PREFER-PrEP: Preference-informed Strategies to Optimize PrEP Persistence

Modified Project Summary/Abstract Section More than 50% of people receiving HIV pre-exposure prophylaxis (PrEP) discontinue PrEP within 6 -12 months of initiation partly due to social and structural barriers, resulting in an unacceptable rate of new infections disproportionately affecting communities with less access to PrEP. While some may appropriately discontinue based on lifestyle changes, HIV seroconversion among those who discontinue is high, indicating premature discontinuation or lack of timely re-engagement in PrEP care. Despite identified barriers to PrEP persistence (encompassing retention and adherence), effective implementation strategies to support persistence are lacking compared to other steps of the HIV prevention continuum such as linkage and uptake. A greater understanding of patient preferences about PrEP persistence and re-engagement, with a focus on the factors most relevant to urban vs. rural clinics, is critical to creating innovative strategies to end the HIV epidemic. This research applies multidisciplinary methods to design and pilot-test preference-informed implementation strategies to improve PrEP persistence in urban and rural settings in Missouri, an Ending the HIV Epidemic priority state due to the burden of both urban and rural epidemics. This career development award will provide Dr. Aditi Ramakrishnan with the mentored training and research expertise to launch her career as an independent clinician-investigator leading the 1) design of preference-informed and community-engaged implementation strategies and 2) rigorous testing through implementation trials in urban and rural contexts. To achieve this goal, Dr. Ramakrishnan has assembled an expert mentoring team and proposed an impactful training plan to develop her skills in 1) stated preference methods for implementation science, 2) human-centered design and community-engaged research methods, and 3) implementation trial design. These training objectives complement a research study with the following Specific Aims: 1) Identify patient and provider preferences for HIV prevention strategies supporting persistence and re-engagement through a discrete choice experiment, 2) Design a multicomponent strategy, PREFER-PrEP, to improve persistence and re-engagement among individuals with ongoing indications for PrEP using human-centered design principles, and 3) Assess implementation outcomes (e.g., acceptability) and persistence (e.g., retention, adherence) of the PREFER-PrEP prototype. This study will leverage robust community-academic partnerships across urban and rural Missouri and provide preliminary data for an R01 application to test the PREFER-PrEP strategy through a Type 3 hybrid effectiveness-implementation cluster randomized controlled trial to optimize HIV prevention services. This career development award training, mentorship, and research, within the rich environment of Washington University in St. Louis School of Medicine, will position Dr. Ramakrishnan to independently lead the design and testing of preference-informed, community-engaged implementation strategies and interventions to improve HIV prevention in priority regions. Project Number: 1K23MH142221-01 | Fiscal Year: 2026 | NIH Institute/Center: National Institute of Mental Health (NIMH) | Principal Investigator: Aditi Ramakrishnan | Institution: WASHINGTON UNIVERSITY, SAINT LOUIS, MO | Award Amount: $786,884 | Activity Code: K23 | Study Section: Special Emphasis Panel[ZRG1 SCIL-G (91)] View on NIH RePORTER: https://reporter.nih.gov/project-details/11253568