Many Title X Clinics in Southern US Refer Young Women Elsewhere for PrEP

By Lisa Rapaport

November 30, 2020

(Reuters Health) - More than a third of Title X family planning clinics in the southern U.S. don't provide any services related to HIV pre-exposure prophylaxis (PrEP) care, a recent study suggests.

Researchers conducted qualitative interviews between March and July 2018 with providers and administrators at 38 Title X family planning clinics across 18 states in the U.S. South to see how often they offered HIV risk assessment, PrEP education, laboratory testing to determine PrEP eligibility, PrEP prescriptions, and ongoing monitoring for patients on PrEP.

Overall, 23 clinics offered at least one of these aspects of PrEP care, and 15 clinics (39%) provided none of these services related to PrEP, the study found.

A total of 8 clinics offered only HIV risk assessment, then referred patients elsewhere for all other services related to PrEP. In addition to risk assessment, 4 clinics also offered education about PrEP before referring patients elsewhere for follow-up.

Just 11 clinics offered all services related to PrEP care, from HIV risk assessment through ongoing monitoring for patients ultimately prescribed this treatment regimen, researchers report in the Journal of Adolescent Health.

"Addressing funding and staffing needs will be required for many clinics to provide PrEP onsite," said senior study author Dr. Anandi Sheth, an associate professor of medicine in the division of infectious diseases at Emory University School of Medicine in Atlanta, Georgia.

"For clinics that are unable to provide PrEP onsite, increasing availability of PrEP educational materials and strengthening linkages to nearby PrEP clinics can increase their patients' access to PrEP," Dr. Sheth said by email.

Most clinics have tools to assess HIV as part of assessing sexual health, including asking patients about sexual partners, condom use, sexually transmitted infection history, and injection drug use, the interviews found. Providers said these tools were most effective when used prior to the start of patient appointments so that clinicians could spend more time during exams discussing the results.

Some clinics offering PrEP education relied on medical assistants or health educators to limit the burden on clinicians to do this during patient appointments, the interviews also found.

The minority of clinics that did required lab testing prior to initiating PrEP found it did not add burden to the workload because staff were already familiar with the tests and minimal training was needed.

Barriers to prescribing PrEP often related to challenges helping patients access financial assistance or navigate insurance policies around this treatment regimen, the interviews found.

For ongoing monitoring, many clinics noted issues with patient adherence to PrEP therapy and quarterly checkups. Clinics that did offer monitoring noted that automated scheduling and reminders could help with this.

One limitation of the study is that it used a convenience sample, and results may not be generalizable to all Title X clinics or all medical practices.

In most cases, PrEP follow-up visits for monitoring every three months can be completed independently by registered nurses, said Kamila Alexander, an assistant professor at the Johns Hopkins School of Nursing in Baltimore who wasn't involved in the study.

Still, the results underscore that the current system at Title X clinics can be strengthened to ensure that adolescent and young adult women have access to PrEP as an option for HIV prevention, Alexander noted.

"Prioritizing the creation of assessment protocols that are systematic and embedded within an existing process of care documentation is key to appropriate identification of PrEP candidates," Alexander said by email. "Staff training at all levels can facilitate PrEP awareness, encourage its promotion, and normalize its use among adolescent and young adult women visiting Title X clinics."

SOURCE: Journal of Adolescent Health, online November 5, 2020.