Implementation of pre-exposure prophylaxis (PrEP) for HIV prevention: three case studies from the PrEP for women initiative in Washington, D.C.

BACKGROUND: Women account for 19% of new HIV diagnoses in the United States, with women of color (WOC) comprising 83% of this group. Pre-exposure prophylaxis (PrEP) is a safe and effective method of HIV prevention for women. Yet, prescribing to WOC remains disproportionately low, leaving a major gap in HIV prevention options for this population. The purpose of this study was to examine PrEP implementation barriers and facilitators in a high HIV incidence setting in order to identify strategies to better provide comprehensive HIV prevention options for WOC. METHODS: This study used a case study approach with qualitative data collection to examine PrEP implementation for WOC as it happened in the “real world” in three clinical settings: a community-based clinic, a pediatric emergency department, and a Federally Qualified Health Center. Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation science framework, two rounds of semi-structured interviews were conducted with clinical staff and providers. Data analysis was completed according to the five steps of the Framework Method. RESULTS: By the end of the one-year implementation period, only three WOC had been prescribed PrEP out of the targeted 387. Staff cited support of PrEP provision among staff and leadership, PrEP alignment with their clinics’ missions, having a centralized PrEP coordinator, and relationships with other implementing sites and within the local community as implementation facilitators. Despite these supportive factors, staff reported time limitations, resistance to PrEP prescribing, discomfort with PrEP counseling, and managing different and changing priorities across clinic departments as implementation barriers. CONCLUSION: Though the clinics seemed well-positioned for PrEP implementation, significant challenges impeded their success. To successfully provide PrEP to women, implementation should include clarifying staff roles and responsibilities, engaging staff and providers through ongoing and targeted feedback, and ensuring care is focused on women’s needs and experiences. The HIV epidemic can only be fought by utilizing all available HIV prevention tools in combination with HIV treatment, delivered with consideration of the local context and population. Specific practice recommendations identified will support clinics as they provide PrEP to WOC