Physicians' Human Papillomavirus Vaccine Communication With Parents of Different Skin Color: Feasibility of Measuring Indicators of Implicit Bias With Virtual Reality.

PURPOSE: Virtual reality (VR) may be a viable method to observe and describe signals of implicit bias. Using the context of the human papillomavirus vaccine counseling, we sought to describe physicians' communication practices exploring differences when counseling parents with different skin colors. METHODS: Physicians (N = 90) at an academic primary care center were recruited for a VR study in which they counseled dark or light-skinned parent avatars who expressed hesitation about human papillomavirus vaccination for their adolescent child. Investigators coded previously recorded simulations. Associations between communication and parent skin color were examined using t-tests and Chi-square tests. RESULTS: Both direct (e.g., addressing the concern immediately) and circuitous (e.g., providing alternative information) communication patterns were observed. Physicians used passive voice less commonly when counseling dark-skinned versus light-skinned avatars (p < .05). DISCUSSION: VR demonstrated feasibility in capturing clinicians' communication behaviors including measuring eight distinct indicators of implicit bias.

Factors Associated With Racially and Ethnically Diverse Sample of Adolescents, Young Adults, and Parents' Intention to Receive a COVID-19 Vaccine.

PURPOSE: Identify variables, including moderating variables, associated with adolescents, young adults, and parents' intention to receive a COVID-19 vaccine in January 2021. DESIGN: Cross-sectional survey. SETTING: United States Midwestern academic medical center. SAMPLE: Adolescents (n = 242); young adults (n = 333); parents (n = 563). MEASURES: Associations between predictors-participant characteristics, general vaccine hesitancy, COVID-19 and vaccine knowledge, perceptions, and normative beliefs-and intention to receive a COVID-19 vaccine (outcome) were assessed. To determine variables impacting the strength of the relationship between predictors and outcome, moderators included 2020/2021 influenza vaccine receipt, having experienced discrimination, and primary sources of information for COVID-19. ANALYSIS: Multivariable logistic regression examined associations, including moderating effects, for adolescents, young adults, parents, and parents for child. RESULTS: With 20,231 email addresses receiving the survey, 1138 participants were included in the analysis. Intention to receive a COVID-19 vaccine was reported by 60.7% adolescents (n = 147), 65.2% young adults (n = 217), and 38.5% parents (n = 217) and 38.2% parents (n = 215) intended to vaccinate their child. Intention was associated with lower general vaccine hesitancy for adolescents (AOR = 1.50), young adults (AOR = 1.39), parents (AOR = 1.18), and parents' intention for their child (AOR = 1.17). Parents citing reputable medical experts as primary source of COVID-19 information positively moderated vaccine perceptions and intention for self (AOR = 8.25) and child (AOR = 6.37). CONCLUSION: Clinician training to address vaccine hesitancy may be effective at promoting positive COVID-19 vaccine perceptions.

Human Papillomavirus Vaccine Hesitancy in the United States.

Although the US Advisory Committee on Immunization Practices recommends vaccinating adolescents against the human papillomavirus (HPV) to prevent HPV-associated cancers, vaccine initiation and completion rates are suboptimal. Parental and provider hesitancy contributes significantly to low HPV vaccine uptake. This review describes sources of HPV vaccine hesitancy using a World Health Organization framework that categorizes determinants of vaccine hesitancy as follows: contextual factors (historical, sociocultural, environmental, or political factors), individual and group factors (personal perception or influences of the social/peer environment), and vaccine/vaccination-specific issues (directly related to vaccine or vaccination).

Impact of a Virtual Reality Curriculum on Human Papillomavirus Vaccination: A Pilot Trial.

