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Prevention Research

PrEP Implementation Behaviors of Community-Based HIV Testing Staff: A Mixed-Methods Approach Using Latent Class Analysis

Turner, DeAnne PhD, MPHa,b; Lockhart, Elizabeth PhD, MPHa; Wang, Wei PhDa,c; Shore, Robert PharmDd; Daley, Ellen M. PhD, MPHa; Marhefka, Stephanie L. PhDa

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: April 15, 2020 - Volume 83 - Issue 5 - p 467-474
doi: 10.1097/QAI.0000000000002289
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Pre-exposure prophylaxis (PrEP) is recommended by the Centers for Disease Control and Prevention1–4 and World Health Organization5,6 as 1 method to assist in the prevention of HIV. In this prevention method, a person takes a daily HIV prevention pill to significantly reduce their risk of acquiring HIV.7,8 Despite the development and recommended use of this prevention method for at-risk populations, many people are still unaware of PrEP.9–12

In the United States, it is unclear who is responsible for ensuring patients are informed about HIV prevention and PrEP. Medical providers may be a natural first step to disseminate information related to PrEP; however, many providers are still unaware of PrEP.13,14 In addition, factors beyond awareness affect whether medical providers talk to their clients about, or prescribe, PrEP, including how at-risk medical providers perceive their patient to be.13,15,16 However, providers may not adequately assess patient risk, as some may not be fully aware of their patients' sexual histories, behaviors, or sexual orientation; others may differentially offer PrEP to clients within certain risk populations15,17 or have biases in prescription practices based on a patient's race.16 Given these shortcomings, locations outside of providers' offices must also be used to increase knowledge and awareness of PrEP.18–22

Alternative locations such as community-based organizations, pharmacies, and clinics specializing in treating sexually transmitted infections have been suggested as possible locations to expand PrEP implementation.18–23 Depending on location and clinical availability, these sites could participate in at least 1 or more of education, counseling, referral, or screening for a possible prescription.18–23 Moreover, studies investigating the role of nonclinical staff in PrEP implementation have found that such staff may be important to education and counseling efforts,14,24 as well as navigating the available resources for PrEP-related financial assistance.24 A recent systematic review even suggested the need to study the integration of PrEP education into routine HIV testing procedures.18 However, the perspectives of staff performing HIV testing have not yet been studied.

HIV testing sites primarily serve people who are uninfected or do not yet know they are living with HIV. Staff at such sites already ask sensitive questions about sexual risk behavior during pretest counseling. For example, in Florida, the DH1628 Laboratory Request Form completed with each publicly funded HIV test requires that counselors ask clients about HIV-related risk factors.25 Counseling during the HIV testing process could be a critical point during which nonclinical staff could intervene and discuss PrEP as an option for HIV prevention or refer people to organizations providing PrEP.18 Yet, little is known about the specific factors affecting PrEP implementation (ie, discussing PrEP or referring clients to an organization providing PrEP) during the HIV testing process.

To best prepare HIV testing staff to take part in PrEP implementation, it is important to understand their current PrEP implementation behaviors. Building on previous research examining the role of nonclinical staff in PrEP implementation,14,24 this study investigates how staff performing HIV testing engage in PrEP implementation. Thus, this study seeks to answer the research questions: (1) What, if any, PrEP implementation subgroups exist among staff providing HIV testing in Florida? and (2) Do PrEP implementation subgroups vary based on staff characteristics?


Study Design

This study used a mixed-methods concurrent triangulation design26 to investigate the unobserved subgroups of staff who provide HIV testing in Florida and how staff characteristics impact engagement in PrEP implementation. In this study, PrEP implementation is described as the degree to which PrEP is discussed and/or a referral to a prescriber occurs. This study was conducted in Florida, a state which has both rural and urban designations, as well as high rates of HIV incidence.27 Data were collected, analyzed concurrently, and triangulated during data analysis and interpretation. The study was approved by the Institutional Review Board at the University of South Florida. Participants electronically provided informed consent.

Data Collection

Participants (ie, HIV testing staff) were recruited between February and May of 2018 through email to complete a 15- to 20-minute online assessment administered through Qualtrics. Contact information for publicly funded HIV testing sites in Florida is freely available on the Internet. Administrators at each community-based, publicly funded testing site were contacted through email with a request to share the survey with staff who perform HIV testing and counseling. Unsuccessful attempts and requests for no further contact were logged daily. Organizations were contacted up to 4 times (ie, a prenotice, followed by up to 3 additional contacts that include the survey link).28 At the end of the quantitative assessment, participants were asked if they would like to enter a raffle for 1 of 3 $50 gift cards and their willingness to be contacted for an in-depth interview. Interview participants were selected from those who indicated interest by quota sampling29 to ensure inclusion of participants with a diverse range of PrEP implementation experiences. Participants who took part in the qualitative interview received a $20 gift card.


