Transition of Individuals With Autism to Adulthood: A Review of Qualitative Studies

Many young adults with autism spectrum disorder experience poor transition outcomes in key areas, including postsecondary employment, higher education, health care, social connectedness, and independent living, yet we lack a clear understanding of the specific factors that impact these outcomes. We reviewed qualitative research in which the perspectives of youth and young adults with autism spectrum disorder, parents, services providers, and other stakeholders were gathered to identify barriers and facilitators to optimal outcomes. Findings revealed that poor transition outcomes are influenced by several factors, including poor person-environment fit, uncertainty about the roles of parents, and the lack of comprehensive or integrated services. These findings also revealed the aspects of familial, organizational, and policy contexts that may be targeted for interventions. Finally, stakeholders emphasized that supports should be individualized and focused on the changing aspects of the young adult's social and physical environment rather than behavior change. We discuss implications for policy and practice and provide recommendations for further research.

Parents' and young adults' perspectives on transition outcomes for young adults with autism

Existing research shows that young adults with autism spectrum disorder have poorer outcomes than their peers with other developmental disabilities in the key areas of independent living, postsecondary education, and employment. However, we understand little about how young adults with autism and their families understand and value outcomes and whether these indicators match their goals and aspirations. We interviewed parents (n = 21) and young adults with autism spectrum disorder (n = 20) about their experiences with the transition to adulthood to understand what they consider to be desirable outcomes and how they seek to achieve them. Understanding these perspectives will help identify areas of need as well as disconnections between service objectives and the goals of young adults and their families. Participants described outcomes as more complex and nuanced than current conceptions and measures account for. They defined and evaluated outcomes in relation to their or their child's individual abilities, needs, and desires. These findings provide important insight into challenges to and facilitators of desired outcomes, which has implications for programming, service delivery, and policy.

Long-term retention in pre-exposure prophylaxis care among men who have sex with men and transgender women in the United States

INTRODUCTION

Retention in HIV pre-exposure prophylaxis (PrEP) care in real-world settings, outside of controlled trials or demonstration projects, remains poorly understood.

METHODS

We evaluated retention in PrEP care outcomes among men who have sex with men (MSM) and transgender women prescribed PrEP through March 2017 at three clinical sites in the United States (US): Jackson, Mississippi; Providence, Rhode Island; and St. Louis, Missouri. We determined retention rates by attendance of clinical visits every three months, per US Centers for Disease Control and Prevention (CDC) guidelines, as well as by the timing of patients' actual clinical visits. Multivariable analyses examined demographic and behavioural factors associated with retention.

RESULTS

From 2013 to 2015, 282 MSM and transgender women were prescribed PrEP; 82% attended a follow-up visit. Based on CDC recommendations, 56% of patients were retained in PrEP care at the first follow-up visit, having attended a visit three months after initiation. However, 76% had a follow-up visit within eight months. Thirty-percent were retained at 12 months by CDC criteria, but 62% were retained when using a 16-month endpoint. Self-reported adherence was strongly correlated with retention. In multivariable analyses, younger age was associated with decreased odds of retention at initial follow-up, and completing college was associated with increased odds of retention at 16 months. Eight participants were newly diagnosed with HIV; six were African American, and seven were under 30 years of age.

CONCLUSIONS

Measuring retention in PrEP care using three-month follow-up intervals may underestimate true retention. Nevertheless, retention in PrEP care is suboptimal in real-world settings and should be the focus of future interventions.

Setbacks and Successes: How Young Adults on the Autism Spectrum Seek Friendship

Objective

To describe the perspectives of young adults on the autism spectrum about how they seek and make friends and explore the diverse ways that some develop satisfying friendships despite social difficulties.

Methods

We conducted semistructured interviews with 20 young adults on the autism spectrum about their lives after high school. Although interviews covered a broad range of topics related to transition, the subject of friendship came up frequently throughout the interviews. We extracted data specifically related to friendship for this article and used an inductive approach derived from grounded theory to identify and examine concepts.

Results

Participants had the most success in relationships in which their atypical behavior was normalized. Specifically, this occurred among friends who accepted and appreciated their social differences and through common interests where these differences were not a concern. In other relationships, participants felt that they were expected to adhere to social norms, but found it uncomfortable and/or were not sure how to act in some contexts. Therefore, finding friends who did not expect this was a welcome relief. Participants who were socially isolated wanted more opportunities to meet other people, such as organized social groups, but were not sure how to access these.

Conclusion

Results suggest that friendship, although challenging, can be navigated successfully for some young adults on the autism spectrum. These findings have implications for supporting young adults in their efforts to make friends in ways that work best for them and for creating measures that more accurately reflect their perspectives and needs. Reframing the concept of friendship to include a wider array of experiences and perspectives, identifying successful strategies, and creating more accurate assessments could present a very different picture of friendship and contribute to better outcomes for this unique population.

