Acceptability and Appropriateness of Information Sessions to Increase Knowledge and Awareness of PrEP and TelePrEP among Latina Women

Abstract

Women of color continue to be disproportionately impacted by HIV. Although PrEP is effective in preventing HIV infection, PrEP coverage and knowledge remain low in this population. To address barriers to PrEP, we implemented women-centered and culturally appropriate Information Sessions delivered by staff from the population they serve to increase knowledge, awareness, and use of PrEP through telemedicine (e.g., PlushCare). We focused our analysis on Latina women (LW) study participants, given the dearth of literature dedicated to the unique needs of LW. We partnered with a woman-led community-based organization (CBO) to implement the strategy with LW clients. Health educators conducted 26 Information Sessions with 94 LW (20 in Spanish and 6 in English). Participants who completed the Information Session were invited to participate in an interview to assess the acceptability and appropriateness of the Information Session as a strategy to increase knowledge and awareness of PrEP and PlushCare. We analyzed qualitative data using thematic analysis. Four themes emerged from the analysis: 1) information sessions increased knowledge and awareness of PrEP and PlushCare; 2) perceived acceptability and appropriateness of information sessions; 3) insufficient reasons to warrant use of PrEP; and 4) positive attitudes about PlushCare. Our findings suggest that a women-centered and culturally appropriate Information Session implemented through a trusted, woman-led CBO is an acceptable and appropriate implementation strategy to inform LW about PrEP.

Introduction

Women of color are disproportionately affected by HIV in the United States (US) (Baeten et al., 2012; Centers for Disease Control and Prevention [CDC], 2022). In 2019, according to the Centers for Disease Control and Prevention (CDC), the rate of HIV infection among Black/African American females was 18.9, which is about 10 times higher than the rate for White females (1.8) and 4 times higher than Hispanic/Latina females (4.9) (CDC, 2021a). Daily oral pre-exposure prophylaxis (PrEP) is highly effective in reducing new HIV infections among cisgender women (Baeten et al., 2012; Thigpen et al., 2012), yet PrEP coverage remains disproportionately low in this population (Huang, 2018; Siegler et al., 2018). In 2020, the CDC estimated that PrEP coverage was nearly three times higher among men who could benefit from PrEP (28%) than women (10%) (CDC, 2021b). In Los Angeles County (LAC), California, women of color have an extremely low estimated rate of PrEP coverage (5%) when compared to Black (40%) and Latino (42%) men who have sex with men (MSM) (Los Angeles County Department of Public Health, Division of HIV and STD Programs, 2021). Low PrEP awareness contributes to lower uptake; women of color have lower levels of awareness than other groups in the U.S. (Auerbach et al., 2014; Collier et al., 2017; Goparaju et al., 2015), which is especially true of Latina women (LW) (Baugher et al., 2021; Raifman et al., 2019).

Even when women of color become aware of PrEP, they face individual, social, structural, and systemic barriers to uptake. Key barriers include HIV- and PrEP-related stigma, lack of time to attend medical appointments, and lack of insurance or access to financial assistance programs (Auerbach et al., 2014; Baldwin et al., 2021; Bradley & Hoover, 2019; Calabrese et al., 2018; Chittamuru et al., 2020; Collier et al., 2017; Pasipanodya et al., 2021). Intimate partner violence (IPV) can also affect a woman’s interest in and willingness to use PrEP [18]. Other barriers to PrEP use include medical mistrust, discrimination and bias in healthcare settings, and a lack of providers using culturally and gender appropriate approaches when recording sexual health history (Cyrus et al., 2023; Sharpless et al., 2022; Tessema et al., 2021).

In 2020, the National Institutes of Health (NIH) issued an Ending the HIV Epidemic (EHE) Initiative supplement announcement for one-year implementation science projects to enhance PrEP access among cisgender women. In our previous work, we found that telemedicine services for PrEP (hereafter: “TelePrEP”) could potentially benefit Latina and Black women due to ease-of-use, convenience, and seamless assistance with enrollment into PrEP financial assistance programs (Üsküp et al., 2022). In studies among Black and Latino/a MSM and transgender women, TelePrEP interventions have been shown to improve PrEP uptake and adherence (Kaiser Family Foundation, 2022; Sun et al., 2020; Touger & Wood, 2019; Wong et al., 2020); however, Latina and Black women have not been prioritized in similar investigations. We addressed this gap by developing and piloting a women-centered and culturally appropriate PrEP Information Session with Latina and Black women to increase their knowledge, awareness, and subsequent use of PrEP through PlushCare. Culturally appropriate refers to an approach that considers both cognitive (i.e., values, beliefs, and traditions) and structural (i.e., social position) aspects of culture (Williamson & Harrison, 2010). We selected PlushCare as our TelePrEP service because of its contractual arrangement with the California Department of Public Health, making PrEP more accessible to populations who could benefit most from PrEP (Advancing Access, 2020b, 2020a).

