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Improving PrEP Implementation Through Multilevel Interventions: A Synthesis of the Literature

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      There are many challenges to accessing PrEP and thus low uptake in the United States. This review (2007–2017) of PrEP implementation identified barriers to PrEP and interventions to match those barriers. The final set of articles (n = 47) included content on cognitive aspects of HIV service providers and individuals at risk for infection, reviews, and case studies. Cognitive barriers and interventions regarding patients and providers included knowledge, attitudes, and beliefs about PrEP. The “purview paradox” was identified as a key barrier—HIV specialists often do not see HIV-negative patients, while primary care physicians, who often see uninfected patients, are not trained to provide PrEP. Healthcare systems barriers included lack of communication about, funding for, and access to PrEP. The intersection between PrEP-stigma, HIV-stigma, transphobia, homophobia, and disparities across gender, racial, and ethnic groups were identified; but few interventions addressed these barriers. We recommend multilevel interventions targeting barriers at multiple socioecological domains.


      Existen muchos desafíos para acceder a PrEP y, por lo tanto, poca aceptación en los Estados Unidos. Esta revisión (2007-17) de la implementación de PrEP identificó las barreras a la PrEP y las intervenciones para hacer coincidir esas barreras. El conjunto final de artículos (n = 47) incluyó contenido sobre los aspectos cognitivos de los proveedores de servicios de VIH y las personas en riesgo de infección, revisiones y estudios de casos. Las barreras cognitivas y las intervenciones con respecto a los pacientes y proveedores incluyeron el conocimiento, las actitudes y las creencias sobre la PrEP. La “purview paradox” se identificó como una barrera clave: los especialistas en VIH a menudo no ven pacientes VIH negativos, mientras que los médicos de atención primaria, que a menudo ven pacientes no infectados, no están capacitados para proporcionar PrEP. Las barreras de los sistemas de salud incluyen la falta de comunicación, financiación y acceso a la PrEP. Se identificó la intersección entre el estigma de la PrEP, el estigma del VIH, la transfobia, la homofobia y las disparidades entre los grupos de género, raciales y étnicos; pero pocas intervenciones abordaron estas barreras. Recomendamos intervenciones multinivel dirigidas a las barreras en múltiples dominios socioecológicos.

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      Most cited references 73

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      Preexposure chemoprophylaxis for HIV prevention in men who have sex with men.