Although the strongest predictor of human papillomavirus (HPV) vaccination is a high-quality recommendation, physicians often provide weak recommendations. Thus, the authors developed Virtual Immersive Communication Training on Recommending Immunizations (VICTORI), a virtual reality (VR)‒based intervention that provided physicians the opportunity to deliberately practice recommendation behaviors. VICTORI included VR simulations during which participants counseled caregiver avatars hesitant to vaccinate. Before participation in VICTORI, participants reviewed a smartphone application on recommendation behaviors. A nonrandomized control trial of VICTORI was conducted with licensed and resident physicians. The intervention group completed the application and VICTORI simulations, whereas a comparison group completed only the application. The hypothesis was that HPV vaccination rates would increase for patients in the intervention group. The preintervention period was defined as the 6 months before allocated training (February 1, 2020-July 31, 2020), and the postintervention period was the 6 months after (October 1, 2020-March 31, 2021). The primary outcome was a change in the rates of human papillomavirus vaccine initiation among eligible patients presenting to clinic before and after. Of 142 eligible physicians, 134 (94%) chose to participate, with 93 of /97 (96%) intervention and 30 of 37 (81%) comparison participants completing study protocols. There was a statistically significant increase in patients' HPV vaccine initiation rates after training within the intervention group (54.3%‒72.4%; 18.1% difference [95% CI=11.0, 25.8]; p<0.001) but not within the comparison group (59.5%‒63.4%; 3.9% difference [95% CI= -11.0, 19.0]; p=0.609). In conclusion, HPV vaccine initiation increased after VR training, and further study is warranted.

A qualitative descriptive study of providers' perspectives on human papillomavirus vaccine administration among Latino/a adolescents in South Texas clinics: barriers and facilitators.

BACKGROUND: South Texas Latinas experience higher cervical cancer incidence and mortality compared to Latinas nationwide. Despite the availability of effective human papillomavirus vaccines, South Texas Latino/a adolescents sub-optimally complete the series. Research shows provider recommendation strongly predicts vaccine uptake, but minority adolescents are less likely to report that their provider recommended the vaccine and series completion. There is also scant information on the HPV vaccine administration process in clinic practices providing vaccination services to Latino adolescents with limited access to healthcare resources. The purpose of the study was to describe providers' experience with administering the HPV vaccine to Latino/a patients in their practices. METHODS: The study used qualitative description to describe the experience of 15 South Texas healthcare providers (doctors and nurses) with the process of HPV vaccine administration in their practices. We conducted open ended, audio-recorded interviews, which were subsequently transcribed verbatim and uploaded into Atlas.(ti) 7.0 for analysis. The interviews yielded detailed descriptions of barriers and facilitators that could potentially impact HPV vaccine uptake. RESULTS: Providers identified parental exposure to provider recommendation as enhancing HPV acceptance and existing policies and implementation of evidence-based practices as facilitators of HPV vaccine uptake. Barriers ranged from parental fears of adolescent sexual activity and potential vaccine side effects to lack of transportation and the cost of the vaccine. CONCLUSION: These findings reflect barriers and facilitators to administering the HPV vaccine previously identified and also highlight issues unique to the situation among Latinos in South Texas. Implications include the need to design and implement efforts to improve provider-parent communication and enhance parental and adolescent patients' understanding of and confidence in the HPV vaccine. Furthermore, policy changes are needed to rectify organizational/structural challenges to HPV vaccine administration.

School Health Service Provider Perceptions on Facilitated Interactive Role-Play Around HPV Vaccine Recommendation.

The purpose of this study was to evaluate a facilitated interactive role-playing activity on increasing human papillomavirus (HPV) vaccine recommendation skills for school nurses and school-based health center staff. A 1-day workshop was implemented for school-based clinicians focused on improving HPV vaccination rates in schools. The workshop included a facilitated interactive role-playing activity involving five scenarios related to recommending the HPV vaccine to parents. Participants completed a usability survey with open-ended questions assessing their experience. A general inductive approach was used to examine responses. Sixteen participants completed the usability survey. The major strength identified specific to the activity included opportunity to practice evidence-based recommendation skills (n = 10). Weaknesses of the activity identified included lack of diversity (n = 4) and complexity within the scenarios (n = 2). Results could shift current educational and clinical paradigms through the implementation of hands-on education strategies to effectively train school-based clinicians to strongly recommend the HPV vaccine.