PrEP implementation group was determined using a latent class analysis (LCA) based on how clients answered a predetermined set of questions regarding multifaceted PrEP implementation: (1) Overall, how often do you talk to clients about PrEP when testing/counseling for HIV?; (2) I talk to clients about PrEP every time I test for HIV; (3) I talk to clients about PrEP when I think they might be eligible (meet the indications to start taking PrEP); (4) I give physical information about PrEP (such as pamphlets, flyers, and written contact information for PrEP-friendly providers) to clients during HIV testing/counseling; and (5) Overall, how often do you give clients physical information about PrEP (such as pamphlets, flyers, and written contact information for PrEP-friendly providers) during HIV testing/counseling? All items were categorical and measured on a 5-point scale (items 1 and 5 from “I never do this” to “every time”; items 2, 3, and 4 from “strongly disagree” to “strongly agree”). This study referred to PrEP as a once daily pill, as emerging methods of PrEP use such as on-demand PrEP were still being investigated at the time of this study. Participant characteristics were assessed, including age, gender, sexual orientation, race, ethnicity, employment status, HIV status, and previous or current personal use of PrEP. The in-depth interview guide was based on the Consolidated Framework for Implementation Research.30

Sample Size

A total of 150 HIV testing staff from 48 organizations were included in quantitative analysis. The qualitative sample size was based on saturation, when no new themes emerge from the data.31 Saturation was reached at 22 participants.

Data Analysis

Quantitative data were exported from Qualtrics32 into SPSS v.24.33 Data were cleaned and examined for suspicious and repeat responses. Forty-nine participants were excluded from analysis: 12 did not meet inclusion criteria, thus were unable to continue to the survey and an additional 18 did not proceed past the consent. Nineteen participants completed between 34% and 55% of the survey. These participants had not yet completed demographic questions, so it was not possible to compare their demographic information to those who completed the survey in its entirety. However, when comparing key variables (eg, existence/nonexistence of an organizational PrEP policy), these participants were not significantly different than the analytic sample. In addition, 21 IP addresses were listed more than once. This was expected, as some organizations have shared IP addresses between employees. These responses were determined to be unique based on investigation into survey answers and demographic characteristics. Descriptive statistics of the remaining analytic sample were conducted.

LCA34,35 was used to determine PrEP implementation groups. The LCA was performed using MPlus v.8.36 All other analyses were performed using SPSS v.24.33 The LCA technique groups participants based on similarities in how they answer a predetermined set of questions. Participants are then categorized based on the likelihood that they belonged to a given class. Five items were included in the LCA (see Table 3 under “results”), asking participants to rank the degree to which they participated in various dissemination activities related to PrEP. The final LCA and corresponding latent classes were determined based on fit indices [eg, BIC (Bayesian Information Criterion)] and LMR (Lo-Mendell-Ruben)] and theoretical interpretation.37 In interpreting BIC, the lower the score the better fit of the model. For LMR, it is suggested that researchers find the model which produces a nonsignificant LMR value, and use 1 less class (k-1).37 Theoretical interpretation included examining how participant responses related to the existing literature.37

To account for clustering (ie, the groups of participants working within the same organization), generalized linear mixed models35 with multinomial distribution, logit link, and robust variance estimator were used to estimate PrEP implementation as a function of key demographic characteristics.

Qualitative interviews were transcribed, verified by the primary author to ensure correct transcription, imported into MaxQDA38 and analyzed thematically.39 The primary author segmented all transcripts based on topic. An initial codebook was created based on the Consolidated Framework for Implementation Research guidelines and emerging codes that arose while conducting the interviews and verifying transcription accuracy. Two researchers trained in qualitative data analysis coded the same transcript independently before discussing revisions and edits for the codebook. The same researchers coded an additional transcript to refine the codebook. After agreement on the codebook, 4 transcripts were independently coded to calculate inter-rater reliability (IRR). At this first attempt, the overall Kappa was K = 0.75. The same 2 coders reviewed these transcripts, discussed interpretation and clarification of codes, and again attempted IRR with 4 new transcripts. IRR was reached, with an overall K = 0.86. The remaining transcripts (n = 12) were coded by the primary author. Trustworthiness of the qualitative data was examined using Guba's model of trustworthiness of qualitative research.40–42