      Antiretroviral chemoprophylaxis before exposure is a promising approach for the prevention of human immunodeficiency virus (HIV) acquisition. We randomly assigned 2499 HIV-seronegative men or transgender women who have sex with men to receive a combination of two oral antiretroviral drugs, emtricitabine and tenofovir disoproxil fumarate (FTC-TDF), or placebo once daily. All subjects received HIV testing, risk-reduction counseling, condoms, and management of sexually transmitted infections. The study subjects were followed for 3324 person-years (median, 1.2 years; maximum, 2.8 years). Of these subjects, 10 were found to have been infected with HIV at enrollment, and 100 became infected during follow-up (36 in the FTC-TDF group and 64 in the placebo group), indicating a 44% reduction in the incidence of HIV (95% confidence interval, 15 to 63; P=0.005). In the FTC-TDF group, the study drug was detected in 22 of 43 of seronegative subjects (51%) and in 3 of 34 HIV-infected subjects (9%) (P<0.001). Nausea was reported more frequently during the first 4 weeks in the FTC-TDF group than in the placebo group (P<0.001). The two groups had similar rates of serious adverse events (P=0.57). Oral FTC-TDF provided protection against the acquisition of HIV infection among the subjects. Detectable blood levels strongly correlated with the prophylactic effect. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; number, NCT00458393.).
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        Antiretroviral preexposure prophylaxis is a promising approach for preventing human immunodeficiency virus type 1 (HIV-1) infection in heterosexual populations. We conducted a randomized trial of oral antiretroviral therapy for use as preexposure prophylaxis among HIV-1-serodiscordant heterosexual couples from Kenya and Uganda. The HIV-1-seronegative partner in each couple was randomly assigned to one of three study regimens--once-daily tenofovir (TDF), combination tenofovir-emtricitabine (TDF-FTC), or matching placebo--and followed monthly for up to 36 months. At enrollment, the HIV-1-seropositive partners were not eligible for antiretroviral therapy, according to national guidelines. All couples received standard HIV-1 treatment and prevention services. We enrolled 4758 couples, of whom 4747 were followed: 1584 randomly assigned to TDF, 1579 to TDF-FTC, and 1584 to placebo. For 62% of the couples followed, the HIV-1-seronegative partner was male. Among HIV-1-seropositive participants, the median CD4 count was 495 cells per cubic millimeter (interquartile range, 375 to 662). A total of 82 HIV-1 infections occurred in seronegative participants during the study, 17 in the TDF group (incidence, 0.65 per 100 person-years), 13 in the TDF-FTC group (incidence, 0.50 per 100 person-years), and 52 in the placebo group (incidence, 1.99 per 100 person-years), indicating a relative reduction of 67% in the incidence of HIV-1 with TDF (95% confidence interval [CI], 44 to 81; P<0.001) and of 75% with TDF-FTC (95% CI, 55 to 87; P<0.001). Protective effects of TDF-FTC and TDF alone against HIV-1 were not significantly different (P=0.23), and both study medications significantly reduced the HIV-1 incidence among both men and women. The rate of serious adverse events was similar across the study groups. Eight participants receiving active treatment were found to have been infected with HIV-1 at baseline, and among these eight, antiretroviral resistance developed in two during the study. Oral TDF and TDF-FTC both protect against HIV-1 infection in heterosexual men and women. (Funded by the Bill and Melinda Gates Foundation; Partners PrEP number, NCT00557245.).
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          The integrative review: updated methodology.

          The aim of this paper is to distinguish the integrative review method from other review methods and to propose methodological strategies specific to the integrative review method to enhance the rigour of the process. Recent evidence-based practice initiatives have increased the need for and the production of all types of reviews of the literature (integrative reviews, systematic reviews, meta-analyses, and qualitative reviews). The integrative review method is the only approach that allows for the combination of diverse methodologies (for example, experimental and non-experimental research), and has the potential to play a greater role in evidence-based practice for nursing. With respect to the integrative review method, strategies to enhance data collection and extraction have been developed; however, methods of analysis, synthesis, and conclusion drawing remain poorly formulated. A modified framework for research reviews is presented to address issues specific to the integrative review method. Issues related to specifying the review purpose, searching the literature, evaluating data from primary sources, analysing data, and presenting the results are discussed. Data analysis methods of qualitative research are proposed as strategies that enhance the rigour of combining diverse methodologies as well as empirical and theoretical sources in an integrative review. An updated integrative review method has the potential to allow for diverse primary research methods to become a greater part of evidence-based practice initiatives.

            Author and article information

            [1 ]ISNI 0000000086837370, GRID grid.214458.e, School of Social Work, , University of Michigan, ; Ann Arbor, MI USA
            [2 ]ISNI 0000000106792318, GRID grid.263091.f, Sociology and Sexuality Studies, , San Francisco State University, ; San Francisco, CA USA
            [3 ]ISNI 0000000086837370, GRID grid.214458.e, Department of Obstetrics and Gynecology, , University of Michigan Medical School, ; Ann Arbor, MI USA
            [4 ]ISNI 0000000086837370, GRID grid.214458.e, University of Michigan School of Social Work, ; Room 2850, 1080 South University, Ann Arbor, MI 48109 USA
            (734) 763-2041 ,
            AIDS Behav
            AIDS Behav
            AIDS and Behavior
            Springer US (New York )
            5 June 2018
            5 June 2018
            : 22
            : 11
            : 3681-3691
            29872999 6208917 2184 10.1007/s10461-018-2184-4
            © The Author(s) 2018

            Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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            © Springer Science+Business Media, LLC, part of Springer Nature 2018


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