"PrEPping" women's healthcare providers: motivational interviewing to support ending the HIV epidemic.

In 2018, cisgender women accounted for nearly 20% of new HIV infections, with women of color disproportionately affected. HIV pre-exposure prophylaxis uptake, adherence, and persistence are paramount to ending the HIV epidemic, but current strategies to promote it have not improved uptake among women. Alternatively, pre-exposure prophylaxis marketing and implementation have traditionally targeted men who have sex with men and transwomen. Women feel most comfortable turning to their primary care and reproductive health providers for HIV and pre-exposure prophylaxis counseling, but prescribing is the lowest among these providers. Thus, reframing pre-exposure prophylaxis counseling and education strategies is crucial to better engage providers and patients. Motivational interviewing is a person-centered counseling style for eliciting behavior change. Providers use 4 core skills-open-ended questions, affirmation, reflective listening, and summarizing-to empower individuals for behavior change, such as pre-exposure prophylaxis use. Motivational interviewing is brief, individualized, and effective in increasing pre-exposure prophylaxis uptake, regardless of patients' readiness to change. Primary care and reproductive health providers can employ motivational interviewing approaches with pre-exposure prophylaxis counseling to increase uptake among cisgender women and end the HIV epidemic.

A National Study of Expedited Partner Therapy Use in Emergency Departments: A Survey of Medical Director Knowledge, Attitudes, and Practices.

BACKGROUND: Emergency departments (EDs) are the primary source of health care for many patients diagnosed with sexually transmitted infections (STIs). Expedited partner therapy (EPT), treating the partner of patients with STIs, is an evidence-based practice for patients who might not otherwise seek care. Little is known about the use of EPT in the ED. In a national survey, we describe ED medical directors' knowledge, attitudes, and practices of EPT. METHODS: A cross-sectional survey of medical directors from academic EDs was conducted from July to September 2020 using the Academy of Academic Administrators of Emergency Medicine Benchmarking Group. Primary outcomes were EPT awareness, support, and use. The survey also examined barriers and facilitators. RESULTS: Forty-eight of 70 medical directors (69%) responded. Seventy-three percent were aware of EPT, but fewer knew how to prescribe it (38%), and only 19% of EDs had implemented EPT. Seventy-nine percent supported EPT and were more likely to if they were aware of EPT (89% vs. 54%; P = 0.01). Of nonimplementers, 41% thought EPT was feasible, and 56% thought departmental support would be likely. Emergency department directors were most concerned about legal liability, but a large proportion (44%) viewed preventing sequelae of untreated STIs as "extremely important." CONCLUSIONS: Emergency department medical directors expressed strong support for EPT and reasonable levels of feasibility for implementation but low utilization. Our findings highlight the need to identify mechanisms for EPT implementation in EDs.

An effectiveness-implementation trial protocol to evaluate PrEP initiation among U.S. cisgender women using eHealth tools vs. standard care.

Background: The United States' (U.S.) initiative to End the HIV Epidemic aims to reduce new HIV infections in areas of high HIV prevalence. Despite national efforts to reduce HIV incidence, cisgender women continue to represent approximately one out of every five new HIV diagnoses in the U.S. Taking pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy; however, PrEP initiation among cisgender women is suboptimal, with only 10% of eligible women receiving PrEP prescriptions in 2019. Methods: We designed a trial to test the effectiveness of interventions to increase PrEP initiation, while evaluating the implementation strategy (hybrid type II trial) in seven obstetrics and gynecology (OB/GYN) clinics (two federally qualified health centers, three community-based, and two academic) in Baltimore, Maryland. A total of 42 OB/GYN providers will be enrolled and randomized (1:1:1) into one of three clinical trial arms (standard of care, patient-level intervention, or multi-level intervention). Eligible patients of enrolled providers will receive a sexual health questionnaire before their appointment through the electronic health record's (EHR) patient portal. The questionnaire will be scored in three tiers (low, moderate, and high) to assess HIV risk. Patients at low risk will be offered an HIV test only, while those who score medium or high risk will be included in the clinical trial and assigned to the clinical trial arm associated with their provider. Differences in PrEP initiation, our primary outcome, across the three arms will be analyzed using generalized linear mixed-effect models with logistic regression. We will adjust results for demographic differences observed between arms and examine PrEP initiation stratified by patient's and provider's race and ethnicity.Additionally, a comprehensive economic analysis for each intervention will be conducted. Discussion: We hypothesize that gathering information on sensitive sexual behaviors electronically, communicating HIV risk in an understandable and relatable format to patients and OB/GYN providers, and deploying EHR alerts will increase PrEP initiation and HIV testing. Trial Registration: The trial is registered with ClinicalTrials.gov (NCT05412433) on 09 June 2022. https://clinicaltrials.gov/ct2/show/NCT05412433?term=NCT05412433&draw=2&rank=1.