Here we describe outcomes from implementing our PrEP Information Session with Latina women (LW). We focus the analysis on LW study participants given their low levels of PrEP awareness (Baugher et al., 2021; Raifman et al., 2019) and the dearth of literature dedicated to the unique needs of this population. Existing literature homogenizes PrEP-related experiences of Latina and Black women. Our study sought to assess: 1) program success in increasing awareness and knowledge of PrEP and PlushCare as an option for accessing PrEP; 2) the acceptability and appropriateness of the Information Session; and 3) motivation for and interest in using PrEP and PlushCare.

Methods

Study Site

We partnered with East Los Angeles Women’s Center (ELAWC), a woman-led community-based organization (CBO), to implement our Information Session with its LW clients. Established in 1976, ELAWC began as the East Los Angeles Rape and Battering Hotline, which served communities in the Greater East Los Angeles area as the first Spanish language, 24-hour crisis hotline for survivors of sexual assault in Southern California. ELAWC’s client population primarily consists of monolingual, Spanish-speaking immigrants from Latin America, and is comprised of staff who culturally mirror the population they serve. Today, ELAWC provides culturally responsive, evidence-based, and trauma-informed services to women who are survivors of IPV and has established HIV prevention and treatment education programs; however, the CBO does not provide on-site clinical services. Taken together, these factors made ELAWC an ideal setting to implement the Information Session about PrEP and PlushCare as an option for accessing PrEP with LW.

Study Phases

The project was implemented between August 2020 and July 2021. In the pre-implementation phase, we developed an Information Session that consisted of 11 steps (See: Appendix 1) and trained ELAWC staff to deliver the sessions.

In the implementation phase, ELAWC staff were asked to conduct Information Sessions with at least 50 LW clients and completed monthly client engagement logs to track their progress. To ensure the sessions were culturally appropriate, health educators were staff who reflected the population of women participating in the sessions and had training and experience providing trauma-informed care. Staff were also encouraged to present the information in a manner they deemed appropriate for their client population (e.g., avoiding medical jargon and using language the women could understand, creating a safe space and inviting space for women to discuss their sexual behaviors without judgement). In addition, the training slides included information specific to women and their potential reasons for accessing PrEP (e.g., informing clients that it takes up to 21 days to build protective levels of PrEP in women and that PrEP is safe to take with birth control) (ViiV Healthcare, 2022). In describing the benefits, staff also could communicate that PrEP might be a great option for women who have difficulty negotiating condom use with partners, which would especially be important for sex workers and women experiencing IPV. Finally, all materials were made available in Spanish (e.g., the PrEP navigational resource) and clients had the option of signing up for a session in the language they felt most comfortable speaking.

In the post-implementation phase, staff referred LW clients who completed the Information Session to participate in a semi-structured interview with the study team. Staff were asked to refer approximately 25 LW to post-Information Session interviews. Recruitment was terminated once data saturation was reached (Hennink et al., 2017).

Data Collection

During the Implementation Phase, ELAWC staff completed client engagement logs to document the number of LW who completed the Information Session, type of session (i.e., individual or group), duration of session in minutes, language of the session (i.e., English or Spanish), and number of LW who expressed an interest in PrEP and/or PlushCare.

Post-Implementation In-Depth Interviews with Participants

A mixed methods approach was utilized during the in-depth interviews to assess the acceptability and appropriateness of the Information Session. As defined by Proctor et al. (2011), acceptability is the perception that a given intervention is agreeable or satisfactory. Appropriateness, on the other hand, refers to the perceived fit, relevance, or compatibility of an intervention for a given setting, population, or to address a particular issue (Proctor et al., 2011). By using a mixed methods approach, we were able to capture the rich and nuanced experiences of our participants while also assessing standardized, quantifiable outcome measures to ultimately achieve a more complete understanding of participant perspectives and program outcomes.

