Abstract
Preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) continue to be underutilized among transgender people despite elevated HIV incidence in this population. Many transgender individuals report that their gender-affirming care (GAC) is their highest health care priority, and an increasing number seek this care via telehealth. We sought to understand clinician perspectives and needs regarding integrating HIV PrEP and HIV PEP into GAC in a telehealth model. We conducted semi-structured interviews with clinicians who self-identified as providing gender-affirming care via telehealth. We used the transdisciplinary approach to evidence-based practice to inform our interview guide and codebook and used thematic analysis to analyze the resulting data. Among our 20 participants interviewed in December 2023 and January 2024, there was enthusiasm to offer trans patients biomedical HIV prevention within GAC. Participants were most comfortable managing oral PrEP. Identified barriers include lab work cadence and issues getting medication to patients (especially the drugs for HIV PEP). PrEP navigators, patient self-advocacy, and trusting patient–clinician relationships were identified as facilitators of co-location. A clinician’s ability to offer a transgender patient both GAC and PrEP/HIV PEP in the same telehealth visit is a promising strategy to tackle the disproportionate incidence of HIV among trans people. Trusting clinical relationships facilitated by the provision of GAC can be utilized to more accurately assess HIV risk and more effectively offer PrEP and HIV PEP.
Introduction
Transgender individuals face a disproportionate HIV burden, with transgender women experiencing HIV acquisition rates 30 times higher than the national average 1 and transgender men also experiencing elevated, but less well-approximated, risk of acquiring HIV. 2 Despite this elevated risk, there has been suboptimal uptake of biomedical HIV prevention among transgender individuals. Preexposure prophylaxis (PrEP), approved by the FDA in 2012, demonstrates high effectiveness for HIV prevention with minimal side effects. 3 However, PrEP uptake among transgender women remains critically low at approximately 33%. 4 Similarly, HIV postexposure prophylaxis (HIV PEP) demonstrates 89% efficacy in preventing seroconversion with perfect adherence, 5 yet transgender individuals face significant access and completion barriers, particularly following traumatic exposures. 6
A myriad of factors contribute to this prevention gap, among them health care-related stigma, clinical guidelines for HIV prevention that are “one size fits all” that clinicians struggle to translate to the needs of their trans patients, concerns about drug–hormone interactions, and competing health care priorities. 7 Many transgender individuals have encountered discrimination, lack of clinician knowledge, and inappropriate care within traditional medical settings. 8 Additionally, public health approaches for biomedical HIV prevention that inappropriately group transgender women with men who have sex with men (MSM) limit targeted outreach effectiveness. 9 For transgender individuals navigating limited health care resources and clinician access, gender-affirming care (GAC), and hormone therapy in particular, may take priority, reflecting both urgent medical necessity and the profound impact of GAC on overall wellbeing. 10
Prior research demonstrates that GAC serves as a foundation for improved health outcomes,10,11 and engagement with GAC has been associated with improved preventive health care utilization, including cancer screenings. 12 Recent literature demonstrates that transgender people receiving GAC experience lower HIV acquisition rates and higher viral suppression rates compared with their peers without regular GAC access. 13 While the mechanisms underlying this association require further study, these findings suggest that GAC settings may represent potential venues for HIV prevention interventions.
Telemedicine-based GAC has expanded through platforms like Plume, Folx, and True U clinic, offering comprehensive services from hormone therapy to surgical support. 14 These platforms collectively serve over 30,000 transgender and gender-diverse individuals, particularly benefiting those in underserved geographic areas. Similarly, other telehealth platforms like Nurx and MISTR have increased access to biomedical HIV prevention (particularly PrEP) and show promise for managing existing PrEP regimens, initiating new treatments, 15 increasing PrEP uptake among transgender populations, 3 and potentially reducing HIV PEP initiation delays. 16 As evidenced during the COVID-19 pandemic, telemedicine platforms also offer an opportunity for patients to consistently access biomedical care during periods of crisis or restricted access to in-person care. 3
Given the established relationship between GAC and improved HIV outcomes, integrating biomedical HIV prevention within telehealth-delivered gender-affirming care represents an opportunity to address prevention gaps via existing trusted relationships and prioritized care pathways. However, clinicians within these expanding telemedicine GAC platforms come from diverse clinical backgrounds, and their familiarity with biomedical HIV prevention has not been previously studied.
