Establishing an evidence base to inform the development and implementation of an online HIV pre-exposure prophylaxis service for GBMSM in Scotland

HIV pre-exposure prophylaxis (PrEP) is a game changing addition to combination HIV prevention strategies wherein people who are HIV-negative take antiretroviral medications before and after possible sexual exposure to HIV to prevent acquisition. PrEP has been available through Scottish NHS sexual health services since July 2017. In Scotland, an online PrEP service is in the early stages of development with the aim of enhancing patient choice, overcoming challenges within current pathways, and scaling up PrEP provision. The aim of this thesis was to establish an evidence base to inform the development and implementation of this online PrEP service.

First, I conducted a scoping review (n=59 studies) to explore the extent to which PrEP-related care had been delivered online. I concluded that additional formative research was required to properly inform the development of the proposed online PrEP service. To this end, I adopted a pragmatic mixed-methods approach, using the Intervention Mapping approach as a guiding framework to develop my research questions which I answered through the following studies.

I included questions in two national online surveys of gay, bisexual and other men who have sex with men (GBMSM): 1) SMMASH3 (n=970) conducted before the Covid pandemic (December 2019 – March 2020), and 2) SMMASH Pan (n=456) conducted during the first national stay-at-home order (June 2020 – July 2020). My survey questions examined online health behaviours and the prospective acceptability of the proposed online PrEP service. The high willingness to engage with online health services, and the high acceptability of the online PrEP service, provided a clear direction for the qualitative studies that followed.

I conducted two qualitative studies to further explore the acceptability of the proposed online PrEP service: 1) semi-structured interviews with potential service users (n=15); and 2) focus groups (n=3) with potential service providers (n=9). Participants found the online PrEP service to be acceptable and provided valuable, nuanced insights into how the service should be developed and implemented to best meet users’ needs. Crucially, participants highlighted the importance of choice and appropriate support.

Overall, this thesis provides a clear rationale for the development of the proposed online PrEP service by synthesising contemporary research findings with the views of PrEP users and clinicians involved in PrEP provision. Accordingly, I conclude by providing specific evidence-based recommendations for the development and implementation of the proposed online PrEP service and specific directions for future research.