Graduation Year


Document Type




Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Public Health

Major Professor

Stephanie Marhefka, Ph.D.

Committee Member

Ellen Daley, Ph.D., M.P.H.

Committee Member

Wei Wang, Ph.D.

Committee Member

Robert Shore, Pharm.D.


HIV prevention, PrEP, Sexual health, Theory


Background: Pre-exposure prophylaxis (PrEP) is a daily pill that can reduce a person’s chances of acquiring HIV. HIV testing and counseling is a critical point during which non-clinical staff could intervene, discuss and/or refer clients for PrEP. However, not all HIV testing/counseling staff take part in PrEP implementation in the same way. This study investigated: 1) the underlying PrEP implementation subgroups of staff who perform HIV testing and 2) PrEP implementation as a function of key constructs from the Consolidated Framework for Implementation Research (CFIR).

Methods: This study was a mixed methods concurrent triangulation design, in which qualitative and quantitative data were collected concurrently and data were triangulated during analysis and interpretation. Latent Class Analysis (LCA) was performed using MPlus.v.8 on a sample of 150 HIV testing/counseling staff in Florida. The LCA technique groups participants based on similarities in how they answer a predetermined set of questions (here, five items related to PrEP-implementation behaviors). The final LCA model and corresponding latent classes were determined based upon fit indices and theoretical interpretation. Two generalized linear mixed models were conducted to estimate PrEP implementation as a function of key variables from the CFIR. A total of 22 interviews were completed and data were analyzed thematically.

Results: A LCA with four models was conducted–containing 1, 2, 3 or 4 classes, respectively. Based on consideration of fit statistics and theoretical relevance, a 3-class LCA was selected. Class one (labeled “Universal”; 42%; n=62) includes HIV testing/counselors who were PrEP advocates; “Universal” participants were likely to talk about PrEP with clients, regardless of client eligibility, and likely to share physical information about PrEP (e.g. brochures). Class two (labeled “Eligibility Dependent”; 33%; n=48) includes staff who were most likely to discuss PrEP if they believed their client met the indications for PrEP. Staff in Class 3 (labeled “Limited”; 25%; n=37) spoke to clients about PrEP inconsistently. Several variables under the CFIR have a statistically significant association with PrEP implementation among HIV testing staff, including race, sexual orientation, relative priority, and available resources. Qualitative data revealed the importance of available resources, cosmopolitanism, and leadership in PrEP implementation within community-based HIV testing sites.

Conclusions: Not all HIV testing and counseling staff discuss PrEP with clients. Some staff differentially discuss PrEP based on eligibility, or inconsistently talk to clients about PrEP. Understanding implementation subgroups can assist in training and program development. Furthermore, understanding the factors that could affect PrEP implementation (e.g. availability of PrEP-related resources) may help organizations to better prepare HIV testing staff to more seamlessly implement PrEP education and referrals.

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Public Health Commons