Pre-exposure Prophylaxis (PrEP) Implementation in a Reproductive Health Setting: Perspectives from Planned Parenthood Providers and Leaders

Abstract

Integrating pregnancy and HIV prevention services would make reproductive healthcare settings an optimal venue for the promotion and delivery of pre-exposure prophylaxis (PrEP) to cisgender women. However, these settings have been slow to adopt PrEP. Planned Parenthood clinicians and leaders possess critical insight that can help accelerate PrEP implementation in reproductive healthcare settings and elements of the Consolidated Framework for Implementation Research (i.e., relative priority of the intervention to staff, implementation climate, available resources to implement the intervention, and staff access to knowledge and information about the intervention) can shed light on elements of Planned Parenthood’s inner setting that can facilitate PrEP implementation. In this study, individual 60-minute interviews were conducted with clinical care team members (n=10), leadership team members (n=6), and center managers (n=2) to explore their perspectives on PrEP implementation and associated training needs. Transcripts were transcribed verbatim and thematically analyzed. Despite having variable PrEP knowledge, participants (100% women, 61% Non-Hispanic White) expressed positive attitudes toward implementing PrEP. Barriers and facilitators toward providing PrEP were reported at the structural, provider, and patient levels. Participants desired PrEP training that incorporated culturally competent patient-provider communication. While participants identified ways that Planned Parenthood uniquely enabled PrEP implementation, barriers must be overcome to optimize promotion and delivery of PrEP to cisgender women.

INTRODUCTION

Daily oral pre-exposure prophylaxis (PrEP) for HIV is a well-tolerated, user-controlled method offering discreet protection against HIV infection. However, even with its demonstrated efficacy (Baeten, et al., 2012; Thigpen, et al., 2012), PrEP uptake among U.S. cisgender women¹– including cisgender women of color, who are disproportionately affected by HIV compared to white cisgender women (Centers for Disease Control and Prevention [CDC], 2021)– remains low (Bradley, et al., 2019b; Hodges-Mameletzis, et al., 2019; Lambert, Marrazzo, Amico, Mugavero, & Elopre, 2018; Siegler, et al., 2018). In 2017, women accounted for only roughly 5% of PrEP users (Siegler, et al., 2018) despite accounting for 19% of new HIV infections in 2019 (CDC, 2021).

Because PrEP can serve as a gateway to sexual and reproductive health services, and vice versa, reproductive healthcare settings may be optimal for the promotion and delivery of PrEP to cisgender women (Hodges-Mameletzis, et al., 2019; Sales, et al., 2019; Seidman, et al., 2018). HIV prevention has been identified as a core component of reproductive care services (Gavin & Pazol, 2016), and research indicates that some women perceive reproductive healthcare settings, including Planned Parenthood, to be the most trusted and appropriate places for the receipt of HIV prevention information and services (Auerbach, et al., 2015). Planned Parenthood is an international nonprofit organization with more than 600 centers across the U.S. serving populations disproportionately impacted by HIV, and over 85% of Planned Parenthood patients are female (Fowler, Gable, & Lasater, Family Planning Annual Report: 2020 National Summary, 2021; Planned Parenthood Federation of America, 2020). Planned Parenthood of Southern New England (PPSNE) has 17 centers providing reproductive and sexual health care services to patients in Connecticut and Rhode Island. Of the 78,050 clients served by PPSNE in 2019, 87% were female and 45% were Black or Latinx (Planned Parenthood of Southern New England, 2019).