Evaluation of HPV Vaccine: Same Way, Same DayTM: A Pilot Study.

Missed clinical opportunities and the lack of strong and consistent vaccine recommendations are key reasons for low HPV vaccination rates. The purpose of this study was to conduct a pilot evaluation of a web-based training's impact on knowledge, attitudes, and self-efficacy related to providing evidence-based HPV vaccine recommendations. Participants completed three online interactive learning modules and the HPV Vaccine: Same Way, Same Day™ smartphone application (app). Participants completed a pre-training survey, immediate post-training survey, and two-month post-survey. Participants demonstrated a statistically significant increase in knowledge scores from T1 to T2 and T1 to T3. Mean attitudes for recommending HPV vaccination for female patients increased from T1 to T2 and T1 to T3. Mean attitudes for recommending HPV vaccination for male patients increased from T1 to T2 and T1 to T3. Mean self-efficacy scores increased from T1 to T2 and T1 to T3. The HPV Vaccine: Same Way, Same Day™ app is a promising strategy for improving HPV vaccine recommendations among physicians. Future research should explore long-term effects and enroll attending and community physicians to examine its efficacy in other physician populations.

Sexual Network Patterns and Their Association With Genital and Anal Human Papillomavirus Infection in Adolescent and Young Men.

PURPOSE: This study aimed to determine individual- and partner-level factors associated with human papillomavirus (HPV) infection in vaccinated and unvaccinated men. METHODS: A total of 747 men, aged 13-26 years, completed a survey of sexual behaviors and were tested for genital and perianal/anal HPV (36 types). Sexual network variables included recent and lifetime concurrency (being in more than one sexual relationship at the same time) and recent sex partner discordance (by race, ethnicity, age, and number of sexual partners). We determined individual-level and sexual network variables associated with ≥1 HPV type and HPV16/18, stratified by vaccination status, using separate multivariable logistic regression models. RESULTS: Participants' mean age was 21.2 years; 64% were positive for ≥1 HPV type and 21% for HPV16/18. Factors associated with ≥1 HPV type in unvaccinated men included recruitment site and lifetime concurrency. Factors associated with ≥1 HPV type among vaccinated men included recruitment site, Chlamydia history, main male partner, number of lifetime female partners, and no condom use with female partner. Factors associated with HPV16/18 in unvaccinated men included race and partner concurrency. Factors associated with HPV16/18 in vaccinated men included ethnicity, main male partner, and recent concurrency. CONCLUSIONS: Sexual network variables associated with HPV infection were different based on vaccination status and HPV type, suggesting risk factors for HPV infection may change as the proportion of vaccinated men increases. In addition, participant report of concurrency and not knowing whether one had practiced concurrency were consistent risk factors; clinicians should consider including concurrency in the sexual history to determine the risk of HPV.

Effectiveness of a Universally Offered Chlamydia and Gonorrhea Screening Intervention in the Pediatric Emergency Department.

PURPOSE: Adolescents represent more than half of the newly diagnosed sexually transmitted infections in the U.S. annually. Emergency departments (EDs) may serve as an effective, nontraditional setting to screen for chlamydia/gonorrhea (CT/GC). The objective was to evaluate the effectiveness of a universally offered CT/GC screening program in two pediatric ED settings. METHODS: This was a prospective, delayed start pragmatic study conducted over 18 months in two EDs within the same academic institution among ED adolescents aged 14-21 years with any chief complaint. Using a tablet device, adolescents were confidentially informed of CT/GC screening recommendations and were offered screening. If patients agreed to CT/GC testing, a clinical decision support tool was triggered to inform the provider and order testing. The main and key secondary outcomes were the proportion of CT/GC testing and positive CT/GC test results in each respective ED. RESULTS: Both EDs experienced modest but statistically significant increases in CT/GC testing post- versus pre-intervention (main: 11.5% vs. 7.9%; confidence interval [CI]: 2.9-4.2; p < .0001 and satellite: 3.8% vs. 2.6%; 95% CI: .7-1.7; p < .0001). Among those tested, the positivity rate at the main ED did not significantly change post- versus pre-intervention (24.1% vs. 23.2%; 95% CI: -1.9 to 3.8; p = .71) but significantly decreased at the satellite ED (7.6% vs. 14.8%; 95% CI: -12.2 to -2.2; p = .01). CONCLUSIONS: A universally offered screening intervention increased the proportion of adolescents who were tested at both EDs and the detection rates for CT/GC at the main ED, but patient acceptance of screening was low.