To qualitatively gauge acceptability, participants were asked to describe: 1) their experience participating in the Information Session, 2) what they liked/did not like about the Information Session, 3) their experience with the health educator who conducted the Information Session, and 4) if they found it easy/difficult communicating with the health educator during the Information Session. To assess appropriateness, participants were asked to describe: 1) how relevant the Information Session was to their life, 2) if the information about PrEP and PlushCare was easy/difficult to understand (and reasons why), and 3) what changes could be made to the Information Session to make it more useful.

To complement our qualitative findings, we integrated validated quantitative measures into the interview guide (e.g., the Acceptability of Intervention Measure [AIM] and the Intervention Appropriateness Measure [IAM]) (Weiner et al., 2017). The AIM measure was assessed using a five-point, Likert-type scale (from “completely agree” to “completely disagree”). To measure acceptability, participants were asked if the Information Session met their “approval,” was “appealing,” and if they “welcomed” the Information Session. The IAM measure was also assessed using a five-point, Likert-type scale (from “completely agree” to “completely disagree”). To measure appropriateness, participants were asked if the Information Session seemed “fitting,” “suitable,” “applicable,” and/or “like a good match.”

In addition, participants were asked to assess their level of concern about contracting HIV and awareness of PrEP and PlushCare prior to the Information Session, each using a four-point rating scale. To assess their knowledge of PrEP after the Information Session, participants were asked to describe basic PrEP-related information (e.g., percent effectiveness of PrEP, length of time after initiation before PrEP protects women, and whether PrEP protects against other STIs/pregnancy). Finally, participants were asked to describe their motivation for, interest in, and perceived advantages of using PrEP and PlushCare.

Interviews were conducted in English by two study team members (O.N. and E.R.C.) and in Spanish by a bilingual ELAWC staff member who was trained by the Project Director (O.N.) but not involved in recruiting study participants or delivering Information Sessions. Each interview was recorded through Zoom. The Institutional Review Board of University of California, Los Angeles approved all study procedures. Each participant provided prior verbal consent before participating and received a $50 e-gift card afterward.

Data Analysis

Qualitative data were analyzed using thematic analysis (Braun & Clarke, 2006). Interviews were transcribed verbatim and Spanish interviews were translated by a certified transcription and translation service. Following transcription, O.N. and E.R.C. used an inductive approach to develop an initial codebook based on transcript reviews, listing how and when to use each code and sub-code. The codebook was refined through an iterative process. Then, 20% of the transcripts were coded and tested for intercoder reliability using ATLAS.ti (version 8.0.42). Once an acceptable inter-coder reliability score was reached (i.e., Cohen’s Kappa > .80), the codebook was finalized and ATLAS.ti was used to code all remaining transcripts. After all data were coded, the study team reviewed coded passages to construct key themes. The study team also compiled the quantitative data collected from the interviews and monthly client engagement logs to calculate descriptive statistics using Microsoft Excel.

Results

Between March and June 2021, health educators at ELAWC conducted 26 Information Sessions with 94 LW. The majority of Information Sessions (77 %; n = 20) were conducted in Spanish and delivered as group sessions (65%). After Information Sessions, 17% and 6% of LW expressed interest in using PrEP and PlushCare, respectively.

Twenty post-implementation in-depth interviews were conducted with LW who completed an Information Session. Table 1 provides participant demographic characteristics, level of concern about HIV, and level of PrEP and PlushCare awareness prior to the Information Session [Table 1 near here]. The average age of participants was 41 years (range=26–62). The majority identified as heterosexual (89.5%), completed at least some high school (65%), were employed (full or part-time) (68.4%), had an annual income of $20,000 or less (70.6%), and had some health insurance (80%). Regarding the level of concern about HIV, the majority (75%) reported they were “not at all” or only “slightly concerned” about HIV.