Reproductive healthcare settings such as Planned Parenthood may be particularly well-suited for PrEP provision to cisgender women for many reasons, including routine sexual health screenings and a shared decision-making approach to care initiation (Pollock & Levison, 2018; Sales, et al., 2019; Seidman & Weber, 2016; Seidman, et al., 2018). However, research to date, most of which has not focused on cisgender women or reproductive healthcare settings (AIDS Vaccine Advocacy Coalition, 2019), also highlights potential challenges, including limited provider time and resources, competing patient needs, and the need for PrEP-specific provider training (Bradley, et al., 2019a; Collier, et al., 2017; Sales, et al., 2019). The Consolidated Framework for Implementation Research (CFIR) provides a practical guide for assessing barriers and facilitators to PrEP implementation (Damschroder et al., 2009). A key domain of the CFIR is the organization’s inner setting, which contains 12 constructs including compatibility between the organization and the intervention; the relative priority of the intervention’s implementation to the organization’s staff; the implementation climate of the organization; the organization’s available resources; and access to knowledge and information about the intervention among organization staff (Damschroder et al., 2009). Further understanding of PrEP implementation barriers, facilitators, and training needs in reproductive healthcare settings—particularly as they relate to these constructs—is needed to optimize PrEP delivery to cisgender women in these settings. In the current qualitative study, we explored prior PrEP knowledge, attitudes toward PrEP, perceptions of PrEP eligibility and provision, and training needs among Planned Parenthood clinical care and leadership team members. We utilized the CFIR to guide our interpretation of findings.

METHODS

Participants

Eighteen interviews were conducted with members of the PPSNE clinical care team (n=10), members of the PPSNE leadership team (n=6), and managers (n=2) of outside reproductive health centers that had already begun offering PrEP. While leadership team members may have had degrees in clinical fields, they had less direct patient interaction compared to clinical care team members. Participants were invited to participate in the study via direct outreach (i.e., email, phone, or in-person by the principal investigator or a co-investigator).

Procedures

Data were collected as part of a needs assessment for a broader study testing different implementation strategies to optimize PrEP delivery. Semi-structured interviews were conducted in English by CS and RG via phone between July and October 2016 and lasted approximately 60–90 minutes. At the time of data collection, PPSNE had recently begun offering PrEP at their health centers. Participants also completed a brief questionnaire assessing their sociodemographic characteristics, medical background, and prior clinical experience with PrEP to describe the sample and contextualize reported experiences. Participants were not compensated for participation per Planned Parenthood policy. However, clinical care and leadership team members received PrEP resource packets to increase their general knowledge of PrEP and aid in their promotion and provision of PrEP to patients.

Interviewees received background information about PrEP in two ways prior to answering interview questions. First, a PrEP training in the form of a PowerPoint presentation and role-play demonstration was provided for members of the PPSNE clinical care team by two study team members (SKC and CS) and two paid consultants.¹ Leadership team members were also welcomed to attend. The training took place prior to the interviews because of clinical demand and to provide participants with a general understanding of PrEP before asking them to share their perspectives about PrEP implementation and training at PPSNE. Training content included the efficacy of PrEP; the eligibility criteria outlined in the CDC clinical practice guidelines; a clinical protocol for PrEP prescription and monitoring; and patient-provider communication about sex. Second, to ensure that even participants who may not have attended the PrEP training had a basic understanding of PrEP before sharing their perspectives about PrEP implementation and training, all participants were read a description of PrEP and post-exposure prophylaxis (PEP) at the time of the interview (Appendix A).

Yale University Institutional Review Board (Human Research Protection Program; HIC Protocol #1603017382) approved all study procedures. Verbal informed consent was obtained from all participants at the outset of the interviews, during which ethical considerations—including confidentiality, risks and benefits associated with study participation, and participant rights—were covered. The interviewer reviewed the research procedures with the participant and invited the participant to ask questions. Participants were informed that data would be used to develop training materials and protocols for the broader PrEP implementation study.

