Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama

Factors Associated with PrEP Stigma Among Gay, Bisexual, and Other Men Who Have Sex with Men (gbMSM): A Systematic Review

Gay, bisexual, and other men who have sex with men (gbMSM) are disproportionately affected by HIV. While pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition, uptake of PrEP among gbMSM is low, which may in part be due to stigma associated with PrEP use. This systematic review aimed to explore experiences of PrEP stigma and to identify factors associated with this. Four databases were searched for papers including terms relating to (i) gbMSM, (ii) PrEP, and (iii) stigma, with narrative synthesis used to analyze results. After screening, 70 studies were included in the final analysis. Experiences of PrEP stigma were found to be characterized by a number of stereotypes and came from a range of sources. Five categories of factors were associated with stigma: (i) healthcare-related factors, (ii) cultural and contextual factors, (iii) sociodemographic factors, (iv) peer-discussion, and (v) psychosocial factors. These findings suggest that stigma can be a common experience for gbMSM. However, some are more at risk than others. Interventions aimed at reducing PrEP stigma may be useful in increasing uptake.

Identifying HIV PrEP Attributes to Increase PrEP Use Among Different Groups of Gay, Bisexual, and Other Men Who Have Sex with Men: A Latent Class Analysis of a Discrete Choice Experiment

Daily pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV among gay, bisexual, and other men who have sex with men (GBMSM), although uptake remains suboptimal. By identifying the features of PrEP that appeal to various subgroups of GBMSM, this study aimed to improve PrEP uptake by examining preferences for PrEP use. Adults ≥ 18 years old in six New England states completed an online discrete choice experiment survey. A latent class analysis (LCA) was conducted to identify groups of GBMSM based on four attributes of choices for PrEP (cost, time, side effects, and mode of administration). Multinominal logistic regression was conducted to compare the association between sociodemographic and behavioral characteristics and class memberships. Data from 675 GBMSM were analyzed. A 3-Class model was selected as the best fit model. Class 1 (47.7% of individuals) was identified as having "no specific preferences". Class 2 (18.5% of individuals) were "Cost- and time-conscious" and were significantly more likely to be older, have prior sexually transmitted infection (STI) testing, have low household income, private insurance, and have extreme concerns about HIV risk than those with no specific preference (Class 1). Finally, Class 3 (34.1% of individuals) were "Side effects-conscious" and were more likely to have low income, private insurance, and have moderate and extreme concerns about HIV risk than those with no specific preference (Class 1). Findings indicate that outreach to GBMSM who have never used PrEP should emphasize low cost and short travel times to increase potential PrEP use.

Factors Associated with Planned Future Use of PrEP in the Next 3 Months and Likelihood to Use PrEP Among Black Cisgender HIV-negative Women in Texas

Identifying and then addressing barriers and leveraging facilitators is important to help increase pre-exposure prophylaxis (PrEP) use among Black women vulnerable to HIV acquisition. The present cross-sectional study examined what factors were associated with future plans to use PrEP, and general likelihood to use it among a convenience sample of 152 adult, Black cisgender women from three metropolitan areas in Texas. The final multivariable logistic regression model revealed that relationship status (aOR = 0.20, 95% CI: 0.05-0.73, p < 0.05), PrEP anticipated stigma (aOR = 0.29, 95% CI: 0.10-0.78, p < 0.05), perceived discrimination (aOR = 0.40, 95% CI: 0.21-0.78, p < 0.01) and interest in learning more about PrEP (aOR = 5.32, 95% CI: 2.60-10.9, p < 0.001) were associated with future plans to use PrEP. The final multivariable linear regression model with maximum likelihood estimation identified that perceived discrimination (β=-0.24, SE: -0.38 - -0.10, p < 0.01), perceived HIV risk (β = 0.33, SE: 0.18-0.49, p < 0.001), willingness to use PrEP with condoms (β = 1.26, SE: 0.94-1.60, p < 0.001), and comfort communicating about PrEP with a provider (β = 0.23, SE: 0.06-0.41, p < 0.01) were associated with general likelihood to use PrEP. Findings reveal key factors that warrant further attention and examination toward improving PrEP use within this population.

Development and Preliminary Validation of the PrEP Empowerment Scale

Informed by the Health Care Empowerment Model, a measure of PrEP Empowerment was developed and assessed for preliminary reliability and validity. Participants (N = 100) were invited to complete a survey during regular clinic visits. A subset (n = 84) volunteered to provide blood samples to assess plasma tenofovir (TFV) levels for recent PrEP adherence. A five-factor measure explained 70% of the total variance. Associations with internalized PrEP stigma, PrEP adherence self-efficacy, and plasma TFV were assessed. Results supported the multidimensional nature of PrEP Empowerment and reliability and validity. Additional research is needed in populations with varying PrEP experience and greater gender and ethnic representation.

