Project SPEED (Streamlined Protocol for Early Engagement and Delivery of HIV Prevention) is a pragmatic, hybrid type III effectiveness-implementation study designed to evaluate the adoption, implementation, and sustainability of a nurse-driven model for the delivery of long-acting injectable cabotegravir (LAI-CAB) for HIV pre-exposure prophylaxis (PrEP) within local public health departments (LPHDs) in Missouri. Although LAI-CAB is highly efficacious for HIV prevention, uptake remains limited in the United States, particularly in rural and resource-limited settings where access to licensed prescribers is constrained. This study addresses a critical implementation gap by testing whether trained registered nurses (RNs), operating under protocol-driven supervision and standing orders, can safely and effectively initiate and manage LAI-CAB PrEP services in real-world public health settings.
The study uses a parallel, two-arm, single-blind, cluster randomized controlled design in which LPHDs are the unit of randomization. Participating LPHDs are stratified by geographic and population characteristics (urban, metropolitan, micropolitan, and rural) and randomized in a 1:1 ratio to either the SPEED intervention or current practice. Eight LPHDs are expected to participate, with four assigned to implement the nurse-driven protocol and four continuing usual care. Participants receiving care at these LPHDs are followed for up to 48 weeks.
The SPEED intervention consists of a structured, nurse-led PrEP delivery model that integrates HIV risk assessment, counseling, laboratory testing, vaccination, rapid initiation of PrEP, and ongoing follow-up within routine public health services. RNs at intervention sites are trained to assess PrEP eligibility, conduct HIV and sexually transmitted infection (STI) testing, review laboratory results under standing orders, administer LAI-CAB injections, and provide adherence and risk-reduction counseling. Nurses operate within a collaborative practice framework that includes access to an experienced PrEP provider for consultation when clinically indicated. Rapid PrEP initiation strategies, including short-term oral cabotegravir bridging while insurance approval is pending, are used to minimize delays in starting prevention.
LPHDs assigned to the control arm continue their existing clinical workflows without additional training, protocol changes, or standardized PrEP delivery processes introduced by the study. At these sites, PrEP services, if offered, occur according to local practice, and individuals interested in PrEP may be referred to external providers. Data collection at control sites focuses on documenting current PrEP-related practices and outcomes to allow comparison with intervention sites.
The study is guided by established implementation science frameworks. The Promoting Action on Research Implementation in Health Services (PARIHS) framework informs the implementation strategy, emphasizing the interaction of evidence, context, and facilitation in achieving successful implementation. Evaluation of implementation outcomes is structured using the RE-AIM framework, assessing reach, effectiveness, adoption, implementation, and maintenance at both the participant and organizational levels. Quantitative data from clinical records and surveys are complemented by qualitative interviews with participants and staff to identify barriers, facilitators, and contextual factors influencing implementation.
Project SPEED is designed to generate actionable, real-world evidence on the feasibility, acceptability, and sustainability of nurse-driven LAI-CAB PrEP delivery in public health settings that serve populations disproportionately affected by HIV. Findings will inform the development of a scalable implementation blueprint to support broader adoption of long-acting PrEP within local public health infrastructures, particularly in rural and underserved communities.