Analysis

Interviews were audio-recorded and transcribed verbatim, and transcripts were imported into NVivo 12® for data management and analysis. The analysis was guided by the Framework Method, a systematic approach to qualitative data analysis that has been specifically recommended for use within multidisciplinary health research (Gale, et al., 2013). The approach encompasses seven stages: transcription, familiarization with the interview, coding, development of a working analytic framework, application of the framework, charting data, and interpretation (Gale, et al., 2013). One of the interviewers (CS) drafted an initial analytic framework containing codes, or descriptive labels used to define concepts (e.g., perceived PrEP effectiveness), which were organized into broader conceptual categories (e.g., PrEP knowledge, attitudes, and perceptions). The framework was subsequently refined through an iterative process, during which two co-authors (BCW and DFO) independently coded transcripts (i.e., applied codes to textual data) and then reconvened, along with the principal investigator (SKC), to discuss, revise, and add new codes. This process allowed for the identification of newly emergent themes. The final analytic framework was used by (BCW and DFO) to code all transcripts, with a 20% overlap of transcripts to ensure consistency in code application.

Reflexivity, or transparency about the biases, values, and experiences that the researchers bring to the study, was sought throughout the process of data collection and analysis (Creswll, 2013). The principal investigator and co-authors entered into this research with prior knowledge of PrEP’s efficacy and the shared belief that PrEP should be accessible to people at risk for HIV infection and provided in reproductive health settings. The interviewers sought to pose interview questions in a neutral manner without conveying personal opinions.

RESULTS

Sample Characteristics

Self-reported participant characteristics are presented in Table 1. Clinical care team members ranged in age from 24 to 55 years [M(SD) = 37(10)] and leadership team members and center managers ranged in age from 35 to 60 years [M(SD)= 46(10)]. Participants, all of whom identified as women and one of whom also identified as gender queer, were primarily (61%) non-Hispanic White. Most (90%) of the clinical care team members reported that they had heard of PrEP and more than half (62%) of clinical care team members indicated that they were “somewhat comfortable” or “very comfortable” prescribing PrEP according to a 5-point scale ranging from “not at all comfortable” to “extremely comfortable.” None of the clinical care team members reported being “extremely comfortable” prescribing PrEP (Table 1). Clinical care team members indicated that they had previously discussed PrEP with an average of 5 (SD=4) HIV-negative patients as part of their clinical practice.

Table 1.

Sociodemographic Characteristics of Participants (n=18)

Sociodemographic Characteristics	Leadership Team (n=8)a	Clinical Care Team (n=10)
	n (%) b	n (%) b
Age (mean, SD)	46 (10)	37 (10)
Gender b
Woman	8 (100)	10 (100)
Gender queer	0 (0)	1 (10)
Race/Ethnicity
Non-Hispanic Black	0 (0)	2(20)
Non-Hispanic White	7 (87)	4 (40)
Hispanic	1 (12)	4 (40)
Previously Heard of PrEP *	N/A
Yes		9 (90)
No		1 (10)
Comfort Prescribing PrEP * c	N/A
Not at all comfortable		2 (25)
A little bit comfortable		1 (12.5)
Somewhat comfortable		1 (12.5)
Very comfortable		4 (50)
Extremely comfortable		0
Yrs. of Clinical Experience (mean, SD) *	N/A	10 (9)
Patients with whom PrEP was Discussed (mean, SD) *	N/A	5 (4)

^aCenter managers from outside reproductive health centers that had already begun offering PrEP (n=2) were combined with PPSNE leadership team members (n=6) to avoid identification

^bTotal exceeds n because one participant endorsed two responses

^cOnly asked of participants who reported previously hearing of PrEP (n = 9); data missing for 1 participant

^*Only asked of clinical care team members

PrEP Attitudes, and Perceptions

The following sections summarize primary qualitative themes identified from the semi-structured interviews related to PrEP attitudes and perceptions. Themes and representative quotes are summarized in Table 2.

Table 2.