Abortion Policy in the United States: The New Legal Landscape and Its Threats to Health and Socioeconomic Well-Being.

Policy Points The historic 2022 Supreme Court Dobbs v Jackson Women's Health Organization decision has created a new public policy landscape in the United States that will restrict access to legal and safe abortion for a significant proportion of the population. Policies restricting access to abortion bring with them significant threats and harms to health by delaying or denying essential evidence-based medical care and increasing the risks for adverse maternal and infant outcomes, including death. Restrictive abortion policies will increase the number of children born into and living in poverty, increase the number of families experiencing serious financial instability and hardship, increase racial inequities in socioeconomic security, and put significant additional pressure on under-resourced social welfare systems.

Creating opportunities to engage with prospective historically marginalized trainees with clinical simulation.

BACKGROUND: Recruiting a diverse group of medical students, house officers, and faculty in medicine is challenging-particularly for predominantly white, midwest institutions that may not be racially or ethnically diverse. PURPOSE: To evaluate a novel clinical simulation program, SiMfest, for recruiting house officers from historically marginalized populations to our institution to demonstrate our leadership's commitment to high-quality education and recruitment of these students to enhance diversity in academic medicine. METHODS: The Office for Health Equity and Inclusion, institutional leadership, and clinical department chairs developed a novel and engaging series of clinical simulations, SiMfest, to engage the pipeline of historically marginalized trainees and demonstrate our leadership's commitment to high-quality education. SiMfest is a two-hour simulation session presented annually (2017-2019) by our institution at the Student National Medical Association Annual Medical Education Conference. RESULTS: Over 800 students participated in SiMfest sessions over three years. Of the 461 participants who completed a survey after participation, 301 identified as female, and 382 indicated a racial category considered as historically marginalized in medicine-91% of whom identified as African American or Black. Thirty percent (n = 125) of respondents identified as pre-medical (e.g., undergraduate, post-baccalaureate) students and 69% (n = 289) identified as current medical students. Over 80% of students would recommend SiMfest to others. Additionally, 73% (n = 87) of pre-medical and 54% (n = 143) of medical students reported exposure to a previously unknown specialty. Thirty-three department representatives reported their SiMfest experience revealed new information about historically marginalized applicants that they may not have engaged with through the traditional application process but would be more likely to engage with in future diversity, equity, and inclusion initiatives. CONCLUSION: SiMfest harnessed our institution's high-quality training, personnel resources, and diversity, equity, and inclusion values to bring historically marginalized students in medicine and department leadership together to learn about one another and offer experiential learning. SiMfest may serve as a model for other institutions to draw on their strengths to develop innovative recruitment programs that promote the education and engagement of undergraduate and medical students from historically marginalized populations while simultaneously promoting diversity, equity, and inclusion culture change.

Youth Knowledge and Perspectives on Expedited Partner Therapy.

PURPOSE: Expedited partner therapy (EPT) is an effective sexually transmitted infection (STI) treatment and prevention practice that allows clinicians to provide treatment to the sexual partner(s) of individuals diagnosed with chlamydia and/or gonorrhea infections without a clinical evaluation. Due to the high incidence of STIs among youth, we sought to understand youth awareness and beliefs about EPT use. METHODS: MyVoice, a national text message survey of youth aged 14-24 years, posed 5 questions on EPT knowledge and perceptions to 1,115 youth in August 2018. Responses were reviewed to identify themes and iteratively develop a codebook. Two reviewers independently coded each question, and a third reviewer resolved discrepancies. Summary statistics were calculated for demographic and thematic analysis. RESULTS: A total of 835 participants responded to at least 1 question (74.9% response rate). Majority of youth (91.9%, n = 730/794) felt that it would be important to help their partners get treatment if they tested positive for chlamydia or gonorrhea. Although most participants were unaware of EPT (86.4%, n = 657/760), 81.3% (n = 624/768) supported the policy stating that it is "pretty darn convenient." Youth also noted they would be interested in asking their provider for EPT. Participants opposing EPT (6.9%, n = 53/768) noted that "they [sexual partner] are responsible for their own health" and preferred to "tell my partner to go to [their] doctor." CONCLUSIONS: Most youth in the MyVoice cohort felt that EPT was a good way to get treatment for their partners, even though the majority were not aware that EPT was available as an STI treatment option.

Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana.

BACKGROUND: A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake. METHODS: We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables. RESULTS: Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.

The future of STI screening and treatment for youth: a National Survey of youth perspectives and intentions.

BACKGROUND: Sexually transmitted infection (STI) rates continue to rise in the U.S., with disproportionately high rates among those aged 15-24 years. Effective programs and policies are necessary to address this growing public health problem. The purpose of this study is to assess the perspectives of a national sample of youth on access to STI care and behaviors regarding STIs. METHODS: MyVoice, a national text message survey of youth, was used to pose four open-ended questions on STI screening and treatment to 1115 youth aged 14-24 in August 2018. A mixed-methods strategy was employed for the study. Qualitative data was analyzed using a modified grounded theory approach. Summary statistics were calculated for demographic data and prevalence of themes. RESULTS: Of the 800 participants who responded to at least one question (72% response rate), mean age was 19 years (SD = 3.1), 55% identified as female, 61% identified as non-Hispanic white, and 33% qualified for free/reduced lunch. A majority felt it would be easy to get screened (69%) or treated (68%) for an STI. Nearly all respondents (95%) stated they would share an STI diagnosis with their sexual partners. CONCLUSIONS: Despite high rates of STIs among youth, most respondents reported that STI screening and treatment is accessible, and they would share an STI diagnosis with their partner.

Adapting to the Pandemic: Protocol of a Web-Based Perinatal Health Study to Improve Maternal and Infant Outcomes.

BACKGROUND: The identification of interconnected health risks during the perinatal period offers an opportunity to prevent negative maternal and infant health outcomes. Marijuana, opioid, and other substance use during pregnancy is a rapidly growing public health concern with significant and costly health consequences for the woman and the developing fetus. Pregnant persons who misuse substances are disproportionately more likely to engage in risky sexual behaviors resulting in sexually transmitted infections (STIs), which are on the rise in this population and can lead to adverse effects on maternal health and on fetal development. OBJECTIVE: Our goal is to continue testing an innovative and low-cost technology-delivered intervention, the Health Check-Up for Expectant Moms (HCEM), which simultaneously targets alcohol and drug use and STI risk during pregnancy, both of which are on the rise during the COVID-19 pandemic. METHODS: We describe the ways in which we have adapted the web-based HCEM intervention to continue recruitment and study enrollment during the pandemic. RESULTS: Study recruitment, visits, and participant safety assessments were all successfully modified during the initial year of the COVID-19 pandemic. Compared to in-person recruitment that occurred prepandemic, remote recruitment yielded a greater proportion of women enrolled in the study (83/136, 61.0% vs 43/52, 83%) in a shorter period (12 months vs 7 months). CONCLUSIONS: Despite study challenges related to the pandemic, including time and effort adapting to a remote protocol, remote recruitment and visits for this study were found to constitute a successful approach. TRIAL REGISTRATION: ClinicalTrials.gov NCT03826342; https://clinicaltrials.gov/ct2/show/NCT03826342. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30367.

Galvanizing for the future: a bottom-up departmental approach to diversity, equity, and inclusion.

As an academic department, we sought to identify effective strategies to engage our faculty and staff in diversity, equity, and inclusion initiatives and programs to build an inclusive department that would address our needs and those of our community and partners. Over a 4-year period, our faculty and staff have participated in town hall meetings, focus group discussions, surveys, and community-building activities to foster stakeholder engagement that will build a leading academic department for the future. We noted that our faculty and staff were committed to building diversity, equity, and inclusion, and our mission and vision were reflective of this. However, communication and transparency may be improved to help support a more inclusive department for all. In the future, we hope to continue with the integration of diversity, equity, and inclusion into our department's business processes to achieve meaningful, sustained change and impact through continued focus on recruitment, selection, retention, development, and wellness of faculty and staff-in addition to the continued recruitment of faculty and staff from underrepresented minority groups. Our findings should serve as a call to action for other academic obstetrics and gynecology departments to improve the health and well-being of the individuals we serve.

Availability of Sexually Transmitted Infection Screening and Expedited Partner Therapy at Federally Qualified Health Centers in Michigan.

Via secret shopper study, we assessed: (1) availability of sexually transmitted infection (STI) screening; (2) provision of expedited partner therapy; and (3) wait times for new patient STI screening appointments at Michigan federally qualified health centers. Of the 147 clinics with STI screening availability, 10.2% (15) confirmed expedited partner therapy provision.

