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

Community recommendations for promoting HIV testing to Black young men who have sex with men in the southern United States

BACKGROUND

Considering the need to increase HIV testing among racial minority youth in the southern United States, we conducted an exploratory study in Alabama to elucidate recommendations on improving testing rates among Black young men who have sex with men (BYMSM).

METHODS

We conducted in-depth interviews and focus groups with BYMSM and prevention and outreach workers. Data collection occurred online and in person between 2020-2022.

RESULTS

Our sample included data from n = 56 BYMSM and n = 12 prevention and outreach workers. BYMSMs' mean age = 24 years. Among prevention and outreach workers, 58% identified as male with mean age = 39 years; 83% identified as Black. Transcripts were coded thematically; five concurrent themes emerged from both BYMSM and prevention and outreach workers: promoting testing at younger ages, need for visibility and outreach, connecting through shared experiences, value of nonjudgmental approaches, and need to increase HIV knowledge in BYMSM.

CONCLUSIONS

Findings suggest that cultivating trust is salient to promoting HIV testing in BYMSM. To end the epidemic in the southern United States, a region that is heavily rural with high rates of HIV, it may be necessary to begin prevention conversations at younger ages and equip prevention and outreach workers with communication skills that leverage de-stigmatizing approaches.

Perspectives on a peer-driven intervention to promote pre-exposure prophylaxis (PrEP) uptake among men who have sex with men in southern New England: a qualitative study

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a highly effective pharmaceutical intervention that prevents HIV infection, but PrEP uptake across the US has been slow among men who have sex with men (MSM), especially among Black/African American (B/AA) and Hispanic /Latino (H/L) MSM. This study investigates the acceptability and essential components of a peer-driven intervention (PDI) for promoting PrEP uptake among MSM, with a specific focus on B/AA and H/L communities.

METHODS

We conducted 28 semi-structured, qualitative interviews with MSM in southern New England to explore the components of a PDI, including attitudes, content, and effective communication methods. A purposive sampling strategy was used to recruit diverse participants who reflect the communities with the highest burden of HIV infection.

RESULTS

Of 28 study participants, the median age was 28 years (interquartile range [IQR]: 25, 35). The sample comprised B/AA (39%, n = 11) and H/L (50%, n = 14) individuals. Notably, nearly half of the participants (46%) were current PrEP users. We found that many participants were in favor of using a PDI approach for promoting PrEP. Additionally, several participants showed interest in becoming peer educators themselves. They emphasized the need for strong communication skills to effectively teach others about PrEP. Moreover, participants noted that peer education should cover key topics like how PrEP works, how effective it is, and any possible side effects.

CONCLUSIONS

Our study shows that effective PDIs, facilitated by well-trained peers knowledgeable about PrEP, could enhance PrEP uptake among MSM, addressing health disparities and potentially reducing HIV transmission in B/AA and H/L communities.

A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi

BACKGROUND

Mississippi (MS) experiences disproportionally high rates of new HIV infections and limited availability of pre-exposure prophylaxis (PrEP). Federally Qualified Health Centers (FQHCs) are poised to increase access to PrEP. However, little is known about the implementation strategies needed to successfully integrate PrEP services into FQHCs in MS.

PURPOSE

The study had two objectives: identify barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs.

METHODS

Semi-structured interviews were conducted with 19 staff and 17 PrEP-eligible patients in MS FQHCs between April 2021 and March 2022. The interview was guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework which covered PrEP facilitators and barriers. Interviews were coded according to the i-PARIHS domains of context, innovation, and recipients, followed by thematic analysis of these codes. Identified implementation strategies were presented to 9 FQHC staff for feedback.

RESULTS

Data suggested that PrEP use at FQHCs is influenced by patient and clinic staff knowledge with higher levels of knowledge reflecting more PrEP use. Perceived side effects are the most significant barrier to PrEP use for patients, but participants also identified several other barriers including low HIV risk perception and untrained providers. Despite these barriers, patients also expressed a strong motivation to protect themselves, their partners, and their communities from HIV. Implementation strategies included education and provider training which were perceived as acceptable and appropriate.

CONCLUSIONS

Though patients are motivated to increase protection against HIV, multiple barriers threaten uptake of PrEP within FQHCs in MS. Educating patients and providers, as well as training providers, are promising implementation strategies to overcome these barriers.

Perceptions of a community-based HIV/STI testing program among Black gay, bisexual, and other MSM in Baltimore: a qualitative analysis

Black gay, bisexual, and other men who have sex with men (GBM) are disproportionately affected by HIV and STIs. Safe Spaces 4 Sexual Health (SS4SH), a community-informed, status-neutral HIV/STI testing intervention combines online outreach via geo-social networking apps and social media with mobile van testing. During 2018-2019, we recruited 25 participants for interviews about their perceptions of SS4SH compared to clinic-based testing. Participants were aged 21-65 years (mean 35); 22 (88%) identified as Black/African American; 20 (80%) identified as gay; and 10 (40%) were living with HIV. Interviews were transcribed, coded, and analyzed using a modified thematic constant comparative approach. Five themes emerged; two related to perceptions of online outreach materials (participants were drawn to eye-catching and to-the-point messages and desired more diversity and representation in messages), and three related to preference for the mobile van (participants found SS4SH provided more comfort, more privacy/confidentiality, and increased accessibility and efficiency). GBM is increasingly using geo-social networking apps to meet sexual partners, and tailored online outreach has the potential to reach historically underserved populations. SS4SH is a barrier-reducing strategy that may serve as an entry to a status-neutral approach to services and help reduce stigma and normalize accessing HIV services.