Summary Themes of PrEP Knowledge Attitudes and Perceptions Identified from Leadership and Clinical Team Member Interviews

Themes and Subthemes	Representative Quotes
PrEP Attitudes and Perceptions
PrEP Attitudes	I think that it’s a great... form of... protection for patients who are maybe at high risk. Um, if, you know, they feel that they’re at high risk or they have multiple partners or a partner with, you know, HIV then, you know, it’s great to be able to offer them something that could potentially, you know, help them from that, from contracting that, that virus. [Clinical Care Team Member 10]
	I think it’s, uh, a wonderful addition to the services we provide. [Leadership Team Member 1]
	I would love to [provide PrEP]. I think – I’m really excited to be part of this. I think it’s a wonderful service to be able to provide. [Clinical Care Team Member 2]
Integrating PrEP Service Delivery	Well, I think that they go hand in hand. So, you know, the same behaviors that lead to pregnancy like sexual intercourse are the same thing that could lead to HIV exposure, and so, they’re just kind of directly related. [Leadership Team Member 6]
	Well, I mean, we have women coming into us all the time for pregnancy prevention and we do a risk assessment, so we assess them for STD risks, which would be theoretically a good time to, um, talk about HIV prevention. [Leadership Team Member 2]
	...they do go hand in hand because if you’re pregnant it’s because unprotected sex happened. Or something failed. The condom broke...and that goes hand in hand with [HIV] exposures as well. [Clinical Care Team Member 4]
Perceived Responsibility for Provision	That staff member [clinical assistant] is, you know, comfortable taking the initial history and comfortable having an initial conversation of what PrEP is and how it fits into an overall HIV risk reduction strategy and then our clinicians are comfortable sort of reviewing that history going through with the patient and, and writing the prescription...all of the health center staff feel pretty capable of, you know, kind of doing a basic explanation of what PrEP is, distributing the information sheets and, and having that conversation about whether, you know, how good a choice it would be for the client. [Center Manager 1]
	The clinician would need to be involved for prescribing the medication and things like that. Um, but I – my hope is that we are all comfortable at least broaching the subject with patients that we feel are appropriate. [Clinical Care Team Member 2]
	Well, ideally, they’d get identified by the medical assistant and then the clinician would be able to tack on extra time at the end of the visit...Because it truly has to be the clinician that does the final assessment. [Leadership Team Member 4]
	I think that...ultimately the clinician is responsible for...prescribing and making that clinical judgement about whether that person is a good candidate. But... trying to assess whether someone can take a pill at the same time every day. I mean, our medical assistants do that now with, um, birth control [Leadership Team Member 6]
PrEP Implementation Barriers and Facilitators
Barriers	I mean, at the beginning there might be some, um, some additional time that will be, that will need to be dedicated to those patients just because we need to assess risk. You need to do a little more legwork than regular, um, than other patients. And then, um, there’s that insurance component. If they donť have insurance then, you know, getting them to be approved by the pharmaceutical for assistance. Those things will take a little longer at the beginning. [Leadership Team Member 1]
	I’m trying to keep up with...this training... we need it, we need it now, so our staff are fully prepared to provide good service in our health centers... I also donť want someone walking into one of our health centers and having a really bad experience because the staff, [say] “PrEP? Whaťs PrEP?”. [Leadership Team Member 5]
	I think people donť take Planned Parenthood seriously. I think, I think a lot of places take us as a joke. I think people think that we only do abortions and pregnancy tests and things like that... So, I’m wondering if some men are going to say, “Well, they only do STD testing. Why am I going to go to get prescribed medication, you know, from them? Why am I going to take them as like a primary care facility?” So, I think that stigma from society may be against us. [Clinical Care Team Member 5]
Facilitators	...the provider would do the initial visit... and the centralized follow-up people would be sending the reminder letters to the patient or calling the patient to say, ‘You’re due for your three-month check.’ [Leadership Team Member 2]
	... because we’re a Planned Parenthood, we already ask really intimate questions, and a lot of our clinicians provide, um, you know, well-rounded healthcare even though we’re focusing on women’s health and STD prevention and so on. [Leadership Team Member 3]
	Um, they trust us, especially with their sexual and reproductive health, which is wonderful... this is what we’re known for... we’re on the cutting edge of a lot of things thankfully. Like, we are way ahead of a lot of things, which is wonderful, um, and our patients know that. [Clinical Care Team Member 2]

PrEP Attitudes.