Breakdown in the expedited partner therapy treatment cascade: from reproductive healthcare provider to the pharmacist.

BACKGROUND: The rising incidence rates of sexually transmitted infections in the United States highlight the need for concurrent treatment of patients and their sexual partners. Expedited partner therapy allows healthcare providers to offer antibiotic prescriptions or medications to an index patient for distribution to their sexual partner(s) without evaluating the partner. We hypothesized that there was a gap between expedited partner therapy policy at the state level and its downstream implementation by community pharmacists. OBJECTIVE: The objectives of our study were to evaluate pharmacists' expedited partner therapy knowledge and practices in 41 expedited partner therapy-permissible US states, to determine whether there were differences in practice based on the length of time expedited partner therapy was permissible in the state and chlamydia incidence rates, and to measure the cost of expedited partner therapy treatment. STUDY DESIGN: A randomized cohort of pharmacists (n=335) was invited to complete a telephone interview from November 2017 through January 2018. Descriptive statistics were calculated and stratified by early, mid, and late expedited partner therapy-adopter status based on the year of the state's expedited partner therapy enactment and the state's chlamydia incidence rate. Fisher's exact test and 1-way analyses of variance were used to compare measures across strata. RESULTS: We had 143 pharmacists (42.7%) agree to complete the survey. Among our respondents, 40.6% (n=58/143) indicated that they were aware of expedited partner therapy; 14.7% (n=21/143) reported that they had ever received an expedited partner therapy prescription, and 97% (n=139/143) reported that they would dispense an expedited partner therapy prescription if they received 1 in the future. These findings were stable across the 6 strata defined by early, mid, or late expedited partner therapy-adopter and high or low incidence rates of chlamydia status. Mean cost of azithromycin 1000 mg and cefixime 400 mg for treatment of chlamydia and gonorrhea was $22.17 (95% confidence interval, 20.29-24.05) and $30.46 (95% confidence interval, 28.65-32.26), respectively. CONCLUSION: Fewer than one-half of the pharmacists were aware of expedited partner therapy. A small minority of pharmacists reported ever having received an expedited partner therapy prescription, regardless of the length of time expedited partner therapy had been legal in their states and the incidence of chlamydia. However, almost all pharmacists reported that they would dispense an expedited partner therapy prescription if they received 1. Additionally, costs were high for expedited partner therapy for self-pay patients. These data suggest that there are opportunities to increase expedited partner therapy utilization by healthcare providers, patients, and pharmacists.

Healthcare providers and community perspectives on expedited partner therapy (EPT) for use with gay, bisexual and other men who have sex with men.

OBJECTIVES: Expedited partner therapy (EPT) is an effective strategy to reduce rates of chlamydia and gonorrhoea infection and ensure sexual partners are treated. Currently, EPT is provided to heterosexual patients; however, EPT is not routinely recommended for use with gay, bisexual and other men who have sex with men (GBMSM) because of concerns about HIV coinfection. The objective of the qualitative study was to understand provider and community views on the use of EPT with GBMSM. METHODS: Using convenience sampling methods, we recruited a sample of 18 healthcare providers and 21 GBMSM to participate in in-depth, semistructured interviews. Interviews were conducted over the phone and included questions about knowledge, experiences and potential barriers and facilitators to the use of EPT with GBMSM. RESULTS: Most providers wanted to provide EPT to GBMSM and believed that the potential barriers and concerns to EPT use were not unique to a patient's sexual orientation. Several providers noted that they were currently providing EPT to GBMSM as part of HIV prevention services. Community members were generally unaware of EPT as a service and most indicated that they would only use EPT if they were in a committed relationship. Barriers included partner allergies and resistance, pharmacy protocols, structural concerns (eg, insurance coverage, pharmacists onsite and transportation) and potential disclosure issues. Facilitators included cultural humility and telemedicine with patients' partners to overcome these barriers. CONCLUSIONS: Acceptability of EPT use for both chlamydia and gonorrhoea was high among providers and community members. Barriers to EPT use, including concerns about patients' partners' allergies and resistance, disclosure concerns and linkage to HIV prevention services can be overcome through cultural humility trainings and telemedicine. Changing EPT recommendations at the national level to be inclusive of GBMSM is critical to curtail the rising STI and HIV epidemic.

Reducing sexual health risks and substance use in the prenatal setting: A study protocol for a randomized controlled trial.

