Improving HIV pre-exposure prophylaxis (PrEP) uptake and initiation: process evaluation and recommendation development from a national PrEP program†
Claudia S. Estcourt A B * , Jennifer MacDonald A , John Saunders C D , Rak Nandwani B E , Ingrid Young F , Jamie Frankis A , Dan Clutterbuck G , Nicola Steedman H , Lisa McDaid I , Jenny Dalrymple A and Paul Flowers JA School of Health & Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK.
B Sandyford Sexual Health Services, NHS Greater Glasgow & Clyde, 6 Sandyford Place, Glasgow G3 7NB, UK.
C Institute for Global Health, University College London, Mortimer Market Centre, London WC1E 6JB, UK.
D HPA Health Protection Services, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK.
E College of Medical, Veterinary & Life Sciences, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK.
F Centre for Biomedicine, Self & Society, Usher Institute, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK.
G Chalmers Sexual Health Centre, NHS Lothian, 2A Chalmers Street, Edinburgh EH3 9ES, UK.
H Chief Medical Officer Directorate, Scottish Government, St Andrew’s House, Regent Road, Edinburgh, EH1 3DG, UK.
I Institute for Social Science Research, The University of Queensland, Brisbane, St Lucia, Qld 4072, Australia.
J School of Psychological Sciences & Health, University of Strathclyde, 16 Richmond Street, Glasgow G1 1XQ, UK.
Sexual Health 20(4) 282-295 https://doi.org/10.1071/SH22170
Submitted: 14 October 2022 Accepted: 19 April 2023 Published: 15 May 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Background: HIV pre-exposure prophylaxis (PrEP) is key to HIV transmission elimination but implementation is challenging and under-researched. We undertook a process evaluation of the first 2 years of a national PrEP program to explore barriers and facilitators to implementation and to develop recommendations to improve implementation, focusing on PrEP uptake and initiation.
Methods: Stage 1 involved semi-structured telephone interviews and focus groups (September 2018–July 2019) with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n = 39), sexual healthcare professionals (n = 54), community-based organisation service users (n = 9) and staff (n = 15) across Scotland. We used deductive thematic analysis, to derive and then map key barriers and facilitators to priority areas that experts agreed would enhance uptake and initiation. In Stage 2, we used analytic tools from implementation science to systematically generate evidence-based, theoretically-informed recommendations to enhance uptake and initiation of PrEP.
Results: Barriers and facilitators were multi-levelled and interdependent. Barriers included the rapid pace of implementation without additional resource, and a lack of familiarity with PrEP prescribing. Facilitators included opportunities for acquisition of practice-based knowledge and normalisation of initiation activities. We refined our 68 ‘long-list’ recommendations to 41 using expert input and the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders.
Conclusions: These evidence-based, theory informed recommendations provide a robust framework for optimising PrEP uptake and initiation in diverse settings to ensure PrEP reaches all who may benefit.
Keywords: Behaviour Change Wheel, HIV prevention, HIV/AIDS, implementation study, pre-exposure prophylaxis, PrEP, process evaluation, recommendation-development.
References
[1] Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010; 363 2587–99.| Preexposure chemoprophylaxis for HIV prevention in men who have sex with men.Crossref | GoogleScholarGoogle Scholar |
[2] Molina JM, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med 2015; 373 2237–46.
| On-demand preexposure prophylaxis in men at high risk for HIV-1 infection.Crossref | GoogleScholarGoogle Scholar |
[3] McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet 2016; 387 53–60.
| Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial.Crossref | GoogleScholarGoogle Scholar |
[4] Molina J-M, Charreau I, Spire B, Cotte L, Chas J, Capitant C, et al. Efficacy, safety, and effect on sexual behaviour of on-demand pre-exposure prophylaxis for HIV in men who have sex with men: an observational cohort study. Lancet HIV 2017; 4 e402–10.
| Efficacy, safety, and effect on sexual behaviour of on-demand pre-exposure prophylaxis for HIV in men who have sex with men: an observational cohort study.Crossref | GoogleScholarGoogle Scholar |
[5] Grulich AE, Guy R, Amin J, Jin F, Selvey C, Holden J, et al. Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study. Lancet HIV 2018; 5 e629–37.
| Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study.Crossref | GoogleScholarGoogle Scholar |
[6] Estcourt C, Yeung A, Nandwani R, Goldberg D, Cullen B, Steedman N, et al. Population-level effectiveness of a national HIV preexposure prophylaxis programme in MSM. AIDS 2021; 35 665–73.