Usability Evaluation of the Novel Smartphone Application, HPV Vaccine: Same Way, Same Day, Among Pediatric Residents.

OBJECTIVE: Scalable, deliberate practice training strategies to administer evidence-based recommendations are necessary to improve human papillomavirus (HPV) vaccination rates. We sought to characterize resident clinicians' perceptions regarding the usability of the HPV Vaccine: Same Way, Same Day smartphone application (app). Usability, a critical aspect of digital programs to promote behavior change, was evaluated. METHODS: Fifteen third-year pediatric residents were recruited to complete a usability evaluation of the HPV Vaccine: Same Way, Same Day app, which includes simulated role-play scenarios in which users interact, as a pediatrician avatar, with an animated parent hesitant to accept the vaccine for her child. The app provides information about the vaccine and utilizes deliberate practice, a purposeful and systematic approach to improve performance, to teach evidence-based vaccine recommendation practices, including motivational interviewing skills. Data were derived from in-depth, semistructured interviews with pediatric residents. We used a constructivist general inductive approach to illuminate perspectives via inductive coding and pattern identification. Garrison's theoretical construct on self-directed learning was used to cluster themes into conceptual categories. RESULTS: We classified interview data in 3 conceptual categories: self-management, internal monitoring and motivational principles. Residents described the app as interactive, easy to use, succinct, informative, engaging, and practical. All residents would recommend the HPV Vaccine: Same Way, Same Day app to a colleague. Residents suggested adding more complex cases for future iterations. CONCLUSIONS: From their perspective, pediatric residents reported that an app using deliberate practice principles has the potential to inform and advance providers' counseling skills regarding the HPV vaccine.

Information Technology-Assisted Screening for Gonorrhea and Chlamydia in a Pediatric Emergency Department.

PURPOSE: The aim of the study was to design and implement a novel, universally offered, computerized clinical decision support (CDS) gonorrhea and chlamydia (GC/CT) screening tool embedded in the emergency department (ED) clinical workflow and triggered by patient-entered data. METHODS: The study consisted of the design and implementation of a tablet-based screening tool based on qualitative data of adolescent and parent/guardian acceptability of GC/CT screening in the ED and an advisory committee of ED leaders and end users. The tablet was offered to adolescents aged 14-21 years and informed patients of Centers for Disease Control and Prevention GC/CT screening recommendations, described the testing process, and assessed whether patients agreed to testing. The tool linked to CDS that streamlined the order entry process. The primary outcome was the patient capture rate (proportion of patients with tablet data recorded). The secondary outcomes included rates of patient agreement to GC/CT testing and provider acceptance of the CDS. RESULTS: Outcomes at the main and satellite EDs, respectively, were as follows: 1-year patient capture rates were 64.6% and 64.5%; 9.9% and 4.4% of patients agreed to GC/CT testing, and of those, the provider ordered testing for 73% and 72%. CONCLUSIONS: Implementation of this computerized screening tool embedded in the clinical workflow resulted in patient capture rates of almost two-thirds and clinician CDS acceptance rates >70% with limited patient agreement to testing. This screening tool is a promising method for confidential GC/CT screening among youth in an ED setting. Additional interventions are needed to increase adolescent agreement for GC/CT testing.

Decline in vaccine-type human papillomavirus prevalence in young men from a Midwest metropolitan area of the United States over the six years after vaccine introduction.