Sexually transmitted infections (STIs) are at a record high in the United States, and STI risk is a critical and costly public health concern for childbearing women. STIs can lead to a number of serious health risks including premature birth, low birth weight, ectopic pregnancy, and fetal death. Similarly, there has been a dramatic increase in substance use during pregnancy, leading to complications during pregnancy and poorer birth outcomes. Women who misuse substances are disproportionately more likely to engage in risky sexual behaviors that can result in STIs. The proposed study will test whether the Health Check-Up for Expectant Moms (HCEM), a computer-delivered brief intervention that simultaneously targets STI risk and alcohol/illicit drug use during pregnancy, reduces antenatal and postpartum risk more than an attention, time, and information matched control condition among pregnant women seeking prenatal care. The study is a two-group, randomized controlled trial in which a diverse sample of 250 pregnant women will be recruited from prenatal care clinics and assigned to either (a) a computer-delivered, single-session brief intervention plus two booster sessions); or (b) a computer-delivered control condition. Follow-up assessments will occur at 2 and 6 months from baseline, and at 6 weeks postpartum. Our objective measures include STI incidence and birth outcomes. The results of this trial will fill a critical gap and provide much-needed data on the efficacy, costs, and resource utilization of a practical computer-delivered, brief motivational intervention tailored to reach high-risk women during pregnancy and extending impact to postpartum.

Empowering HIV-infected women in low-resource settings: A pilot study evaluating a patient-centered HIV prevention strategy for reproduction in Kisumu, Kenya.

BACKGROUND: Female positive/male negative HIV-serodiscordant couples express a desire for children and may engage in condomless sex to become pregnant. Current guidelines recommend antiretroviral treatment in HIV-serodiscordant couples, yet HIV RNA viral suppression may not be routinely assessed or guaranteed and pre-exposure prophylaxis may not be readily available. Therefore, options for becoming pregnant while limiting HIV transmission should be offered and accessible to HIV-affected couples desiring children. METHODS: A prospective pilot study of female positive/male negative HIV-serodiscordant couples desiring children was conducted to evaluate the acceptability, feasibility, and effectiveness of timed vaginal insemination. Eligible women were 18-34 years with regular menses. Prior to timed vaginal insemination, couples were observed for two months, and tested and treated for sexually transmitted infections. Timed vaginal insemination was performed for up to six menstrual cycles. A fertility evaluation and HIV RNA viral load assessment was offered to couples who did not become pregnant. FINDINGS: Forty female positive/male negative HIV-serodiscordant couples were enrolled; 17 (42.5%) exited prior to timed vaginal insemination. Twenty-three couples (57.5%) were introduced to timed vaginal insemination; eight (34.8%) achieved pregnancy, and six live births resulted without a case of HIV transmission. Seven couples completed a fertility evaluation. Four women had no demonstrable tubal patency bilaterally; one male partner had decreased sperm motility. Five women had unilateral/bilateral tubal patency; and seven women had an HIV RNA viral load (≥ 400 copies/mL). CONCLUSION: Timed vaginal insemination is an acceptable, feasible, and effective method for attempting pregnancy. Given the desire for children and inadequate viral suppression, interventions to support safely becoming pregnant should be integrated into HIV prevention programs.

Improving Women's Health and Combatting Sexually Transmitted Infections Through Expedited Partner Therapy.

Sexually transmitted infections (STI), including Chlamydia trachomatis and Neisseria gonorrhoeae, have reached record high rates in the United States. Sexually transmitted infections disproportionately affect reproductive-aged females aged 15-44 years, who account for 65% and 42% of the total reported C trachomatis and N gonorrhoeae cases, respectively. Undiagnosed STIs can result in serious health complications that put women at an increased risk for pelvic inflammatory disease, ectopic pregnancy, and tubal factor infertility. Many of these women are seen by physicians (eg, obstetrician-gynecologists, family medicine doctors, pediatricians) or other clinicians (eg, nurse practitioners, midwives, physician assistants) who care for women. These clinicians have the opportunity to help curb the continued increase in STI incidence rates with the implementation and use of expedited partner therapy. Expedited partner therapy is a proven effective health care practice that allows clinicians to give patients medications or prescriptions to distribute to their partners. Despite expedited partner therapy's proven effectiveness, there are barriers to its implementation that must be understood to enhance STI treatment and prevention efforts. In this commentary, we discuss these barriers, and appeal to women's health clinicians to implement or increase use of expedited partner therapy for the treatment of women with STIs and their sexual partners.