Responding to the HIV Health Literacy Needs of Clients in Substance Use Treatment: The Role of Universal PrEP Education in HIV Health and Prevention

Health literacy, particularly HIV health literacy, is a key social determinant of health and can be significantly improved through targeted health education. This paper explores the often-overlooked potential of pre-exposure prophylaxis (PrEP) education as a powerful tool to enhance HIV health literacy among people with substance use disorders (PWSUD), a population notably susceptible to HIV. Given the syndemic interplay of substance use disorders (SUDs) and HIV, health professionals, especially substance use counselors, are uniquely positioned to bolster HIV health literacy and positively influence health outcomes. This article offers a brief introduction to PrEP, delineates potential barriers and facilitators to its use and education, and proposes strategies for effective PrEP education, implementation, and adherence. By equipping substance use counselors with essential knowledge and skills, we aim to encourage and promote the integration of PrEP education into substance use treatment. The overarching objective is to empower counselors to proactively engage in HIV prevention efforts, thereby fulfilling pressing health literacy needs and contributing to improved health outcomes among PWSUD.

Communicative appeals and messaging frames in visual media for HIV pre-exposure prophylaxis promotion to cisgender and transgender women

Women in the USA represent 15% of new HIV diagnoses but only 5% of pre-exposure prophylaxis (PrEP) users. We sought to characterise communicative appeals and messaging frames used in US visual media to cultivate PrEP demand among cisgender and transgender women using content analysis methodology. We catalogued and coded media items (images and videos) from US PrEP marketing campaigns featuring women. Production and content characteristics were abstracted, and communicative appeals from media items were qualitatively coded in duplicate. We then descriptively summarised production and content characteristics and identified discrete subgroups of media items, clustering around specific messaging frames, through qualitative thematic analysis. Racial/ethnic minorities and sexual/gender minority women were heavily featured, and numerous media items leveraged cognitive and social communicative appeals to promote PrEP. We identified three unique messaging frames emerging from coded media items, portraying PrEP as: (1) necessary prevention (protection frame), (2) a desirable yet accessible commodity (aspiration frame), and (3) a conduit to sexual autonomy (empowerment frame). To effectively communicate PrEP information and promote PrEP to women, PrEP marketing should leverage alternative appeals (subjective norms, self-efficacy), address anticipated barriers to uptake (stigma, cost, medication interactions), and deconstruct misconceptions of PrEP use(rs).

Barriers to Pre-Exposure Prophylaxis (PrEP) use for HIV: an integrative review

OBJECTIVES

to identify and synthesize scientific evidence on the barriers and difficulties for Pre-exposure Prophylaxis (PrEP) use and compliance for HIV.

METHODS

an integrative literature review, using the MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier and Scopus (Elsevier) databases.

RESULTS

all (100%) the articles included identified that PrEP users experience some type of structural barrier related to health services such as long distance from the units, suboptimal logistics for taking pills and professional resistance to prescribing PrEP. Furthermore, 63.21% identified social barriers, such as stigma about sexuality and HIV, in addition to individual barriers such as alcohol use, adverse effects, and concerns about long-term toxicity.

CONCLUSIONS

the barriers to PrEP use are multifactorial. Effective interventions are needed to support PrEP users in accessing, complying with, and retaining health services.

Low knowledge of antiretroviral treatments for the prevention of HIV among precarious immigrants from sub-Saharan Africa living in the greater Paris area: Results from the Makasi project

INTRODUCTION

In France, combination prevention tools, particularly antiretroviral treatment for HIV prevention has been available for several years. We described the knowledge of these antiretroviral treatments among immigrants from sub-Saharan Africa, who are particularly affected by HIV, and the factors associated with this knowledge.

METHODS

The data come from the Makasi study, which was conducted between 2019 and 2020 among precarious immigrants from sub-Saharan Africa recruited through a community-based outreach approach in the greater Paris area (n = 601). We described levels of knowledge of HIV treatment effectiveness (HTE), treatment as prevention (TasP), post-exposure prophylaxis (PEP), and pre-exposure prophylaxis (PrEP), by sex with chi2 test. We investigated factors associated with their knowledge with logistic regressions adjusted for sociodemographic characteristics, living conditions and sexual behaviors (p≤0.2).

RESULTS

Respondents were mostly men (76%), from West Africa (61%), in precarious situation: 69% were unemployed, 74% were undocumented and 46% had no health coverage. Among this population, knowledge of HIV preventive treatments was heterogeneous. While HTE was well known (84%); TasP was known by only half of the respondents (46%), and PEP and PrEP were hardly known: 6% and 5%, respectively. Multivariate regressions models showed that these antiretroviral treatments for the prevention of HIV was better known by people with a higher level of education (PEP: aOR = 3.33 [1.09-10.20], p = 0.03; HTE: aOR = 4.33 [1.87-10.04], p<0.001), those who had a social network in France (TasP: aOR = 1.90, [1.33-2.73], p<0.001), those who had access to the health system and those who were exposed to sexual risks (TasP: aOR = 3.17, [1.03-9.69], p = 0.04; PrEP: aOR = 2.60 [0.72-9.34], p = 0.14).

CONCLUSIONS

There is a need for specific communication on antiretroviral treatment for HIV prevention that targets sub-Saharan immigrants, particularly those who have no access to the health-care system and those who are less educated.