We aimed to elucidate clinician perspectives and needs regarding integrating biomedical HIV prevention services within telehealth-delivered GAC.
Methods
Design and interview procedures
We conducted semi-structured interviews with clinicians who self-identified as GAC clinicians about their experiences and comfort with providing PrEP and HIV PEP and their thoughts about colocating HIV prevention with GAC. We used the transdisciplinary approach to evidence-based practice 17 to frame our interviews, focusing on elucidating clinician expertise, as well as elements of the CFIR 2.0 framework to explore barriers and facilitators to care. 18 The a priori codes reflected these theoretical frameworks (Fig. 1).
Adapted transtheoretical framework for HIV prevention at telehealth GAC provider. Adapted from Satterfield et al., Towards a transdisciplinary model of evidence-based practice (2009)23.
This study was approved by the University of Pennsylvania Institutional Review Board. All participants provided informed consent prior to participation. Interviews were conducted over the phone or via Zoom and were transcribed verbatim. Resulting transcripts were then checked for accuracy, and identifying information was removed.
Recruitment
We recruited GAC clinicians from two sources: staff clinicians at a single gender-affirming telehealth company and clinicians registered for a national Google Groups listserv of GAC clinicians. All clinicians interviewed offered patients gender-affirming hormone treatment via telemedicine on an ongoing basis.
For both groups, clinicians were given a short description of the study and the link to a survey to supply their contact information if they were interested. Interested clinicians were contacted by the researcher during data collection to schedule an interview. Participants were compensated $50 at the end of the interview.
Data analysis
The data were analyzed using a thematic analysis approach, an iterative process in which researchers determine themes present in the data. We used a combination of a priori codes to determine barriers and facilitators of co-locating PrEP/HIV PEP with GAC, as well as inductive codes based on patterns that emerged during data collection.
Two coders double-coded 20% of the transcripts (n = 4) and met to resolve differences in coding and to adjust the codebook (κ > 0.75). One researcher then coded the remaining transcripts (n = 16). All coding was done using NVivo Qualitative Data Analysis Software (QSR International, Version 14, 2024).
Results
Participants
Between December 2023 and January 2024, we completed 20 semi-structured interviews with GAC clinicians (Table 1). Of the 20 candidates, 25% were recruited from a telehealth GAC company. Participants were 20% cisgender men, 55% cisgender women, and 25% nonbinary (NB) or gender nonconforming (GNC). The median age was 39 (IQR of 36–44; Table 1).
Demographics of Provider Respondents
GAC, gender-affirming care; SD, standard deviation; NB/GNC, non-binary/gender non-conforming.
Clinicians’ experiences with PrEP
Clinicians were uniformly familiar with, and actively prescribing, PrEP. There was noticeable variety in the percentage of each participant’s patient census that was on PrEP. When asked, participants gave ranges from less than 1% of their patient census were seeking HIV prevention from that clinician to roughly 30% of patients. All of the interviewed clinicians also managed other forms of care for their patients, usually acting as their primary care clinician. When asked what they knew about PrEP, some participants simply said it was an effective form of HIV prevention, while others would give more detailed answers about the necessary labs to order and dosing information.
“Well, I’ve been doing [PrEP] for a while. I’m very used to prescribing Truvada, Descovy, all of that. I’m very comfortable with it.” (Participant 112)
Not all participants offered injectable PrEP to their patients, either because they were not comfortable managing that form or because there were more logistics involved. While injectable PrEP is newer than oral-route PrEP, participants were more likely to cite the labor of prior authorizations as the reason for not offering it, as opposed to their own lack of knowledge.
None of the participants worked for practices where electronic medical records highlighted which patients were at an elevated risk for HIV, though this emerged as a potential facilitator during interviews. However, several had standardized intake questionnaires that surveyed for HIV risk and prevention behaviors. Some clinicians were probed for how often their patients were initiating conversations about PrEP, and the majority of participants reported that those patients were in the minority. However, one participant working in a federally qualified health center, said patients frequently came to them looking for PrEP.
