BACKGROUND:People with substance use disorder (SUD) are at increased risk of HIV infection. HIV testing and pre-exposure prophylaxis (PrEP) are evidence-based practices to prevent HIV infection, yet these approaches are not regularly provided in SUD treatment programs. To address this evidence-to-practice gap, this study aimed to identify facilitators and barriers to implementing PrEP services in SUD treatment programs from the perspective of non-medical staff and administrators. METHODS:Semi-structured interviews were conducted from February to June 2022 with non-medical staff (N = 10) and administrators (N = 11) from 3 academic and 8 community-based SUD treatment programs in Philadelphia. Interview guides were developed using the Consolidated Framework for Implementation Research (CFIR). Qualitative descriptive techniques were used to examine interview data and identify key facilitators and barriers, which were grouped within CFIR domains and constructs. RESULTS:Of the 11 SUD treatment programs, 5 provided PrEP services. Most interviewees at programs without PrEP services reported high levels of receptivity to implementing PrEP and identified leadership engagement as a key determinant, but several lacked comfort with PrEP counseling. Inner setting facilitators included compatibility with workflows (eg, intake assessments), alignment with cultures of holistic care, and programs' longstanding community trust. Inner setting barriers included limited time to discuss PrEP, insufficient resources and staff (eg, phlebotomy), perception of clients' HIV risk, and lower prioritization of HIV prevention versus other services. Intervention facilitators included robust evidence and addressing costs through grants and drug pricing programs, and barriers included the time needed to initiate PrEP, loss to follow-up, and HIV stigma. CONCLUSIONS:Successful implementation of HIV testing and PrEP in SUD treatment programs requires addressing multi-level barriers. Including perspectives of non-medical staff and administrators is important for implementation. Potential strategies include supporting organizational networks, leveraging peer specialists' expertise, and packaging PrEP to better meet client priorities and needs.

The syndemic of substance use and HIV is a well-recognized global phenomenon that threatens to undermine the priorities outlined by the national "Ending the HIV Epidemic" initiative. There has been a resurgence of HIV among people who inject drugs which, by extension, affects marginalized youth who enter shared sexual and drug use networks. The increasing availability of biomedical prevention options for both opioid use disorder (OUD) and HIV represents an important opportunity to improve care for youth placed at risk. This qualitative study used in-depth, semi-structured interviews with 19 purposively sampled, academic and community-based AYA healthcare providers who had previously prescribed MOUD and/or PrEP. Barriers and facilitators to integrated MOUD and HIV prevention services were explored using a chart-stimulated recall technique, which enables the use of clinicians' own documentation of actual patient encounters to stimulate recall of their medical decision-making and clinical recommendations. Interviews were audio-recorded and transcribed. All interview transcripts were imported into NVivo 12.0, double coded, and analyzed using modified grounded theory. Of the providers sampled, the majority were medical doctors (63%), with the remainder representing physician assistants and nurse practitioners. Nearly half of the study population (47%) had completed their professional training in the last 5 years, with the most sampled specialties being internal medicine (37%) and family medicine (26%). All participating clinicians recommended HIV screening at varying intervals depending on risk assessment. However, few counseled on or prescribed PrEP to patients on MOUD. Barriers to PrEP prescriptions included patient-level (e.g., stigma surrounding PrEP use, adherence challenges, and competing social or mental healthcare needs), provider-level (e.g., provider perception of low risk and lack of training/experience) and system-level factors (e.g., restricted visit types). Facilitators of PrEP prescriptions in this population included patient-initiated requests, electronic health record system reminders, and the availability of consistent support staff (i.e., PrEP navigators, certified recovery specialists). Our study confirms that discussions about HIV prevention and PrEP prescriptions may be rare for AYA patients receiving MOUD. The barriers and facilitators identified in this study will inform the development of provider-informed, youth-centered, multi-level interventions to increase the integration of PrEP delivery within the context of OUD care among AYA populations.

BACKGROUND:Medications for opioid use disorder (MOUD) are under-prescribed to adolescents and young adults (AYA). Few published studies have explored challenges to and opportunities to enhance continuous provision of MOUD for AYA. Our report focuses on this emergent theme that was identified as part of a larger qualitative study. METHODS:We purposively sampled and enrolled medical providers who prescribed MOUD to AYA. Semi-structured individual interviews using chart-stimulated recall explored barriers and facilitators to MOUD retention. We used modified grounded theory in our qualitative analysis, with double coding of interviews. RESULTS:Barriers to retention on MOUD included patient-level (i.e., return to substance use) and system-level factors (i.e., cost, delayed receipt, pharmacy challenges, and in-person visit requirements). Facilitators included patient-level (i.e., motivation, support networks) and system-level factors (i.e., telehealth access, availability of certified recovery specialists). CONCLUSIONS:Our study is the first to look at retention for this key age group, setting it apart from the existing body of literature that looks at medication initiation. Our findings confirm that significant systemic barriers exist to AYA patients' retention on MOUD. Further research is needed to develop interventions that facilitate continuous delivery of high-quality care among this key population.