| Population-level effectiveness of a national HIV preexposure prophylaxis programme in MSM.Crossref | GoogleScholarGoogle Scholar |
[7] Smith DK, Sullivan PS, Cadwell B, Waller LA, Siddiqi A, Mera-Giler R, et al. Evidence of an association of increases in pre-exposure prophylaxis coverage with decreases in human immunodeficiency virus diagnosis rates in the United States, 2012–2016. Clin Infect Dis 2020; 71 3144–51.
| Evidence of an association of increases in pre-exposure prophylaxis coverage with decreases in human immunodeficiency virus diagnosis rates in the United States, 2012–2016.Crossref | GoogleScholarGoogle Scholar |
[8] The World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, 2nd ed. The World Health Organization; 2016. Available at https://www.who.int/publications/i/item/9789241549684 [Accessed 18 January 2023]
[9] Sullivan PS, Siegler AJ. Getting pre-exposure prophylaxis (PrEP) to the people: opportunities, challenges and emerging models of PrEP implementation. Sex Health 2018; 15 522–27.
| Getting pre-exposure prophylaxis (PrEP) to the people: opportunities, challenges and emerging models of PrEP implementation.Crossref | GoogleScholarGoogle Scholar |
[10] UNAIDS. Fast-tracking combination prevention. UNAIDS; 2015. Available at https://www.unaids.org/sites/default/files/media_asset/20151019_JC2766_Fast-tracking_combination_prevention.pdf [Accessed 18 January 2023]
[11] Nandwani R. Pre-exposure prophylaxis is approved in Scotland. Lancet HIV 2017; 4 e238–9.
| Pre-exposure prophylaxis is approved in Scotland.Crossref | GoogleScholarGoogle Scholar |
[12] Health Protection Scotland and Information Services Division. Implementation of HIV PrEP in Scotland: first year report. Health Protection Scotland and Information Services Division; 2019. Available at https://www.hps.scot.nhs.uk/web-resources-container/implementation-of-hiv-prep-in-scotland-first-year-report/ [Accessed 18 January 2023]
[13] Health Protection Scotland. Implementation of HIV PrEP in Scotland: second year report. Health Protection Scotland; 2019. Available at https://www.hps.scot.nhs.uk/web-resources-container/implementation-of-hiv-prep-in-scotland-second-year-report/ [Accessed 18 January 2023]
[14] Health Protection Scotland. HIV infection in Scotland: quarterly report to 30 September 2019. Health Protection Scotland; 2019. Available at https://www.hps.scot.nhs.uk/web-resources-container/hiv-diagnoses-in-scotland-quarterly-report-to-30-september-2019 [Accessed 18 January 2023]
[15] Brady M, Rodger A, Asboe D, Cambiano V, Clutterbuck D, Desai M, et al. BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018. HIV Med 2019; 20 s2–80.
| BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018.Crossref | GoogleScholarGoogle Scholar |
[16] Flowers P, MacDonald J, McDaid L, Nandwani R, Frankis J, Young I, et al. How can we enhance HIV Pre Exposure Prophylaxis (PrEP) awareness and access?: Recommendation development from process evaluation of a national PrEP programme using implementation science tools. MedRxiv 2022;
| How can we enhance HIV Pre Exposure Prophylaxis (PrEP) awareness and access?: Recommendation development from process evaluation of a national PrEP programme using implementation science tools.Crossref | GoogleScholarGoogle Scholar |
[17] MacDonald J, Estcourt C, Flowers P, Nandwani R, Frankis J, Young I, et al. Improving HIV pre-exposure prophylaxis (PrEP) adherence and retention in care: recommendation development from a national PrEP programme. MedRxiv 2022;
| Improving HIV pre-exposure prophylaxis (PrEP) adherence and retention in care: recommendation development from a national PrEP programme.Crossref | GoogleScholarGoogle Scholar |
[18] Scottish Government. Scottish index of multiple deprivation 2020. 2020. Available at https://www.gov.scot/collections/scottish-index-of-multiple-deprivation-2020/ [Accessed 18 January 2023]
[19] Presseau J, McCleary N, Lorencatto F, Patey AM, Grimshaw JM, Francis JJ. Action, actor, context, target, time (AACTT): a framework for specifying behaviour. Implement Sci 2019; 14 102
| Action, actor, context, target, time (AACTT): a framework for specifying behaviour.Crossref | GoogleScholarGoogle Scholar |
[20] Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3 77–101.
| Using thematic analysis in psychology.Crossref | GoogleScholarGoogle Scholar |
[21] Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011; 6 42
| The behaviour change wheel: a new method for characterising and designing behaviour change interventions.Crossref | GoogleScholarGoogle Scholar |
[22] Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci 2012; 7 37
| Validation of the theoretical domains framework for use in behaviour change and implementation research.Crossref | GoogleScholarGoogle Scholar |
[23] Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med 2013; 46 81–95.
| The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions.Crossref | GoogleScholarGoogle Scholar |
[24] Michie S, Atkins L, West R. The behaviour change wheel: a guide to designing interventions. London: Silverback Publishing; 2014.