“A lot of patients come to me looking for PrEP. So it’s like if anyone says ‘I want PrEP,’ we’ll talk about those questions, but I don’t—not that I don’t care about the answers. But if someone says ‘I feel at risk [sic] for PrEP,’ I will always start their PrEP. And so that’s the other fast way to get on PrEP is just asking for it.” (Participant 117)
All participants had a working knowledge of the logistical workflow of starting someone on PrEP and routinely asked patients about PrEP eligibility during clinical encounters. Many clinicians began with education about PrEP and which drug would be appropriate for the patient, while others would use the conversation to counsel their patients about what financial resources were available to them. Several participants emphasized efforts to ensure their patients leave that appointment with as many of the next steps taken care of as possible.
“Yeah, I usually would educate people if I thought that they were a good candidate for PrEP. Or if they were having an HIV test, then we had to wait 15 min anyway. So, it would be like, oh, have you heard about PrEP? Let’s take this opportunity to demystify and talk through [it]. So, I would just do a lot of resourcing like, this is how you get PrEP, this is how you can get PrEP at no cost to you, these are the side effects, this is that.” (Participant 107)
Clinicians commonly mentioned having or wanting the aid of a PrEP navigator—someone who could help with the logistics of a patient starting and maintaining PrEP. PrEP navigators, especially influential in the forms of PrEP clinicians, were able to offer to their patients. At least one participant said they did not offer injectable PrEP because of the paperwork that prior authorization required. Comparatively, another participant mentioned starting to offer more injectable PrEP to local patients because their clinic was having regular trainings about how to handle prior authorizations. PrEP navigators were also cited as a way to help patients and clinicians handle insurance requirements, as well as aiding patients in signing up for drug assistance programs, or other cost-reduction program if patients were uninsured or underinsured.
“In the sexual health clinic that I worked at, we had a whole team that was our PrEP navigation team, and we would have a PrEP Navigator come in and help connect people to those resources directly from Gilead to try to have the cost covered.” (Participant 107)
Notably, attitudes and (non) use of injectable PrEP did not differ among clinicians who saw patients primarily in person or primarily via telemedicine.
Clinicians’ experiences with HIV PEP
Compared to PrEP, participants were less familiar with managing HIV PEP prescriptions. All participants had heard of HIV PEP, and all said they would be able to offer a patient HIV PEP if they asked for it. However, clinicians generally commented that they prescribed HIV PEP with far less frequency than PrEP, instead saying they were more familiar with DoxyPEP. When probed about the disparity, one participant said there was likely inadequate clinician education about PEP.
“I think it’s an afterthought or I think we think about it in the context of occupational exposure but not necessarily non-occupational exposure and PEP so I’m trying to think through why it is not talked about as much as PrEP. Because it’s the same idea, more or less you just to take a couple more meds. To be honest, I don’t want to say the marketing but just the educational push has been around PrEP and not PEP. Does that makes sense? The—all of [Continuing Medical Education] stuff you are in anything that you see around HIV prevention is more around PrEP and little about PEP.” (Participant 113)
Participants generally regarded HIV PEP and PrEP as complementary tools in their HIV prevention toolkits. For example, one participant mentioned using the “PEP to PrEP” model when they had continuity of care with their patients because patients who ask for HIV PEP have a demonstrated interest in preventing HIV. Another discussed writing HIV PEP prescriptions for patients who struggled with the strict adherence PrEP requires but were still at high risk of HIV exposure. That clinician also offered HIV PEP prescriptions as advance provision—a “pill in pocket” plan the patient could fill when they thought they had been exposed to HIV.
“It’s hard, right, because you don’t want somebody who’s at high risk for HIV to not have any connection to the clinic if they were to take PEP. And it’s just sort of like, okay, well, this is better than nothing, start taking it and just come in, but you’ll have it so you can start taking it.” (Participant 107)
Additionally, patients were far more likely to initiate conversations about HIV PEP than they were about PrEP; several clinicians mentioned that those conversations were almost exclusively started because a patient scheduled the appointment to ask for HIV PEP, typically after a high-risk event like a sexual assault. A few clinicians mentioned HIV PEP was part of their care checklists for patients who had disclosed a sexual assault, along with testing for other sexually transmitted infections.
The logistics of accessing HIV PEP varied. Multiple participants commented that prescribing HIV PEP is straightforward medically but logistically complicated. The resources that facilitated PrEP access (ongoing education, PrEP navigators, etc.) did not have HIV PEP counterparts, leaving unfamiliar logistical work to individual clinicians. Time constraints and sourcing issues were the two biggest hurdles that clinicians encountered when trying to get their patients HIV PEP.