The majority of participants expressed positive attitudes toward PrEP, referring to it as “great” and “important” and stressed the potential benefit to patients at high risk for HIV. When asked how they would feel about PrEP being offered at Planned Parenthood specifically, most felt that it would be a “wonderful addition” to the services already offered. However, two participants, both members of the clinical care team, expressed ambivalence toward PrEP due to the possibility of risk compensation. One of the participants (Clinical Care Team Member 5) explained: “… I’m worried that people are not going to want to use condoms … that people are going to think that they’re invincible and they’re not at risk for any STDs…”

Perceptions Regarding Integrating PrEP Service Delivery at PPSNE.

Most participants believed that HIV and pregnancy prevention were directly connected. Clinical Team Member 4 explained: “…they do go hand in hand because if you’re pregnant it’s because unprotected sex happened…and that goes hand in hand with [HIV] exposures as well.” Several participants compared PrEP to birth control, both in its function and the long-term nature of its use. However, one participant (Clinical Care Team Member 6) did not see HIV prevention and pregnancy prevention as related, given the demographic of patients accessing HIV prevention services: “I really think that they’re a little bit different…because most of the patients who are at high-risk for HIV that we have seen in this office are men having sex with men.”

Perceptions Regarding Responsibility for PrEP Provision.

Participants felt that all Planned Parenthood staff members, including non-clinicians, should be able to provide patients with “a basic explanation of what PrEP is.” Clinical Care Team Member 9 stated: “…we all share that responsibility…You know, us ACAs [advanced clinic assistants] and our clinician…our front desk person….” Participants felt that clinic assistants and clinicians should both be involved in the process of PrEP provision but in different capacities. Specifically, clinic assistants, who ordinarily conduct sexual/social histories, would be tasked with gathering a medical history and conducting a risk assessment that could identify potential PrEP indications. Then, clinicians would be responsible for confirming the information gathered by the clinic assistants, discerning PrEP candidacy, ordering the appropriate lab work, and writing the prescription.

PrEP Implementation Barriers and Facilitators

The following sections summarize primary qualitative themes identified from the semi-structured interviews related to PrEP implementation barriers and facilitators. Themes and representative quotes are summarized in Table 2.

Barriers.

Participants identified both actual and perceived structural-, provider-, and patient-oriented barriers and facilitators to PrEP implementation at Planned Parenthood. The most commonly noted structural barriers were potential insurance issues—including coverage for patients and reimbursement for Planned Parenthood—and the anticipated increased time associated with PrEP visits, which could disrupt clinic flow. In addition, Center Manager 2 mentioned the cost of fourth generation HIV tests as an actual barrier to PrEP implementation at a Planned Parenthood where PrEP was already being offered: “…we looked into the fourth-generation rapid test. Um, it’s significantly more costly and…It’s the patients who are at high risk for HIV where the fourth-generation test becomes much more relevant…the window [period between exposure and detection of infection] is smaller…so it’s…a dilemma in our transition to providing PrEP….”

The most common provider-oriented barrier named by participants was the need for additional PrEP-specific training among staff to increase staff comfort and familiarity with PrEP, accurately identify patients for whom PrEP is appropriate, and answer patient questions regarding PrEP. Center Manager 1 also mentioned the need to get “really good training out to staff” as an actual barrier to PrEP implementation that she had experienced.

One potential patient-oriented PrEP implementation barrier commonly identified by participants was patient non-adherence to the medication and/or visit schedule. Another common patient-oriented barrier that participants perceived was the negative and sometimes inaccurate perceptions that some people have about Planned Parenthood. Clinical Care Team Member 5 shared: “…I think people think that we only do abortions and pregnancy tests and things like that… So, I think that stigma from society may be against us.”

Facilitators.

Structural factors that could potentially facilitate PrEP implementation at Planned Parenthood included securing buy-in from staff and leadership, publicizing that Planned Parenthood offers PrEP, and utilizing the centralized follow-up department – a team of nurse practitioners who monitor the electronic medical record and provide positive STI and abnormal pap smear results – to order labs and remind patients of subsequent visits required for PrEP maintenance. Center Manager 1 also mentioned being able to follow up with patients as an actual (not just perceived) facilitator to PrEP implementation: “…so that’s a huge facilitator because…there are a number of labs that you do at baseline and having [the centralized follow-up] department really informed about PrEP…has really helped…they have a major role to play in the roll out.”

