A Tale of Two Cities: Exploring the Role of Race/Ethnicity and Geographic Setting on PrEP Use Among Adolescent Cisgender MSM

A Mixed Methods Investigation Examining the PrEP Cascade Among 13-18-Year-Old Latino Adolescent Sexual Minority Men

Latino adolescent sexual minority men (ASMM) are at high risk of HIV. Limited research has explored the impact of parent-adolescent communication and beliefs on PrEP adoption among Latino ASMM. Our objective was to examine how parental support and beliefs influence decisions regarding PrEP use. We analyzed PrEP-related attitudes and behaviors within a national cohort of 524 Latino ASMM aged 13-18. Out of the participants, 60.5% were suitable for PrEP. Among them, 59.7% were in the precontemplation stage (stage 1), indicating a lack of willingness or belief of unsuitability. However, 86.4% moved to reach the contemplation stage (stage 2), demonstrating willingness and suitability for PrEP. Only 16.8% moved on to the PrEParation stage (stage 3), indicating their intention to start using PrEP. Furthermore, 4.3% progressed to the PrEP action stage and initiation (stage 4), signifying they had received a prescription, and all reported high adherence (stage 5). Factors associated with reaching later stages included older age, parental support of sexual orientation, and previous HIV/STI testing. The qualitative findings revealed diverse attitudes towards parental involvement in PrEP care among Latino ASMM, including positive, negative, and ambivalent perspectives. Notably, Spanish-speaking participants expressed specific barriers to PrEP communication between ASMM and their parents. Given that parental support and attitudes emerged as significant factors in both our quantitative and qualitative findings, it is evident that public health approaches aiming to disseminate education and awareness about PrEP to parents and families could alleviate the burden on adolescents to educate their parents and enhance support.

Assessing Structural Racism and Discrimination Along the Pre-exposure Prophylaxis Continuum: A Systematic Review

Structural racism and discrimination (SRD) is deeply embedded across U.S. healthcare institutions, but its impact on health outcomes is challenging to assess. The purpose of this systematic literature review is to understand the impact of SRD on pre-exposure prophylaxis (PrEP) care continuum outcomes across U.S. populations who could benefit from HIV prevention. Guided by PRISMA guidelines, we conducted a systematic review of the published literature up to September 2023 using PubMed and PsycInfo and included peer-reviewed articles meeting inclusion criteria. At least two authors independently screened studies, performed quality assessments, and abstracted data relevant to the topic. Exposure variables included race/ethnicity and any level of SRD (interpersonal, intra- and extra-organizational SRD). Outcomes consisted of any steps of the PrEP care continuum. A total of 66 studies met inclusion criteria and demonstrated the negative impact of SRD on the PrEP care continuum. At the interpersonal level, medical mistrust (i.e., lack of trust in medical organizations and professionals rooted from current or historical practices of discrimination) was negatively associated with almost all the steps across the PrEP care continuum: individuals with medical mistrust were less likely to have PrEP knowledge, adhere to PrEP care, and be retained in care. At the intra-organizational level, PrEP prescription was lower for Black patients due to healthcare provider perception of higher sex-risk behaviors. At the extra-organizational level, factors such as homelessness, low socioeconomic status, and incarceration were associated with decreased PrEP uptake. On the other hand, healthcare provider trust, higher patient education, and access to health insurance were associated with increased PrEP use and retention in care. In addition, analyses using race/ethnicity as an exposure did not consistently show associations with PrEP continuum outcomes. We found that SRD has a negative impact at all steps of the PrEP care continuum. Our results suggest that when assessing the effects of race/ethnicity without the context of SRD, certain relationships and associations are missed. Addressing multi-level barriers related to SRD are needed to reduce HIV transmission and promote health equity.

Racial differences in the association of undetectable HIV viral load and transportation to an HIV provider among men who have sex with men in Atlanta, Georgia: a health equity perspective

There are inequities in HIV outcomes among Black gay, bisexual, and other sexual minority men who have sex with men (GBMSM) compared to GBMSM overall, including access to transportation to HIV care. It is unclear if the relationship between transportation and clinical outcomes extends to viral load. We assessed the relationship between transportation dependence to an HIV provider and undetectable viral load among Black and White GBMSM in Atlanta. We collected transportation and viral load information from GBMSM with HIV from 2016-2017 (n = 345). More Black than White GBMSM had a detectable viral load (25% vs. 15%) and took dependent (e.g. public) transportation (37% vs. 18%). Independent (e.g. car) transportation was associated with undetectable viral load for White GBMSM (cOR 3.61, 95% CI 1.45, 8.97) but was attenuated by income (aOR. 2.29, 95% CI 0.78, 6.71), and not associated for Black GBMSM (cOR 1.18, 95% CI 0.58, 2.24). One possible explanation for no association for Black GBMSM is that there are more competing barriers to HIV care for Black GBMSM than White GBMSM. Further investigation is needed to confirm whether 1) transportation is unimportant for Black GBMSM or 2) transportation interacts with additional factors not considered in this analysis.

