Start the Conversation: Evaluating Implementation of a Multi-level PrEP Initiative for Black Cisgender Women in New Orleans, Louisiana
Phase: NA
Conditions: Preexposure Prophylaxis, HIV Infections
Sponsor: Duke University

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Start the conversation: Evaluating implementation of a multi-level 
PrEP initiative for Black cisgender women in New Orleans, Louisiana  
Protocol Version/Date: 1.0/April 17, 2023 
 
 
Principal Investigators: 
Amy Corneli, PhD, MPH 
Associate Professor 
Duke University School of Medicine 
Department of Population Health Sciences 
(919) 668-9238 
amy.corneli@duke.edu 
 
Meredith Clement, MD 
Department of Medicine, Section of Infectious Diseases 
University Medical Center New Orleans 
Assistant Professor of Medicine 
Louisiana State University Health Sciences Center 
(504) 568-5204 
mclem5@lsuhsc.edu 
 
Co-Investigator:  
Sheree Schwartz, PhD 
Associate Professor  
Johns Hopkins School of Public Health 
Associate Scientist 
443-983-2564 
sschwartz@jhu.edu 
 
Consultant:  
Whitney Irie, PhD, MSW 
Consultant  
whitney.irie@bc.edu 
 
Duke Study Coordinator:  
Nneka Molokwu, MSW 
Clinical Research Coordinator 
Department of Population Health Sciences 
Duke University  
(919) 681-6801 
nneka.molokwu@duke.edu  
 
LSUHSC Study Coordinator: 
Clare Kelsey, BS, MS 
Clinical Research Coordinator 
Department of Medicine, Section of Infectious Diseases 
Louisiana State University Health Science Center–New Orleans 
(504) 252-1698 
ckelse@lsuhsc.edu 
 
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Start the conversation: Evaluating implementation of a multi-level 
PrEP initiative for Black cisgender women in New Orleans, Louisiana  
  
1. Introduction 
Profound sexual health disparities exist for Black cisgender women living in Louisiana, 
where the rate of HIV diagnosis is more than 7 times higher than that of White women. New 
Orleans, Louisiana (NOLA) is heavily impacted by the HIV epidemic and is a priority jurisdiction 
for the Ending the HIV Epidemic (EHE) Initiative.1 Yet PrEP awareness and uptake have been 
poor among Black cisgender women, including in NOLA.2–4 Culturally-sensitive strategies are 
critically needed to reduce HIV infections among Black cisgender women.  
In our 2019 NIH-funded Ending the HIV Epidemic Administrative Supplement grant, a team 
of collaborators—investigators, the Louisiana Department of Health, and members of NOLA’s 
Black Women and PrEP (BWAP) Task Force—partnered to identify determinants to PrEP 
uptake among Black cisgender women in NOLA and implementation strategies to address 
them. The BWAP Task Force consists of 25 Black female community representatives of diverse 
backgrounds; many are engaged in PrEP-related efforts for Black women in NOLA. Informed by 
formative research findings from our qualitative interviews with Black cisgender women using 
and not using PrEP, the BWAP Task Force identified two main barriers to PrEP uptake: Black 
cisgender women do not know of other Black cisgender women taking PrEP, and Black women 
are not offered PrEP during routine medical care. The BWAP Task Force identified two linked 
strategies to “Start the Conversation” around PrEP: a social media campaign to increase 
awareness of Black cisgender women using PrEP and a provider combined-care model to 
encourage providers to discuss PrEP with Black cisgender women. The Task Force stressed 
the importance of using a multi-level approach that includes both patient and provider-level 
strategies.  
We received NIH R34 funding to develop and evaluate implementation of the Start the 
Conversation PrEP initiative. A previous protocol focused on the development of the initiative 
(Duke: #Pro00109957; LSU: #2163). This protocol focuses on evaluating the implementation of 
the initiative at the Louisiana State University (LSU) GYN resident clinic based at the University 
Medical Center-New Orleans (UMCNO).  
 
2. Study Objectives 
 
The study objectives are to: 
 
• 
Evaluate implementation outcomes from piloting the Start the Conversation Initiative 
• 
Assess initial indicators of clinical effectiveness among patients engaged in the Start the 
Conversation Initiative  
 
3. Initiative Overview 
 
The Start the Conversation Initiative includes a PrEP combined-care model and a social 
media campaign.  
 