"Why You Putting This Drug in Your Body to Fight off Something that You Don't Have?" Perceptions About PrEP Use Among Black and Latino Men Who Have Sex with Men in the U.S. South

PrEP use has steadily increased since its introduction, yet uptake remains slow among MSM of color in the U.S. South. Findings presented are from a qualitative study conducted in 2016 exploring factors related to remaining HIV negative among Black (n = 99) and Latino (n = 51) MSM in Atlanta, Baton Rouge, New Orleans, Jackson, and Miami. One-hour in-depth interviews were analyzed using a qualitative content analysis approach. MSM perceived PrEP as providing relief from fear and as an insurance policy against HIV infection but were likely to consider themselves at low risk for HIV. Identified factors influencing PrEP use included side effects, medical mistrust, and stigma. Cost and access were not seen as major barriers. Findings suggest MSM of color in the South may view PrEP as too risky for their HIV prevention needs. PrEP providers can address medical mistrust, discuss side effects, and emphasize positive aspects of PrEP use to increase uptake. (150 words).

Changes in high-risk sexual behavior, HIV and other STI testing, and PrEP use during the COVID-19 pandemic in a longitudinal cohort of adolescent men who have sex with men 13 to 18 years old in the United States

The COVID-19 pandemic has disrupted sexual health services among those most vulnerable to HIV acquisition, such as adolescent men who have sex with men (AMSM). We sought to characterize the changes in sexual-risk behaviors, HIV and other STI testing, and pre-exposure prophylaxis (PrEP) use among a longitudinal cohort of AMSM aged 13 to 18 years before and during the COVID-19 pandemic. We observed a significant decline in HIV testing and a marginal decrease in other STI testing since the pandemic began in March 2020. Outreach efforts and innovative remote delivery of sexual health services are needed to support access to healthcare services among AMSM as the pandemic persists.

Rapid qualitative analysis approach to stakeholder and client interviews to inform mobile-based HIV testing in the U.S. Deep South

BACKGROUND

The severity of the HIV epidemic in the United States' rural South highlights geographic, socioeconomic, and racial disparities that disproportionately affect poor Black Americans. Approximately 16% of Alabamians living with HIV remain undiagnosed and just 37% of rural Alabamians have ever been tested for HIV.

METHODS

We conducted in-depth interviews with 22 key stakeholders involved in HIV prevention, testing, treatment, or community health initiatives, and 10 adults living in rural communities across Alabama to explore HIV testing challenges and opportunities. We utilized a rapid qualitative analysis approach and engaged community partners for feedback and discussion. This analysis will inform the implementation of a mobile HIV testing service in rural Alabama.

RESULTS

The following themes were identified: (1) Cultural norms, racism, poverty, and rurality impair access to healthcare. (2) Lack of sex education, low knowledge of HIV and perception of risk reinforce stigmas. (3) Messaging about "Undetectable = Untransmissible" (U = U) is not well understood in communities. (4) Community involvement may promote communication and trust between communities and testing advocates. (5) Novel testing strategies are acceptable and may diminish barriers.

CONCLUSIONS

Working with community "gatekeepers" may be a key strategy to understand and promote acceptability of interventions new to rural Alabama and ameliorate stigma within communities. The implementation of new HIV testing strategies requires building and maintaining relationships with advocates, especially faith-based leaders, who engage people across many demographics.

HIV and Addiction Services for People Who Inject Drugs: Healthcare Provider Perceptions on Integrated Care in the U.S. South

This qualitative study evaluates physician training and experience with treatment and prevention services for people who inject drugs (PWID) including medications for opioid use disorder (MOUD) and HIV pre-exposure prophylaxis (PrEP). The Behavioral Model of Healthcare Utilization for Vulnerable Populations was applied as a framework for data analysis and interpretation. Two focus groups were conducted, one with early career physicians (n = 6) and one with mid- to late career physicians (n = 3). Focus group transcripts were coded and analyzed using thematic analysis to identify factors affecting implementation of treatment and prevention services for PWID. Respondents identified that increasing the availability of providers prescribing MOUD was a critical enabling factor for PWID seeking and receiving care. Integrated, interdisciplinary services were identified as an additional resource although these remain fragmented in the current healthcare system. Barriers to care included provider awareness, stigma associated with substance use, and access limitations. Providers identified the interwoven risk factors associated with injection drug use that must be addressed, including the risk of HIV acquisition, notably more at the forefront in the minds of early career physicians. Additional research is needed addressing the medical education curriculum, health system, and healthcare policy to address the addiction and HIV crises in the U.S. South.

Using Health Care Professionals' Perspectives to Refine a Clinical Decision Support Implementation Strategy for Increasing the Prescribing of HIV Preexposure Prophylaxis (PrEP) in Alabama

Pre-exposure prophylaxis (PrEP) is underused in the southern United States (US), a region with high HIV incidence. Clinical decision support (CDS) tools could increase PrEP prescriptions. We explored barriers to PrEP delivery and views of CDS tools to identify refinements for implementation strategies for PrEP prescribing and PrEP CDS tools. We conducted focus groups with health care providers from two federally qualified health centers in Alabama and analyzed the results using rapid qualitative methods. Barriers to PrEP included providers' lack of training in PrEP, competing priorities and time constraints during clinical visits, concerns about side effects, and intensive workload. We identified refinements to the planned implementation strategies to address the barriers, including training all clinic staff in PrEP and having CDS PrEP alerts in electronic health records sent to all staff. Development and deployment of CDS tools in collaboration with providers has potential to increase PrEP prescribing in high-priority jurisdictions.