“I don’t feel logistically well set up to do that, but the medical aspect of it is straightforward.” (Participant 122)
Some participants worked for clinics with in-house pharmacies where in-person patients left with their full month of HIV PEP, while others would only give patients 5–7 days of pills and require follow-up appointments. No one commented directly on sending PEP directly to a patient’s home. At least one participant said sourcing HIV PEP was very challenging in their region, requiring them to call around to several pharmacies and frequently sending patients to fill their prescriptions in unfamiliar areas.
Several participants cited the timeframe for starting HIV PEP as another barrier to patients fully benefiting from HIV PEP. Sometimes patients were not able to see their clinicians in time, and the timeframe compounded issues with sourcing the prescription and clearing the prescription with a patient’s insurance. One clinician who worked in a smaller practice said those logistics directly hindered their ability to successfully prescribe a patient HIV PEP.
“I can never get anyone PEP. I find that none of the pharmacies have enough tablets in stock. One pharmacy will stock one medication but not the other. I find it’s really challenging to physically get hands on the medication, have insurance coverage for it and do it all in the time frame.” (Participant 111)
Clinicians’ perspectives on bundling HIV prevention and GAC
Everyone interviewed thought it was advantageous for clinicians to integrate GAC and HIV prevention to care for the whole person and avoid segmenting a patient’s care across multiple clinicians. Several participants reported that trans people often experience significant medical trauma and barriers to care, but that being part of a patient’s medical transition can establish a positive patient–clinician relationship. From there, clinicians can help care for other parts of a patient’s health, such as their sexual health.
“I think it’s important that these things are offered together. I’m a big believer in full scope primary care; I think there’s pretty clear data that full scope primary care that’s longitudinal and builds relationships is better for clinicians and for patients. I think particularly for trans and gender diverse people who continue to be wildly discriminated against in health care settings, it’s absolutely essential to have a longitudinal and trusting relationship with a primary care clinician so that folks can connect with someone who they trust about more vulnerable or sensitive topics like STI prevention and treatment, talking about sexual health and lifestyle in a place that is not quite as stigmatized, able to talk about sexual violence, able to talk about mental health.” (Participant 111)
One clinician discussed how the arduous process of accessing medical transition frequently results in patients deprioritizing or wholly not getting other forms of medical care. This participant emphasized that being able to offer other medical care during routine hormone visits would help trans patients round out their medical care.
“People are like zeroed in on that and they’re not really thinking about other stuff.” (Participant 112)
When asked to envision their ideal version of co-located HIV prevention and GAC, many cited similar care philosophies to what they currently practiced. Participants wanted to change workflows or other logistical aspects of patient access. They wanted longer appointments with patients and resources within their practice that helped with care navigation and insurance approvals, such as in-house/mail-order pharmacies and PrEP/HIV PEP navigators.
“Mostly just longer visits with patients [would help my care], so we have time to talk about everything. As we’re going through this, I’m realizing obviously I have been missing opportunities to tell patients in advance about the existence of PEP and that I can prescribe it. I think that’s why I don’t get too many people asking about it, is that I talk about PrEP and I forget to talk about PEP.” (Participant 115)
The most commonly cited barriers to integrating GAC and HIV prevention were cost, the regular lab work that PrEP requires, and older prescribing guidelines that grouped MSM and transgender women and did not provide specific guidance for transgender men or nonbinary individuals. Participants mentioned the various ways their patients struggled to afford medications. Some were worried about prescribing HIV PEP in an emergency and their patient getting an unexpected bill they could not afford. Others mentioned participants who were unable to be open about their transgender identity and not able to utilize their insurance coverage as it would reveal their transgender status to their families.
Participants mentioned the surveillance blood work required by PrEP would be challenging for trans patients to accommodate, as they already have appointments for regular surveillance of hormones. (Participants did not mention the possibility of coordinating those appointments together.) Participants reported patients struggling with the logistics of getting to appointments regularly, and adding more appointments/tests made things challenging for patients. One clinician pointed out that patients who were deemed “high risk” for HIV likely had other factors in their lives that made it hard to keep regular appointments and thus reduce their HIV risk.