[25] Philpot SP, Murphy D, Chan C, Haire B, Fraser D, Grulich AE, Bavinton BR. Switching to non-daily pre-exposure prophylaxis among gay and bisexual men in Australia: implications for improving knowledge, safety, and uptake. Sex Res Social Policy 2022; 19 1979–88.
| Switching to non-daily pre-exposure prophylaxis among gay and bisexual men in Australia: implications for improving knowledge, safety, and uptake.Crossref | GoogleScholarGoogle Scholar |
[26] Smith AKJ, Haire B, Newman CE, Holt M. Challenges of providing HIV pre-exposure prophylaxis across Australian clinics: qualitative insights of clinicians. Sex Health 2021; 18 187–94.
| Challenges of providing HIV pre-exposure prophylaxis across Australian clinics: qualitative insights of clinicians.Crossref | GoogleScholarGoogle Scholar |
[27] Chan PA, Glynn TR, Oldenburg CE, Montgomery MC, Robinette AE, Almonte A, et al. Implementation of preexposure prophylaxis for human immunodeficiency virus prevention among men who have sex with men at a New England sexually transmitted diseases clinic. Sex Transm Dis 2016; 43 717–23.
| Implementation of preexposure prophylaxis for human immunodeficiency virus prevention among men who have sex with men at a New England sexually transmitted diseases clinic.Crossref | GoogleScholarGoogle Scholar |
[28] Parsons JT, Rendina HJ, Lassiter JM, Whitfield THF, Starks TJ, Grov C. Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States: the motivational PrEP cascade. J Acquir Immune Defic Syndr 2017; 74 285–92.
| Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States: the motivational PrEP cascade.Crossref | GoogleScholarGoogle Scholar |
[29] Pathela P, Jamison K, Blank S, Daskalakis D, Hedberg T, Borges C. The HIV pre-exposure prophylaxis (PrEP) cascade at NYC sexual health clinics: navigation is the key to uptake. J Acquir Immune Defic Syndr 2020; 83 357–64.
| The HIV pre-exposure prophylaxis (PrEP) cascade at NYC sexual health clinics: navigation is the key to uptake.Crossref | GoogleScholarGoogle Scholar |
[30] Zhang C, McMahon J, Fiscella K, Przybyla S, Braksmajer A, LeBlanc N, et al. HIV pre-exposure prophylaxis implementation cascade among health care professionals in the United States: implications from a systematic review and meta-analysis. AIDS Patient Care STDs 2019; 33 507–27.
| HIV pre-exposure prophylaxis implementation cascade among health care professionals in the United States: implications from a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar |
[31] Blashill AJ, Brady JP, Rooney BM, Rodriguez-Diaz CE, Horvath KJ, Blumenthal J, Morris S, Moore DJ, Safren SA. Syndemics and the PrEP cascade: results from a sample of young Latino men who have sex with men. Arch Sex Behav 2020; 49 125–35.
| Syndemics and the PrEP cascade: results from a sample of young Latino men who have sex with men.Crossref | GoogleScholarGoogle Scholar |
[32] European Centre for Disease Prevention and Control. HIV pre-exposure prophylaxis in the EU/EEA and the UK: implementation, standards and monitoring – operational guidance. European Centre for Disease Prevention and Control; 2021. Available at https://www.ecdc.europa.eu/en/publications-data/HIV-PrEP-eueea-and-uk-implementation-standards-monitoring-guidance [Accessed 18 January 2023]
[33] UNAIDS. Fast-track commitments to end AIDS by 2030. UNAIDS; 2016. Available at https://www.unaids.org/sites/default/files/media_asset/fast-track-commitments_en.pdf [Accessed 18 January 2023]
[34] Vanhamel J, Rotsaert A, Reyniers T, Nöstlinger C, Laga M, Van Landeghem E, et al. The current landscape of pre-exposure prophylaxis service delivery models for HIV prevention: a scoping review. BMC Health Serv Res 2020; 20 704
| The current landscape of pre-exposure prophylaxis service delivery models for HIV prevention: a scoping review.Crossref | GoogleScholarGoogle Scholar |
[35] Pinto RM, Berringer KR, Melendez R, Mmeje O. Improving PrEP implementation through multilevel interventions: a synthesis of the literature. AIDS Behav 2018; 22 3681–91.