"Let's take that [stop sign] down." Provider perspectives on barriers to and opportunities for PrEP prescription to African American girls and young women in Alabama

HIV disproportionately impacts many groups, including Black adolescent girls and young women (AGYW) aged 13-24 living in the Deep South. Current prevention efforts have the potential to further exacerbate disparities within this population as HIV pre-exposure prophylaxis (PrEP) remains underutilized by Black AGYW in the South. We conducted in-depth interviews (IDIs) grounded in Andersen's Model of Healthcare Utilization exploring providers' PrEP prescribing practices to Black AGYW in Alabama. Eleven providers completed IDIs exploring providers' PrEP prescription knowledge and experiences. Cross-cutting themes included: (1) Community and provider-level stigmas (including those propagated by legislation) relating to HIV and sexuality limit sexual health discussions with Black AGYW clients; (2) Low PrEP knowledge and comfort with guidelines limits PrEP conversations and reinforces low uptake and prescriptions; (3) Healthcare systems and structural barriers impede PrEP access for youth. Multi-level (structural, community, and provider) barriers to PrEP prescription demands high activation energy for providers to prescribe PrEP. We present recommendations in training in sexual health assessment, updates to PrEP guidelines to accommodate risk assessment appropriate for AGYW, and increased implementation science focused on PrEP prescription for Black AGYW in order to reduce HIV incidence for this population.

The Relationship Between HIV Pre-exposure Prophylaxis Stigma and Treatment Adherence Among Current HIV Pre-exposure Prophylaxis Users in the Southeastern U.S

Despite efficacy in HIV prevention, Pre-exposure Prophylaxis (PrEP) is underutilized in the US, especially among populations at highest risk. PrEP-related stigma may play a role. We developed measures of PrEP-related stigma dimensions and PrEP adherence. We administered them to current PrEP users. We hypothesized that PrEP-related stigma would negatively impact PrEP adherence. Questionnaire measures were developed using data from previous qualitative work and existing validated HIV-related stigma measures. The resultant survey was administered to current PrEP users from two Birmingham, Alabama PrEP clinics. Plasma tenofovir disoproxil fumarate levels were collected to measure PrEP adherence. Exploratory factor analyses were performed to determine the factor structure of each PrEP-related stigma dimension (internalized, perceived, experienced, anticipated, disclosure concerns). Separate binary logistic (or linear) regressions were performed to assess associations between PrEP-related stigma dimensions and adherence (treatment adherence self-efficacy, self-reported adherence, and plasma tenofovir levels), adjusting for education, race, and time on PrEP. In 2018, 100 participants completed the survey, with 91 identifying as male and 66 as white. Only internalized stigma was associated with lower self-reported PrEP adherence. Exploratory mediation analyses suggested that the association between all stigma dimensions and self-reported PrEP adherence is mediated by PrEP adherence self-efficacy. No associations were found between any PrEP-related stigma measures and plasma tenofovir levels. Internalized PrEP stigma may reduce PrEP adherence, possibly by reducing PrEP adherence self-efficacy among experienced PrEP users. Further investigation of how stigma dimensions affect PrEP adherence in populations at risk for HIV may shed light on drivers of PrEP underutilization.

Relationships among Substance Use, Sociodemographics, Pre-Exposure Prophylaxis (PrEP) Awareness and Related Attitudes among Young Adult Men Who Have Sex with Men

Men who have sex with men (MSM) account for two-thirds of new HIV diagnoses. Pre-exposure prophylaxis (PrEP), a highly efficacious HIV preventive medication, is underutilized. Identifying correlates of PrEP awareness and attitudes may help increase PrEP use. Thus, we evaluated (1) PrEP awareness; (2) differences in awareness related to substance use and sociodemographics; (3) initial PrEP information sources; and (4) possible associations between information sources and PrEP-related attitudes.

Young adult (ages 18-30) HIV-negative MSM from Southern U.S. undertook a web survey including questions about substance use, sexual behaviors, perceived HIV risk, and PrEP. Participants were recruited using in-person and online approaches between January 2018-January 2020.

Of 506 participants, 89% were aware of PrEP. Participants with high alcohol consumption and greater perceived HIV risk had higher odds of PrEP unawareness with a trend for minority race/ethnicity. PrEP-aware participants reported high overall perceived safety, confidence in PrEP's efficacy, and low perceived difficulties with adherence though those with higher perceived HIV risk and individuals who used tobacco had less favorable attitudes. Most participants first heard about PrEP from the internet. There were no statistically significant differences in PrEP-related attitudes across initial information sources.

Associations between substance use and racial/ethnic minority status and lack of PrEP awareness suggest priority subgroups for educational campaigns. Future campaigns may tailor outreach materials to the respective audience (e.g., Spanish materials for Hispanic people) and disseminate where individuals who use substances may be more likely to see them (e.g., liquor and convenience stores).

Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2022.2040030 .