Data integration was included in the study design, methods, and interpretation. During data collection and analysis, connecting was used to identify participants for the qualitative phase.26,43 Data were also merged after data collection, a technique that involves combining the quantitative and qualitative data sets.43,44 During data interpretation, a narrative approach and utilization of joint display of data were used to integrate the data.44


Participant Characteristics

A total of 150 staff providing HIV testing (participants) from 48 organizations were included in analysis. Participants were an average of 41.4 years old, ranging in age from 20 to 73 (Table 1). The sample was diverse in terms of both gender (53.7% male; 43.6% female) and sexual orientation (48.3% heterosexual; 40.9% homosexual). Just over half of the participants indicated their race as white, while just over 20% indicated being black. Most participants worked fulltime at their organization (78.1%); however, some worked part time (10.1%) or volunteered (11.8%). Notably, nearly 20% (19.3%) of participants were living with HIV.

Participant Characteristics (N = 150)

Qualitative interview participants (N = 22) were similar to the larger sample, with slight variations. These participants were slightly younger, and more likely to be white and/or male than the full sample. Qualitative participants were an average of 37.4 years (range: 21–64), 63.6% white, 63.6% male, 54.5% heterosexual, and 18.2% were living with HIV.

Classes of PrEP Implementation

A total of 4 LCAs were conducted—each containing 1, 2, 3, or 4 classes, respectively (Table 2). The 1-class and 4-class models each had poor model fit; the 2-class and 3-class models were further investigated. Although the 2-class model had the best model fit as determined by the BIC criteria, the 3-class model had the better fit when considering LMR and theoretical interpretation. Based on consideration of fit statistics and theoretical relevance, a 3-class LCA was selected and used for all further analyses.

Comparison of Latent Class Models

As a model approaches one, it approaches full delineation of latent classes, referred to as entropy45; entropy for the LCA was 0.914. After reviewing the classes, or grouping of participants, each group was assigned a label to be used throughout analysis and data reporting. The name of each label was determined based on the characteristics of their latent class group. The PrEP implementation behaviors of the latent groups were often reiterated in the qualitative data.

Class 1: Universal PrEP Implementation

Class 1 (42%; n = 62) included staff performing HIV testing who were PrEP advocates; these participants were highly likely to talk about PrEP with their clients, regardless of client eligibility. This group was labeled Universal because participants indicated talking about PrEP with all or most of the clients they see, as well as handing out PrEP-related materials (such as pamphlets, flyers, and written contact information for PrEP-friendly providers) to clients regularly. In qualitative interviews, some members of the Universal group stated that they believed everyone should be aware of PrEP, regardless of their current level of risk. In addition, participants in the Universal group often confirmed discussing PrEP with clients on a frequent basis during the qualitative interviews, such as “I'm obligated as somebody who's doing HIV prevention and testing to talk to somebody about this (PrEP). (Participant 113)” or “I think it's great because it's a resource that everyone should know about. Regardless if you don't use it (PrEP) or use it, you know, if you know someone that can use it, you can always recommend them to it (Participant 116).” This theme was less present in the Eligibility Dependent group and not present in the Limited group.

Class 2: Eligibility Dependent PrEP Implementation

Class 2 (33%; n = 48) included staff who often talked to clients about PrEP, but were most likely to discuss the prevention method if they felt their client was eligible, thus referred to as Eligibility Dependent. This group also provided physical materials to clients, but not as consistently as participants in the Universal group. Eligibility Dependent participants often highlighted the need for a more selective discussion of PrEP based on perceived side effects or risk criteria, such as “Like I said, if you're married and you have one partner, then you're taking PrEP to damage your liver or your kidneys, and so on and so on. It doesn't make sense (to use PrEP). (Participant 103)” or “We have many people that we know are in serodiscordant relationships, so we want to help them (Participant 107).” These participants weighed the pros and cons of PrEP for their client and determined whether PrEP should be discussed based on their client's level of risk.

Class 3: Limited PrEP Implementation

Class 3 (25%; n = 37) was the most discriminate group with regards to PrEP implementation—these participants sometimes spoke to clients about PrEP, but not as systematically as those in the Universal or Eligibility Dependent groups, thus referred to as Limited. This group was also the least likely group to provide physical information about PrEP, such as brochures or referral cards. In LCA, the Limited group was found to have inconsistent discussions about PrEP with clients. This lack of systematic rationale for PrEP implementation was captured by the varied qualitative responses within this group. This group discussed concerns regarding PrEP but did not have salient qualitative rationale for why they did, or did not, discuss PrEP with clients.

