressed concerns about the inability of individuals to maintain a daily medication regime due to their personal circumstances such as being unhoused while a PCP expressed concerns about PrEP giving individuals a false sense of security.
Regardless of the type of role and setting of practice, participants reported similar perspectives about PrEP being an effective strategy to prevent HIV acquisition. They felt PrEP is an important tool against HIV acquisition if used properly.
Physicians shared their perspectives about possible side effects of PrEP. Specifically, the PCPs described the side effects impacting on PHRA’s willingness to continue the medication when prescribed.
Physicians and SHC managers described their perceptions of PrEP based on their knowledge about PrEP prescription, testing and protocols required before and after administrating the medication.
Theme 2: Implementation of PrEP
Participants described barriers to the implementation of PrEP such as lack of role clarity among staff, staff shortages or reduced staff capacity, limited time for patient follow-up, lack of medical directors, limited local healthcare providers, and rebuilding after the COVID-19 pandemic.
Managers identified other barriers including lack of physicians’ interest in PrEP and view of PrEP as a complicated medication, lack of dedicated sexual health physicians lack of adequate knowledge on PrEP and PrEP program not being a priority within the health unit and lack of PrEP specific training for healthcare providers
The SHC Managers believe they require more staff resources, PrEP specific training for healthcare providers and medical directives to implement PrEP. The PCPs feel additional staff resources are required and this was supported by the SHC managers.
Other resources identified by the SHC Manager and PCPs include PrEP guidelines and policies, dedicated physician support and funding to recruit additional nurses or practitioners
Theme 3: population at risk of HIV and barriers
The PCPs and SHC managers described similar populations they believed were at risk of HIV transmission and willing to use PrEP. These identified groups of people at risk of HIV acquisition are mainly gay and bisexual men, injection drug use population and sex workers
The SHC managers described barriers to PRHAs accessing PrEP including stigma around HIV and the use of PrEP, cost of PrEP and medical insurance processes to acquire the medication, PRHAs’ mental health status and concerns about the side effect of PrEP.
Additionally, the PCPs highlighted other barriers to PRHA accessing PrEP including; PRHAs’inability to start conversations about PrEP and reluctance and concerns about disclose to the PCPs
Theme 4: Partnerships
Participants (PCPs and SHC managers) was described as an important facilitator/barrier for PrEP.
SHC managers noted that there was a limited to no partnership with the government. This was mainly linked to lack of access to funding for additional resources required to implement or prescribe PrEP.
The PCPs supported this view by highlighting the potential benefits of government partnership on PrEP including making it easier for physicians and nurse practitioners to get involved with PrEP
Theme 5: Recommendations
The PCPs and SHC managers suggested
Increasing community awareness on PrEP through the promotion of provincial campaigns.
Providing concise PrEP training for healthcare professionals.
Increasing efforts to eliminate stigma associated with PrEP.
Developing strategies to incentivize PHRA to use PrEP.
Providing education/ information for people on how and where to access prep.
AIM 1. Conduct formative work with Primary Care Providers
Specific Objectives
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To identify the PCP’s level of willingness and intention to become consistent PrEP prescribers.
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To identify PrEP adoption determinants among PCP, managers, and other key stakeholders.
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To gather recommendations to address adoption barriers.
Methods
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1.1.- Online survey in Qualtrics.
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1.2 - Qualitative interviews with potential adopters and low intention PCP.
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1.3 - Qualitative interview with PCPs and managers of sexual health clinic.
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1.4 - Team discussion to delineate strategies.
Our AIM number 1 consisted in a situational analysis of experiences with PrEP among primary care providers (PCPs) and adoption of PrEP among public health settings, in particular sexual health clinics.
Use of the CFIR to delineate determinants and strategies to address barriers of adoption (organizational) and PrEP experiences (individual)
Consolidated Framework for Implementation Research (CFIR). Adapted figure by the Centre for Implementation
We selected the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to practice change and to design implementation strategies for PrEP adoption (organizational) and prescription (individual). The CFIR was chosen a priori to guide the evaluation by highlighting what works well and identifying opportunities for improvement throughout the implementation process.
The framework comprises five main domains that may affect PrEP implementation.
The first domain concerns the characteristics of the intervention, which includes primary care providers’ perceptions of PrEP sources, adaptability, and complexity, among other factors. The second domain, the outer setting, encompasses the economic, political, and social context in which an organization operates. In our case, it refers to the political and health systems that public health settings are part of, as well as how organizations address the needs, resources, and preferences of people disproportionally affected by HIV, alongside relevant guidelines and external pressures.
The inner setting domain focuses on the organizational characteristics of sexual health clinics, examining elements such as organizational structure, community connections, culture, and the overall implementation climate. The fourth domain addresses the characteristics of individuals involved in PrEP experience, including their knowledge and self-efficacy.
Finally, the process domain covers the steps of implementation—planning, engaging stakeholders, executing the plan, and reflecting on and evaluating the efforts. In this study, we explored the various factors that have facilitated its successful adoption.
Outcomes of AIM 1
Determinants of PrEP prescription in PCPs (report No 1 and Publication)
Barriers and facilitators in Sexual health clinics (Report no 2)
Mapping of barriers and facilitators with strategies and interventions (Report No 3)