Alignment of PrEP use and sexual behavior over four months among men who have sex with men in the southern United States

Unlike antiretrovirals for HIV treatment, pre-exposure prophylaxis (PrEP) does not require continual adherence to be fully effective; rather, PrEP adherence is important only in the context of episodes of sexual risk. Therefore, studies of PrEP adherence and persistence must incorporate contemporaneous measurement of sexual behavior. Short, frequent surveys of PrEP use and sexual behavior allow for the measurement of the alignment between PrEP use and sexual behavior. We assessed the feasibility of using biweekly PrEP use and sexual behavior questionnaires to measure adherence and persistence on PrEP over a period of four months. We also measured the alignment of PrEP use and condomless anal sex. PrEP-using MSM in the southern US were recruited using online advertisements. Participants completed a baseline survey followed by brief surveys every two weeks for 16 weeks to report their PrEP use and sexual behavior over the preceding two-week period. Study retention was high: 91% of participants completed the baseline and final survey and, overall, 86% of study surveys were completed. Self-reported PrEP adherence and persistence were high, but instances of PrEP non-adherence were observed to frequently overlap with episodes of condomless anal sex. The most prominent reasons cited for missing PrEP doses were being too busy, not having PrEP on hand, and not being sexually active. Completing short, biweekly surveys of PrEP use and sexual behavior is feasible and acceptable to MSM in the southern US. Future studies should investigate incorporating biomarker measurements to validate self-reported adherence.

Lessons Learned in Centering Youth Voices in HIV Prevention: The Adolescent Health Working Group

BACKGROUND

There remains critical need for community-based approaches to HIV prevention which center youth voices and needs.

OBJECTIVES

We established an adolescent health working group (AHWG) to convene youth, parents, providers, and advocates in agenda-setting for interventions to increase pre-exposure prophylaxis uptake in Durham.

METHODS

Our three study phases included six AHWG meetings from 2019 to 2020, youth-only meetings guided by a participatory engagement framework (Youth Generate and Organize), and interviews (n=13) and surveys with youth in the community (N=87). We also developed materials such as an AHWG mission statement, a list of themes and informational needs, and documented strategies about pivoting the project during the onset of the COVID-19 global pandemic.Lessons Learned/Conclusions: Engaging adults in youth-focused HIV prevention differs greatly to engaging youth themselves. Creating spaces to promote adolescent sexual Health requires trust building, breaking down sensitivities and stigma to, and flexibility to navigate both virtual and in-person spaces to do so.

Exploring Awareness, Perceptions, and Willingness to Use HIV Pre-Exposure Prophylaxis: A Qualitative Study of Ghanaian Immigrants in the United States

HIV/AIDS disproportionately burdens African immigrants in the United States. Oral pre-exposure prophylaxis (PrEP) is an effective prevention tool for people at high HIV risk, yet uptake is low among racial and ethnic minorities-particularly immigrants. This study explores the awareness, perception, and willingness to use PrEP among Ghanaian immigrants in the United States. WhatsApp, a social media platform, was used to recruit and conduct semi-structured oral interviews with 40 Ghanaian immigrants in March 2020. Interview questions explored awareness of PrEP (whether the participants knew or had knowledge of PrEP before the study), perceptions of PrEP and PrEP users, and willingness to use PrEP. Interviews were audiorecorded, and transcribed. We used NVivo-12 Plus to analyze transcripts for emergent themes. Our sample consisted of Ghanaian adult immigrants (N = 40, 57% male, 71% college educated, age = 32.8 ± 5.7 years, 68% had lived in the United States between 1 and 10 years) residing in 12 US cities. Four major themes emerged: (1) low awareness of PrEP; (2) positive perception of PrEP for HIV prevention; (3) divergent views on PrEP users; and (4) mixed views on willingness to use PrEP. This study presents formative qualitative work, which suggests that Ghanaian immigrants, despite having low awareness of PrEP, may be willing to use PrEP. A key study implication was that stigma reduction interventions might facilitate PrEP scale-up in this population.

Stigma, HIV Risk, and Access to HIV Prevention and Treatment Services Among Men Who have Sex with Men (MSM) in the United States: A Scoping Review

In light of recent advances in HIV prevention and treatment, we reviewed the literature to understand how different types of stigma impact HIV risk; access to HIV prevention, care, and treatment services; and related health outcomes among men who have sex with men (MSM) in the US. We conducted a scoping literature review of observational and qualitative studies that examined stigma and HIV-related outcomes among MSM. Our search identified 5794 studies, of which 47 met the eligibility criteria and were included in the final analysis. The review suggests that stigma remains a formidable barrier to engaging in HIV prevention and treatment among both HIV-negative and HIV-positive MSM. Among the studies of HIV-positive MSM, internalized stigma was related to lower levels of treatment engagement. HIV-positive MSM in the Southern part of the US were also more likely to engage in risky sexual behavior. Perceived health care discrimination was negatively associated with PrEP awareness, particularly among HIV-negative Black MSM. Among young MSM of color, intersectional stigma compounded the social structural barriers to PrEP adherence. Findings indicate that stigma reduction interventions should be implemented in diverse MSM communities to address the disproportionate burden of HIV along with critical gap in the care continuum. Further research should examine how individual types of stigma, including intersectional stigma, affect viral suppression and PrEP uptake and adherence, especially among MSM of color.

