PrEP Implementation Behaviors of Community-Based HIV Testing Staff

A Mixed-Methods Approach Using Latent Class Analysis

DeAnne Turner, PhD, MPH; Elizabeth Lockhart, PhD, MPH; Wei Wang, PhD; Robert Shore, PharmD; Ellen M. Daley, PhD, MPH; Stephanie L. Marhefka, PhD


J Acquir Immune Defic Syndr. 2020;83(5):467-474. 

In This Article

Abstract and Introduction


Background: Pre-exposure Prophylaxis (PrEP) is an important option for HIV prevention, but the approach has reached a limited number of people at risk of HIV infection.

Methods: A mixed-methods concurrent triangulation design was used to investigate unobserved subgroups of staff who provide community-based, publicly funded HIV testing in Florida (USA). PrEP implementation groups, or classes, were determined using latent class analysis. Generalized linear mixed models were used to estimate PrEP implementation as a function of staff characteristics. In-depth interviews based on the Consolidated Framework for Implementation Research were analyzed thematically.

Results: Based on fit statistics and theoretical relevance, a 3-class latent class analysis was selected. Class 1 ("Universal") staff were highly likely to talk about PrEP with their clients, regardless of client eligibility. Class 2 ("Eligibility dependent") staff were most likely to discuss PrEP if they believed their client was eligible. Class 3 ("Limited") staff sometimes spoke to clients about PrEP, but not systematically. In multivariate analyses, only race and sexual orientation remained significant predictors of the PrEP implementation group. Staff who identified as a racial or sexual minority were less likely to be in the Limited group than their heterosexual or white counterparts. Age, gender, ever having taken PrEP, and HIV status did not impact the odds of being in a specific PrEP implementation group.

Conclusions: A subset of HIV testing staff differentially discuss PrEP based on perceived client eligibility; others inconsistently talk to clients about PrEP. Targeted training based on PrEP implementation groups may be beneficial.


Pre-exposure prophylaxis (PrEP) is recommended by the Centers for Disease Control and Prevention[1–4] and World Health Organization[5,6] as 1 method to assist in the prevention of HIV. In this prevention method, a person takes a daily HIV prevention pill to significantly reduce their risk of acquiring HIV.[7,8] Despite the development and recommended use of this prevention method for at-risk populations, many people are still unaware of PrEP.[9–12]

In the United States, it is unclear who is responsible for ensuring patients are informed about HIV prevention and PrEP. Medical providers may be a natural first step to disseminate information related to PrEP; however, many providers are still unaware of PrEP.[13,14] In addition, factors beyond awareness affect whether medical providers talk to their clients about, or prescribe, PrEP, including how at-risk medical providers perceive their patient to be.[13,15,16] However, providers may not adequately assess patient risk, as some may not be fully aware of their patients' sexual histories, behaviors, or sexual orientation; others may differentially offer PrEP to clients within certain risk populations[15,17] or have biases in prescription practices based on a patient's race.[16] Given these shortcomings, locations outside of providers' offices must also be used to increase knowledge and awareness of PrEP.[18–22]

Alternative locations such as community-based organizations, pharmacies, and clinics specializing in treating sexually transmitted infections have been suggested as possible locations to expand PrEP implementation.[18–23] Depending on location and clinical availability, these sites could participate in at least 1 or more of education, counseling, referral, or screening for a possible prescription.[18–23] Moreover, studies investigating the role of nonclinical staff in PrEP implementation have found that such staff may be important to education and counseling efforts,[14,24] as well as navigating the available resources for PrEP-related financial assistance.[24] A recent systematic review even suggested the need to study the integration of PrEP education into routine HIV testing procedures.[18] However, the perspectives of staff performing HIV testing have not yet been studied.

HIV testing sites primarily serve people who are uninfected or do not yet know they are living with HIV. Staff at such sites already ask sensitive questions about sexual risk behavior during pretest counseling. For example, in Florida, the DH1628 Laboratory Request Form completed with each publicly funded HIV test requires that counselors ask clients about HIV-related risk factors.[25] Counseling during the HIV testing process could be a critical point during which nonclinical staff could intervene and discuss PrEP as an option for HIV prevention or refer people to organizations providing PrEP.[18] Yet, little is known about the specific factors affecting PrEP implementation (ie, discussing PrEP or referring clients to an organization providing PrEP) during the HIV testing process.

To best prepare HIV testing staff to take part in PrEP implementation, it is important to understand their current PrEP implementation behaviors. Building on previous research examining the role of nonclinical staff in PrEP implementation,[14,24] this study investigates how staff performing HIV testing engage in PrEP implementation. Thus, this study seeks to answer the research questions: (1) What, if any, PrEP implementation subgroups exist among staff providing HIV testing in Florida? and (2) Do PrEP implementation subgroups vary based on staff characteristics?