PrEP combined-care model overview: We will train LSU GYN residents to (1) start the 
PrEP conversation with all potentially eligible patients (per CDC guidelines), (2) prescribe 
PrEP for interested patients, and (3) create a plan for PrEP follow up either at the GYN 
clinic or a local PrEP clinic. Patients will choose whether to receive follow-up care at the 
LSU GYN resident clinic or be referred to care at a local PrEP provider. We anticipate 
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providing a monthly training prior to each resident clinic block, with approximately 4 to 6 
residents at each training.  
 
We may also engage PrEP champions (e.g., a provider or resident at the GYN resident 
clinic) to follow-up on patients' laboratory assessments and whether they filled their PrEP 
prescription. The PrEP champion may contact the patient as part of regular patient care. 
 
Social media overview: We will implement a social media campaign focusing on raising 
awareness about Black cisgender women engaging in PrEP care. The content and 
strategy were developed as part of our previous protocol (Duke: #Pro00109957; LSU: 
#2163). Selected members of the BWAP Task Force who are active influencers, other 
identified influencers, and local organizations will distribute all social media content via 
their standard channels and approaches for communicating with their followers (e.g., 
Facebook, TikTok). All social media content will link Black cisgender women to a PrEP 
navigator located at the Louisiana Department of Health Office of Public Health 
STD/HIV/Hepatitis Program’s (SHHP). SHHP will refer women to a PrEP provider/location 
of their choice. 
 
4. Study design 
 
We will layer data collection and the implementation of the combined-care model and 
social media campaign over three phases. Phase 1 is the pre-intervention phase and it 
will last for 4 months (months 1-4). The only study activity during the pre-intervention 
phase is the collection of routine PrEP uptake data to establish a baseline for PrEP 
prescribing at the GYN residency clinics and local PrEP clinics. Phase 2 is the 
implementation of the combined-care model at the LSU GYN residency clinic at UMCNO 
for 4 months (months 5-8). Phase 3 adds implementation of the social media campaign in 
the NOLA area for 4 months (months 9-12); implementation of the combined-care model 
at LSU GYN residency clinic at UMCNO will continue during this time (Figure 1). The 
layered approach allows for an opportunity to assess the effect of the combined-care 
model, and subsequently, to what extent the social media campaign additionally engages 
Black women and builds demand for PrEP.  
 
We also include a comparator arm to evaluate changes in PrEP uptake due to other 
secular trends in the area and increases due to the social media campaign. The three 
comparator clinics are: (1) another GYN resident program (Tulane Downtown GYN 
Clinic), (2) the UMCNO PrEP clinic (Clement, PI, is a provider), and the Tulane PrEP 
clinic. 
 
 
Figure 1: Study design 
 
 
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5. Study Outcomes 
 
We will assess both implementation outcomes (Table 1) and clinical outcomes (Table 2).  
 
The implementation outcomes are guided by Proctor et al and include: acceptability, feasibility, 
appropriateness, adoption, fidelity, and maintenance.5 These outcomes will be assessed 
qualitatively through in-depth interviews (IDIs), debriefing sessions with GYN residents and 
leadership, medical chart reviews and/or de-identified Epic queries, training records, 
discussions with the BWAP Task Force, and social media metrics. 
 
Table 1: Implementation Outcomes 
Outcomes 
Measurement 
Data sources & level of analysis 
Acceptability 
Satisfaction of complexity, content, relative 
advantage, and credibility of implementation 
strategies being delivered. 
Provider: Debriefing sessions & IDIs 
Patient: IDIs 
Community stakeholders: Regular 
meeting with the BWAP Task Force 
Feasibility 
Fit from site perspective, suitability for everyday 
use, practicability. 
Provider: Debriefing sessions & IDIs 
Appropriateness 
Perceived fit and relevance to needs of Black 
cisgender women and suitability for GYN 
residents to implement 
Provider: Debriefing sessions & IDIs 
Patient: IDIs 
Community stakeholders: Regular 
meeting with the BWAP Task Force 
Adoption 
• 
# residents trained/# residents rotating 
through GYN clinic 
• 
# residents initiating PrEP/# residents 
rotating through GYN clinic 
• 
Time between training providers & their 
beginning to implement 
Provider: Training records, chart 
review 
Fidelity 
• 
Time to implement: Average response time 
from social media inquiries by PrEP 
navigator 
• 
Completeness of combined care model 
delivery per eligible clients  
(% discussed PrEP; % provided PrEP 
counseling; % made a PrEP follow up plan;  
# monthly feedback sessions occurring) 
• 
Quality of implementation strategy delivery 
• 
Consistency of fidelity within and across 
providers 
Social media: Records of inquiries, 
calls and responses; metrics (e.g., 
post frequency, specific post reach, 
likes and amplification rates as a 
marker of quality)   
Provider: Epic data pull, chart 
review (completion/consistency);  
IDIs (quality) 
Patient: IDIs (quality) 
Maintenance 
• 
Adoption (see above) by providers over time 
• 
Fidelity of completeness (see above) of 
delivery over time 
Provider: Epic data pull, chart 
review 
Reach 
• 
# social media video views; # jingle plays; # 
campaign Facebook site visits 
Social media: Platform metrics (e.g. 
Facebook, TikTok) 
 
