AIDS and Behavior

, Volume 23, Issue 7, pp 1803–1811 | Cite as

Health Care Facility Characteristics are Associated with Variation in Human Immunodeficiency Virus Pre-exposure Prophylaxis Initiation in Veteran’s Health Administration

  • Marissa M. MaierEmail author
  • Ina Gylys-Colwell
  • Elliott Lowy
  • Puja Van Epps
  • Michael Ohl
  • Maggie Chartier
  • Lauren A. Beste
Original Paper


To quantify health care facility-level variation in pre-exposure prophylaxis (PrEP) use in the Veteran’s Health Administration (VHA); to identify facility characteristics associated with PrEP use. Retrospective analysis of the health care facility-level rate of PrEP initiation in VHA through June 30, 2017. Standardized PrEP initiation rates were used to rank facilities. Characteristics of facilities, prescribers, and PrEP recipients were examined within quartiles. Multiple linear regression was used to identify associations between facility characteristics and PrEP use. We identified 1600 PrEP recipients. Mean PrEP initiation rate was 20.0/100,000 (SD 22.8), ranging from 3.0/100,000 (SD 2.0) in the lowest quartile to 48.1/100,000 (SD 29.1) in the highest. PrEP prescribing was positively associated with proportions of urban dwellers and individuals < 45, tertiary care status, and location. Variability in PrEP uptake across a national health care system highlights opportunities to expand access in non-tertiary care facilities and underserved areas.


Pre-exposure prophylaxis HIV Health care Initiation 


Para cuantificar la variación a nivel de las instalaciones de atención médica en el uso de la profilaxis previa a la exposición (PrEP) en la Administración de Salud para Veteranos (VHA); para identificar las características de las instalaciones asociadas con el uso de PrEP. Análisis retrospectivo de la tasa de nivel de establecimiento de atención médica de inicio de PrEP en VHA hasta el 30 de junio de 2017. Se utilizaron índices de inicio de PrEP estandarizados para clasificar los establecimientos. Las características de las instalaciones, los prescriptores y los receptores de PrEP se examinaron dentro de los cuartiles. Se utilizó regresión lineal múltiple para identificar asociaciones entre las características de la instalación y el uso de PrEP. Identificamos 1600 beneficiarios de PrEP. La tasa media de iniciación de PrEP fue de 20.0/100.000 (SD 22.8), variando desde 3.0/100.000 (SD 2.0) en el cuartil más bajo hasta 48.1/100.000 (SD 29.1) en el más alto. La prescripción de PrEP se asoció positivamente con proporciones de habitantes urbanos e individuos < 45, estado terciario y ubicación. La variabilidad de la captación de PrEP a través de un sistema nacional de atención de salud resalta las oportunidades para ampliar el acceso en instalaciones no terciarias y áreas subatendidas o comunidades con bajos recursos.



This work was prepared independently with no external funding source. The authors are employees of the Veterans Health Administration, which supported their work.

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with animals performed by any of the authors. Under guidance from the VHA Office of Research Oversight (ORO), the HIV, Hepatitis, and Related Conditions Office in Specialty Care Services has the authority to perform the analyses presented here as part of their healthcare operations work which does not require Institutional Review Board approval.

Supplementary material

10461_2018_2360_MOESM1_ESM.docx (14 kb)
Electronic supplementary material 1 (DOCX 14 kb)