Revitalizing HIV Prevention Programs: Recommendations From Those Most Impacted by the HIV in the Deep South

PURPOSE

The incidence of new HIV infections is disproportionately high among Black men who have sex with men (BMSM) in Mississippi. Community-based organizations received funding through the ACCELERATE! initiative to implement interventions aimed at increasing BMSM's access to HIV prevention, treatment and care interventions.

APPROACH

We conducted a mixed methods evaluation of the ACCELERATE! initiative to assess its impact. We also explored factors that act as barriers to and facilitators of BMSM's engagement in HIV prevention interventions.

SETTING

Interviews were conducted between July 2018 and February 2020.

PARTICIPANTS

Thirty-six BMSM and 13 non-grantee key informants who worked in the field of HIV in Mississippi participated.

METHOD

The qualitative data from the interview transcripts was analyzed using an iterative, inductive coding process.

RESULTS

We identified 10 key recommendations that were most common across all participants and that were aligned with UNAIDS Global AIDS Strategy strategic priorities. Several recommendations address the reduction of HIV- and LGBT-stigma. Two of the most common recommendations were to increase representation of the target population in health promotion program leadership and to include HIV with other Black health issues in community-based health education programs rather than singling it out. Another recommendation called for programs aimed at addressing underlying factors associated with HIV-risk behaviors, such as mental illness.

CONCLUSION

Our results indicate that HIV education interventions in the Deep South need to be revitalized to enhance their reach and effectiveness.

Slow Uptake of PrEP: Behavioral Predictors and the Influence of Price on PrEP Uptake Among MSM with a High Interest in PrEP

Despite the improved availability and affordability of PrEP in the Netherlands, PrEP uptake is low among men who have sex with men (MSM). To optimize uptake, it is important to identify facilitators and barriers of PrEP use. During our study period, the price of PrEP dropped significantly after generic PrEP was introduced. We investigated whether the price drop predicts PrEP uptake, alongside behavioral and demographic characteristics. Participants (N = 349) were recruited online and completed three questionnaires over a period of 6 months, between February 2017 and March 2019. After 6 months, 159 (45.6%) participants were using PrEP. PrEP uptake was greater among MSM who ever had postexposure prophylaxis (PEP) treatment, among MSM with a better perceived financial situation, and when the price of PrEP dropped. MSM in a tighter perceived financial situation may use PrEP more when it would be free or fully reimbursed.

Missed Prevention Opportunities: Why Young, Black MSM with Recent HIV Diagnosis did not Access HIV Pre-exposure Prophylaxis Services

In the United States, HIV infection rate inequities persist, with new infections highest among young, Black men who have sex with men (YBMSM) in the South. We conducted 23 in-depth interviews with YBMSM newly diagnosed with HIV to explore awareness of and barriers to uptake of HIV pre-exposure prophylaxis (PrEP). Participants were recruited from two university-based HIV Clinics in Alabama and were: (1) 16-29 years of age, (2) diagnosed with HIV within the prior 365 days, (3) Black race, (4) self-identified as a cis-gender male reporting sex with men AND (5) did not report prior PrEP use. Interview guides were grounded in Anderson's Behavioral Healthcare Utilization Model (ABM), with embedded constructs from the situated Information, Motivation and Behavioral Skills theoretical framework. Coding was conducted by three independent coders using thematic analysis methods. Participants (N = 23) median age was 24, more than two-thirds reported annual incomes less than $15,000 and the majority (84%) identified as gay. Major themes that emerged as barriers to accessing PrEP included low prioritization and interests in using PrEP; low perceived HIV risk due to feelings of invincibility and trust in sex partners; lack of information about accessing PrEP; negative beliefs around PrEP; and the suggestion to change PrEP messaging from only targeting YBMSM. These findings indicate that there are important missed opportunities for HIV prevention with PrEP among YBMSM in the South. In these high-risk young men, tailored interventions are needed to better inform and frame perceptions around risk, knowledge, access and prioritization of PrEP.

Socio-Sexual Experiences and Access to Healthcare Among Informal PrEP Users in the Netherlands

The aim of this qualitative study was to explore the experiences of informal PrEP users regarding access to PrEP and PrEP-related healthcare, community responses, sexual behavior and well-being. We interviewed 30 men who have sex with men (MSM) in semi-structured online interviews between March and August 2018. Interviews were analyzed using interpretive description. Informal PrEP users were well informed about the use of PrEP, but sometimes did not make use of renal testing. Participants reported a lack of PrEP knowledge among healthcare providers, which limited their access to PrEP and put them at risk, as they received incorrect information. Although some participants reported negative reactions from potential sex partners, most received positive reactions and were sometimes seen as more desirable sex partners. PrEP healthcare services should not only be accessible to formal PrEP users, but also to PrEP users who procure PrEP informally.

Exploring adults as support persons for improved pre-exposure prophylaxis for HIV use among select adolescents and young adults in the Deep South

PURPOSE

Pre-exposure prophylaxis for HIV (PrEP) is an effective yet underutilized biomedical tool for adolescents and young adults' (AYA) HIV prevention due to barriers such as PrEP adherence. We assessed HIV prevention knowledge, attitudes and beliefs from adults who self-identified as a primary support person to an AYA.

METHODS

We surveyed AYA primary support persons at an academic hospital. Univariate and multivariate regression analyses were completed to identify factors associated with the belief AYAs engaging in HIV-associated behaviors should use PrEP and willingness to support AYAs on PrEP.

