Abstract

Purpose of Review

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

Recent Findings

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

Summary

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

中文翻译：

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提高 PrEP 水平：系统和结构层面的实施策略，以扩大 PrEP 在美国的使用

摘要

审查目的

尽管存在高效的生物医学 HIV 暴露前预防 (PrEP) 方案，但 PrEP 的吸收率不理想阻碍了美国在结束这一流行病方面取得的进展。实施科学将我们所知道的受控临床试验设置与旨在部署有效工具的背景和环境联系起来。在这篇综述中，我们重点关注针对系统或结构层面的 PrEP 使用障碍的策略，探索在分散的美国医疗保健系统背景下的影响和机遇。

最近的发现

任务转移可能会增加 PrEP 处方者的数量，但在美国，有效性证据很少，而且通常集中在城市环境中。将 PrEP整合到现有的医疗保健基础设施中可以集中相关资源，但示范项目很少会出现重新调整工作人员的资源影响。通过扩大远程医疗来改变服务地点可以改善更多农村人口的服务，尽管互联网连接、技术获取以及与确定生物医学资格相关的挑战仍然是美国一些负担最重的社区的后勤障碍。最后，量身定制的护理导航和协调方法已成为 PrEP 服务提供的高效组成部分，试图直接修改个人经历的 PrEP 使用的系统级决定因素。

概括

我们重点介绍有关任务转移、集成、服务交付和定制的最新进展和证据。除了量身定制的护理导航之外，证据是混杂的，任务转移和护理整合的下游影响和可持续性需要进一步关注。为了最大限度地提高 PrEP 效果，研究需要继续检查个人、诊所、医疗保健系统及其运作的相关政策之间的相互作用。