Low Self-Perceived Need for PrEP and Behavioral Indications of MSM Who Recently Refused Daily PrEP: A Mixed Methods Study in Three U.S. Cities

Pre-exposure prophylaxis (PrEP) reduces sexual risk for HIV transmission by 99% when used appropriately, but remains underutilized among gay, bisexual, and other men who have sex with men (MSM). In this mixed-method study, we describe reasons for PrEP refusal associated with low self-perceived need for PrEP among MSM who recently declined daily oral PrEP when offered by a provider. Data are from a quantitative behavioral survey of MSM (N = 93) living in Atlanta, Chicago, and Raleigh-Durham, who also either responded to an in-depth interview (n = 51) or participated in one of 12 focus groups (n = 42). Themes of low self-perceived need for PrEP were: low self-perceived risk for HIV acquisition (33% of respondents); confidence in remaining HIV-negative (35%); using condoms (81%); limiting number of partners and choosing partners carefully (48%); asking partners about their HIV status before having sex (45%); engaging in safer sexual positions or oral sex (28%); being in a monogamous relationship or exclusivity with one partner (26%); and regular HIV testing (18%). Low self-perceived risk for HIV acquisition and high confidence in other prevention strategies were important factors related to low self-perceived need in MSM refusing daily oral PrEP when offered. Providers should continue to discuss the benefits of PrEP as a safe and highly effective option for HIV prevention.

Influences affecting decision-making regarding use of pre-exposure prophylaxis among black men who have sex with men in the USA: a systematic review and meta-synthesis

AIM

To systematically identify, evaluate, and synthesise qualitative research examining positive and negative influences affecting decision-making behaviour among black men who have sex with men (BMSM) in the USA regarding use of pre-exposure prophylaxis (PrEP).

BACKGROUND

Used correctly, PrEP is highly efficacious in preventing HIV infection and is available via healthcare services throughout the USA. BMSM are a key target population for HIV prevention services, however their engagement with these services is low. With potential barriers to access ranging from systemic to personal, a phenomenological perspective on the influences affecting individuals' decision-making is essential, helping to better understand the needs of this target population and guide development and delivery of more effective future policy and intervention services.

DESIGN

Qualitative meta-synthesis with meta-aggregation.

DATA SOURCES

The electronic databases Medline, CINAHL, APA PsycInfo, Embase and Ovid Emcare were comprehensively searched from inception to 21 January 2022.

REVIEW METHODS

Systematic identification, quality assessment and synthesis of existing qualitative research according to protocols of meta-aggregation. This included identifying salient study findings and corroborating illustrations from the data, sorting like findings into descriptive themed categories and developing transformative synthesised statements from aggregate appraisal of category findings.

RESULTS

Seventeen studies met the inclusion criteria and were assessed to be of acceptable quality. Synthesis of study data yielded 30 categories grouped under five themes: Stigma, Discrimination, Mistrust, PrEP positivity and PrEP negativity. Twelve synthesised statements were produced to provide a summary of the results and suggest improvements to the delivery of future PrEP services and interventions.

CONCLUSION

A more targeted approach focused on advocacy and ambassadorship outside of clinical settings may be more influential in positive decision-making regarding use of PrEP in BMSM populations than relying on traditional outreach methods via institutions and their representatives where stigma, mistrust and structural inequalities perpetuate.

Social, Structural, Behavioral, and Clinical Barriers Influencing Pre-exposure Prophylaxis (PrEP) Use Among Young Black Men Who Have Sex with Men in the South: A Qualitative Update to a 2016 Study

Antiretroviral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV. Despite its promise, PrEP use is low, especially among young Black men who have sex with men (YBMSM). The prevalence of HIV in Mississippi (MS) is among the highest in the United States, with the bulk of new infections occurring amongst YBMSM living in Jackson, MS. We recruited 20 PrEP-eligible YBMSM and 10 clinic staff from MS health clinics between October 2021 and April 2022. Data were collected remotely using in-depth interviews and a brief survey, which lasted approximately 45-60 min. Interview content included PrEP knowledge/experiences, HIV risk perception, and PrEP use barriers and facilitators. Qualitative data were coded then organized using NVivo. Using thematic analysis methodology, data were assessed for current barriers to PrEP use. An array of barriers were identified by participants. Barriers included structural factors (cost of PrEP, lack of discreet clinics, time commitment, competing interests); social factors (unaware of HIV risk, stigma and homophobia, fear that partners would find out about PrEP use, not knowing anyone on PrEP); behavioral factors (sexual risk factors, denial, less priority for prevention vs treatment); and clinical factors (misunderstood side effects, fear PrEP won't work). Significant barriers to PrEP use among YBMSM stem from structural, social, behavioral, and clinical factors. These results will inform intervention efforts tailored to mitigate barriers and improve PrEP uptake among YBMSM in the southern United States.