A full description of categorical response distribution can be found in Table 3.

Categorical Distribution of Final Latent Class Analysis

Variation in Group Membership Based on Participant Characteristics

In bivariate analyses (Table 4), significant differences existed between the Eligibility Dependent participants and the Limited participants in age, race, sexual orientation, and ever taken PrEP status. Significant differences were found between Universal and Limited participants in sexual orientation. No statistically significant differences were found between the Eligibility Dependent participants and the Universal participants in bivariate analyses.

Generalized Linear Mixed Model Estimating PrEP Implementation as a Function of Key Demographic Characteristics

In multivariate analyses, only race and sexual orientation remained significant predictors of the PrEP implementation group (Table 4). Participants who identified as a racial minority were less likely to be in the Limited group {compared with both the Universal [3.78 (1.48–9.68)] or Eligibility Dependent [6.79 (2.31–19.98)] groups} compared with their white counterparts; however, race did not differentiate the odds of group affiliation when comparing the Eligibility Dependent vs. Universal groups. Sexual orientation played a role in differentiating between the Limited vs. Eligibility Dependent and Universal groups—participants who identified as a sexual minority were less likely to be in the Limited group compared to the Eligibility Dependent [8.41 (2.26–31.30)] or Universal [4.85 (1.47–15.97)] groups; however, sexual orientation did not differentiate between Eligibility Dependent vs. Universal groups. Age, gender, ever having taken PrEP, and HIV status did not impact the odds of being in a specific PrEP implementation group.


This study sought to understand PrEP implementation at community-based HIV testing locations in Florida. An LCA revealed 3 distinct classes of PrEP implementation—Universal, Eligibility Dependent, and Limited. Entropy was 0.914 (approaching 1), indicating delineation between classes.45 Qualitative data provided triangulation, thus additional information and characterization of these classes.

Using the LCA approach34,35 allowed for the grouping of participants into mutually exclusive subgroups within the larger population of staff who provide HIV testing. This approach takes the complex nature and specific combinations of PrEP-related implementation activities into account.34,35 The joint analysis of the qualitative data and the LCA results provided greater insight into the PrEP implementation behaviors of HIV testing staff than either method would alone.

Participants in the Limited group were inconsistent in their PrEP implementation behaviors, despite state guidelines indicating the importance of linkage to prevention resources, including PrEP.46 These findings may speak to the need for targeted interventions for HIV testing staff with characteristics of the Limited group. Future work should illuminate the factors impacting inconsistent PrEP implementation among this subgroup. Organizational and community-level characteristics may impact PrEP implementation and should be studied to better understand the barriers to PrEP implementation among HIV testing staff.

Participants in both the Universal and Eligibility Dependent groups meet the testing procedure guidelines in that they are able to provide linkages and client-centered risk assessments during the counseling process.46 The understanding of what it means to provide client-centered risk assessments could be 1 differentiating factor between these groups. Participants in the Eligibility Dependent group may feel that discussing PrEP with clients they believe would not meet the indications for PrEP diverts from the recommendation of client-centered counseling. It is also important to note that the level of risk HIV testing staff perceive a client to have may not always be accurate. Clients may not be fully truthful with the staff providing the HIV testing service47; similarly, staff providing testing may make assumptions about the client based on the way clients present themselves or demographic characteristics.15,16,48 Thus, although some participants in the Eligibility Dependent group may be accurately determining which clients could benefit from knowing about PrEP, others may be missing the opportunity to tell clients about a potentially valuable prevention method. Although the Universal participants may be sharing information about PrEP with those who do not meet the indications, they are not missing clients who may benefit from the innovation. By sharing this information with all clients, participants in the Universal group are also increasing the general community-level knowledge of PrEP, which in turn may reduce associated stigma.

There is a growing body of work on the role that client characteristics and provider biases may have in PrEP prescription,13,15,16 but little information indicating how provider characteristics (eg, provider race and sexual orientation) impact these interactions. In this study, we did not capture the demographic characteristics of clients typically served by the testing staff nor the organization. As such, the role that client characteristics have in relation to PrEP referral or discussion cannot be examined. Future work should examine the degree to which client demographic characteristics and client-staff racial or sexual orientation concordance have on communication patterns related to PrEP referral.

