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


This study sought to understand PrEP implementation at community-based HIV testing locations in Florida. An LCA revealed 3 distinct classes of PrEP implementation—Universal, Eligibility Dependent, and Limited. Entropy was 0.914 (approaching 1), indicating delineation between classes.[45] Qualitative data provided triangulation, thus additional information and characterization of these classes.

Using the LCA approach[34,35] allowed for the grouping of participants into mutually exclusive subgroups within the larger population of staff who provide HIV testing. This approach takes the complex nature and specific combinations of PrEP-related implementation activities into account.[34,35] The joint analysis of the qualitative data and the LCA results provided greater insight into the PrEP implementation behaviors of HIV testing staff than either method would alone.

Participants in the Limited group were inconsistent in their PrEP implementation behaviors, despite state guidelines indicating the importance of linkage to prevention resources, including PrEP.[46] These findings may speak to the need for targeted interventions for HIV testing staff with characteristics of the Limited group. Future work should illuminate the factors impacting inconsistent PrEP implementation among this subgroup. Organizational and community-level characteristics may impact PrEP implementation and should be studied to better understand the barriers to PrEP implementation among HIV testing staff.

Participants in both the Universal and Eligibility Dependent groups meet the testing procedure guidelines in that they are able to provide linkages and client-centered risk assessments during the counseling process.[46] The understanding of what it means to provide client-centered risk assessments could be 1 differentiating factor between these groups. Participants in the Eligibility Dependent group may feel that discussing PrEP with clients they believe would not meet the indications for PrEP diverts from the recommendation of client-centered counseling. It is also important to note that the level of risk HIV testing staff perceive a client to have may not always be accurate. Clients may not be fully truthful with the staff providing the HIV testing service;[47] similarly, staff providing testing may make assumptions about the client based on the way clients present themselves or demographic characteristics.[15,16,48] Thus, although some participants in the Eligibility Dependent group may be accurately determining which clients could benefit from knowing about PrEP, others may be missing the opportunity to tell clients about a potentially valuable prevention method. Although the Universal participants may be sharing information about PrEP with those who do not meet the indications, they are not missing clients who may benefit from the innovation. By sharing this information with all clients, participants in the Universal group are also increasing the general community-level knowledge of PrEP, which in turn may reduce associated stigma.

There is a growing body of work on the role that client characteristics and provider biases may have in PrEP prescription,[13,15,16] but little information indicating how provider characteristics (eg, provider race and sexual orientation) impact these interactions. In this study, we did not capture the demographic characteristics of clients typically served by the testing staff nor the organization. As such, the role that client characteristics have in relation to PrEP referral or discussion cannot be examined. Future work should examine the degree to which client demographic characteristics and client-staff racial or sexual orientation concordance have on communication patterns related to PrEP referral.

Staff who identified with a sexual minority group were more likely than heterosexual staff to talk to clients about PrEP. It may be possible that those who identify as members of a sexual minority group are more prone to talking about PrEP than their peers because HIV disproportionately affects gay, bisexual, and other men who have sex with men.[49] Large scale studies have found that gay men are more likely than their heterosexual counterparts to be aware of PrEP.[50] Although all HIV testing staff should be aware of PrEP, it is possible that knowledge of PrEP among HIV testing staff could also vary based on demographic characteristics such as sexual minority status and thus impact the degree to which staff discuss PrEP with clients.

In this study, staff in all PrEP implementation classes reported a greater likelihood to discuss PrEP if a client specifically asked about PrEP. Similarly, among medical providers, PrEP-related discussions are often initiated by clients.[51] However, waiting for clients to initiate conversations about PrEP puts an unnecessary burden on the client. Studies have indicated that some gay men may be less likely to initiate conversations related to HIV risk, PrEP, and/or their sexual behaviors/identity if they perceive their provider to be heterosexual.[52] It is possible that heterosexual staff are less likely to discuss PrEP with their clients because the clients are choosing to not initiate the conversation with them. Alternatively, heterosexual men and women being tested for HIV may be less likely than their lesbian, gay, or bisexual counterparts to initiate conversations about PrEP due to low levels of PrEP awareness.[53,54] These findings reinforce the need for staff initiated discussions about PrEP, including during postcounseling HIV testing.

We found that staff who identify with a racial minority group were less likely than white staff to be in the Limited group, implying they were more likely to talk with their clients about PrEP. HIV disproportionately impacts people who are black and Hispanic;[55] similar to sexual minority staff, people who identify as a racial minority may have a greater drive to discuss PrEP and reduce community HIV prevalence. There is a growing literature on the role that race and medical mistrust may have on a person's decision to initiate PrEP,[56,57] but less information regarding the role that provider race has on these decisions. It is possible that, during HIV testing, the race of the staff member providing the HIV test could impact medical mistrust or client receptivity to PrEP. If racial concordance/discordance impacts PrEP receptivity, our findings that staff who identify with a racial minority group are more likely to talk about PrEP than their white counterparts are particularly important—especially given the low rates of PrEP uptake in black and Hispanic communities.[58] Promoting PrEP implementation during HIV testing may help to reduce racial disparities in PrEP uptake and knowledge. The need to further examine the role of provider race and patient–provider concordance has been noted in the literature[16] and is supported in these findings within the context of HIV testing staff.

The study was limited to a convenience sample from community-based organizations within 1 state in the southern United States. Some aspects of PrEP implementation may vary geographically, as both rates of PrEP uptake[59] and HIV-related stigma[60] have been found to vary based on geographic location. The lack of validated scales measuring PrEP implementation led to literature-driven development of relevant items; however, use of LCA provided some strength to the outcome variable. Literature-driven development of items used in LCA has been used in other understudied contexts.[61] This study was also based on 1 type of PrEP—use of a daily pill. Alternative formulations for PrEP, as well as alternative dosing strategies, are currently being studied and have been used by some PrEP clients. The advent of alternative forms of PrEP, however, did not appear to be a major limitation. To account for these newer strategies, participants were asked if their likelihood of talking to a client about PrEP would change if on-demand forms of PrEP were widely recommended or if PrEP injections were available; most participants (75% and 85%, respectively) indicated their likelihood of talking about PrEP with clients would be about the same.

A major strength of this study is the mixed-methods approach, in which the quantitative and qualitative findings were triangulated to provide a comprehensive look at PrEP implementation during HIV testing. This study took place in Florida, a state with high HIV prevalence and incidence.[27] Much can be learned from PrEP implementation in Florida as it is geographically and ethnically diverse, as well as entering a statewide push for PrEP implementation. Finally, this study is among the first to examine PrEP implementation from the perspective of staff who provide HIV testing to the clients.