 
 
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Table 2: Clinical outcomes, primary and secondary 
 
Primary 
• 
Total number of women overall and number of Black cisgender women 
initiating PrEP at the LSU GYN clinic during the pre-implementation 
period (Phase 1: months 1-4) compared to during the two implementation 
period phases (Phase 2: months 5-8 and Phase 3: months 9-12).  
• 
Comparison of the difference in patient numbers at the LSU GYN clinic 
during pre-implementation and the two implementation period phases 
with the difference in patient numbers during the same time frame at the 
Tulane GYN clinic. 
• 
Comparison of the difference in patient numbers at LSU GYN clinic and 
UMC PrEP clinic combined to the Tulane GYN and Tulane PrEP clinics 
combined during the same time frame to further investigate trends 
outside of the GYN clinics potentially impacted by the social media 
campaign. 
Secondary  
• 
Proportion of PrEP-eligible women overall and Black cisgender women 
initiating PrEP at the LSU GYN clinic across the two implementation time 
periods (combined-care model only, Phase 2—months 5-8; combined 
care model plus social media company, Phase 3—months 9-12)  
• 
Proportion of women choosing follow-up care at the LSU GYN resident 
clinic versus transition to a local PrEP provider 
• 
Proportion of women initiating PrEP at the LSU resident GYN clinic who 
complete their first follow-up PrEP care visit (can only assess at the LSU 
GYN resident clinic or UMC PrEP clinic) 
• 
LDH navigator logs (number of contacts, number of appointments made 
through the PrEP navigator) 
 
 
6. Data collection 
 
Chart reviews, use of electronic medical records, and provider surveys 
  
For baseline data collection (Phase 1, months 1-4), we will retrospectively collect data at the 
LSU GYN resident clinic, Tulane Downtown GYN Clinic, and the LSU PrEP clinic at the end of 
Phase 1 for the previous 4 months. Data will consist of the number of new PrEP prescriptions 
per month (overall among women and number of Black cisgender women specifically). No 
identifiable data will be collected. We may also collect baseline data for up to 12 months prior to 
Phase 2 initiation to compare trends over time.  
 
Because the number of PrEP prescriptions among women at the Tulane Downtown GYN clinic 
and the Tulane PrEP clinic is extremely low, we will administer a survey to clinic leadership or 
another representative to gather the aggregate, de-identified data throughout implementation of 
this study. We will not access patient records at these sites. To collect data from the UMC PrEP 
clinic, in which Dr. Clement (study PI) is a provider, we will collect the de-identified data via 
provider survey if feasible (since numbers are also low), or if necessary, through patients’ 
electronic medical records (EMR).  
 
We will continue to collect data on PrEP prescriptions at the Tulane Downtown GYN Clinic, the 
Tulane PrEP clinic, and the LSU PrEP clinic until the end of Phase 3.   
 
For data collection during the implementation phase (Phases 2 and 3, months 5-12) at the LSU 
GYN resident clinic, we will collect the number of new PrEP initiation counts for cisgender 
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women by date, race, and provider through provider notes. We will also collect data to inform 
the primary and secondary clinical and implementation outcomes (LSU site only) through Epic 
data pulls (i.e., provider note templates will incorporate ‘smartlists’ and ‘smartphrases’ with 
extractable data elements), and if necessary, provider notes and chart review of GYN patients 
seen. If chart review is required, and depending on the volume of patients seen, we may use a 
stratified random sampling approach to select patients for the chart review. Additionally, we may 
also track EMR prescription data to trend PrEP initiations and follow initiation patterns (and thus 
adoption metrics) across providers for all patients seen during the study period.  
 