PURPOSE: The aim of this study was to determine changes in human papillomavirus (HPV) prevalence among young men from a Midwest metropolitan area over the six years after vaccine introduction, including HPV prevalence in men overall, in vaccinated men to examine vaccine impact and in unvaccinated men to examine herd protection. An exploratory aim was to examine associations between number of vaccine doses and HPV prevalence. METHODS: Men aged 14-26 years reporting male-female and/or male-male sexual contact were recruited from a primary care clinic, sexually transmitted disease clinic, and community setting during two waves of data collection: 2013-2014 (N = 400) and 2016-2017 (N = 347). Participants completed a questionnaire and were tested for penile, scrotal and anal HPV. Changes in prevalence of any (≥1 type) and vaccine-type HPV (HPV6, 11, 16, and/or 18) were examined using propensity score weighted logistic regression. Associations between number of doses and HPV infection were determined using chi-square tests and logistic regression. RESULTS: The proportion of men with a history of ≥1 HPV vaccine doses increased from 23% to 44% (p < 0.001) from waves 1 to 2. After propensity score weighting, infection with ≥1 vaccine-type HPV significantly decreased among all men (29% to 20%; 31% decrease; odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.44-0.88) and unvaccinated men (32% to 21%; 36% decrease; OR = 0.56, 95%CI = 0.34-0.86); there was a non-significant decrease (21%) among vaccinated men. Associations between number of doses and HPV prevalence were not statistically significant. CONCLUSIONS: Prevalence of vaccine-type HPV decreased among all, vaccinated, and unvaccinated men six years after HPV vaccine recommendation, supporting vaccine impact and herd protection. Decreases in vaccine-type HPV in all men appear to be due to decreases in unvaccinated men, suggesting that the full impact of vaccination has yet to be realized. Continued monitoring and efforts to vaccinate men prior to sexual initiation are warranted.

Risk perceptions after human papillomavirus vaccination are not subsequently associated with riskier behaviors or sexually transmitted infections in HIV-infected young women.

Concerns have been raised that risk perceptions after human papillomavirus (HPV) vaccination may lead to riskier sexual behaviors or sexually transmitted infection (STI) diagnosis. The aims of this study were to determine whether risk perceptions immediately after HPV vaccination (perceived risk of HPV, perceived risk of STIs other than HPV, and perceived need for safer sexual behaviors, measured using 5-item scales) were associated with number of sexual partners, condom use at last sexual intercourse, or STI diagnosis over the subsequent 48 weeks in HIV-infected young women (N = 99, 17-24 years of age) participating in an HPV vaccine clinical trial. Generalized estimating equation models demonstrated that lower perceived need for safer sexual behaviors was associated subsequently with lower total number of sexual partners (adjusted odds ratio (AOR) = 1.05, 95% confidence interval (CI) = 1.01-1.09) and lower perceived risk of HPV was associated with subsequent report of having used condoms at last sex (AOR = 0.36, AOR = 0.14-0.92). Lower perceived risk of other STIs was not associated with subsequent sexual behaviors. None of the three risk perceptions was associated with subsequent risk of STIs. The findings suggest that inappropriate risk perceptions after HPV vaccination such as lower perceived need for safer sexual behaviors and lower perceived risk of HPV or other STIs were not subsequently associated with risky behaviors or STI diagnosis in HIV-infected young women.

Evidence for cross-protection but not type-replacement over the 11 years after human papillomavirus vaccine introduction.