Table 1:

Participant Demographic Information, Concern about HIV, Awareness of PrEP and PlushCare prior to Information Session (N=20)

Characteristic	N (%) or M, Range, SD
Age (in years)	M=41, Range=26–62, SD=7.7
Language of Interview
Spanish	15 (75.0)
English	5 (25.0)
Sexual Orientation (N=19)1
Straight/heterosexual	17 (89.5)
Bisexual	1 (5.3)
Don’t know/not sure	1 (5.3)
Relationship Status (N=19)1
Single and not dating anyone special	4 (21.1)
Partnered or married in a closed relationship	9 (47.4)
Dating someone in a closed relationship	3 (15.8)
Dating someone in an open relationship	2 (10.5)
Other2	1 (5.3)
Education level
8th grade (junior high) or less	3 (15.0)
Some high school	7 (35.0)
HS diploma or received GED	6 (30.0)
Some college, professional, vocational, or trade school	3 (15.0)
Bachelor’s degree	1 (5.0)
Employment Status (N=19)1
Unemployed	6 (31.6)
Working full-time	6 (31.6)
Working part-time	5 (26.3)
Other3	2 (10.5)
Income (N=17)1
$0–9,999	8 (47.1)
$10,000–19,999	4 (23.5)
$20,000–39,999	3 (17.7)
$40,000–59,999	1 (5.9)
$60,000–99,999	1 (5.9)
Health Insurance
Does not have health insurance	4 (20.0)
Medi-Cal	9 (45.0)
Private medical insurance or employer-provided insurance	1 (5.0)
Other insurance4	6 (30.0)
Concern about HIV
Not at all concerned	8 (40.0)
Slightly concerned	7 (35.0)
Somewhat concerned	3 (15.0)
Moderately concerned	0 (0.0)
Extremely concerned	2 (10.0)
Awareness of PrEP prior to Information Session
Nothing at all	12 (60.0)
Only a little	5 (25.0)
A moderate amount	2 (10.0)
A lot	1 (5.0)
A great deal	0 (0.0)
Awareness of PlushCare prior to Information Session (N=18)1
Nothing at all	18 (100.0)
Only a little	0 (0.0)
A moderate amount	0 (0.0)
A lot	0 (0.0)
A great deal	0 (0.0)

¹Only includes participants who answered the questions.

²Other includes “Single and sometimes I go out with someone”

³Other includes “Housewife”

⁴Others include: “LA Care,” “MyHealth LA,” and “Covered CA”

Four themes emerged from our qualitative data analysis, which include: 1) Information Sessions increased knowledge and awareness of PrEP and PlushCare; 2) Perceived Acceptability and appropriateness of Information Sessions; 3) Insufficient reasons to warrant use of PrEP; and 4) Positive attitudes about PlushCare.

Theme 1: Information Sessions increased knowledge and awareness of PrEP and PlushCare

LW participating in the Information Session consistently reported learning about PrEP for the first time or learning things they previously did not know about the medication. One participant shared:

I didn’t know there was medication to prevent HIV. I only knew about the medication for when you’re positive.

(Spanish speaker, age 42)

Despite low levels of prior awareness, LW demonstrated knowledge gained from the Information Session by answering PrEP-related questions correctly:

One of the things I learned [from the Information Session] is that you can take that pill daily, just like contraceptive pills… Women need to take it for more than a week to stay protected. It prevents HIV from entering the body in case you are with someone who’s HIV-positive.

(Spanish speaker, age 54)

The Information Sessions also increased knowledge and awareness of PlushCare. Unlike PrEP, PlushCare was new to all LW participants. Even still, some LW were able to describe PlushCare functions and system navigation after the Information Session:

You don’t have to go in person to set up an appointment. You basically do the appointment through the app and then submit your documentation…they ask you for whatever information that they may need through the app.

(English speaker, age 34)

Theme 2: Perceived Acceptability and Appropriateness of Information Sessions

Acceptability

Participants viewed the Information Session as an acceptable strategy to receive PrEP information, frequently commenting that the content was engaging and instructive:

I liked learning about this medication because I didn’t know it existed. I hadn’t heard of it. It was very informative. There wasn’t anything I didn’t like. I found everything interesting.

(Spanish speaker, age 42)

Health educators delivering the sessions positively impacted session acceptability, helping participants feel more comfortable discussing their sexual health:

I feel like she was very knowledgeable on the subject, and I just feel like she presented herself in a way where I could ask any questions. I felt comfortable talking to her. I felt like I was in a safe place to talk.

(English speaker, age 34)

LW also commented that PrEP and PlushCare information was easy to understand and comprehensive. In evaluating AIM measures [Table 2 near here], all participants either “completely agreed” or “agreed” that they liked the Information Session. Moreover, the vast majority of participants either “completely agreed” or “agreed” that the Information Session met their approval (95%) and was appealing (95%).