HIV Prevention and Treatment Interventions for Black Men Who Have Sex With Men in Canada: Scoping Systematic Review

BACKGROUND

Black men who have sex with men (MSM) experience disproportionately high HIV incidence globally. A comprehensive, intersectional approach (race, gender, and sexuality or sexual behavior) in understanding the experiences of Black MSM in Canada along the HIV prevention and care continuums has yet to be explored.

OBJECTIVE

This scoping review aims to examine the available evidence on the access, quality, gaps, facilitators, and barriers of engagement and identify interventions relevant to the HIV prevention and care continuum for Black MSM in Canada.

METHODS

We conducted a systematic database search, in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist, of the available studies on HIV health experience and epidemiology concerning Black MSM living with or without HIV in Canada and were published after 1983 in either English or French. Searched databases include MEDLINE, Excerpta, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, the NHUS Economic Development Database, Global Health, PsycInfo, PubMed, Scopus, and Web of Science. From the 3095 articles identified, 19 met the inclusion criteria and were analyzed.

RESULTS

Black MSM in Canada consistently report multiple forms of stigma and lack of community support contributing to an increased HIV burden. They experience discrimination based on their intersectional identities while accessing HIV preventative and treatment interventions. Available data demonstrate that Black MSM have higher HIV incidences than Black men who have sex with women (MSW) and White MSM, and low preexposure prophylaxis knowledge and HIV literacy. Black MSM experience significant disparities in HIV prevention and care knowledge, access, and use. Structural barriers, including anti-Black racism, homophobia, and xenophobia, are responsible for gaps in HIV prevention and care continuums, poor quality of care and linkage to HIV services, as well as a higher incidence of HIV.

CONCLUSIONS

Considering the lack of targeted interventions, there is a clear need for interventions that reduce HIV diagnoses among Black MSM, increase access and reduce structural barriers that significantly affect the ability of Black MSM to engage with HIV prevention and care, and address provider's capacity for care and the structural barriers. These findings can inform future interventions, programming, and tools that may alleviate this HIV inequity.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-043055.

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.

Attitudes Toward and Experiences With Discussing Pre-exposure Prophylaxis With Sexual Partners Among US Adolescents and Young Adults Living With HIV

PURPOSE

Sexual partners of youth living with HIV are a key population for pre-exposure prophylaxis (PrEP). Among youth engaged in HIV medical care, we examined awareness of PrEP and experiences with and attitudes toward discussing PrEP with sexual partners.

METHODS

We recruited 25 15-24-year olds from an adolescent/young adult HIV clinic to complete individual interviews. Interviews assessed demographics, PrEP knowledge, sexual behaviors, and experiences with, intentions toward, barriers, and facilitating factors to discussing PrEP with partners. Transcripts were analyzed using framework analysis.

RESULTS

Mean age was 18.2 years. Twelve participants were cis-female, 11 cis-male, and two transgender female. Seventeen participants (68%) identified as Black, non-Hispanic. Nineteen acquired HIV sexually. Of 22 participants who had ever had sex, eight reported condomless sex in the prior 6 months. Most youth (17/25) were aware of PrEP. Only 11 participants had discussed PrEP with a partner; 16 reported high intention to discuss PrEP with future partners. Barriers to discussing PrEP with partners included participant-related barriers (i.e., discomfort disclosing HIV status), partner-related barriers (i.e., not open to or unfamiliar with PrEP), relationship-related barriers (i.e., new relationship, lack of trust), and stigma about HIV. Facilitating factors included positive relationship factors, educating partners about PrEP, and partners being receptive to learning about PrEP.

DISCUSSION

Although many youth living with HIV were aware of PrEP, fewer had discussed PrEP with a partner. PrEP use by partners of these youth may be improved by educating all youth about PrEP and offering opportunities for partners to meet with clinicians to discuss PrEP.

'There are people like me who will see that, and it will just wash over them': Black sexual minority men's perspectives on messaging in PrEP visual advertisements

The high incidence of HIV among US Black sexual minority men is a public health crisis that pre-exposure prophylaxis (PrEP) for HIV can help address. Public health campaigns, which often include pictures of Black sexual minority men alongside PrEP-related messaging, have been developed to encourage PrEP awareness and uptake. However, the acceptability of the messaging within these campaigns among Black sexual minority men is unclear. We conducted four focus groups with 18 HIV-negative Black sexual minority men in Washington, DC to explore their perspectives regarding promotional messaging (textual elements) in PrEP visual advertisements, including their reactions to three large-scale public health campaigns. Primary themes included: (1) the need for additional information about PrEP, (2) preference for slogan simplicity, (3) the desire to normalise PrEP use, and (4) mixed views on the inclusion of condoms. Results indicated that the messaging in current PrEP visual advertisements may not sufficiently address Black sexual minority men's questions about PrEP. Providing basic PrEP information and methods to access more information; using simple, unambiguous language; presenting PrEP use in a destigmatising, normalising fashion; and conveying the relevance of condoms if included in the advertisement could help increase the acceptability of future PrEP advertising among Black sexual minority men.