We anticipate that 32 to 48 LSU GYN residents will be trained in the combined-care model. The 
LSU GYN clinic at UMC sees 60 to 80 patients per week; it is estimated that ~30/week will be 
eligible for PrEP, of which we anticipate ~2 will be initiated per week. This will result in an 
estimated 2,400 women seen over the 8-months of implementation, of which ~1,000 will be 
PrEP-eligible and around 70 will take up PrEP in the GYN clinic.  
 
In-depth interviews 
 
We will also conduct IDIs with 12 GYN residents who were trained and 12 patients who were 
offered PrEP using the “Start the Conversation” guidance and materials.  
 
LSU GYN residents and leadership: We aim to interview a diverse group of LSU GYN 
residents based on their varying experiences in starting a PrEP conversation with patients and 
prescribing PrEP. We will work with the residency program’s PrEP leadership to identify and 
purposefully select residents to invite for the IDIs. This will be coupled with Epic data pull 
reviews to document adoption and fidelity of provider implementation during the pilot. Adoption 
and fidelity outcomes will be summarized by provider, including the number of PrEP 
conversations started and the number of PrEP prescriptions provided by patient demographics 
(i.e., race and age). Any patient information will be de-identified, and the list provided to study 
staff. We will aim to purposefully select (1) three residents who frequently started a PrEP 
conversation but did not prescribe PrEP, (2) three residents who infrequently started a PrEP 
conversation, and (3) three residents who frequently prescribed PrEP. Modifications in our 
selection process may be needed based on the number of residents who start a PrEP 
conversation or prescribe PrEP. Study staff will contact each selected resident to invite them to 
participate in an IDI. Interested residents will be connected to study staff to receive an 
information sheet about the study and scheduling. We will also interview members of the GYN 
leadership team, such as attending preceptors and the LSU GYN residency program director(s). 
 
PrEP patients: We aim to interview a diverse group of Black cisgender women who initiated 
PrEP during the pilot based on their decisions on the location of their PrEP follow-up care and 
whether they attended their month 1 follow-up PrEP visit. Among Black women prescribed 
PrEP, GYN residents or leadership will inform patients that the PrEP program is part of a larger 
study and that they may be contacted by study staff for possible participation in an IDI. Using 
the list of women who initiated PrEP, the PrEP Champion or another provider will review 
women’s medical records to identify the choice of follow-up care and whether the woman 
attended her month 1 follow-up PrEP visit. The list will then be de-identified and provided to 
study staff. Among those who chose to remain with the LSU GYN residency program for their 
PrEP follow-up care, we will purposefully select three women who attended their month 1 follow-
up PrEP care and three women who did not. Among those who chose to attend PrEP follow-up 
care with a routine PrEP provider, we will purposefully select three women who attended their 
month 1 follow-up PrEP care and three women who did not. We may need to modify the 
proposed participants to interview and the number of interviews per group based on patient 
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choices and retention outcomes during implementation (e.g., most patients chose the LSU GYN 
residency program for PrEP follow-up care, most patients did or did not attend month 1 follow 
up).  
 
All interviews will be conducted via Zoom or on the telephone and audio-recorded with 
participant permission; we will take detailed notes for participants who wish not to be 
audio-recorded. We will use an encrypted recorder to audio-record interviews; interviews 
will not be video- or audio-recorded using Zoom. All audio files will be transcribed by 
GMR transcription.  
 
PrEP Navigation Logs 
 
Currently, logs documenting calls to existing PrEP navigators at SHHP from women in the 
community interested in PrEP are recorded at the Louisiana Department of Health. For our 
study, de-identified logs will be collected by the study team during each phase of the study to 
understand the volume of PrEP navigation interactions and potential linkages facilitated by the 
social media campaign.  
 
7. Adaptation  
 
We will conduct monthly feedback sessions throughout the study (e.g., at the end of each 
month-long rotation) with the LSU GYN residents and leadership. The purpose is to 
discuss their experiences with implementing the Start the Conversation initiative and make 
adaptations to the combined-care model (e.g. adjustments, additions and/or subtractions 
of action steps) as needed. The residents will receive information regarding their fidelity 
during the end of month feedback session and will have an opportunity to provide 
suggestions of components to change, add, or subtract to increase feasibility and 
acceptability. Residents and leadership will be informed that we will use information 
discussed at these meetings for research purposes (e.g., describing adaptations made 
during research dissemination). We will also use Epic data pulls of extractable data 
elements as needed to inform components that may need adaptation (e.g. was a PrEP 
conversation initiated, were shared decision-making talking points used).  
 