Table 2:

Acceptability and Appropriateness of the Information Session (N=20)

Characteristic	N (%)
Acceptability of Intervention Measure (AIM) (Weiner et al., 2017)
The Information Session meets my approval
Completely agree	9 (45.0)
Agree	10 (50.0)
Neither agree nor disagree	1 (5.0)
Disagree	0 (0.0)
Completely disagree	0 (0.0)
The Information Session is appealing to me
Completely agree	10 (50.0)
Agree	9 (45.0)
Neither agree nor disagree	1 (5.0)
Disagree	0 (0.0)
Completely disagree	0 (0.0)
I like the Information Session
Completely agree	14 (70.0)
Agree	6 (30.0)
Neither agree nor disagree	0 (0.0)
Disagree	0 (0.0)
Completely disagree	0 (0.0)
I welcome the Information Session
Completely agree	12 (60.0)
Agree	8 (40.0)
Neither agree nor disagree	0 (0.0)
Disagree	0 (0.0)
Completely disagree	0 (0.0)
Intervention Appropriateness Measure (IAM) (Weiner et al., 2017)
The Information Session seems fitting
Completely agree	8 (40.0)
Agree	12 (60.0)
Neither agree nor disagree	0 (0.0)
Disagree	0 (0.0)
Completely disagree	0 (0.0)
The Information Session seems suitable
Completely agree	10 (50.0)
Agree	9 (45.0)
Completely disagree	1 (5.0)
Disagree	0 (0.0)
Completely disagree	0 (0.0)
The Information Session seems applicable
Completely agree	8 (40.0)
Agree	9 (45.0)
Neither agree nor disagree	1 (5.0)
Disagree	2 (10.0)
Completely disagree	0 (0.0)
The Information Session seems like a good match
Completely agree	8 (40.0)
Agree	10 (50.0)
Neither agree nor disagree	2 (10.0)
Disagree	0 (0.0)
Completely disagree	0 (0.0)

Appropriateness

LW saw the Information Session as being relevant and “useful” to their lives, sexual health, and overall well-being:

I think it is very important to know that we have effective tools to take care of our health, not only our health but also our partners’ health.

(Spanish Speaker, age 43)

A participant who was formerly incarcerated described the sexual health concerns facing her community and potential benefits of PrEP and HIV testing:

I just paroled from prison 13 days ago and I see a lot of women in risk. I come from a very toxic community and stuff like that, so that’s what makes me interested in all this PrEP and getting tested for HIV and stuff like that.

(English Speaker, age 26)

Responding to the IAM measures, all participants “completely agreed” or “agreed” that the Information Session seemed fitting. Furthermore, the majority of LW either “completely agreed” or “agreed” that the Information Session seemed suitable (95%), applicable (85%), and like a good match (90%).

Theme 3: Insufficient reasons to warrant use of PrEP

When discussing the potential use of PrEP to prevent HIV infection, the majority of LW did not feel they had enough reasons to warrant using the medication because they were not engaging in behavior that would increase their chances of contracting HIV (e.g., being in a monogamous relationship or having no sexual partners):

I’m not concerned [about HIV], but I just want to make sure. I don’t feel like

I’m [at] risk…

(English Speaker, age 34)

Even still, LW liked knowing that PrEP is available as an option to help protect them from HIV, especially if they experience a change in sexual behaviors that would increase their likelihood of acquiring HIV:

Although I don’t have a relationship right now, I am interested, and I am concerned about what they explained to us because…for me, it is very important to know more about this and be able to get the medication because the moment I have a sexual relationship, I know I will be protected in many ways.

(Spanish speaker, age 50)

Theme 4: Positive attitudes about PlushCare

LW expressed favorable attitudes about PlushCare, viewing the platform as time-saving, convenient, and easy to use. A 34-year-old, English-speaking woman commented:

You don’t have to go anywhere. So, if you didn’t have a car, you want to save gas or save the trip of not going, it can all be done at home or at work or whatever the case may be. So, I think that would be its convenience.