Exploring the Association Between Gender Affirmation and PrEP use Among Transgender Women in New York City

Black and Hispanic/Latina transgender women are inequitably impacted by HIV; yet gaps in PrEP use exist. Among a sample of mostly Black and Hispanic/Latina transgender women in New York City, we aim to examine whether PrEP use was associated with gender affirmation and the use of gender-affirming health services. We found that PrEP use was more prevalent among those who used hormone therapy and those who had a provider they were comfortable speaking to about gender-related issues. In separate models, these associations were attenuated when adjusting for race/ethnicity, with those who use hormones being marginally more likely to report PrEP use and with Hispanic/Latina transgender women being more likely to have used PrEP, compared to Black transgender women. We found evidence of a potential association between medical gender affirmation and PrEP use. More research is needed to explore the social and structural contexts that are influenced by race/ethnicity that may serve to prevent PrEP uptake.

"This Is To Help Me Move Forward": The Role of PrEp in Harnessing Sex Positivity and Empowerment Among Black Sexual Minority Men in the Southern United States

In the United States (U.S.), Black sexual minority men (BSMM) are disproportionately burdened by HIV. Prevention advances, such as HIV pre-exposure prophylaxis (PrEP), play a key role in reducing HIV transmission and improving our understanding of sexual expression and health. Despite these advances, little is known regarding the potential link between PrEP use and positive sexuality, including the benefits that BSMM see in accessing PrEP. We conducted a thematic analysis of 32 interviews with BSMM in the Southern U.S. regarding their PrEP beliefs. We developed five themes: (1) Sexual freedom, (2) Agency and empowerment, (3) Making PrEP normative, (4) Behavioral health practices, and (5) Committed relationship tensions. Our findings suggest that BSMM are increasingly concerned about freedom of choice and invested in sexual empowerment as related to their PrEP use. Further, unanticipated benefits, community support, and relationship tensions are salient factors in considerations of PrEP use among BSMM. These findings have implications for how we might understand a broader movement toward sexual empowerment and positivity, and the pivotal role that PrEP serves in this movement.

Implementation of Client-Centered Care Coordination for HIV Prevention with Black Men Who Have Sex with Men: Activities, Personnel Costs, and Outcomes-HPTN 073

BACKGROUND

Black men who have sex with men (MSM) experience disproportionate rates of HIV infection in the USA, despite being no more likely to engage in sexual risk behaviors than other MSM racial/ethnic groups. HIV pre-exposure prophylaxis (PrEP) has been shown to reduce risk of HIV acquisition; however, rates of PrEP use among Black MSM remain low. Clinical, psychosocial, and structural factors have been shown to impact PrEP use and adherence among Black MSM. Care coordination of HIV prevention services has the potential to improve PrEP use and adherence for Black MSM, as it has been shown to improve HIV-related care outcomes among people living with HIV.

METHODS

Client-centered care coordination (C4) is a multi-level intervention designed to address clinical, psychosocial, and structural barriers to HIV prevention services for Black MSM within HPTN 073, a PrEP demonstration project among Black MSM in three cities in the USA. The current study examined the implementation process of C4, specifically investigating the activities, cost, time, and outcomes associated with the C4 intervention.

RESULTS

On average, participants engaged in five care coordination encounters. The vast majority of care coordination activities were conducted by counselors, averaging 30 min per encounter. The cost of care coordination was relatively low with a mean cost of $8.70 per client encounter.

CONCLUSION

Although client-centered care coordination was initially implemented in well-resourced communities with robust HIV research and service infrastructure, our findings suggest that C4 can be successfully implemented in resource constrained communities.

Co-occurring Epidemic Conditions Among Southern U.S. Black Men Who Have Sex with Men in an Online eHealth Intervention

Black men who have sex with men (BMSM) face disproportionately higher risks for adverse sexual health outcomes compared to their non-Hispanic White counterparts. This disparity can be attributable to overlapping and intersecting risk factors at the individual and structural levels and can be understood through syndemic theory. Using longitudinal data from the HealthMPowerment trial (n = 363), six conditions related to stigma syndemics were indexed as a cumulative risk score: high alcohol use, polydrug use, depression and anxiety symptomology, and experiences of racism and sexual minority stigma. Using Poisson regression, we found a positive association between baseline risk scores and sexual risk behavior (b: 0.32, SE: 0.03, p < 0.001). Using a Generalized Estimating Equation, we also found a 0.23 decrease in the within-participant risk scores at 3-month follow-up (SE: 0.10, p < 0.020). Future work examining how care and prevention trials improve health outcomes in this population is needed.