The Association of Depression, Social Determinants and PrEP Uptake Among Black Sexual Minority Men in the Deep South

Despite its known efficacy in reducing HIV acquisition, pre-exposure prophylaxis (PrEP) uptake and utilization remains alarmingly low among key populations, including Black sexual minority men (SMM). Additionally, research has shown that SMM are at elevated risk of adverse mental health outcomes, including depression, anxiety, illegal drug use, and suicidality. However, there is limited data examining the impact of depression on PrEP uptake among Black SMM. This study analyzes survey data obtained from the ViiV ACCELERATE! Initiative between January 2016 and September 2017 to examine the association between depressive symptoms and uptake of PrEP among a sample of HIV-negative Black SMM ages 18-65 years (N=170) residing in Mississippi, the poorest state in the USA. We found that PrEP-eligible Black SMM reporting depressive symptoms were 60% less likely to take PrEP (aOR = 0.40, CI: 0.18-0.74, p = 0.05). Similarly, PrEP-eligible men lacking health insurance were 63% less likely to start PrEP (aOR = 0.37; CI: 0.17-0.94; p = 0.035). Given the low uptake of PrEP among Black SMM, there is an urgent need for the development and implementation of combination HIV prevention interventions that incorporate access to mental health services among this highly stigmatized and marginalized population.

Novel Latent Profile Analysis of a Test of Concept, Stigma Intervention to Increase PrEP Uptake Among Black Sexual Minority Men

BACKGROUND

Pre-exposure prophylaxis (PrEP) has demonstrated efficacy for HIV prevention, yet uptake of PrEP among populations in urgent need of prevention tools (eg, Black sexual minority men) is limited, and stigma and medical mistrust remain strong barriers to accessing PrEP.

PURPOSE

To evaluate a test of concept brief intervention to address stigma and medical mistrust as barriers to PrEP uptake using novel latent profile analysis.

METHODS

Participants (N = 177) residing in the southeastern US were randomized to 1 of 4 arms to establish the potential impact of a brief, stigma focused counseling intervention (referred to as Jumpstart ) to increase PrEP uptake. We estimated intervention effect size (Cramer's V) for PrEP uptake and then explored differential intervention effects across latent profiles of psychosocial barriers to PrEP use.

RESULTS

The intervention resulted in small, but meaningful effect size, with self-reported PrEP uptake increasing across Jumpstart conditions with the control condition reporting 24% uptake and Jumpstart plus text/phone calls (the most intensive intervention arm) reporting 37% uptake, and a similar pattern emerging for biologically confirmed PrEP use. Among participants 30 and older, Jumpstart participants were more likely to move to a postintervention profile with fewer barriers than control participants and reported the highest uptake of PrEP.

CONCLUSIONS

Addressing social/emotional barriers to PrEP uptake is an essential component of bridging the gap between advances being made in biomedical forms of HIV prevention, and establishing and supporting access to those advances.

Targeted social marketing of PrEP and the stigmatization of black sexual minority men

Disparities in HIV incidence and PrEP uptake suggest a need to prioritize Black sexual minority men (SMM) in PrEP social marketing initiatives. However, images linking Black SMM to HIV and PrEP may inadvertently reinforce stigma. We examined HIV-negative/status-unknown Black SMM's responses to targeted PrEP advertisements using mixed methods, including an experiment embedded in a longitudinal online survey (Time 1: n = 96; Time 2 [eight weeks]: n = 73) and four focus groups (n = 18). The full factorial experiment included between-groups and within-subjects comparisons. For between-groups comparisons, each participant was randomly assigned to view one of 12 advertisements, which varied by couple composition (Black SMM couple/Black heterosexual couple/multiple diverse couples/no couples) and campaign (PrEPare for the Possibilities/PlaySure/PrEP4Love). We examined couple composition, campaign, and interaction effects on: advertisement judgments (Time 1), PrEP stigma (Time 1), PrEP motivation (Times 1 and 2), and PrEP behavior (Time 2). For within-subjects comparisons, each participant viewed all 12 advertisements, and we examined couple composition, campaign, and interaction effects on advertisement judgments (Time 2). Focus group participants discussed advertising preferences and responded to the same set of advertisements. For between-groups and within-subjects comparisons, we found significant couple composition effects but no or limited campaign and interaction effects on advertisement judgments. Advertisements featuring Black SMM exclusively were judged as more stigmatizing than advertisements without couples. Advertisements with diverse (vs. no) couples were considered more eye-catching and motivating. There were minimal effects of couple composition and campaign on PrEP stigma, motivation, and behavior. Focus group participants corroborated concerns about the potential for PrEP advertisements to be stigmatizing, suggesting advertisements featuring Black SMM exclusively could be alienating and fuel conspiracy theories. Focus group participants generally favored diverse and less sexualized advertisements, particularly for public spaces. Findings collectively highlight the potential for targeted PrEP advertisements to stigmatize Black SMM and support diverse representation.

A Principal Investigator as a PrEP-Using Peer Change Agent for HIV Prevention among Black Gay and Bisexual Men: An Autoethnography

HIV pre-exposure prophylaxis (PrEP) use remains suboptimal among Black gay and bisexual men (GBM). Multilevel factors such as medication costs, intersectional stigma, patient-clinician communication, medical mistrust, side effect concerns, and low perceived HIV risk (PHR) are well-established PrEP initiation barriers for this group. Peer change agents (PCAs) are culturally congruent interventionists who can circumvent multilevel PrEP barriers among Black GBM. I led an intervention as a PrEP-using PCA to improve PHR and PrEP willingness among 69 Black GBM from 2019-2022 and conducted an autoethnography to better understand multilevel barriers and identify the personal/professional challenges of being an in-group HIV interventionist serving Black SMM. Findings provide novel perspectives regarding PrEP barriers, the role of cultural homophily in behavior change interventions, and how interpersonal dynamics can impact staff fatigue, protocol fidelity, and research participation. Recommendations to prepare and support culturally congruent research staff are also provided.