Staff members’ knowledge of sexual health and whole-person, non-judgmental approach were the most commonly identified provider-oriented factors that could serve to facilitate PrEP implementation at Planned Parenthood. Potential patient-oriented PrEP implementation facilitators identified by participants included the prevalence of HIV risk behavior reported among Planned Parenthood’s clientele (e.g., transactional sex, injection drug use) and patient perceptions of Planned Parenthood as being “cutting edge”, and therefore a likely source for PrEP.

PrEP Implementation Support Needs

The following sections summarize perceived training and resources needed to support PrEP implementation that were identified from the semi-structured interviews. Themes and representative quotes are summarized in Table 3.

Table 3.

Summary Themes of PrEP Training Attitudes and Perceptions Identified from Leadership and Clinical Team Member Interviews

Themes and Subthemes	Representative Quotes
Training Attitudes and Perceptions
Perceived Additional Training Needs	Yeah, gathering everyone for staff meeting... maybe some role play around it, um, as well, like how to talk to patients, some language to use, um, guidelines on who would be appropriate candidates and who we should be talking to about it, yeah. [Clinical Care Team Member 2]
	So maybe, um, more role playing where the, um, the patient’s more difficult and has more in-depth question. [Clinical Care Team Member 3]
	Um, well, I certainly, you know, require medical information. But I think certain sensitivity training is also important. And you know, training around vocabulary and...just learning about different communities... [Leadership Team Member 6]
	Group activities...Um, just more hands on. Like, so non-formal. Like this, how we’re talking, I don’t feel like any, like, pressure... just a comfortable environment ready for everyone to just learn and just soak up some information. [Clinical Care Team Member 9]
Perceived Need for Ongoing Access to Resources	Someone that you can call that knows what they’re talking about in case you do get a question you can’t answer or [don’t] have an answer to. [Clinical Care Team Member 3]
	Uh, yeah. Sure. Just a contact. Either we can e-mail and/or call...I would probably just be like, “Hey, I have a question.” Um, but, yeah, just having that contact information if we did have any, you know, questions or concerns. [Clinical Care Team Member 9]
	You know what’s nice to have in general? ...it’s like a chart. Uh – algorithms!...We love algorithms. We love, like, if you do this, do this, do that, do this...Yeah, we like, like, cheat sheets, like one-page cheat sheets. [Clinical Care Team Member 1]
	...it’d be nice to have like a checklist of, like, reminders for PrEP, um, just like a check – like bullet points of information just like I think that lengthy written things can kind of get lost when it comes to the staff. They’re busy, they’re seeing patients, so, just kind of like a little checklist of, like, reminders or helpful things to know or facts, PrEP facts. [Clinical Care Team Member 7]

Perceived Additional Training Needs.

Even those participants who had received prior PrEP training reported that additional/ongoing training was needed. Among the specific recommendations provided were additional role play activities that focus on communicating information about PrEP to different types of patients in a culturally-sensitive manner and other hands-on activities.

Perceived Need for Ongoing Access to Resources.

When asked about resources needed to support the provision of PrEP, participants identified both human and non-human resources. Having a specialist available to answer clinical care team members’ PrEP-related questions, either in-person or via phone, was the most common human support identified by participants. Clinical Care Team Member 3 explained: “Someone that you can call that knows what they’re talking about in case you do get a question you can’t answer or [don’t] have an answer to.” Non-human resources suggested by participants included algorithms for identifying appropriate candidates, flow diagrams for prescribing and clinical monitoring, and fact sheets. Clinical Care Team Member 7 shared: “…it’d be nice to have like a checklist… like bullet points of information…or facts, PrEP facts.”

