Evaluating PEACHES: Pleasure-Inclusive Implementation Strategies to Enable Healthcare Workers to Address Anal Sex Stigma During HIV Service Encounters

Stigma toward anal sex hinders HIV prevention by limiting equitable access to sexual health services. To mitigate this hindrance, we developed a clinician- and community-informed package of anti-stigma implementation strategies using the Behaviour Change Wheel and its Capability, Opportunity, Motivation, Behaviour (COM-B) Model. The package, "Partnering to Enhance Anal Health Communication and HIV-related Evidence-based Services" (PEACHES 1.0), combined training strategies with quality improvement (QI) strategies. We implemented a pilot evaluation of PEACHES 1.0 among HIV workers in the Southern USA and assessed pre/post-shifts in participants' self-reported proximal outcomes (mechanisms of action like knowledge, comfort, skills) and their frequency of anal sex-specific health promotion. In two clinics that received organization-specific QI meetings, we also assessed patient uptake of anal sex-related HIV services based on aggregated medical record data. We conducted paired t-tests on longitudinal survey responses, thematic analysis of longitudinal in-depth interviews and open-ended survey responses, and non-statistical comparison of rates for patient uptake of services. Post-PEACHES, HIV workers reported 8% to 54% improvements (all p < .01) in proximal outcomes like knowledge, comfort, and skills. Frequency of self-reported anal health promotion increased 15% to 25% (p < .01). Clinics that received QI sessions differed in their QI engagement and had diverging patient uptake of services. Clinic A, with greater QI engagement, saw a 60% increase in anorectal STI screening, and a 28% increase in new PrEP prescriptions; Clinic B, with less engagement, saw 17% and 18% decreases, respectively. Qualitative findings indicated that the QI strategies-placing pleasure-inclusive visual cues linked to a website of informational resources in the clinic environment and clinic-specific QI meetings-enabled workers to destigmatize discussions about anal sex within HIV services. Future research should standardize elements of QI, and evaluate scalability with fidelity as well as the potential impact on client outcomes in a fully-powered hybrid implementation-effectiveness trial.