Desires for Individual- and Interpersonal-Level Patient Portal Use for HIV Prevention Among Urban Sexual Minority Men: Cross-sectional Study

BACKGROUND

Gay, bisexual, and other sexual minority men have expressed the acceptability of patient portals as tools for supporting HIV prevention behaviors, including facilitating disclosure of HIV and other sexually transmitted infection (STI/HIV) laboratory test results to sex partners. However, these studies, in which Black or African American sexual minority men were undersampled, failed to determine the relationship of reported history of discussing HIV results with sex partners and anticipated willingness to disclose web-based STI/HIV test results using a patient portal.

OBJECTIVE

Among a sample of predominantly Black sexual minority men, this study aimed to (1) determine preferences for patient portal use for HIV prevention and (2) test the associations between reported history of discussing HIV results and anticipated willingness to disclose web-based STI/HIV test results with most recent main and nonmain partners using patient portals.

METHODS

Data come from audio-computer self-assisted interview survey data collected during the 3-month visit of a longitudinal cohort study. Univariate analysis assessed patient portal preferences by measuring the valuation rankings of several portal features. Multiple Poisson regression models with robust error variance determined the associations between history of discussing HIV results and willingness to disclose those results using web-based portals by partner type, and to examine criterion validity of the enhancing dyadic communication (EDC) scale to anticipated willingness.

RESULTS

Of the 245 participants, 71% (n=174) were Black and 22% (n=53) were White. Most participants indicated a willingness to share web-based STI/HIV test results with their most recent main partner. Slightly fewer, nonetheless a majority, indicated a willingness to share web-based test results with their most recent nonmain partner. All but 2 patient portal features were valued as high or moderately high priority by >80% of participants. Specifically, tools to help manage HIV (n=183, 75%) and information about pre- and postexposure prophylaxis (both 71%, n=173 and n=175, respectively) were the top-valuated features to include in patient portals for HIV prevention. Discussing HIV test results was significantly associated with increased prevalence of willingness to disclose web-based test results with main (adjusted prevalence ratio [aPR] 1.46, 95% CI 1.21-1.75) and nonmain partners (aPR 1.54, 95% CI 1.23-1.93).

CONCLUSIONS

Our findings indicate what features Black sexual minority men envision may be included in the patient portal's design to optimize HIV prevention, further supporting the criterion validity of the EDC scale. Efforts should be made to support Black sexual minority men's willingness to disclose STI/HIV testing history and status with partners overall as it is associated significantly with a willingness to disclose testing results digitally via patient portals. Future studies should consider discussion behaviors regarding past HIV test results with partners when tailoring interventions that leverage patient portals in disclosure events.

Uptake and Acceptability of MyChoices: Results of a Pilot RCT of a Mobile App Designed to Increase HIV Testing and PrEP Uptake Among Young American MSM

Young men who have sex with men (YMSM) remain at disproportionate risk for HIV acquisition in the United States (US), yet use of evidence-based prevention strategies, including routine HIV testing and pre-exposure prophylaxis (PrEP), remain low. Smartphones and mobile app usage are nearly ubiquitous in this population. Given the potential for scalability, a mobile app to increase HIV testing and PrEP use among YMSM has the potential to make an extraordinary public health impact if efficacious. Based on extensive formative, community-engaged research, we developed a theory-driven mobile app-MyChoices-to increase HIV testing and PrEP uptake among YMSM. In a pilot randomized controlled trial (RCT), participants (n = 60) were randomized 2:1 to receive MyChoices or standard of care (SOC). Data from 3 to 6-month post-baseline assessments demonstrate that the app was highly acceptable (System Usability Score; mean = 75.8, SD = 10.7) and feasible (94% used the MyChoices app at least once; mean = 15.3 sessions, SD = 9.8). While not powered to assess efficacy, those in the MyChoices arm had 22% higher prevalence of HIV testing over follow-up compared to those in the SOC arm (NS). There was no difference in PrEP uptake. A fully-powered efficacy trial is warranted; if efficacy is demonstrated, the MyChoices app could be easily scaled to reach YMSM across the US.

Development of an HIV Prevention Intervention for African American Young Men Who Have Sex With Men (Y2Prevent): Study Protocol

BACKGROUND

African American young men who have sex with men (YMSM) possess many intersecting identities that may increase their vulnerability to social stigmatization and discrimination, which yields a negative influence on their well-being and behaviors. These experiences often manifest as increased general and sexual risk-taking behaviors that place this particular group at an increased risk for HIV. This scenario is exacerbated by the lack of HIV prevention interventions specifically designed for African American YMSM.