DISCUSSION

Given the dismal uptake of PrEP among U.S. cisgender women, PrEP studies have begun and should continue to focus on this population (Calabrese, et al., 2019; Hodges-Mameletzis, et al., 2019). This study provides novel and needed insight by illuminating the perspectives of reproductive health leaders and providers regarding PrEP implementation and training needs. Regarding aspects of PPSNE’s inner setting, key findings include the importance of integrating PrEP with reproductive health services; the existence of both barriers and facilitators to PrEP implementation at multiple levels; and desire for ongoing training and access to a PrEP specialist and other resource needs to support PrEP implementation.

According to the CDC and the Office of Population Affairs, HIV prevention services fall under the umbrella of family planning services (Gavin & Pazol, 2016). Researchers have advocated for the integration of PrEP specifically into reproductive services (Aaron, et al., 2018; AIDS Vaccine Advocacy Coalition, 2019; Siedman & Weber, 2016; Unger, et al., 2020), and the American College of Obstetricians and Gynecologists has endorsed the use of PrEP among obstetrician–gynecologists (American College of Obstetricians and Gynecologists, 2014). Likewise, participants in our study believed that HIV prevention was connected to pregnancy prevention and compared PrEP to birth control, underscoring the compatibility between PrEP and PPSNE and its potential integration with existing services (Damschroder et al., 2009). Similar to other studies of staff at women-serving organizations (Bradley, et al., 2019a; Collier, et al., 2017), attitudes toward implementing PrEP were overwhelmingly positive. Clinical care team members were motivated to offer PrEP if available through PPSNE, which is promising given that women may look to their providers to inform them of HIV prevention options (Aaron, et al., 2018; Auerbach, et al., 2015). Moreover, research has shown that sexual and reproductive healthcare settings are the primary or only sources of care for many women, underscoring the role of providers in these settings in the discussion and provision of PrEP (Hall, 2017; Kaiser Family Foundation, 2014). Staff attitudes toward PrEP also demonstrate the relative priority of PrEP implementation to PPSNE staff (Damschroder et al., 2009).

Consistent with other studies, participants in our study identified barriers to PrEP implementation at the structural level (e.g., increased visit time) (Calabrese, et al., 2016; Seidman, et al., 2018), provider level (e.g., the need for additional PrEP-specific education and training) (Bradley, et al., 2019a; Bleasdale, et al., 2020; Seidman, et al., 2018), and patient level (e.g., patient non-adherence) (Calabrese, et al., 2016) One emergent barrier unique to Planned Parenthood, and perhaps reproductive healthcare settings more broadly, was the negative and often inaccurate perceptions that people have about Planned Parenthood, such as the misperception that it is an abortion-only facility. Participants in our study also identified facilitators at the structural, provider, and patient levels, including the use of the centralized follow-up department, staff expertise in sexual health, and positive patient perceptions of Planned Parenthood. The barriers identified by PPSNE staff shed light on the implementation climate of PPSNE, or its capacity for change (Damschroder et al., 2009), and must be minimized to facilitate effective implementation.

Participants in our study advocated for more training that would facilitate culturally-sensitive conversations with patients; access to a PrEP specialist; and access to printed or electronic reference materials. Similarly, clinicians in other studies have highlighted the importance of cultural sensitivity training and ongoing access to human and non-human resources (Bleasdale, et al., 2020; Calabrese, et al., 2016). Interestingly, compared to more traditional didactic teaching methods (e.g., PowerPoint presentation, webinar, etc.), participants in our study felt strongly that role play activities would be an especially effective format for future trainings. The training and resource needs identified by staff also underscore the current state of available resources at PPSNE as well as the staff’s access to knowledge and information that would facilitate the implementation of PrEP (Damschroder, et al., 2009)

Limitations

Findings from our study should be considered in light of several limitations. First, our study utilized a purposeful sampling strategy to gain key insights pertaining to PPSNE; although some of the insights may also apply to other reproductive health settings, results are not intended to be broadly generalizable. Our sample lacked the diversity that may be characteristic of other settings, with all participants identifying as women (and one identifying as both a woman and gender queer) and most identifying as White. Additionally, participants were primarily recruited from Planned Parenthood centers on the east coast of the United States.