“Financial issues in terms of transportation to reach frequent labs. I think that the patients that I see as benefiting from [PrEP and PEP] not just with my trans population, but also with anyone else. Their lives sometimes feel a little bit chaotic if I identify them as high risk, but also knowing that now we really don’t look at high risk versus not high risk. We just look at this is something you can do. I would say that patients that are having more of a high-risk lifestyle can benefit from it a bit more in terms of exposure. Their life is a little bit difficult in terms of making sure they’re getting regular care.” (Participant 110)
Finally, several participants highlighted the inconsistent or outdated prescribing guidelines for PrEP, which frequently do not offer meaningful guidance for trans patients. Some forms of PrEP are approved for “men,” but it is unclear whether trans men are included in that group. Comparatively, trans women are included in the category of MSM and are assumed to be high risk without taking into account their actual behaviors. Participants reported that public health messaging tends to use gender and sexual orientation as discrete categories for messaging about risk, but those categories lose coherence when applied to trans people.
“… I think this is changing a bit, but historically, trans men, like Transmasc and AFAB [assigned female at birth] folks were either like overtly or subtly discouraged from being on PrEP. So I actually had a patient who thankfully, it was not me that had declined the PrEP for the patient. But another clinician had told my patient who was a trans man that he wasn’t at high enough risk for HIV to be put on PrEP. And this was someone who had disclosed that he was sleeping with [gay] men. And then unsurprisingly he seroconverted. And to me, it’s mind boggling, because we could have averted that entire thing like in this was years ago that it happened. But I did have several AFAB folks in that time period of like 2010 to 2016 or 17, probably who had said that they’ve been told by other clinicians that they didn’t have high risk or that they weren’t high risk enough.” (Participant 127)
Discussion
Based on the results of the qualitative interviews, we found that there is significant enthusiasm and comfort in integrating GAC and biomedical HIV prevention in a telehealth setting. Clinicians were comfortable with managing oral PrEP prescriptions, experienced barriers in being able to offer patients injectable PrEP, and had less experience with offering patients HIV PEP, especially in nonemergency room situations. Commonly cited barriers to co-location were the cadence of lab work, sourcing HIV PEP, and delivery of both PrEP and HIV PEP to patients in telehealth models. Conversely, PrEP navigators, patient-initiated conversations, and clinical decision supports based on robust social histories of behavioral risks (not demographic factors) were regularly reported to facilitate clinician’s ability to offer GAC patients biomedical HIV prevention.
Among both our interviewees and relevant literature, there is disagreement about whether the additional blood tests and lab work required by PrEP would be a burden to trans people or if they would be easily integrated into the existing bloodwork people on HRT complete. 19 Initially, trans people have panels drawn every three months to check their hormone levels, the same cadence as PrEP testing guidelines. However, that is only during the first year—after a maintenance dose is established, people have hormone levels and associated labs checked once a year. If a patient starts both HRT and PrEP at the same time, clinicians should be cognizant to time the initiations so that patients are able to have both sets of panels collected in the same appointment.
As referenced by several participants, locating the drugs for HIV PEP and delivering them to patients was a significant barrier to successful HIV PEP initiation. Those hurdles were amplified by the short timeline to start HIV PEP. However, clinics with embedded pharmacies would better navigate those logistics by ensuring HIV PEP is regularly stocked. In a telehealth model, clinics and companies could establish relationships with pharmacies that would regularly have HIV PEP on hand to be delivered to patients shortly after their prescriber recommends it. Alternatively, clinics could adopt a “PEP in Pocket” (PIP) model where patients who felt HIV PEP was the best HIV prevention method for them would get a full course of HIV PEP and take it when they felt they had been exposed. 20 Given the high rates of sexual assault 21 and transactional sex 22 among trans women, the PIP model could reduce medical gatekeeping and allow them to act on suspected exposures within the necessary timeframe. Similarly, rapid and consistent access to PrEP would help patients successfully initiate their biomedical HIV prevention while they are motivated and recently educated by their clinicians.
Clinicians and clinics who are able to employ PrEP navigators cited numerous benefits, namely, having a dedicated person who could help patients and clinicians with insurance logistics. PrEP navigators are also a helpful resource in registering patients for drug assistance programs, scheduling blood work, and generally helping patients adhere to prescribing guidelines. Clinics could employ PrEP and HIV PEP navigators to ease the administrative burdens on clinicians and reduce the work patients need to do themselves.
