Implementation Determinants of PrEP and Behavioral Health Treatment Referral among HIV Test Counselors

Pre-exposure prophylaxis (PrEP), an effective biomedical prevention intervention, is not sufficiently reaching populations experiencing high HIV incidence. Behavioral health (BH) treatment addressing mental health and substance use similarly requires increased reach to HIV-affected populations. HIV testing is an opportunity to refer individuals to PrEP and BH treatment. This study, conducted in Miami-Dade County, FL, a domestic HIV epicenter, aimed to assess (1) self-reported rates at which HIV test counselors refer clients to PrEP and BH treatment, (2) barriers and facilitators to PrEP and BH treatment referral, and (3) the relationship between barriers and facilitators and test counselors' referral rates. Among 127 HIV test counselors, the average PrEP referral rate was 63.8% (SD = 41.5) of those potentially meeting PrEP indications. Insufficient time was associated with lower PrEP referral (OR: 0.64, 95% CI: 0.42-0.99, p = 0.023) and training in PrEP screening was associated with higher rates of PrEP referral (OR: 1.27, 95% CI: 0.98-1.64, p = 0.034). The average BH treatment referral rate was 52.7% (SD = 44.4) of clients who the counselor felt would potentially benefit from treatment. Counselors lacking knowledge of screening (OR: 0.4, 95% CI: 0.2-0.78, p = 0.004), referral procedures (OR: 0.45, 95% CI: 0.23-0.87, p = 0.008), or locations to refer clients (OR: 0.47, 95% CI: 0.25-0.86, p = 0.008), as well as those with higher caseloads (OR: 0.998, 95% CI: 0.997-0.999, p < 0.001) were less likely to refer for BH. Training in substance use screening (OR: 1.26, 95% CI: 0.96-1.64, p = 0.046) and referral (OR: 1.28, 95% CI: 0.99-1.66, p = 0.029) were associated with increased BH referral. Implementation strategies are needed to address key barriers to PrEP and BH referrals in HIV testing contexts.