Examination of cross-protection and type replacement after human papillomavirus (HPV) vaccine introduction is essential to guide vaccination recommendations and policies. The aims of this study were to examine trends in non-vaccine-type HPV: 1) genetically related to vaccine types (to assess for cross-protection) and 2) genetically unrelated to vaccine types (to assess for type replacement), among young women 13-26 years of age during the 11 years after HPV vaccine introduction. Participants were recruited from a hospital-based teen health center and a community health department for four cross-sectional surveillance studies between 2006 and 2017. Participants completed a survey that assessed sociodemographic characteristics and behaviors, and cervicovaginal swabs were collected and tested for 36 HPV genotypes. We determined changes in proportions of non-vaccine-type HPV prevalence and conducted logistic regression to determine the odds of infection across the surveillance studies, propensity-score adjusted to control for selection bias. Analyses were stratified by vaccination status. Among vaccinated women who received only the 4-valent vaccine (n = 1,540), the adjusted prevalence of HPV types genetically related to HPV16 decreased significantly by 45.8% (adjusted odds ratio [AOR] = 0.48, 95% confidence interval [CI] = 0.31-0.74) from 2006-2017, demonstrating evidence of cross-protection. The adjusted prevalence of HPV types genetically related to HPV18 did not change significantly (14.2% decrease, AOR = 0.83, 95% CI = 0.56-1.21). The adjusted prevalence of HPV types genetically unrelated to vaccine types did not change significantly (4.2% increase, AOR = 1.09, CI = 0.80-1.48), demonstrating no evidence of type replacement. Further studies are needed to monitor for cross-protection and possible type replacement after introduction of the 9-valent HPV vaccine.

Human Papillomavirus Vaccine Effectiveness and Herd Protection in Young Women.

BACKGROUND: Clinical trials of the 4-valent human papillomavirus (HPV) vaccine demonstrate high efficacy, but surveillance studies are essential to examine the long-term impact of vaccine introduction on HPV prevalence in community settings. The aims of this study were to determine during the 11 years after vaccine introduction the prevalence of (1) vaccine-type HPV in adolescent and young adult women who were vaccinated (to assess vaccine effectiveness) and (2) vaccine-type HPV in women who were unvaccinated (to assess herd protection). METHODS: Young women 13 to 26 years of age were recruited from hospital-based and community health clinics for 4 surveillance studies from 2006 to 2017. We determined the proportion of vaccinated and unvaccinated women who were positive for vaccine-type HPV across the studies, and the odds of positivity for vaccine-type HPV using logistic regression; all analyses were propensity score-adjusted to control for between-wave differences in participant characteristics. RESULTS: Vaccination rates increased from 0% to 84.3% (97% of study participants received the 4-valent vaccine). Among women who were vaccinated, 4-valent vaccine-type HPV detection decreased from 35% to 6.7% (80.9% decline; odds ratio 0.13, 95% confidence interval 0.08 to 0.22). Among women who were unvaccinated, 4-valent vaccine-type HPV detection decreased from 32.4% to 19.4% (40% decline; odds ratio 0.50, 95% confidence interval 0.26 to 0.97). Estimated vaccine effectiveness was 90.6% in wave 3 and 80.1% in wave 4. CONCLUSIONS: In this study in which trends in HPV in a US community >10 years after 4-valent HPV vaccine introduction and after 9-valent vaccine introduction were examined, we found evidence of vaccine effectiveness and herd protection. Further research is needed to examine trends in 9-valent vaccine-type HPV after higher rates of vaccination are achieved.

Pre-vaccination prevalence of anogenital and oral human papillomavirus in young HIV-infected men who have sex with men.

The aims of this study were to: 1) determine prevalence of anogenital and oral HPV, 2) determine concordance between HPV at anal, perianal, scrotal/penile, and oral sites; and 3) describe factors associated with anogenital HPV types targeted by the 9-valent vaccine. Data were collected from 2012 to 2015 among men who have sex with men 18-26 years of age enrolled in a vaccine trial (N = 145). Penile/scrotal, perianal, anal, and oral samples were tested for 61 HPV types. Logistic regression was used to identify factors associated with types in the 9-valent vaccine. Participants' mean age was 23.0 years, 55.2% were African-American, and 26.2% were Hispanic; 93% had anal, 40% penile, and 6% oral HPV. Among those with anogenital infection, 18% had HPV16. Concordance was low between anogenital and oral sites. Factors independently associated with a 9-valent vaccine-type HPV were: race (African-American vs. White, OR=2.67, 95% CI=1.11-6.42), current smoking (yes vs. no, OR=2.37, 95% CI=1.03-5.48), and number of recent receptive anal sex partners (2+ vs. 0, OR=3.47, 95% CI=1.16-10.4). Most MSM were not infected with HPV16 or HPV18, suggesting that they may still benefit from HPV vaccination, but anogenital HPV was very common, highlighting the importance of vaccinating men before sexual initiation. CLINICAL TRIAL NUMBER: NCT01209325.