BACKGROUND:Low rates of HIV pre-exposure prophylaxis (PrEP) prescribing contribute to the disproportionate burden of HIV in the United States. Among adolescent and young adults (AYA) with opioid use disorder, HIV testing and PrEP co-prescription rates are poorly characterized. METHODS:We performed a retrospective analysis involving deidentified data from Philadelphia's Medicaid beneficiaries ages 16-29 years who were prescribed medication for opioid use disorder (MOUD) from 2015 to 2020 and continuously Medicaid-enrolled for ≥6 months prior to that prescription. After identifying the presence of a qualifying diagnosis signifying a PrEP indication, we examined the outcome of appropriate PrEP co-prescriptions and HIV testing using generalized estimating equations (GEE) modeling. RESULTS:We identified 795 AYA Medicaid beneficiaries with 1269 qualified treatment episodes. We calculated a PrEP prescribing rate of 29.47 per 1000 person-years among AYA receiving MOUD. The HIV testing rate was 63.47 per 1000 person-years among AYA receiving MOUD. GEE modeling revealed that individuals receiving methadone were more likely (aOR=2.62, 95% CI=1.06-6.49) to receive HIV testing within 6 months after a PrEP-qualifying diagnosis compared to those receiving other MOUD medications. Those who only saw outpatient behavioral health providers were less likely (aOR=0.48, 95% CI=0.24-0.99) to have received an HIV test within 6 months after the PrEP-qualifying diagnosis compared to those receiving inpatient behavioral health services. CONCLUSIONS:Co-prescription of PrEP and HIV testing among AYA receiving MOUD was rare in this large urban publicly insured population. Interventions are needed to increase HIV prevention services for this key population of AYA at risk for HIV infection.

BACKGROUND:The syndemic of substance use and human immunodeficiency virus (HIV) is a well-recognized global phenomenon that threatens to undermine the priorities outlined by the National Institutes of Health "Ending the HIV Epidemic" initiative. There are few published studies on preexposure prophylaxis (PrEP) for adolescents and young adults (AYAs) with opioid use disorder (OUD) despite increasing availability of biomedical prevention options and Centers for Disease Control and Prevention recommendations to offer PrEP to this group.METHODS:Healthcare providers who previously prescribed medications for OUD (MOUDs) and/or PrEP for AYA were purposively sampled. Audio-recorded in-depth individual interviews were conducted using chart-stimulated recall to explore barriers and facilitators to integrated MOUD and HIV prevention services. Interviews were double-coded, and qualitative analysis was performed using a modified grounded theory.RESULTS:Of 19 providers sampled, most were physicians (63%). All recommended HIV screening at varying intervals; however, few counseled on (19%) or prescribed (11%) PrEP to patients on MOUD. Barriers to PrEP prescriptions included patient-level (ie, stigma surrounding PrEP use, adherence challenges, and competing social or mental healthcare needs), provider (perception of low risk, lack of training/experience), and system-level factors (including restricted visit types). Facilitators of PrEP prescriptions included patient-initiated requests, electronic health record system reminders, and the availability of consistent support staff (ie, navigators, certified recovery specialists).CONCLUSIONS:Our study confirms that discussions about HIV prevention and PrEP prescriptions may be rare for AYA patients receiving MOUD. Further research is needed to develop interventions that increase the integration of PrEP delivery within the context of OUD care among this key AYA population.

Background: Chlamydia trachomatis (CT) is a highly prevalent sexually transmitted infection in adolescents that can lead to serious complications. San Francisco has one of the highest rates of CT infections in the United States. At baseline, screening rates at the Children's Health Center were significantly below national and network levels. This project aimed to increase screening rates for female patients age 16-24 from 29.2% to 44% in an 18-month period. Methods: The organization engaged providers, residents, and nursing staff to understand the root causes and choose the screening approach. The following strategies were used to implement this approach in primary and urgent care: (1) universal urine collection, (2) provider and staff education, and (3) adoption of faculty Maintenance of Certification (MOC) credit and resident physician financial incentives. Results: The annual screening rate for CT in primary care female patients 16-24 years old increased from 29.2% to 61.5% in 18 months, and improved to 71.2% one year after the project. Screening rates for female patients over age 15 seen in the colocated urgent care also increased significantly. The research team found no instances of false positive results and had 4 positive results in high-risk patients who initially reported abstinence. Conclusions: The intervention design and engagement of stakeholders with incentives was associated with significant and sustainable improvements in the CT screening rate for female adolescent primary care patients. This work shows how universal opt-out screening can be a sustainable and effective method to address common barriers to increasing screening for CT in adolescents.