OBJECTIVE

In this paper, we discuss the development of research designed to refine, pilot, and evaluate the feasibility, acceptability, and preliminary efficacy of a behavioral intervention designed to build resilience and reduce substance use and HIV risk behaviors among African American YMSM. The overarching aim of this research, funded by the National Institutes of Health, is to further refine and pilot test an intervention called Young Men's Adult Identity Monitoring (YM-AIM). YM-AIM is a theory-driven, group-level intervention designed to help African American YMSM develop a healthy vision for their future (or possible future self) by defining a set of short-term and long-term goals in the areas of education, health, family, and intimate relationships.

METHODS

Through partnerships with community members and community-based organizations, we will further strengthen and refine YM-AIM to include 3 new components: biomedical HIV prevention strategies (pre-exposure prophylaxis and postexposure prophylaxis); HIV and sexually transmitted infection (STI) testing and HIV care referral, drug screening, and drug treatment referral; and a youth mentoring component. We will recruit African American YMSM, aged 18 to 24 years, into 2 working groups; each group will consist of 6 to 8 members and will convene on a weekly basis, and each meeting will focus on one specific YM-AIM topic. This feedback will be used to further refine the intervention, which will then be evaluated for its feasibility and acceptability. Intervention outcomes include drug use in the past 30 days and 3 months, alcohol use, condomless sex, number of sex partners, and increasing condom use intention, condom use self-efficacy, HIV and STI testing recency and frequency, and linkage to care.

RESULTS

As of June 2022, we completed phase 1 of Y2Prevent and launched phase 2 of Y2Prevent to begin recruitment for working group participants. Phase 3 of Y2Prevent is anticipated to be launched in September and is expected to be completed by the end of this project period in December 2022.

CONCLUSIONS

Few youth-focused interventions have sought to help youth identify and develop the skills needed to navigate the social and structural factors that contribute to individual-level engagement in prevention among sexual minority youth. This research seeks to promote young men's adoption and maintenance of HIV-protective behaviors (eg, safer sex, pre-exposure prophylaxis use, HIV and STI testing, and health care use).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36718.

Implementing PrEP Services in Diverse Health Care Settings

BACKGROUND

Uptake of pre-exposure prophylaxis (PrEP) in the US has been limited. Evidence for why and how PrEP has been successfully integrated into some clinical settings, but not in others is minimal. To address this gap, we conducted a qualitative study to identify contextual factors that facilitated and challenged the implementation of PrEP services.

SETTING

In partnership with the NYC Department of Health, we convened a planning committee with expertise with groups highly affected by the HIV epidemic employed in diverse health care settings, to guide the project. Representatives from programs within New York were targeted for participation initially and subsequently expanded nationally to enhance diversity in program type.

METHODS

Using an interview guide informed by the Consolidated Framework for Implementation Research, we conducted 20 interviews with participants who successfully implemented PrEP programs in different settings (eg, primary care, emergency department, sexual health clinics), using different delivery models. We used template and matrix analysis to identify and characterize contextual determinants and implementation strategies.

RESULTS

Participants frequently described determinants and strategies fluidly and conceptualized them in context-specific terms. Commonly discussed Consolidated Framework for Implementation Research constructs included implementation climate (tension for change, compatibility, relatively priority), stakeholders' knowledge (or lack thereof) and beliefs about PrEP, and costs associated with PrEP implementation.

CONCLUSION

Our work identifies patterns in PrEP program implementation, describing how organizations dealt with determinants in their own context. Our research points to the need to connect rigorous implementation research with how frontline implementers conceptualize their work to inform and improve PrEP implementation.

Identification of Determinants and Implementation Strategies to Increase PrEP Uptake Among Black Same Gender-Loving Men in Mecklenburg County, North Carolina: The PrEP-MECK Study

BACKGROUND

Pre-exposure prophylaxis (PrEP) use is low among Black same gender-loving men (BSGLM) in Mecklenburg County, NC, an Ending the HIV Epidemic priority jurisdiction. We created PrEP-MECK-an investigator partnership among a community-based organization representative, a PrEP provider, and researchers-and conducted iterative preparation research to identify determinants of PrEP uptake and implementation strategies to address them.

METHODS

We first established the PrEP-MECK Coalition of community stakeholders. Next, informed by PrEP-MECK Coalition input and PRECEDE-PROCEED's educational/ecological assessment phase, we conducted focus group discussions with BSGLM not using PrEP and in-depth interviews with BSGLM who were currently or had previously taken PrEP to describe determinants and suggest implementation strategies. Based on interim findings, we partnered with clinics participating in the Mecklenburg County PrEP Initiative, which offers free PrEP services to uninsured individuals. We also conducted Consolidated Framework for Implementation Research-informed organizational assessments with community-based organizations and clinics to assess readiness to pilot the implementation strategies.

RESULTS

We conducted 4 focus group discussions, 17 in-depth interviews, and 6 assessments. BSGLM were aware of PrEP yet perceived that costs made it unattainable. Awareness of how to access PrEP and the Mecklenburg County PrEP Initiative was lacking, and clinic scheduling barriers and provider mistrust limited access. We identified client-level implementation strategies, primarily focusing on engaging the consumer, to increase comfort with and awareness of how to access PrEP, and clinic-level implementation strategies focusing on changing clinic infrastructure, to make PrEP access easier.

CONCLUSION

We plan to evaluate implementation of these strategies once fully developed to determine their acceptability and other outcomes in future research.