| Improving PrEP implementation through multilevel interventions: a synthesis of the literature.Crossref | GoogleScholarGoogle Scholar |
[36] Lazarou M, Fitzgerald L, Warner M, Downing S, Williams OD, Gilks CF, Russell D, Dean JA. Australian interdisciplinary healthcare providers’ perspectives on the effects of broader pre-exposure prophylaxis (PrEP) access on uptake and service delivery: a qualitative study. Sex Health 2020; 17 485–92.
| Australian interdisciplinary healthcare providers’ perspectives on the effects of broader pre-exposure prophylaxis (PrEP) access on uptake and service delivery: a qualitative study.Crossref | GoogleScholarGoogle Scholar |
[37] Nicholls EJ, Rosengarten M. PrEP (HIV pre-exposure prophylaxis) and its possibilities for clinical practice. Sexualities 2020; 23 1327–42.
| PrEP (HIV pre-exposure prophylaxis) and its possibilities for clinical practice.Crossref | GoogleScholarGoogle Scholar |
[38] Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The impact of patient race on clinical decisions related to prescribing HIV pre-exposure prophylaxis (PrEP): assumptions about sexual risk compensation and implications for access. AIDS Behav 2014; 18 226–40.
| The impact of patient race on clinical decisions related to prescribing HIV pre-exposure prophylaxis (PrEP): assumptions about sexual risk compensation and implications for access.Crossref | GoogleScholarGoogle Scholar |
[39] Calabrese SK, Tekeste M, Mayer KH, Magnus M, Krakower DS, Kershaw TS, et al. Considering stigma in the provision of HIV pre-exposure prophylaxis: reflections from current prescribers. AIDS Patient Care STDs 2019; 33 79–88.
| Considering stigma in the provision of HIV pre-exposure prophylaxis: reflections from current prescribers.Crossref | GoogleScholarGoogle Scholar |
[40] Stangl AL, Earnshaw VA, Logie CH, van Brakel W, Simbayi LC, Barré I, Dovidio JF. The health stigma and discrimination framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med 2019; 17 31
| The health stigma and discrimination framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas.Crossref | GoogleScholarGoogle Scholar |
[41] Collier KL, Colarossi LG, Sanders K. Raising awareness of pre-exposure prophylaxis (PrEP) among women in New York City: community and provider perspectives. J Health Commun 2017; 22 183–9.
| Raising awareness of pre-exposure prophylaxis (PrEP) among women in New York City: community and provider perspectives.Crossref | GoogleScholarGoogle Scholar |
[42] Sevelius JM, Poteat T, Luhur WE, Reisner SL, Meyer IH. HIV testing and PrEP use in a national probability sample of sexually active transgender people in the United States. J Acquir Immune Defic Syndr 2020; 84 437–42.
| HIV testing and PrEP use in a national probability sample of sexually active transgender people in the United States.Crossref | GoogleScholarGoogle Scholar |
[43] McMahon JM, Myers JE, Kurth AE, Cohen SE, Mannheimer SB, Simmons J, et al. Oral pre-exposure prophylaxis (PrEP) for prevention of HIV in serodiscordant heterosexual couples in the United States: opportunities and challenges. AIDS Patient Care STDS 2014; 28 462–74.
| Oral pre-exposure prophylaxis (PrEP) for prevention of HIV in serodiscordant heterosexual couples in the United States: opportunities and challenges.Crossref | GoogleScholarGoogle Scholar |
[44] Madhani A, Finlay KA. Using the COM-B model to characterize the barriers and facilitators of pre-exposure prophylaxis (PrEP) uptake in men who have sex with men. Br J Health Psychol 2022; 27 1330–53.
| Using the COM-B model to characterize the barriers and facilitators of pre-exposure prophylaxis (PrEP) uptake in men who have sex with men.Crossref | GoogleScholarGoogle Scholar |
[45] Devarajan S, Sales JM, Hunt M, Comeau DL. PrEP and sexual well-being: a qualitative study on PrEP, sexuality of MSM, and patient-provider relationships. AIDS Care 2020; 32 386–93.
| PrEP and sexual well-being: a qualitative study on PrEP, sexuality of MSM, and patient-provider relationships.Crossref | GoogleScholarGoogle Scholar |
[46] Maloney KM, Krakower DS, Ziobro D, Rosenberger JG, Novak D, Mayer KH. Culturally competent sexual healthcare as a prerequisite for obtaining preexposure prophylaxis: findings from a qualitative study. LGBT Health 2017; 4 310–14.
