Adaptation and Assessment of a Shared Decision-Making Tool for HIV Prevention in Title X Family Planning Clinics Restricted; Files Only
Anderson, Katherine (Fall 2025)
Abstract
Approximately 20% of new HIV infections in the United States occur among women, primarily from heterosexual contact. These infections are preventable. Title X Family Planning (FP) clinics provided care to >2 million sexually active women in 2023 but performed fewer than half as many HIV tests. Still, in 2023, Title X clinics diagnosed ~8% of new HIV cases in the US. While essential, HIV testing levels are suboptimal, and testing remains a reactive approach to HIV prevention compared with proactive counseling. Title X clinicians may lack resources- such as FP-HIV integrated counseling materials- to conduct recommended universal prevention counseling. Responsively, we aimed to systematically adapt and assess perceived feasibility and acceptability of an integrated FP/HIV/STI shared decision-making tool to inform future implementation, effectiveness testing, and scaling.
Thirteen FP providers at Georgia FP clinics and 28 cisgender women in FP care in Atlanta completed formative interviews. Key adaptations were identified via rapid qualitative analysis and underwent modified Delphi review by 18 FP/HIV practitioners and experts. Adaptations were systematically documented using the FRAME framework; surveys assessing perceived feasibility/acceptability were conducted with 15 Title X providers and 33 cisgender female clients.
Providers endorsed perceived risk-based HIV prevention counseling with minimal counseling tool availability. Preferences included concise, accessible language, availability for pre-visit patient engagement, with information on HIV prevalence, prevention method comparison, and guided questions. Women preferred non-judgmental universal counseling with opportunities to conduct independent research. Expert review highlighted usefulness of comparison charts, physical materials with QR codes, and conversation prompts. Information on PrEP and comparison to condoms were prioritized. Iterative adaptation yielded the Integrated Sexual Health Decision-Making (I-DM) Tool. In preliminary testing, providers and women expressed high acceptability, feasibility, and usefulness of the I-DM tool.
Title X clinics represent a high-impact environment for reaching women with HIV prevention counseling, dependent on patient- and provider-sensitive implementation tools and acceptable processes. The I-DM tool shows promise for facilitating universal integrated counseling to promote HIV prevention uptake, reducing the burden of HIV on cisgender women.
Table of Contents
Table of Contents
Introductory Literature Review 1
HIV Risk Among Cisgender Women 1
HIV Prevention for Cisgender Women 2
Existing HIV Prevention Interventions for Cisgender Women 5
Promising Pathways for HIV Prevention among Cisgender Women 8
Shared Decision-Making 9
Patient Decision Aids 11
Trauma-Informed Care 13
Gender Responsivity 16
Reaching Cisgender Women for HIV Prevention 19
HIV Prevention Counseling 19
Family Planning Settings and HIV Prevention 23
The Title X National Family Planning Program 26
Implementation of HIV Prevention Interventions 30
Health Care Providers as Intervention Deliverers 32
Clinics as The Inner Setting of Implementation 34
The Process of Adaptation 36
Specific Aims 41
References 42
Manuscript 1: Perspectives and Needs for HIV Prevention Counseling in Family Planning Settings in the South: Qualitative Findings from Providers and Cisgender Female Patients 75
Abstract 75
Introduction 76
Methods 82
Results 89
Discussion 117
References 128
Manuscript 2: Preliminary Acceptability and Feasibility of the Integrated Sexual Health Decision-Making (I-DM) Tool for Family Planning and Preventative HIV/STI Counseling with Title X Providers and Patients in the U.S. South 141
Abstract 141
Introduction 143
Methods 147
Results 155
Discussion 163
References 169
Manuscript 3: Development of the Integrated Sexual Health Decision-Making (I-DM) Tool for Combined Family Planning and HIV/STI Prevention Counseling Using the ADAPTT-IT Framework 180
Abstract 180
Introduction 181
Methods 184
Results 189
Discussion 198
References 205
Discussion 214
Overview of Research 214
Individual Women’s Positioning, Perceptions, and Preferences for HIV Prevention 216
The Intersection of Perceived Risk and Knowledge 216
Facilitating Access to Knowledge and Information 220
Populations Warranting Additional Considerations 225
Individual FP/SRH Providers as Intervention Deliverers 228
Barriers to Provider Engagement in Delivery 228
Provider Biases as an Impediment to Quality Care 231
The Potential of Delivering Universal Counseling 234
Interpersonal Patient-Provider Communication 235
Communication, Power, and Mistrust 235
SDM to Improve Patient-Provider Communication 239
Implementation in the Clinical Setting 241
Prioritization of Integrated Sexual Health Counseling 242
Time as a Keystone Resource 245
Access to Knowledge and Information 247
The Title X, Insurance, and the Sociopolitical Landscape of Sexual Health Services 249
Limitations of the Current Research and Future Directions 255
Conclusions 258
References 260
Supplemental Materials 283
Aim 2 Supplemental Materials 283
Aim 3 Supplemental Materials 292
Aim 3 Supplemental File 1. The Integrated Sexual Health Decision-Making (I-DM) Tool 313
References 353
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File download under embargo until 12 January 2032 | 2025-12-16 12:34:48 -0500 | File download under embargo until 12 January 2032 |
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