8. Data analysis 
 
We will evaluate the primary clinical outcomes using a difference-in-differences 
approach6 to account for changes within time periods (pre- and post-implementation) 
and across sites (LSU versus Tulane). Poisson regression will be used to determine 
synergistic effects of the social media layering using weekly PrEP initiation counts, 
comparing uptake across implementation periods and sites and employing a product 
term to assess the impact of jointly implementing the combined-care model and social 
media campaign. We will analyze the secondary clinical outcomes using descriptive 
statistics.  
 
We will use thematic analysis to analyze the qualitative data from the IDIs. Informed by the 
Proctor outcomes5  and the Consolidated Framework for Implementation Research,7 analysts 
will first develop a structural codebook based on predetermined topics explored during data 
collection. Next, content codes will be developed to capture emergent content. Transcripts will 
be coded by two or more analysts. Analysts will conduct inter-coder reliability assessments on 
approximately 25% of the transcripts; discrepancies will be resolved through discussion, 
codebooks will be updated as appropriate, and subsequent text will be recoded as needed. 
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NVivo software will be used to apply codes to transcripts. After coding, analysts will examine 
code frequencies across transcripts to 1) identify the most salient themes, and 2) create 
matrices to highlight the intersection or co-occurrence of deductive and inductive codes. We will 
focus on identifying which of the CFIR domains are most relevant to implementation, as well as 
how these codes interplay with Proctor’s outcomes (acceptability, feasibility, appropriateness, 
and fidelity). An analytic report will be written to summarize findings. 
 
9. Reimbursement 
 
All GYN residents/leadership and women who participate in the interviews will receive $50.  
 
10. Ethics    
 
In-depth interviews 
 
a. Informed Consent 
 
We are asking for a waiver of written informed consent for the IDIs per federal regulations under 
45 CFR 46.117(c)(1) which states that: An IRB may waive the requirement for the investigator to 
obtain a signed informed consent form for some or all subjects if it finds any of the following: 
 
(i) That the only record linking the subject and the research would be the informed 
consent form and the principal risk would be potential harm resulting from a breach of 
confidentiality. Each subject (or legally authorized representative) will be asked whether 
the subject wants documentation linking the subject with the research, and the subject’s 
wishes will govern; 
 
(ii) That the research presents no more than minimal risk of harm to subjects and 
involves no procedures for which written consent is normally required outside of the 
research context; or 
 
(iii) If the subjects or legally authorized representatives are members of a distinct cultural 
group or community in which signing forms is not the norm, that the research presents 
no more than minimal risk of harm to subjects and provided there is an appropriate 
alternative mechanism for documenting that informed consent was obtained. 
 
We believe we qualify under ii above. Additionally, the regulation states: In cases in which the 
documentation requirement is waived, the IRB may require the investigator to provide subjects 
or legally authorized representatives with a written statement regarding the research. 
 
We will obtain oral consent from patients prior to their participation in the IDIs. We will provide 
residents and GYN leadership with an informational sheet, in replace of any consent (written or 
oral), that describes the purpose of the data collection activities and other related information 
(e.g., risks). 
 
b. Description of Risks  
 
We do not believe that participating in the IDIs will lead to any physical, emotional, legal, or 
social harms.  All potential participants will be informed that they are free to decline participation 
in the IDIs, and that their decision to participate or not participate has no impact on their health 
care. Participants will also be told that they can decline to answer any question during the IDI, 
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and can terminate their participation at any time. At the beginning of each IDI, we will remind 
participants again verbally that they can decline to answer and question or terminate their 
participation at any time. Participants can accept or decline to be audio-recorded during the 
IDIs; if participants choose not to be audio-recorded, detailed notes will be taken instead. The 
potential loss of confidentiality is a risk; participants will be informed that although every effort 
will be made to protect their privacy and to keep their information confidential, there is no 
guarantee that privacy and confidentiality can be fully maintained.  
 
c. Anticipated Benefits  
 
We do not anticipate any direct benefits to women from the IDIs. Patients, however, may 
appreciate or have a sense of satisfaction by contributing to developing strategies that may 
PrEP use among Black cisgender women in their community.  
 
d. Protection of Confidentiality  
 
Every effort will be made to protect participants’ confidentiality; however, as with all research, 
there is no guarantee that confidentiality can be fully maintained.   
 
