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Leveling Up PrEP: Implementation Strategies at System and Structural Levels to Expand PrEP Use in the United States

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Abstract

Purpose of Review

Despite highly effective biomedical HIV pre-exposure prophylaxis (PrEP) options, suboptimal PrEP uptake impedes progress towards ending the epidemic in the United States of America (USA). Implementation science bridges what we know works in controlled clinical trial settings to the context and environment in which efficacious tools are intended to be deployed. In this review, we focus on strategies that target PrEP use barriers at the system or structural level, exploring the implications and opportunities in the context of the fragmented USA healthcare system.

Recent Findings

Task shifting could increase PrEP prescribers, but effectiveness evidence is scarce in the USA, and generally focused in urban settings. Integration of PrEP within existing healthcare infrastructure concentrates related resources, but demonstration projects rarely present the resource implications of redirecting staff. Changing the site of service via expanded telehealth could improve access to more rural populations, though internet connectivity, technology access, and challenges associated with determining biomedical eligibility remain logistical barriers for some of the highest burden communities in the USA. Finally, a tailored care navigation and coordination approach has emerged as a highly effective component of PrEP service provision, attempting to directly modify the system-level determinants of PrEP use experienced by the individual.

Summary

We highlight recent advances and evidence surrounding task shifting, integration, service delivery, and tailoring. With the exception of tailored care navigation, evidence is mixed, and the downstream impact and sustainability of task shifting and care integration require further attention. To maximize PrEP outcomes, research will need to continue to examine the interplay between individuals, clinics, and the healthcare system and associated policies within which they operate.

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Funding

Dr. Rutstein was supported by Doris Duke Charitable Foundation grant #2015213 and University of North Carolina at Chapel Hill Center for AIDS Research (P30AI50410). Drs. Rutstein and Muessig were supported by R61AI174285.

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  1. Division of Infectious Diseases, Department of Medicine, University of North Carolina, 130 Mason Farm Road, Chapel Hill, NC, 27599, USA

    Sarah E. Rutstein

  2. Institute On Digital Health and Innovation, College of Nursing, Florida State University, Tallahassee, USA

    Kathryn E. Muessig

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  1. Sarah E. Rutstein
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  2. Kathryn E. Muessig
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Correspondence to Sarah E. Rutstein.

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Rutstein, S.E., Muessig, K.E. Leveling Up PrEP: Implementation Strategies at System and Structural Levels to Expand PrEP Use in the United States. Curr HIV/AIDS Rep 21, 52–61 (2024). https://doi.org/10.1007/s11904-024-00697-x

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