| Culturally competent sexual healthcare as a prerequisite for obtaining preexposure prophylaxis: findings from a qualitative study.Crossref | GoogleScholarGoogle Scholar |
[47] Sullivan PS, Rosenberg ES, Sanchez TH, Kelley CF, Luisi N, Cooper HL, et al. Explaining racial disparities in HIV incidence in black and white men who have sex with men in Atlanta, GA: a prospective observational cohort study. Ann Epidemiol 2015; 25 445–54.
| Explaining racial disparities in HIV incidence in black and white men who have sex with men in Atlanta, GA: a prospective observational cohort study.Crossref | GoogleScholarGoogle Scholar |
[48] Grimshaw C, Estcourt CS, Nandwani R, Yeung A, Henderson D, Saunders J. Implementation of a national HIV pre-exposure prophylaxis service is associated with changes in characteristics of people with newly diagnosed HIV: a retrospective cohort study. Sex Transm Infect 2022; 98 53–7.
| Implementation of a national HIV pre-exposure prophylaxis service is associated with changes in characteristics of people with newly diagnosed HIV: a retrospective cohort study.Crossref | GoogleScholarGoogle Scholar |
[49] Medland N, Guy R, Grullich A, Bavinton B, Keen P, Ellard J, et al. Successful national PrEP scale-up in Australia: evaluation of uptake, adherence, discontinuation and HIV seroconversion from April 2018 to September 2019 using national dispensing data. 23rd International AIDS Conference; San Francisco, CA, USA (virtual); 6–10 July 2020. (abstr OAC0802). Available at https://programme.aids2020.org/Abstract/Abstract/4702
[50] Nakasone SE, Young I, Estcourt CS, Calliste J, Flowers P, Ridgway J, et al. Risk perception, safer sex practices and PrEP enthusiasm: barriers and facilitators to oral HIV pre-exposure prophylaxis in Black African and Black Caribbean women in the UK. Sex Transm Infect 2020; 96 349–54.
| Risk perception, safer sex practices and PrEP enthusiasm: barriers and facilitators to oral HIV pre-exposure prophylaxis in Black African and Black Caribbean women in the UK.Crossref | GoogleScholarGoogle Scholar |
[51] Smith M, Elliott L, Hutchinson SJ, Metcalfe R, Flowers P, McAuley A. Perspectives on pre-exposure prophylaxis for people who inject drugs in the context of an HIV outbreak: a qualitative study. Int J Drug Policy 2021; 88 103033
| Perspectives on pre-exposure prophylaxis for people who inject drugs in the context of an HIV outbreak: a qualitative study.Crossref | GoogleScholarGoogle Scholar |
[52] Radix AE, Harris AB, Goldstein ZG. How can we improve uptake of oral HIV pre-exposure prophylaxis for transgender individuals? Expert Rev Anti Infect Ther 2020; 18 835–38.
| How can we improve uptake of oral HIV pre-exposure prophylaxis for transgender individuals?Crossref | GoogleScholarGoogle Scholar |
[53] Waverley Care and Scottish Trans. “There needs to be care throughout”: exploring the access of non-binary people, trans men and trans women to sexual health services in Scotland. Waverley Care and Scottish Trans; 2020. Available at https://www.waverleycare.org/application/files/2716/0992/0912/There_needs_to_be_care_throughout_DIGITAL_Dec20.pdf [Accessed 18 January 2023]
[54] Doblecki-Lewis S, Liu A, Feaster D, Cohen SE, Cardenas G, Bacon O, et al. Healthcare access and PrEP continuation in San Francisco and Miami after the US PrEP demo project. J Acquir Immune Defic Syndr 2017; 74 531–38.
| Healthcare access and PrEP continuation in San Francisco and Miami after the US PrEP demo project.Crossref | GoogleScholarGoogle Scholar |
[55] Scottish Government. Reset and Rebuild – sexual health and blood borne virus services: recovery plan [Strategy/plan]. 2021. Available at https://www.gov.scot/publications/reset-rebuild-recovery-plan-sexual-health-blood-borne-virus-services/ [Accessed 18 January 2023]
[56] UK Government. HIV in the UK: towards zero HIV transmissions by 2030 . 2020. Available at https://www.gov.uk/government/news/hiv-in-the-uk-towards-zero-hiv-transmissions-by-2030 [Accessed 18 January 2023]