The data our group is analyzing is a focus group discussion among family planning providers exploring the attitudes towards and feasibility and acceptability of integration of PREP (pre-exposure prophylaxis for prevention of HIV acquisition) into title X funded family planning clinics.
Several themes emerged during our review of this transcript including: Acceptability of PrEP, training for PrEP provision, package of services required to provide PrEP, understanding risk for HIV acquisition, availability of time to provide additional services, appropriateness of PrEP as a family planning service, sustainability of PrEP services at family planning clinics, correlates between adherence to PrEP and contraception.
This memo focuses on provider perceptions of HIV risk among patients at family planning clinics and acceptability of PrEP as a service offered at family planning clinics utilizing some of the themes described above.
“Family planning providers freak out”
An interesting concept that emerged was whether providers were equipped to diagnose HIV. Along with PrEP provision at a clinic comes a “package of services” including increased screening of high-risk patients for HIV. Providers differentiated HIV from other STIs that we routinely screen for (specifically chlamydia). “There is a lot of comfort around EC (emergency contraception) and Chlamydia but when someone has a rapid positive,…” one participant expressed about a family planning provider, “the provider freaked out and said you might have HIV” he/she continued (line 225-229). “When someone sero-coverts,” another participant said, “family planning providers freak out.” (line 221-222).
“Shift from we do birth control and pap smears”
In addition to comfort with diagnosing HIV, participants discussed feeling ill-equipped to provide the package of services required to provide PrEP. “I think unless you are prepared to provide adequate HIV services and referrals and active linkages or services on site then you are really providing an unsupportive stop-gap that you know again that we talked about how it’s ok to be HIV positive and you will live a long and normal life and then we loose our minds” (line 252-254). One participant described provision of PrEP as broadening the domain of family planning from provision of women’s health services to provision of reproductive health and sexual health services. “You have to take that whole picture)- shift from we do birth control and pap smears to now, you know, working with MSM populations” said one participant (line 300-301).
“It is not just a medication PrEP is a program” said one participant (line 288-289). “When it comes down to it most family planning settings are equipped to deal with and support folks who are testing positive upon entry to a PrEP program. You know I think like that’s like the real challenge . . . .” (line 246-249) said one participant.
“I think everyone should get PrEP,” said one provider, “I’m on the bandwagon. But for family planning from what I’m hearing it sounds like maybe you just need to be educating people and not necessarily providing it because of all the other parts that come with it” (line 278-281). “How could we possibly educate and put people in place to do this [PrEP provision]? What are ways that we can education enough providers and enough support staff so that it’s even doable?” asked one participant.
A theme that emerged was that providers perceive their patients to be interested receiving pap tests and chlamydia screening from them and not PrEP. The statement, “low income urban setting women who want birth control land chlamydia treatment” suggests that this provider doesn’t feel his/her patients want PrEP services. There was a sense that providers are uncertain their patient’s want this service, provided by family planning providers.”
“I think it feels so hard”
Staff also described feeling overburdened by their current responsibilities and therefore overwhelmed by the introduction of PrEP provision, another entirely new package of services to provide for patients. Said one participant: “I think family planning providers are already taxed like there are too few family planning providers for like low income urban setting women who want birth control and chlamydia treatment that I look at like additionally the new guidelines and doing that in the context of the work we are already doing that ask for PrEP I think it feels so hard” (line 201-206). Said another participant, “That do you push back—I mean I don’t think that it is but I think the perception among staff, particularly front line staff is that like we can’t do this” (line 208-209). “It’s a challenging mind game to play with staff,” said one participant, “ who have like a lot going on and who are already seeing too many patients and trying to et their census up and like in these setting that like are not always the most supportive of continuing education” (line 342-346).
In summary, providers expressed support of PrEP services for patients in the community. They expressed doubt about the feasibility of integration of PrEP services into their practice. Barriers identified were the package of services required to sustain PrEP provision, diagnosis new cases of HIV and provide linkage services to newly diagnosed patients, and simply the time and knowledge to provide PrEP effectively. Providers questioned whether it fit into the domain of family planning – viewed primarily as contraception care and whether it changed family planning as field, in a way that was sustainable, to introduce services that support reproductive and sexual health more broadly.