Others liked knowing they could select Spanish-speaking providers through PlushCare and believed that PlushCare was a good option for women not comfortable going to a clinic for HIV services:

The benefit is that you can do it from the comfort of your home without having to go through the embarrassment of going to a clinic where there is a lot of people or being seen on the street entering a certain clinic. I think it’s beneficial in terms of confidentiality.

(Spanish Speaker, age 36)

Discussion

Our findings indicate that a women-centered and culturally appropriate Information Session delivered by staff who reflect the population they serve and offered through a woman-led CBO is an acceptable and appropriate strategy to help increase knowledge and awareness of PrEP among LW. While LW did not perceive themselves to be at high enough risk to justify PrEP usage, they were able to speak to PrEP and PlushCare benefits. In the following paragraphs, we expand on each theme and discuss potential implications for implementing PrEP Information Sessions with LW.

Consistent with existing literature, most LW who participated in the Information Sessions reported low levels of PrEP awareness (Auerbach et al., 2014; Collier et al., 2017; Goparaju et al., 2015; Üsküp et al., 2022). These findings suggest a need to educate LW about PrEP. Past research has demonstrated that once informed about PrEP, women are more willing to learn more about this prevention strategy and share this information with other women in their communities (Auerbach et al., 2014; Edelstein et al., 2014; Sales et al., 2019).

The implementation setting of ELAWC was imperative in LW viewing the Information Session as an acceptable and appropriate strategy for learning about PrEP and PlushCare. The service setting and deliverer are critical components of implementation acceptability (Proctor et al., 2011). Trusted women-serving organizations that provide gender, culturally, and linguistically appropriate services can be well-suited to support the PrEP-related needs of LW (Auerbach et al., 2014; Calabrese et al., 2018; Cohen, 2009; Felsher et al., 2018; Jackson et al., 2022; Johnson et al., 2021; Razon et al., 2021; Weiner et al., 2017). Within CBOs, such as ELAWC, trusted health education staff with a stigma free approach can enable LW to have candid conversations about their sexual health. Health educators in our study were all LW, aware of the population’s cultural context, and viewed as knowledgeable and trustworthy. They were relatable to the target population (e.g., shared cultural experiences) and exhibited key interpersonal skills including sensitivity, understanding, respectfulness, and adeptness in listening that can foster a safe and inviting space for women to learn about PrEP and discuss sexual behaviors (Lennox et al., 2021). As noted in the literature, integrating a culturally appropriate, women’s focus to PrEP information can serve as a facilitator to PrEP uptake among women (Walters et al., 2021). Future interventions seeking to increase PrEP uptake among LW might benefit from utilizing our Information Session model to provide LW with information and encouragement to make an informed decision about using PrEP.

While participants did not feel they had sufficient reasons to warrant using PrEP, they did recognize its possible advantages. Prior research among MSM and transgender women suggests that PrEP users experience many benefits after adopting PrEP, including reduced fear and anxiety about HIV, the ability to engage in serodiscordant relationships, and greater control/autonomy over their sexual health (Brooks et al., 2022; Carlo Hojilla et al., 2016; Collins et al., 2017; Whitfield et al., 2019). This latter benefit is especially significant for women who experience IPV or coercive relationships and are unable to negotiate condom use (Teitelman et al., 2022; Willie et al., 2017). Even with these benefits in mind, our interviews with LW found that the decision to initiate PrEP ultimately depended on each woman’s perceived risk of acquiring HIV. Prior research indicates women move in and out of periods of HIV risk as the context of their life evolves (e.g., change in relationship status, periodically engaging in sex work or survival sex) (Felsher et al., 2018). Conducting multiple Information Sessions, or booster sessions as new information becomes available (i.e., injectable PrEP) over time with LW may be essential given their evolving sexual risk behaviors.

Despite their low perceived HIV risk, LW expressed enthusiasm about PlushCare as an option for accessing PrEP in the future. One potential benefit of PlushCare and other similar telemedicine services is that it allows women to avoid the long wait times, limited clinic hours, stigma, and lack of anonymity they may face when seeking HIV prevention services in-person, which have been identified as barriers to PrEP services in past studies (Collier et al., 2017; Hirschhorn et al., 2020). Additionally, LW appreciated having the ability to tailor the online services to their language needs and provider preferences. These positive views of PlushCare suggest that TelePrEP is a promising tool that can benefit LW and others at risk for HIV.