RESULTS

200 primary support persons completed the survey. Participants were predominately female (77%) and black (56%). Nearly all primary support persons believed AYAs engaging in HIV-associated behaviors should take PrEP (94%) and 98% would support an AYA taking PrEP via transportation to appointments, assistance with refilling prescriptions, medication reminders, or encouragement.

CONCLUSIONS

Primary support persons are willing to support AYAs using PrEP.

Determinants of pre-exposure prophylaxis (PrEP) persistence in a high-risk population in Central Florida

Orlando has the second highest HIV incidence in the USA. Tenofovir disoproxil fumarate/emtricitabine is approved as pre-exposure prophylaxis (PrEP) to minimize HIV transmission. Our study describes the PrEP care continuum and factors impacting PrEP persistence during the first year of PrEP care at a sexual health clinic in Orlando. Patients initiating PrEP between 2014 and 2017 with at least 1 year of follow-up were eligible for inclusion. Demographic and clinical factors were extracted from medical records. At the end of the first year of PrEP care, patients seen within the last 6 months were defined as 'persistent' whereas patients lost to follow-up for ≥6 months were defined as 'not persistent'. We evaluated factors associated with PrEP persistence with Firth's multivariable logistic regression. Of 300 patients meeting inclusion criteria, 96% were male, 59% were ≥30 years old, 59% identified as men who have sex with men and 57% endorsed recent condomless anal intercourse. Of PrEP initiators, 133 (44.3%) were persistent in the first year, whereas 167 (55.7%) were not persistent. PrEP persistence was positively associated with age ≥30 years (OR 1.04, 95% CI 1.0 to 1.08) and negatively associated with non-white race (OR 0.33, 95% CI 0.12 to 0.83). There were no HIV seroconversions among persistent patients. In our study, younger and minority patients were less likely to persist in PrEP care and persistence was poor despite many being insured and 'high-risk'. Further research is needed to identify and address barriers that hinder PrEP persistence, specifically among younger, minority patients.

Addressing Syndemics and Self-care in Individuals with Uncontrolled HIV: An Open Trial of a Transdiagnostic Treatment

Interventions addressing syndemics and ART adherence are needed for individuals with uncontrolled HIV and psychosocial problems. Twenty-seven participants with detectable HIV plasma viral load (PVL) or recent STI participated in an open trial of transdiagnostic adherence counseling and cognitive behavioral therapy. Outcomes were collected at baseline, 4-, and 8-months. Log PVL improved from baseline to 4-month (γ = - 1.13, 95% CI - 1.72, - 0.55, p < 0.001) and 8-month (γ = - 0.93, 95% CI - 1.57, - 0.30, p = 0.006), with more participants suppressed at 4- (χ2(1) = 9.09, p = 0.001) and 8-month (χ2(1) = 5.14, p = 0.016). Self-reported adherence improved across major assessments (γ = 0.87, 95% CI 0.28, 1.46, p = .005); Wisepill adherence did not. Negative affect declined during treatment (γ = - 0.28, 95% CI - 0.40, - 0.16, p < 0.001), with improvement at 4- (γ = - 4.34, 95% CI - 6.99, - 1.69, p = 0.002) but not 8-month. Positive affect trended positively during treatment and from baseline to 4-month, with significant 8-month improvement (γ = 3.84, 95% CI 0.33, 7.44, p = 0.04). Depressive symptoms did not change. In a complicated sample of participants selected for uncontrolled HIV, the intervention yielded improved PVL and self-reported adherence. Efforts to end HIV should improve upon strategies such as these, addressing syndemics. Registration: clinicaltrial.gov: NCT02696681.

Community-Informed Development of a Campaign to Increase HIV Pre-exposure Prophylaxis (PrEP) Awareness Among African-American Young Adults

Pre-exposure prophylaxis (PrEP) for HIV prevention can help reduce racial/ethnic HIV disparities in the USA. However, the benefits of PrEP have not been equally distributed across races. Community-informed, culturally tailored media has the potential to increase PrEP awareness and acceptability among vulnerable African-American populations. More research is needed to identify media preferences around PrEP for these groups in order to optimize effectiveness of health messaging. This study details the development of a community-informed multimedia (print, digital, Internet radio, website, social media) campaign to increase PrEP awareness among African-American young adults (age 18-29 years). Eleven focus groups with African-American young adults and a community advisory board informed the intervention. Focus group participants expressed concerns with PrEP safety, efficacy, accessibility, the universality of HIV vulnerability, and representation. Campaign elements were then developed based on this feedback. Future studies should examine the effectiveness of culturally tailored multimedia PrEP campaigns.