As mentioned previously, clinicians felt there were roughly equal chances their patients would bring up PrEP initiation as the clinicians starting those conversations, but patients were much more likely to start conversations about HIV PEP. Clinicians reported referencing social histories and what patients disclosed in appointments to determine PrEP eligibility and need. Similarly, clinicians reported having an easier time remembering to offer HIV PEP when it was part of a checklist for post-sexual assault care. As a result, clinical decision supports in electronic medical records are likely a facilitator of increasing PrEP and HIV PEP uptake, especially once patients and clinicians have established trusting relationships and are able to create robust and accurate social histories.
Finally, our data suggest that algorithms and clinical decision supports be built on behavioral risk profiles instead of demographic characteristics. Currently, many clinics and guidelines use a patient’s status as a trans or cis person as their primary criteria in determining patient risk, resulting in potentially inaccurate assessments of HIV seroconversion. While clinical guidelines are updated with research, the literature indicates many guidelines for PrEP still conflate trans women into the umbrella of MSM, assuming these disparate communities share risk and resource profiles. As a result, many trans patients, specifically trans women, are not being reached by current public health messaging about PrEP and HIV PEP.9,23 However, messaging and guidelines more focused on behavioral risk factors have both shown promise in the relevant literature and been advocated for by participants in this study. 24 While building such robust social histories would require significant upfront work from clinicians and health care systems, the resulting trust and improved decision-making may merit the investment. This finding in our telemedicine study corresponds to prior studies focusing on in-person encounters, where focusing on behaviors rather than gender identity was identified by both patients and clinicians as key to bridging the HIV prevention gap among transgender people. 25
Finally, it must be acknowledged that trans people, their health care, and HIV have become controversial topics in the current political era. 26 Accessing gender-affirming care, and possibly biomedical HIV prevention, is likely to become more difficult, especially for people who previously used government-funded programs to overcome financial barriers to care. As noted earlier, a telehealth model could also offer an alternative for people who would face additional barriers and restrictions to accessing in-person care. 3
These findings have several limitations. First, given the increasing prevalence of telehealth startups specializing in GAC, this study would have been strengthened by more focused sampling among those clinicians, allowing for an in-depth analysis of how biomedical HIV prevention would be integrated into existing business models. Our use of a national Google Group for GAC clinicians may have introduced bias into our sample, given that clinicians self-nominate to the group and self-identify as providing care via telemedicine (credentials are validated by group administrators). Additionally, the reliance on electronic recruitment biases toward more technologically savvy clinicians. Because data collection took place toward the beginning of the widespread availability of long-acting PrEP, the clinicians included in this study were not able to speak to the exact logistics of managing injectable PrEP via telehealth.
Despite these challenges, our interviews showed no thematic differences among the clinicians recruited from the telehealth company and the Google Group. Additionally, electronic recruitment and data collection methods allowed us to include clinicians from a wider geographic spread than we would be limited by with in-person recruitment and interviews. We were also able to interview clinicians in a wide range of roles and practice types, again without thematic differences between roles and clinic structure. We quickly reached thematic saturation, despite the diversity of clinician types and settings.
In conclusion, clinicians are well-prepared and enthusiastic to integrate biomedical HIV prevention with GAC via telemedicine, and leveraging their expertise will be essential in designing synergistic models of HIV prevention and GAC. Integrating biomedical HIV prevention with GAC via telemedicine offers a promising strategy to reduce new cases of HIV among transgender individuals, a community that has experienced disproportionate rates of HIV acquisition. By building on trusting clinical relationships, clinicians can move beyond demographics into individual risk assessment and client-centered HIV prevention, more effectively serving those most in need of HIV prevention.
Authors’ Contributions
N.A. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. N.A.: Funding acquisition, concept, design (lead), data acquisition, analysis, and interpretation, and writing—original draft and revision. C.S.O.: Data acquisition and curation, analysis, and interpretation, and writing—original draft (lead) and revision. M.K.: Concept, design, data acquisition, and writing—revision. N.D.: Concept and design and writing—revision. F.M.: Concept and design and writing—revision.
Footnotes
Acknowledgments
The authors are grateful to all study participants who made this work possible and to the telehealth clinician who supported this partnership.
Author Disclosure Statement
M.K. was employed by Plume Health, Inc. as their research coordinator at the time of study development. All other authors declare no conflicts of interest.
Funding Information
This work was supported by the Penn Center for AIDS Research Center Developmental Pilot Award (P30AI045008) to N.A.