Staff who identified with a sexual minority group were more likely than heterosexual staff to talk to clients about PrEP. It may be possible that those who identify as members of a sexual minority group are more prone to talking about PrEP than their peers because HIV disproportionately affects gay, bisexual, and other men who have sex with men.49 Large scale studies have found that gay men are more likely than their heterosexual counterparts to be aware of PrEP.50 Although all HIV testing staff should be aware of PrEP, it is possible that knowledge of PrEP among HIV testing staff could also vary based on demographic characteristics such as sexual minority status and thus impact the degree to which staff discuss PrEP with clients.

In this study, staff in all PrEP implementation classes reported a greater likelihood to discuss PrEP if a client specifically asked about PrEP. Similarly, among medical providers, PrEP-related discussions are often initiated by clients.51 However, waiting for clients to initiate conversations about PrEP puts an unnecessary burden on the client. Studies have indicated that some gay men may be less likely to initiate conversations related to HIV risk, PrEP, and/or their sexual behaviors/identity if they perceive their provider to be heterosexual.52 It is possible that heterosexual staff are less likely to discuss PrEP with their clients because the clients are choosing to not initiate the conversation with them. Alternatively, heterosexual men and women being tested for HIV may be less likely than their lesbian, gay, or bisexual counterparts to initiate conversations about PrEP due to low levels of PrEP awareness.53,54 These findings reinforce the need for staff initiated discussions about PrEP, including during postcounseling HIV testing.

We found that staff who identify with a racial minority group were less likely than white staff to be in the Limited group, implying they were more likely to talk with their clients about PrEP. HIV disproportionately impacts people who are black and Hispanic55; similar to sexual minority staff, people who identify as a racial minority may have a greater drive to discuss PrEP and reduce community HIV prevalence. There is a growing literature on the role that race and medical mistrust may have on a person's decision to initiate PrEP,56,57 but less information regarding the role that provider race has on these decisions. It is possible that, during HIV testing, the race of the staff member providing the HIV test could impact medical mistrust or client receptivity to PrEP. If racial concordance/discordance impacts PrEP receptivity, our findings that staff who identify with a racial minority group are more likely to talk about PrEP than their white counterparts are particularly important—especially given the low rates of PrEP uptake in black and Hispanic communities.58 Promoting PrEP implementation during HIV testing may help to reduce racial disparities in PrEP uptake and knowledge. The need to further examine the role of provider race and patient–provider concordance has been noted in the literature16 and is supported in these findings within the context of HIV testing staff.

The study was limited to a convenience sample from community-based organizations within 1 state in the southern United States. Some aspects of PrEP implementation may vary geographically, as both rates of PrEP uptake59 and HIV-related stigma60 have been found to vary based on geographic location. The lack of validated scales measuring PrEP implementation led to literature-driven development of relevant items; however, use of LCA provided some strength to the outcome variable. Literature-driven development of items used in LCA has been used in other understudied contexts.61 This study was also based on 1 type of PrEP—use of a daily pill. Alternative formulations for PrEP, as well as alternative dosing strategies, are currently being studied and have been used by some PrEP clients. The advent of alternative forms of PrEP, however, did not appear to be a major limitation. To account for these newer strategies, participants were asked if their likelihood of talking to a client about PrEP would change if on-demand forms of PrEP were widely recommended or if PrEP injections were available; most participants (75% and 85%, respectively) indicated their likelihood of talking about PrEP with clients would be about the same.

A major strength of this study is the mixed-methods approach, in which the quantitative and qualitative findings were triangulated to provide a comprehensive look at PrEP implementation during HIV testing. This study took place in Florida, a state with high HIV prevalence and incidence.27 Much can be learned from PrEP implementation in Florida as it is geographically and ethnically diverse, as well as entering a statewide push for PrEP implementation. Finally, this study is among the first to examine PrEP implementation from the perspective of staff who provide HIV testing to the clients.


This study sought to investigate how HIV testing staff engage in PrEP implementation and the underlying behaviors of distinct implementation subgroups. These findings have implications for research, practice, and policy. Methodologically, this study demonstrates the benefits of using joint analysis of LCA and thematically coded interview data to determine program or training needs. In practice, these findings may help organizations determine the best way to provide PrEP-related training and program development, accounting for staff who may differentially discuss PrEP based on perceived client eligibility, or inconsistently talk to clients about PrEP. Policies at the organizational level may be beneficial for increasing PrEP implementation in HIV testing venues; future studies are warranted.


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HIV; PrEP; HIV testing; mixed methods; latent class analysis

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