A Pilot Study of a Patient Navigation Intervention to Improve HIV Pre-exposure Prophylaxis Persistence Among Black/African American Men Who Have Sex With Men

BACKGROUND

Suboptimal HIV pre-exposure prophylaxis (PrEP) care outcomes among Black/African American men who have sex with men (MSM) limits its population-level effects on HIV incidence. We conducted a pilot study of a brief patient navigation intervention aimed at improving PrEP initiation and persistence among Black/African American MSM in the Southern United States.

SETTING

Community health center in Jackson, MS.

METHODS

We recruited 60 Black/African American MSM aged 18-34 years who were newly prescribed PrEP. Participants were randomized to receive the clinic's current standard of care or an intervention condition including a single patient navigation session to discuss and address perceived barriers to initiating and maintaining access to PrEP and biweekly check-ins. Participants were followed over 6 months using survey assessments, medical chart review, and pharmacy purchase records to ascertain PrEP initiation and persistence.

RESULTS

Participants in the intervention condition were more likely to pick up their initial PrEP prescription [RR: 1.47; 95% confidence interval (CI): 1.10 to 1.97], be retained in PrEP care at 3 months (RR: 1.62; 95% CI: 1.01 to 2.59) and 6 months (RR: 1.38; 95% CI: 0.64 to 2.93), and have access to PrEP medications greater than 80% of all study days based on pharmacy fill records (RR: 3.00; 95% CI: 1.50 to 5.98).

CONCLUSION

A brief patient navigation intervention demonstrated proof-of-concept in improving PrEP initiation and persistence among Black/African American MSM in the Southern United States.

"Let's Be a Person to Person and Have a Genuine Conversation": Comparing Perspectives on PrEP and Sexual Health Communication Between Black Sexual Minority Men and Healthcare Providers

Patient-provider communication is a key factor affecting HIV pre-exposure prophylaxis (PrEP) awareness and access among Black sexual minority men (SMM). Optimizing patient-provider communication requires a deeper understanding of communication dynamics. In this study, we investigated the perspectives of both HIV-negative/status-unknown Black SMM and practicing community healthcare providers regarding patient-provider communication about PrEP and sexual health. We conducted eleven semi-structured qualitative focus groups (six with Black SMM; five with providers) in the Northeastern USA and thematically analyzed transcripts. A total of 36 Black SMM and 27 providers participated in the focus groups. Our analysis revealed points of alignment and divergence in the two groups' perspectives related to patient-provider communication. Points of alignment included: (1) the importance ascribed to maximizing patients' comfort and (2) belief in patients' right to non-discriminatory healthcare. Points of divergence included: (1) Black SMM's preference for sexual privacy versus providers' preference that patients share sexual information, (2) Black SMM's perception that providers have an ethical responsibility to initiate conversations about PrEP with patients versus providers' perception of such conversations as being optional, and (3) Black SMM's preference for personalized sexual health conversations versus providers' preference for standardized conversations. Findings underscore a need for providers to offer more patient-centered sexual healthcare to Black SMM, which should entail routinely presenting all prevention options available-including PrEP-and inviting open dialogue about sex, while also respecting patients' preferences for privacy about their sexuality. This approach could increase PrEP access and improve equity in the US healthcare system.

Intersectional Stigma and Prevention Among Gay, Bisexual, and Same Gender-Loving Men in New York City, 2020: System Dynamics Models

Objectives. To create causal loop diagrams that characterize intersectional stigma experiences among Black, gay, bisexual, same gender-loving, and other men who have sex with men and to identify intervention targets to reduce stigma and increase testing and prevention access. Methods. Between January and July 2020, we conducted focus groups and in-depth interviews with 80 expert informants in New York City, which were transcribed, coded, and analyzed. These qualitative insights were developed iteratively, visualized, and validated in a causal loop diagram (CLD) using Vensim software. Results. The CLD revealed 3 key feedback loops-medical mistrust and HIV transmission, serosorting and marginalization of Black and gay individuals, and family support and internalized homophobia-that contribute to intersectional HIV and related stigmas, homophobia, and systemic racism. On the basis of these results, we designed 2 novel intervention components to integrate into an existing community-level anti-HIV stigma and homophobia intervention. Conclusions. HIV stigma, systemic racism, and homophobia work via feedback loops to reduce access to and uptake of HIV testing, prevention, and treatment. Public Health Implications. The CLD method yielded unique insights into reciprocal feedback structures that, if broken, could interrupt stigmatization and discrimination cycles that impede testing and prevention uptake. (Am J Public Health. 2022;112(S4):S444-S451. https://doi.org/10.2105/AJPH.2022.306725).

PrEParing for NextGen: Cognitive Interviews to Improve Next Generation PrEP Modality Descriptions for Young Men Who have Sex with Men

Next generation PrEP formulations may circumvent factors that impede daily oral pre-exposure prophylaxis (PrEP) use among young men who have sex with men (YMSM). We conducted video-based cognitive interviews with 20 YMSM (age 16-24) recruited in the US Northeast to assess participants' attitudes and comprehension of written descriptions of next generation PrEP modalities. Participants were predominately racial/ethnic minorities and half used daily oral PrEP. We identified four main areas for improvement of descriptions: defining scientific terms and balancing medical jargon and casual language; referencing more established products to contextualize PrEP formulations (e.g., hormonal implants); ensuring clarity and reducing redundancy; and including imagery (e.g., rectal douche applicator). The refined descriptions serve as exemplar text that may be used in future studies examining YMSM's preferences across next generation PrEP modalities. Accurate descriptions of next generation PrEP products strengthen measurement accuracy and can help roll-out products that become approved for clinical use.