Facilitators and Barriers of Pre-exposure Prophylaxis (PrEP) Uptake Among Rural Men who have Sex with Men Living in the Midwestern U.S

Facilitators and barriers of Pre-exposure Prophylaxis (PrEP) uptake have been established in prior studies; however, most of these studies comprise samples of MSM from metropolitan cities and hypothetical PrEP use. There is a dearth of literature on the uptake factors among rural U.S. MSM who are prescribed PrEP. Thirty-four rural Midwestern MSM who currently take PrEP participated in semi-structured telephone interviews about their barriers and facilitators to their PrEP use. Interviews were analyzed using an inductive thematic analysis approach. There were four barriers: (1) lack of rural dissemination of PrEP information, (2) concern about side and adverse effects of using PrEP, (3) cost of PrEP uptake and engagement, and (4) lack of access to PrEP care and PrEP care quality. Individual and social facilitators that participants utilized to overcome these barriers are discussed. Findings elevate the importance of multilevel interventions that address PrEP adoption from a patient, provider, and healthcare system perspective.

Qualitative Contributions to Implementation Research on HIV Prevention and Treatment

BACKGROUND

The advantages of conducting implementation research as part of the development, as well as delivery and use of HIV prevention and treatment interventions, are increasingly being recognized. Qualitative methods are gaining recognition in implementation-oriented research on HIV as vehicles for examining particular implementation outcomes and for identifying barriers and facilitators to intervention uptake. However, they have more to offer. This article presents 3 case examples illustrating the use of qualitative research to explain intervention processes and outcomes, with the goal of clarifying "how and why" they work.

METHODS/CASE EXAMPLES

The first example identifies active ingredients in an intervention aimed at improving antiretroviral therapy (ART) adherence. The second proposes an explanation of the processes through which community-based HIV testing with follow-up support may bring about linkage to care and prevention services. The third unpacks the dynamics of a novel strategy of delivering oral pre-exposure prophylaxis and ART to HIV serodiscordant couples, showing how the organization of services positively impacted participating couples, enabling them to use oral pre-exposure prophylaxis and ART effectively to prevent HIV transmission.

RESULTS/DISCUSSION

Qualitative methods contribute to implementation research for HIV intervention development by (1) offering an alternative to framework-driven investigation, (2) providing tools for understanding user experience of interventions, and (3) developing local explanations of intervention processes and outcomes.

CONCLUSION

In various ways, qualitative methods contribute to implementation research by deepening and "thickening" conceptualization of implementation problems. Stronger conceptualizations lead to stronger implementation strategies and, thus, to increased use of evidence-based interventions for HIV prevention and treatment as they are made available to the public worldwide.

Barriers and Facilitators to PrEP Use Among People Who Inject Drugs in Rural Appalachia: A Qualitative Study

The opioid crisis has increased risks for injection drug use-associated HIV outbreaks in rural communities throughout the United States. Existing research has examined pre-exposure prophylaxis (PrEP) utilization among people who inject drugs (PWID); however, no studies have been conducted to explore barriers and facilitators of PrEP use among rural PWID in Appalachia. We conducted qualitative interviews with PWID (n = 48) in two rural counties in West Virginia to explore barriers and facilitators of PrEP use. Among our participants, the majority (68.8%) had never heard of PrEP. Upon learning about PrEP, most participants expressed willingness to use it. Rural PWID described several factors that may impede PrEP utilization (e.g., housing instability, forgetting to take PrEP). Participants also identified practical strategies to support sustained PrEP utilization, such as integrating PrEP services into venues PWID access. This research provides important insights into the barriers and facilitators of PrEP utilization among rural PWID.

Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review

Antiretroviral pre-exposure prophylaxis (PrEP) to prevent HIV transmission was first approved by the US Food and Drug Administration in 2012. Despite correlations of decreases in new HIV infections being greatest where PrEP has been deployed, the uptake of PrEP is lagging, particularly among populations with disproportionate HIV burden. This narrative review seeks to identify individual and systemic barriers to PrEP usage in the USA. A comprehensive search of recent literature uncovered a complex array of structural, social, clinical, and behavioral barriers, including knowledge/awareness of PrEP, perception of HIV risk, stigma from healthcare providers or family/partners/friends, distrust of healthcare providers/systems, access to PrEP, costs of PrEP, and concerns around PrEP side effects/medication interactions. Importantly, these barriers may have different effects on specific populations at risk. The full potential of PrEP for HIV prevention will not be realized until these issues are addressed. Strategies to achieve this goal should include educational interventions, innovative approaches to delivery of HIV care, financial support, and destigmatization of PrEP and PrEP users. Until then, PrEP uptake will continue to be suboptimal, particularly among those who need it most.

Exploring the Pre-exposure Prophylaxis (PrEP) Health Care Experiences Among Men Who Have Sex With Men (MSM) Who Live in Rural Areas of the Midwest

Most pre-exposure prophylaxis (PrEP) research samples men who have sex with men (MSM) who live in metropolitan cities. There is a limited understanding of the PrEP experiences among rural MSM. Thirty-four semi-structured interviews were conducted to explore the PrEP health care experiences among 34 rural Midwestern MSM. Of the 34 participants, 23 obtained PrEP from their non-primary care provider (PCP). Three themes were present: (1) PrEP is unavailable in rural areas, (2) PrEP is inaccessible in rural areas due to PCPs being unwilling to prescribe PrEP, and (3) PrEP services are unamicable in rural areas due to stigmatizing attitudes and behaviors of PCPs. It is important to address PrEP care continuum factors in all settings; however, these factors are often exacerbated in rural areas due to social determinants. Without further research and programming, organizational and social determinants may contribute to lower rates of PrEP outcomes in rural areas.