  1. 1.
    Centers for Disease Control and Prevention. HIV Surveillance Report, 2016, vol. 28. Published November 2017. Accessed 7 Dec 2017.
  2. 2.
    Choopanya K, Martin M, Suntharasamai P, et al. Antiretroviral prophylaxis for HIV infection among people who inject drugs in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083–90.CrossRefGoogle Scholar
  3. 3.
    Grohskopf LA, Chillag KL, Gvetadze R, et al. Randomized trial of clinical safety of daily oral tenofovir disoproxil fumarate among HIV-uninfected men who have sex with men in the United States. J Acquired Immune Defic Syndr. 2013;64(1):79–86.CrossRefGoogle Scholar
  4. 4.
    Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99.CrossRefGoogle Scholar
  5. 5.
    Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410.CrossRefGoogle Scholar
  6. 6.
    Elopre L, Kudroff K, Westfall AO, Overton ET, Mugavero MJ. The right people, right place, and right practices: disparities in PrEP access among African American Men, Women, and MSM in the deep South. J Acquir Immune Defic Syndr. 2017;74(1):56–9.CrossRefGoogle Scholar
  7. 7.
    Misra K, Udeaqu CC. Disparities in awareness of HIV postexposure and preexposure prophylaxis among notified partners of HIV-positive individuals, New York City 2015–2017. J Acquir Immune Defic Syndr. 2017;76(2):132–40.CrossRefGoogle Scholar
  8. 8.
    Kuhns LM, Hotton AL, Schneider K, Garofalo R, Fujimoto K. Use of pre-exposure prophylaxis (PrEP) in young men who have sex with men is associated with race, sexual risk behavior, and peer network size. AIDS Behav. 2017;21(5):1376–82.CrossRefGoogle Scholar
  9. 9.
    Snowden JM, Chen YH, McFarland W, Raymond HF. Prevalence and characteristics of users of pre-exposure prophylaxis (PrEP) among men who have sex with men, San Francisco, 2014 in a cross-sectional survey: implications for disparities. Sex Transm Infect. 2017;93(1):52–5.CrossRefGoogle Scholar
  10. 10.
    Emory University, Rollins School of Public Health. AIDSVu ( Accessed 7 Dec 2017.
  11. 11.
    Wu H, Mendoza MC, Huang YA, Hayes T, Smith DK, Hoover KW. Uptake of HIV preexposure prophylaxis among commercially insured persons—United States, 2010–2014. Clin Infect Dis. 2017;64(2):144–9.CrossRefGoogle Scholar
  12. 12.
    Krakower D, Ware N, Mitty JA, Maloney K, Mayer KH. HIV providers’ perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study. AIDS Behav. 2014;18(9):1712–21.CrossRefGoogle Scholar
  13. 13.
    National Center for Veterans Analysis and Statistics. US Department of Veterans Affairs. VA utilization profile FY 2016. November 2017. Accessed 29 Dec 2017.
  14. 14.
    van Epps P, Maier M, Lund B, et al. Medication adherence in a nationwide cohort of veterans initiating pre-exposure prophylaxis (PrEP) to prevent HIV infection. J Acquired Immune Defic Syndr. ePub ahead of print 11 Dec 2017.Google Scholar
  15. 15.
    Veterans Health Administration. About VHA. Accessed 29 Dec 2017.
  16. 16.
    Hart LG, Larson EH, Lishner DM. Rural definitions for health policy and research. Am J Public Health. 2005;95(7):1149–55.CrossRefGoogle Scholar
  17. 17.
    Veterans Health Administration. 2012 VHA facility quality and safety report. September 2012. Accessed 29 Dec 2017.
  18. 18.
    US Department of Commerce, Economics and Statistics Administration, US Census Bureau. Census regions and division of the United States. Accessed 7 Dec 2017.
  19. 19.
    Ohl ME, Tate J, Duggal M, et al. Rural residence is associated with delayed care entry and increased mortality among veterans with Human Immunodeficiency Virus (HIV) Infection. Med Care. 2010;48(12):1064–70.CrossRefGoogle Scholar
  20. 20.
    Schafer KR, Albrecht H, Dillingham R, et al. The continuum of HIV care in rural communities in the United States and Canada: what is known and future research directions. J Acquired Immune Defic Syndr. 2017;75(1):344–55.Google Scholar
  21. 21.
    McKenney J, Sullivan PS, Bowles KE, Oraka E, Sanchez TH, DiNenno E. HIV risk behaviors and utilization of prevention services, urban and rural men who have sex with men in the United States: results from a National Online Survey. AIDS Behav. 2017. Scholar
  22. 22.
    Kirsh SR, Ho PM, Aron DC. Providing specialty consultant expertise to primary care: an expanding spectrum of modalities. Mayo Clin Proc. 2014;89(10):1416–26.CrossRefGoogle Scholar
  23. 23.
    Kirsh S, Su GL, Sales A, Jain R. Access to outpatient specialty care: solutions from an integrated health care system. Am J Med Qual. 2015;30(1):88–90.CrossRefGoogle Scholar
  24. 24.
    Centers for Disease Control and Prevention. HIV in the United States: at a glance. Accessed 6 Apr 2018.

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2018

Authors and Affiliations

  1. 1.VA Portland Health Care System, Infectious DiseasesPortlandUSA
  2. 2.HIV, Hepatitis, and Related Conditions Programs, Office of Specialty Care ServicesVeterans Health AdministrationWashingtonUSA
  3. 3.Division of Infectious DiseasesOregon Health and Science UniversityPortlandUSA
  4. 4.VA Puget Sound Health Care System, Health Services Research and DevelopmentSeattleUSA
  5. 5.School of Public HealthUniversity of WashingtonSeattleUSA
  6. 6.Geriatric Research Education and Clinical CenterLouis Stokes Cleveland VA Medical CenterClevelandUSA
  7. 7.Division of Infectious DiseaseCase Western School of MedicineClevelandUSA
  8. 8.Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityUSA
  9. 9.Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa CityIowa CityUSA
  10. 10.VA Puget Sound Health Care System, General Medicine ServiceSeattleUSA
  11. 11.Division of General Internal MedicineUniversity of WashingtonSeattleUSA

Personalised recommendations