Participatory Design of a Web-Based HIV Oral Self-Testing Infographic Experiment (HOTIE) for Emerging Adult Sexual Minority Men of Color: A Mixed Methods Randomized Control Trial

Health communication is a key health promotion approach for translating research findings into actionable information. The purpose of this study was to use participatory design to create and then test the usability and comprehension of an HIV self-testing infographic in a sample of 322 emerging adult, sexual minority men of color. Our study objectives addressed three challenges to HIV self-testing: (1) correct usage of the test stick, (2) understanding the number of minutes to wait before reading the result, and (3) how to correctly interpret a negative or a positive HIV result. This study was a two-phase, sequential, mixed methods, pilot, online, randomized controlled trial. Results suggested a significant mean difference between the control and intervention groups on HIV self-testing knowledge, with the control group outperforming the intervention group. However, two-thirds or better of the participants in the intervention group were able to comprehend the three critical steps to HIV self-testing. This was a promising finding that has resulted in the authors' development of additional recommendations for using participatory design for visual aid development in HIV prevention research. Participatory design of an HIV self-testing infographic is a rigorous approach, as a health communication strategy, to address public health priorities.

Preference for using a variety of future HIV pre-exposure prophylaxis products among men who have sex with men in three US cities

BACKGROUND

Daily oral pre-exposure prophylaxis (PrEP) is available and recommended for men who have sex with men (MSM) at risk for HIV infection. Other HIV prevention products are being developed, including long-acting injectable (LAI) and event-based oral and topical formulations. Understanding preferences for potential products by MSM can help direct further development of prevention messaging.

METHODS

We present baseline data from HIV-negative participants enrolled in the US Mobile Messaging for Men (M-cubed) Study. Participants were asked their likelihood of and rank order preference for using daily oral PrEP and various potential prevention products (one- to -three-month injections, 2-1-1 sexual event oral dosing, anal or penile gel, or anal suppository), and their sociodemographic characteristics. Bivariate and multivariable logistics regression assessed demographic associations with likelihood of use and rank order preference.

RESULTS

Overall, most MSM reported a likelihood of using LAI (74%), sexual event-based pills (67%) and penile gel (64%). Men who reported recent unprotected (condomless and PrEPless) anal sex most preferred a penile gel formulation (74%), followed closely by LAI and event-based pills (73% each). Current PrEP users (vs. non-users) had greater odds of reporting likelihood to use LAI (AOR = 3.29, 95% CI = 2.12 to 5.11), whereas men reporting recent unprotected anal sex had a greater odds of likelihood to use a penile gel (AOR = 1.79, 95% CI = 1.27 to 2.52) and an anal suppository (AOR = 1.48, 95% CI = 1.08 to 2.02). Hispanic/Latino (vs. White) MSM (AOR = 2.29, 95% CI = 1.40 to 3.73) and, marginally, Black MSM (AOR = 1.54, 95% CI = 1.00 to 2.38) had greater odds of reporting likelihood to use penile gel. Similar patterns were found for rank ordering preference of products, including condoms.

CONCLUSIONS

Most MSM were interested in using various potential future HIV prevention products, especially LAI. However, two typologies of potential users emerged: men who prefer sexual event-based methods (condoms, event-based pill, sexual gels and suppositories) and men who prefer non-sexual event-based methods (daily pill, LAI). Men who reported recent unprotected anal sex preferred a penile gel product most, followed closely by sexual event-based pills and LAI. Racial/ethnic differences were noted as well. These findings on product preferences can help in formulation development and messaging.

Reasons Why Young Men Who Have Sex with Men Report Not Using HIV Pre-Exposure Prophylaxis: Perceptions of Burden, Need, and Safety

Uptake of pre-exposure prophylaxis (PrEP) has dramatically increased but remains well below the estimated number of individuals who could benefit from PrEP in the United States, and uptake remains limited among young men who have sex with men (YMSM) and MSM of color. Reasons for not adopting PrEP as a prevention strategy among those at elevated risk for HIV is an important area of inquiry that could advise efforts to better position PrEP as an active part of prevention programs. As part of a mixed methods study investigating experiences with repeat HIV testing, we identified main themes emerging from in-depth interview data pertaining to reasons why YMSM report not using PrEP, among YMSM with frequent access to HIV testing services. Themes from 14 in-depth interviews with predominantly Latino MSM for not using PrEP included perceived burden of daily dosing, feeling that risk was not high enough to warrant PrEP, and beliefs that PrEP would have severe adverse events affecting the kidneys and bones. Less prominent but noteworthy themes included stigma as a PrEP user, social or provider influence on decisions not to use PrEP, and preference for current prevention strategy. No differences in PrEP discourse were noted across those at different levels of HIV risk. Results suggest that efforts are needed to engage communities and individuals around PrEP-related education, facilitate risk evaluation, and reduce PrEP stigma. New formulations and nondaily regimens may also be of particular interest to YMSM who may perceive daily PrEP regimens as highly burdensome.