Maternal Factors and Sexual Orientation-Related Disparities in Cervical Cancer Prevention.

OBJECTIVES: Our objective was to explore how mothers' attitudes and relationships with their daughters may impact the cervical cancer prevention behaviors of daughters with diverse sexual orientations. METHODS: We examined 8,143 mother-daughter dyads from the Nurses' Health Study 2 and Growing Up Today Study. During the daughter's adolescence, each mother reported her beliefs about the importance of regular Pap testing for her daughter, the frequency of communication with her daughter about Pap testing, her beliefs about Pap testing and human papillomavirus (HPV) vaccines, and her acceptance of sexual minorities (e.g., bisexuals, lesbians). Mothers and daughters separately reported relationship satisfaction. Log-binomial models were used to examine the longitudinal association between maternal factors and daughter's receipt of a Pap test and HPV vaccination. RESULTS: Nearly all maternal factors predicted the daughter's likelihood to have a Pap test and HPV vaccination. Higher levels of acceptance for sexual minorities and better relationship quality were also positively associated with these cervical cancer prevention behaviors. Yet, after adjusting for the maternal factors, there was little attenuation of the existing sexual orientation-related disparities in Pap tests or HPV vaccination. CONCLUSIONS: Mothers can play an important role in their daughters' cervical cancer prevention behaviors through novel processes like being more accepting of sexual minorities and having a good relationship quality. However, in this study, maternal factors did not explain much of the sexual orientation-related disparities in cervical cancer prevention. Efforts to ensure a mother is accepting of sexual minorities and has a good relationship quality with her daughter may improve that daughter's reproductive health.

Primary Care Physician Attitudes and Intentions Toward the Use of HIV Pre-exposure Prophylaxis in Adolescents in One Metropolitan Region.

PURPOSE: Understanding the attitudes of physicians toward the use of pre-exposure prophylaxis (PrEP) for HIV prevention among youth is critical to improving access to PrEP. We examined PrEP-related attitudes among physicians who provide primary care to 13- to 21-year-old adolescents. METHODS: Individual, in-depth, semistructured interviews were conducted with 38 physicians from adolescent medicine, family practice, internal medicine/medicine-pediatrics, obstetrics/gynecology, and pediatrics who care for any adolescents younger than 18 years. Interviews assessed familiarity with PrEP, perceived benefits and barriers to providing PrEP to adolescents, facilitating factors for prescribing PrEP, and likelihood of recommending and prescribing PrEP to adolescents. RESULTS: Mean age was 44.6 years (standard deviation 10.9). Fourteen physicians (37%) reported being somewhat or very familiar with PrEP. Perceived benefits of prescribing PrEP included decreased acquisition/rates of HIV, improved provision of sexual health services, and improved patient awareness of HIV risk. Barriers to PrEP were reported at the patient (e.g., lack of acceptability to patients), provider (e.g., concerns about patient adherence, safety/side effects, parents as a barrier to PrEP use), and system (e.g., high cost) levels. Facilitating factors for prescribing PrEP included low cost/coverage by insurance, physician education about PrEP, patient educational materials, and clinical guidelines for PrEP use in youth. A higher proportion of physicians reported being highly or somewhat likely to recommend (N = 16, 42%) than prescribe PrEP (N = 13, 34%). CONCLUSIONS: In this study of primary care physician attitudes toward PrEP prescribing for adolescents, physicians identified numerous barriers to providing PrEP. Addressing these barriers may increase adolescents' access to PrEP.