Individual and structural-level Correlates of Pre-exposure Prophylaxis (PrEP) lifetime and current use in a nationwide sample of young sexual and gender minorities

The objective of this analysis was to describe individual and structural-level factors associated with pre-exposure prophylaxis (PrEP) use among a sample of sexual and gender minorities (SGM) at risk for HIV recruited using limited interaction strategies. SGM (N = 3330), ages 15-34, without HIV enrolled in a nationwide limited interaction cohort study from 2017 to 2020. A baseline cross-sectional single-survey design examined individual and structural-level correlates of PrEP lifetime use and current use using logistic regression. PrEP lifetime use and current use were reported by 31.2% and 23.9%, respectively, of SGM with PrEP data (n = 3077). PrEP use outcomes (lifetime or current use) in cisgender MSM were associated with being over age 18, Black or other race, Hispanic/Latina/x/o ethnicity, being gay, being out to one's healthcare provider, having health insurance, being a college graduate, and having a greater number of PrEP peers. PrEP use outcomes (lifetime use or current use) in transgender/non-binary participants were associated with being over age 24, being Latinx, being transgender vs. non-binary, being assigned male at birth, being out to their healthcare provider, living in the western or northeastern United States, and having more peers on PrEP. More work is needed to address lower PrEP uptake in SGM under 18 and those whose sex risk may be more dynamic (e.g., non-binary, pansexual/queer, and bisexual SGM) and such strategies should consider utilizing peers to provide information and ameliorate structural barriers.

Recognizing and disrupting stigma in implementation of HIV prevention and care: a call to research and action

INTRODUCTION

There is robust evidence that stigma negatively impacts both people living with HIV and those who might benefit from HIV prevention interventions. Within healthcare settings, research on HIV stigma has focused on intra-personal processes (i.e. knowledge or internalization of community-level stigma that might limit clients' engagement in care) or inter-personal processes (i.e. stigmatized interactions with service providers). Intersectional approaches to stigma call us to examine the ways that intersecting systems of power and oppression produce stigma not only at the individual and interpersonal levels, but also within healthcare service delivery systems. This commentary argues for the importance of analysing and disrupting the way in which stigma may be (intentionally or unintentionally) enacted and sustained within HIV service implementation, that is the policies, protocols and strategies used to deliver HIV prevention and care. We contend that as HIV researchers and practitioners, we have failed to fully specify or examine the mechanisms through which HIV service implementation itself may reinforce stigma and perpetuate inequity.

DISCUSSION

We apply Link and Phelan's five stigma components (labelling, stereotyping, separation, status loss and discrimination) as a framework for analysing the way in which stigma manifests in existing service implementation and for evaluating new HIV implementation strategies. We present three examples of common HIV service implementation strategies and consider their potential to activate stigma components, with particular attention to how our understanding of these dynamics can be enhanced and expanded by the application of intersectional perspectives. We then provide a set of sample questions that can be used to develop and test novel implementation strategies designed to mitigate against HIV-specific and intersectional stigma.

CONCLUSIONS

This commentary is a theory-informed call to action for the assessment of existing HIV service implementation, for the development of new stigma-reducing implementation strategies and for the explicit inclusion of stigma reduction as a core outcome in implementation research and evaluation. We argue that these strategies have the potential to make critical contributions to our ability to address many system-level form stigmas that undermine health and wellbeing for people living with HIV and those in need of HIV prevention services.

Evidence and implication of interventions across various socioecological levels to address pre-exposure prophylaxis uptake and adherence among men who have sex with men in the United States: a systematic review

BACKGROUND

Pre-exposure prophylaxis (PrEP) represents a proven biomedical strategy to prevent HIV transmissions among men who have sex with men (MSM) in the United States (US). Despite the design and implementation of various PrEP-focus interventions in the US, aggregated evidence for enhancing PrEP uptake and adherence is lacking. The objective of this systematic review is to synthesize and evaluate interventions aimed to improve PrEP uptake and adherence among MSM in the US, and identify gaps with opportunities to inform the design and implementation of future PrEP interventions for these priority populations.

METHODS

We followed the PRISMA guidelines and conducted a systematic review of articles (published by November 28, 2021) with a focus on PrEP-related interventions by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO). Details of PrEP interventions were characterized based on their socioecological level(s), implementation modalities, and stage(s) of PrEP cascade continuum.