Second, since several study co-investigators were affiliated with Planned Parenthood, social desirability bias may have affected the personal behaviors, attitudes, and preferences reported by our participants. However, we attempted to minimize bias by having research team members unaffiliated with PPSNE conduct the interview and by posing interview questions in a neutral manner without conveying personal opinions. Additionally, Planned Parenthood-affiliated co-investigators did not access the transcripts in full or have knowledge of the participant identity affiliated with any given excerpt.

A final consideration in interpreting these findings is that all participants were provided with a basic description of PrEP (embedded in the interview) and seven of the ten clinical care team members underwent a 1.5-hour training session, which was led in part by members of the study team. The training took place prior to all interviews, but attendance at the training was not a prerequisite for study inclusion. During the interview, all participants were asked whether they attended the training to quantify the proportion who did. Although both the description of PrEP and the training session were intended to be factual, they nonetheless may have influenced participant responses. Specifically, attendance at the training session likely increased the number of participants who reported on the background questionnaire that they had previously heard of PrEP. Additionally, exposure to the training likely influenced perceived implementation support needs in particular. For example, a participant’s recommendation of role play activities related to patient-provider PrEP communication may have been prompted by the patient-provider communication role play to which she was exposed during the training. Future research should explore the impact of different training content and formats on providers’ PrEP implementation attitudes.

Future Directions and Clinical Implications

Increased PrEP uptake among U.S. cisgender women will depend in large part on (a) PrEP being provided in healthcare settings accessed by such women and (b) providers who are knowledgeable, are appropriately trained, and have the infrastructural resources to incorporate PrEP service delivery into patient care. Planned Parenthood may be an optimal venue for PrEP health promotion and delivery to cisgender women given clinicians’ existing expertise in sexual health and family planning. Participants expressed positive views toward PrEP and identified ways that Planned Parenthood’s inner setting uniquely enabled implementation. However, the findings underscore a continued need for PrEP and cultural sensitivity training among providers as well as clinic protocols to maximize efficiency in clinic flow and streamline payment and insurance navigation.

Appendix A: PrEP and PEP Description Provided at Time of Interview

PrEP and PEP are both medications that help people who are HIV-negative stay HIV negative. They can be prescribed for people who are at risk for HIV because of sexual behavior, drug behavior, or both; this includes heterosexual women, heterosexual men, gay and bisexual men, transgender women, and injection drug users. PrEP in particular can be used with heterosexual couples who are trying to get pregnant when one of the partners is HIV-positive. PrEP refers to pre-exposure prophylaxis. It is antiretroviral medication taken on an ongoing basis by individuals BEFORE they engage in behavior that puts them at risk for HIV. Right now, there is just one form of PrEP approved in the U.S.: A once-a-day pill called Truvada. PEP refers to post-exposure prophylaxis. It is an antiretroviral regimen taken by individuals for 28 days immediately AFTER they think they’ve been exposed to HIV in order to prevent the HIV virus from establishing an infection within their body. The medication ought to be started within 72 hours of the exposure event. So, to summarize, PrEP is usually taken to prevent HIV for ongoing risk, whereas PEP is taken in emergency situations after a risk event has already occurred.

Right now, PPSNE does not offer either PrEP or PEP. However, they plan to implement PrEP in the near future¹. In 2015, Planned Parenthood released guidelines for prescribing PrEP at its centers, which are based on national guidelines issued by the CDC. According to these guidelines, the initial visit involves a risk assessment, HIV and STI testing, and other lab work. The client returns for follow-up appointments every 3 months, at which time HIV and STI testing are repeated and routine assessment and counseling around PrEP adherence and sexual risk are performed. Although PPSNE will be rolling out PrEP at its centers this year, there are no immediate plans to roll out PEP, the 28-day emergency medication that we also described.