Integrating preexposure prophylaxis into gynecologic care: determinants and strategies

Preexposure prophylaxis (PrEP) is highly effective for HIV prevention, yet cisgender women remain underrepresented among PrEP users relative to their HIV burden in the United States. Obstetrics and gynecology (OB/GYN) settings-where many women receive routine sexual and reproductive health care-represent a promising but underutilized venue for PrEP delivery. Despite professional guidance endorsing PrEP discussion and prescribing in OB/GYN practice, implementation remains limited.

We conducted a qualitative implementation study with two linked components in an academic OB/GYN clinic: semistructured interviews with 12 clinicians and clinical staff, and four multidisciplinary stakeholder workgroups focused on strategy refinement. Interview transcripts were analyzed using directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR 2.0). Finalized determinants were brought to stakeholder workgroups, where participants reviewed interview findings and collaboratively identified and prioritized implementation strategies. Strategies were labeled using Expert Recommendations for Implementing Change (ERIC) terminology.

Five implementation determinants were identified: preventive care misfit within problem-focused visit structures, limited cognitive integration of PrEP into routine gynecologic care, fragmented care continuity and unclear role ownership, administrative and access burden, and lack of patient activation infrastructure. Stakeholders concluded that implementation failure reflected a workflow placement problem rather than a motivation problem. Strategies requiring clinicians to absorb additional counseling or coordination tasks during already time-limited visits were viewed as unlikely to succeed. Stakeholders instead refined a clinic-facing strategy bundle centered on nurse-led PrEP navigation, supported by EHR-embedded referral prompts, standardized handoff workflows, brief provider education and protocol clarification, pharmacy and insurance coordination partnerships, and structured tracking and follow-up systems.

PrEP underimplementation in this gynecologic setting appeared to be driven less by clinician willingness than by the absence of a reliable workflow location for counseling, coordination, and follow-up. A nurse-led navigation model supported by referral prompts and access coordination may offer a feasible approach to integrating PrEP into women's health care. Future work should test this strategy bundle in multi-site women's health settings and pair clinic-facing approaches with patient-facing activation strategies.