The following procedures will be put in place to keep participant data confidential. First, 
participant names and contact information (collected for interview scheduling and facilitation 
purposes, and to disseminate study results) will not be recorded on any data collection 
instrument/transcript; a unique code will be assigned and used on all instruments/transcripts in 
place of participants’ names. Second, participants will not be mentioned by name in any report 
or publication. Third, any hard copies of data will be logged and maintained in locked file 
cabinets when not in use. Access to the locked file cabinets will be limited to key research staff, 
who will pull materials only as needed to complete data entry, analysis, and management tasks. 
Fourth, all electronic data files and databases (Word, Excel, RedCap, Qualtrics) will be stored 
on a limited-access network drive in the Department of Population Health Sciences and shared 
with LSU via the secure Duke Box. Digital voice recordings from the interviews will also be 
stored securely on the Department of Population Health’s network drives and on approved 
drives at the transcription company (GMR transcription). Audio-recordings will be destroyed 
after publication of the study’s main findings. The link between study participants and study ID 
numbers will be destroyed when study activities are complete.  
 
e. Protection of Privacy 
 
We will suggest to participants that they find a private place for the Zoom- or telephone-based 
interview. Interviewers will also conduct the interviews in a private location. We will also protect 
participants’ identities by password-protecting the central participant ID# log (that includes 
participants’ names and contact information), storing it on a secure drive at LSU and Duke 
University, and limiting its access to a small number of staff.  
 
Chart reviews 
 
We do not anticipate any risks from abstracting data from provider notes on their use of the 
combined-care model. Only individuals who have existing access to provider and patient 
records will be engaged in the chart review (e.g., GYN residents and the PrEP Champions). All 
data provided to study staff will be de-identified. All LSU GYN residents will be informed that 
review of provider records will be conducted as part of the primary and secondary outcomes of 
the study and for the augmentation component. We will not obtain informed consent for the 
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chart reviews. Provider employment stability will not be directly impacted by the chart reviews, 
and residents’ standing will not be impacted if they do not implement or inconsistently 
implement the combined-care model. 
 
Electronic medical records 
 
We do not anticipate any risks specific to Epic data pulls. All data provided to study staff will be 
de-identified. All data transferred from Epic will be stored on password-protected files only 
accessible to study personnel and stored on secure servers at LSUHSC. Each participant will 
be assigned a random study identification number. A separate password-protected log will be 
created linking the study ID numbers to the medical record numbers (MRN) of participants. The 
purpose of this log is to avoid duplication of charts, to allow researchers to return to charts to 
check the accuracy of the data contained in our files if necessary. The log linking study ID 
numbers to MRN will be destroyed when data analyses are complete. Any physical copies of 
data will be kept in locked filing cabinets at LSUHSC. Following publication and dissemination of 
the results, all data will be destroyed. We will also request a waiver of written consent and a 
HIPAA waiver. Our research could not practically be conducted without these waivers: the 
informed consent process could potentially affect potential participants’ willingness to start PrEP 
and attend their follow-up PrEP visits because they know they are being monitored for research. 
Further, no identifiable information will be obtained by the study team. 
 
PrEP Navigation Logs 
 
Data from the SHHP PrEP navigation logs will be reported to study staff in aggregate numbers 
by gender and race; neither individual level records nor identifiable data will be collected by the 
research team. Informed consent will not be required for this activity as individual information 
will not be sought; only aggregate numbers reported from patient logs will be obtained. 
 
 
11. Ethics Training  
 
All study staff will have completed all required research ethics training prior to contact with any 
participant or their data.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1. Priority Jurisdictions: Phase I. HIV.gov. Accessed February 19, 2023. 
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3. Chandler R, Hull S, Ross H, et al. The pre-exposure prophylaxis (PrEP) consciousness of 
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Immune Defic Syndr. 2019;80(5):527-532. doi:10.1097/QAI.0000000000001950 
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implementation of health services research findings into practice: a consolidated framework 
for advancing implementation science. Implement Sci. 2009;4:50. doi:10.1186/1748-5908-4-
50 
 
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