Limitations

While the study resulted in important findings, we note some limitations and challenges of this short-term project. Anecdotal evidence from our post-implementation conversations with health educators suggests that the limited number of sessions (one plus a follow-up conversation by request per participant) and short timeline (four months) to complete the project might need to be revised to establish the trust needed to engage LW in starting and continuing with PrEP. Future PrEP implementation efforts should be mindful of the time required to work with LW to build trust and confidence in PrEP as an option for HIV prevention.

Conclusion

There is an urgent need to implement innovative strategies to increase knowledge of, trust in, and access to PrEP among LW. Unfortunately, LW are poorly prioritized in HIV prevention programming and continually lag behind other marginalized groups in their understanding of PrEP and its availability. Effective implementation strategies, such as our PrEP Information Session, can help LW understand the benefits and risks associated with using PrEP and options to access it (i.e., TelePrEP services and brick-and-mortar clinics). Our findings suggest that providing information through a trusted, woman-led CBO is key to successfully reaching LW. Finally, PrEP education efforts must be culturally appropriate to address LW’s specific needs and experiences.

Appendix

Appendix 1: Information Session Checklist for Health Educators

UCLA TelePrEP Project: Information Session Checklist

Please have the following documents ready before each session:

• TelePrEP Study Flyer

• PrEP Navigation Resource Sheet

• PlushCare Step-by-Step Tutorial

Find the documents at:

• Step 1: Identify women whom you believe may benefit from PrEP and conduct the TelePrEP Information Session.

  • If in your interactions with clients you identify women who are sexually active, you should go forward with providing the TelePrEP Information Session.
  • You may choose to initiate the TelePrEP session during these initial conversations or schedule a separate meeting via Zoom to discuss (1) PrEP and (2) PlushCare as an option for accessing PrEP.
  • You may conduct either individual or group information sessions with clients.
  • Inform clients that East Los Angeles Women’s Center is conducting these information sessions as part of the UCLA TelePrEP Project.
• Step 2: Assess the level of awareness and knowledge about PrEP with each client.

  • For example, you might ask: “Have you ever heard about Pre-Exposure Prophylaxis or PrEP for HIV prevention?”
  • If they say they have heard about PrEP, ask them to tell you what they know: “So, what do you know about PrEP?”
• Step 3: Provide education and fill-in knowledge gaps about PrEP.

  • Example statements can include: “PrEP is a medication that can prevent HIV by more than 90% when taken daily (1 pill every day). In order to maintain your PrEP prescription, you must see a doctor every 3 months and get tested regularly for HIV and sexually transmitted infections.”
  • Please note that this is a necessary step even among those who are aware of PrEP. It will also be important to correct any misinformation that may come up.
  • Examples of misinformation:

    • PrEP is a “magic pill” that will prevent all STIs
    • PrEP prevents against pregnancy
    • PrEP takes 7 days (or a week) to become effective in women
• Step 4: Discuss the benefits of PrEP with your clients.

  • For example, you might say: “There are some real advantages to using PrEP. For example, it may help reduce any fear, stress, or anxiety you have when having sex, particularly if you are concerned about getting HIV.”
  • You might also say: ““PrEP might also be a good option if you have difficulty talking to your partner or don’t know your partner’s HIV status.”
  • At this point, you may ask the client if they are interested in using PrEP. If a client expresses interest in PrEP, proceed to step 5.

    • If a client does not express interest in PrEP, proceed to steps 8–10 to conclude the session.

      • Make sure to note this in the client engagement log and document the reason why once the information session has ended.
• Step 5: Assess the level of awareness and knowledge about PlushCare for accessing PrEP with clients.

  • Begin by transitioning from the conversation from PrEP: “Now that we have discussed PrEP, I want to talk through some of the different options you have for accessing the medication. For example, have you ever heard of the online service called PlushCare?”
  • If they say they have heard about PlushCare, ask them to tell you what they know: “So, what do you know about PlushCare?”
• Step 6: Provide education and fill-in any knowledge gaps about using PlushCare for PrEP.

  • For example, you might say: “PlushCare is an app-based service you can use to access PrEP. You are able to schedule a virtual visit with a physician to see if you are eligible for PrEP, complete regular testing for HIV and other sexually transmitted infections at a participating Quest Diagnostics/LabCorp facility or in the privacy of your home [Tentative start date: February, 2021], and have the medication delivered directly to an address of your choosing.”