RESULTS

Among the 1363 articles retrieved from multiple databases, 42 interventions identified from 47 publications met the inclusion criteria for this review. Most individual-level interventions were delivered via text messages and/or apps and incorporated personalized elements to tailor the intervention content on participants' demographic characteristics or HIV risk behaviors. Interpersonal-level interventions often employed peer mentors or social network strategies to enhance PrEP adoption among MSM of minority race. However, few interventions were implemented at the community-, healthcare/institution- or multiple levels.

CONCLUSIONS

Interventions that incorporate multiple socioecological levels hold promise to facilitate PrEP adoption and adherence among MSM in the US given their acceptability, feasibility, efficacy and effectiveness. Future PrEP interventions that simultaneously address PrEP-related barriers/facilitators across multiple socioecological levels should be enhanced with a focus to tackle contextual and structural barriers (e.g., social determinants of health, stigma or medical mistrust) at the community- and healthcare/institution-level to effectively promote PrEP use for MSM of color.

Racial disparities in access to reproductive health and fertility care in the United States

PURPOSE OF REVIEW

To examine the status of racial and ethnic inequalities in fertility care in the United States (U.S.) at inception of 2022. This review highlights addressable underpinnings for the prevalent differentials in access to and utilization of infertility treatments and underscores gaps in preventive care as key contributors to racial and ethnic disparities in risk burden for subfertility and infertility.

RECENT FINDINGS

Significant gaps in access to and utilization of fertility care are consistently reported among racial and ethnic minorities, particularly Black and Hispanic women. Access to and utilization of contraceptives, human papilloma virus vaccination rates, preexposure prophylaxis use, and differentials in treatment of common gynecologic disorders are relevant to the prevalent racial and ethnic disparities in reproductive health. The spectrum of differential in reproductive wellness and the magnitude of reproductive health burden afflicting racial minorities in the U.S. raise concerns regarding systemic and structural racism as plausible contributors to the prevalent state of affairs.

SUMMARY

Despite efforts to reform unequal reproductive health practices and policies, racial and ethnic disparities in fertility care are pervasive and persistent. In addition to measures aimed at reducing barriers to care, societal efforts must prioritize health disparity research to systematically examine underpinnings, and addressing structural racism and interpersonal biases, to correct the prevalent racial inequities and mitigate disparities.

Reddit on PrEP: Posts About Pre-exposure Prophylaxis for HIV from Reddit Users, 2014-2019

Social media forums provide a window into how gay, bisexual, and other men who have sex with men talk about pre-exposure prophylaxis for HIV prevention (PrEP) outside of research contexts. To examine information exchange about this important pillar of HIV prevention, discussions around PrEP were collected from the r/askgaybros subreddit of the social media site Reddit (2014-2019). Post titles and asks were qualitatively coded to identify themes describing the primary purpose of the post. In all, 1163 PrEP posts were identified, and a 23.3-fold increase in post volume was seen from 2014 (n = 20) to 2019 (n = 466). The most common post type was a mention of PrEP in a post primarily discussing: an assessment of risk after a sexual encounter (19.2%); a sexual or romantic relationship (6.0%); or other (29.3%). Access challenges (19.1%), information seeking (17.5%), and the cultural effects of PrEP on the gay community (16.3%) were other common themes. Posts regarding the initiation of PrEP (11.8%) and PrEP side-effects (9.4%) were moderately represented. Posts addressing promotion, shade, stigma, and usage were infrequent (≤ 5.5% of posts, respectively). Over time, discussion of PrEP has increased exponentially on r/askgaybros, which may reflect the normalization of PrEP. Qualitative analysis of these posts can be a rich source of data for scientists, practitioners, and healthcare providers interested in increasing uptake of PrEP and decreasing barriers to its use.

Vaccine Attitudes and COVID-19 Vaccine Intentions and Prevention Behaviors among Young People At-Risk for and Living with HIV in Los Angeles and New Orleans