    • To find a Quest Diagnostics lab near you, visit the following link: https://appointment.questdiagnostics.com/patient/confirmation
    • To find a LabCorp facility near you, visit the following link: https://www.labcorp.com/labs-and-appointments-advanced-search
  • It will also be important to correct any misinformation that may come up about PlushCare.

    • Examples of misinformation include the belief that PlushCare can only be accessed as a subscription service that clients will have to pay for monthly.
• Step 7: Discuss the advantages of using PlushCare to access PrEP.

  • For example, you might say: “There are some real advantages to using PlushCare to access PrEP. For example, PlushCare is a good option for women who want to use PrEP but are working multiple jobs or caring for children or loved ones, and don’t have the time to see a doctor in-person every three months.”
  • You might also say: “PlushCare is also a good option for women who do not want to go to a local clinic where they may be recognized by peers or family members.”
• Step 8: Provide the link to the UCLATelePrEP Study Flyer to ALL clients who participated in the information sessions.

  • Here is some language you might use: “As part of this project, UCLA is conducting interviews with clients who participated in an information session. If you are interested in participating, call the number on the study flyer. You will receive a $50 e-gift card for completing the interview.”
• Step 9: Provide the PrEP Navigation Resource Sheet to assist clients with accessing and paying for PrEP.

  • This should be provided to ALL clients who participate in the information session.
  • Accessing PrEP

    • You should first note that PlushCare is an option for accessing PrEP remotely/from the privacy of their own home.

      • You may then direct clients to the other options for accessing PrEP listed on the resource sheet.
    • Paying for PrEP
    • You should first direct clients to information about the California PrEP Assistance Program (PrEP-AP).

      • Clients can sign up for PrEP-AP either by calling an enrollment worker through the PrEP-AP Call Center (844-421-7050) or by scheduling an appointment at one of the enrollment sites (see: PrEP- AP enrollment site tracker).

        • Note: Some enrollment sites have switched to virtual visits. Instruct clients to call the site ahead of time to see if they can apply remotely or if they have to schedule an in-person visit.
      • You may then direct clients to the other medication assistance programs listed on the resource sheet that they may apply for.
      • This includes the $200 credit available through the UCLA TelePrEP Study to all clients who use PlushCare to access PrEP.

        • The $200 credit can be used for PrEP-related medical appointments (consultation fee or co-pay) and lab tests.
    • At this point, you may ask the client if they are interested in using PlushCare to access PrEP.

      • If the client is interested in using PlushCare, proceed to step 10.
      • If the client is not interested in using PlushCare, they may contact the project staff in the future at (310) 794–0229 to access the $200 credit.
• Step 10: Provide PlushCare step-by-step tutorial and agency project code.

  • If a client has expressed interest in using PlushCare to access PrEP, you may choose to walk her through downloading the application on their mobile device and/or signing up for an account online. These instructions are also outlined in the PlushCare step-by-step tutorial, which is made available in both video and PDF format.
  • Clients can download the PlushCare app through the app store on their Android or Smartphone. They may also sign up with PlushCare through their web browser.
  • Provide an assigned agency project code to the client and instruct them to enter the code when providing payment information on PlushCare to redeem the $200 credit. You can choose to email or text the project code to the client.

    • When discussing the project code, you might say: “If you decide to use PlushCare for PrEP, you can use your assigned project code to access the $200 credit available through the study. Please provide the project code when you enter your payment information.”
    • You might also say: “The purpose of the project code is to get a group snapshot of women who access PlushCare after completing an information session with our agency. For example, this can include the number of women who access PlushCare for PrEP, receive a prescription, and complete follow-up visits. All data will be anonymous.”
  • If you or a client has questions about the PlushCare application or how to pay for PrEP services through PlushCare, please contact the PlushCare Navigation Team at 800-221-5140 or prepap@plushcare.com.
• Step 11: Complete the client engagement log after each session.

  • Find blank logs in the UCLA Box.
  • Make sure to include the following information:

    • Session type (individual or group session)
    • # BLCW participating in the TelePrEP information session
    • Approximate time spent talking about PrEP and PlushCare (in minutes)
    • # BLCW interested in PrEP
    • # BLCW interested in using PlushCare for PrEP
    • Any relevant notes or significant information about the session.
  • Upload completed logs in the ELAWC folder or BWW folder at the end of each month.