Sexual and gender minority (SGM) and racial or ethnic minority youth at-risk for or living with HIV may have higher risk of SARS-CoV-2 infection. However, there are few data on vaccine hesitancy/acceptance and COVID-19 self-protective behaviors among this population. Youth aged 15-24 years (n = 440), predominantly African American and Latine (73%, n = 320) SGM, from Los Angeles and New Orleans reported their vaccine attitudes and COVID-19 and HIV preventive behaviors in October 2020. Latent class analyses categorized individuals into groups based on their vaccine attitudes and preventive behaviors. Relationships between these groups and other factors were analyzed using Fisher's exact tests, ANOVA, and logistic regression. Most youth had accepting vaccine attitudes (70.2%, n = 309), with 20.7% hesitant (n = 91), and 9.1% resistant (n = 40). SGM and African Americans were significantly less accepting than their cis-gender and heterosexual peers. About two-thirds (63.2%, n = 278) of the respondents reported consistent COVID-19 self-protective behaviors. Youth with pro-vaccine attitudes were most consistently self-protective; however, only 54.4% (n= 168/309) intended to take a COVID-19 vaccine. Homelessness history, race, and sexual orientation were associated with vaccine attitudes. Accepting vaccine attitudes and consistent COVID-19 self-protective behaviors were closely related. COVID-19 attitudes/behaviors were not associated with HIV risk and only loosely associated with SARS-CoV-2 vaccine intentions.

'How come they don't talk about it in school?' Identifying adolescent barriers to PrEP use

Although 21% of new human immunodeficiency virus (HIV) diagnoses in the United States are in youth aged 13-24 years, adolescent awareness and uptake of the HIV prevention medication pre-exposure prophylaxis (PrEP) are low. This study explores the attitudes and challenges that adolescents face while taking PrEP. Thirty interviews were conducted with Black and Latine (we use the gender-inclusive term Latine rather than Latinx for more appropriate Spanish pronunciation) students aged 15-17 who received care at school-based health centers (SBHCs) in the Bronx, NY. Transcripts were coded inductively and deductively using thematic analysis. Most participants were unaware of PrEP, but nearly all were enthusiastic when informed about it; a majority denied that they would feel any stigma when taking PrEP. Despite this high receptivity, multiple barriers were identified, particularly confidentiality from parents, low perceived need of PrEP and concerns about daily adherence and side effects. Adolescents overall were enthusiastic about the availability of PrEP and felt it empowered them to have control over their health. SBHCs were considered trusted sources of confidential, accessible care, and we believe that they can be uniquely positioned to mitigate barriers to PrEP distribution in the future.

"It's Very Inconvenient for Me": A Mixed-Method Study Assessing Barriers and Facilitators of Adolescent Sexual Minority Males Attending PrEP Follow-Up Appointments

Researching PrEP retention in adolescent sexual minority men (ASMM) is critical to increasing persistence of PrEP in this priority population, yet this research is lacking. ASMM (N = 1433) completed a baseline survey for an online HIV prevention program between 2018 and 2020. Open- and closed-ended survey items identified their beliefs about attending 3-month PrEP follow-up appointments and examined the association of Andersen's Behavioral Model factors (predisposing, enabling, and need) and confidence to attend these appointments. Qualitative and quantitative findings show that perceived parental support is a salient factor in ASMM attending PrEP follow-up appointments. Participants did not want to have to go to the doctor and get bloodwork done trimonthly, and qualitative findings elucidated rationales for this, such as perceptions that follow-ups might be time-consuming, costly, and could out their sexuality to their parents. This study suggests that parents are gatekeepers for ASMM to initiate and sustain the PrEP care continuum.

Evaluation of an HIV Pre-Exposure Prophylaxis Referral System: From Sexual Health Center to Federally Qualified Health Center Pre-Exposure Prophylaxis Clinic

Innovative delivery strategies are needed to facilitate access to HIV pre-exposure prophylaxis (PrEP). The objective of this study was to evaluate a navigator-facilitated PrEP referral process from a sexual health center (SHC) to a co-located PrEP clinic as an alternative delivery model. Electronic health record (EHR) data were used to calculate the number of clients seen at the SHC in 2019. Charts were manually reviewed to determine whether a PrEP clinic referral was made and document type of referral method: face-to-face appointment scheduling with the navigator (warm handoff), EHR messaging to navigator to schedule the appointment at a later time (EHR message), or provision of navigator's contact information to the client (card only). In 2019, 2481 unique potentially PrEP-eligible clients were seen at the SHC; 220 (9%) received a PrEP referral. Of referred clients, median age was 30 years (interquartile range, 24-34), 182 (83%) were male, 89 (40%) were non-Hispanic Black, and 24 (11%) were Latinx. In total, 94/220 (43%) referred clients attended an initial PrEP visit with a provider, and the proportion attending by referral method was 81%, 36%, and 27% for warm handoff, EHR message, and card only, respectively (p < 0.0001). Despite co-location of these two clinics, there were significant drop-offs along the PrEP care continuum for this referral system. Warm handoff was the most effective referral method, but further efforts are needed to understand barriers to referral. Implementation of same-day PrEP services at SHCs is one potential solution to engaging additional clients.