Lay Summary

Background:: Young adults on the autism spectrum often have difficulty making friends due to challenges with social communication. Nevertheless, some do enjoy friendships with their peers. The purpose of this article is to describe friendship seeking from the perspectives of young adults on the autism spectrum and explore the diverse ways that some develop satisfying friendships despite social difficulties. This information can be used to support young adults in their efforts to make friends by identifying the approaches and strategies that work best for them.About This Study:: The information in this article comes from a study we conducted about the transition to adulthood for young adults. We interviewed 20 young adults about their life experiences in their late teens and 20s. Friendship was very important for most of them and they described their desires to have friends, their efforts to make friends, and the significant difficulties and frustrations they faced. They attributed these difficulties to being seen as different from others and too few opportunities to socialize. They had the most success by finding friends who accepted and appreciated their social differences. In these relationships, they did not have to worry about social norms the way they usually did. Several participants found it easier to relate to others on the spectrum and participated in organized social groups. Still others made friends around shared interests where their autism was not a primary concern. Overall, our interviews showed that young adults on the autism spectrum seek friends in a variety of ways.What This Information Tells Us:: Researchers and service providers often conclude that friendship for people on the autism spectrum is lacking when compared with their typically developing peers. However, the experiences of some young adults can tell a story of difference rather than deficit. From this and other studies, it is clear that people on the autism spectrum may perceive friendship differently, have different priorities or goals for friendship, and have different ways of seeking and experiencing friendship than their typical peers. If we broaden our ideas of friendship to be more inclusive, things might appear very differently. Even so, many young adults struggle to make friends. By understanding their experiences with friendship, identifying where they need help, and identifying strategies and approaches that might work best for them, we can better support their efforts.

Loss to Follow-Up and Re-Engagement in HIV Pre-Exposure Prophylaxis Care in the United States, 2013-2019

Retention in HIV pre-exposure prophylaxis (PrEP) care is critical for effective PrEP implementation. Few studies have reported long-term lost to follow-up (LTFU) and re-engagement in PrEP care in the United States. Medical record data for all cisgender patients presenting to the major Rhode Island PrEP clinic from 2013 to 2019 were included. LTFU was defined as no PrEP follow-up appointment within 98 days. Re-engagement in care was defined as individuals who were ever LTFU and later attended a follow-up appointment. Recurrent event survival analysis was performed to explore factors associated with PrEP retention over time. Of 654 PrEP patients, the median age was 31 years old [interquartile range (IQR): 25, 43]. The majority were male (96%), White (64%), non-Hispanic (82%), and insured (97%). Overall, 72% patients were ever LTFU and 27% of those ever LTFU re-engaged in care. Female patients were 1.37 times [crude hazard ratio (cHR): 1.37; 95% confidence interval (CI): 0.86-2.18] more likely to be LTFU than male patients, and a 1-year increase in age was associated with a 1% lower hazard of being LTFU (cHR: 0.99; CI: 0.98-0.99). Being either heterosexual (aHR: 2.25, 95% (CI): 1.70-2.99] or bisexual (aHR: 2.35, 95% CI: 1.15-4.82) was associated with a higher hazard of loss to follow-up compared with having same-sex partners only. The majority of PrEP users were LTFU, especially at the first 6 months of PrEP initiation. Although a significant number were re-engaged in care, targeted interventions are needed to improve retention in PrEP care. This study characterized the natural projection of loss to follow-up and re-engagement in HIV PrEP care using a longitudinal clinic cohort data and explored associated factors for guiding future interventions to improve retention in PrEP care.

Paying for PrEP: A qualitative study of cost factors that impact pre-exposure prophylaxis uptake in the US

BACKGROUND

Concerns about the actual and perceived costs of pre-exposure prophylaxis (PrEP) continue to be a major barrier to uptake among gay, bisexual and men who have sex with men (GBMSM) in the United States.

METHODS

We conducted semi-structured interviews with 25 GBMSM who presented for routine health care at a STD clinic in the northeastern United States. The cohort included GBMSM who were or were not currently taking PrEP and represented varied health care coverage and financial resources. We used a structured coding scheme to analyze transcripts and identify themes relevant to cost factors.

RESULTS

Participants shared their perspectives about PrEP and their experiences with accessing and paying for PrEP. Our findings suggest that health care coverage or financial assistance were essential to PrEP access but were not easily accessible to all people and did not always cover all costs. Therefore, paying for PrEP had to be balanced with other life expenses. Participants had multiple sources for information about PrEP cost and assistance from clinic and pharmacy staff helped reduce burden and resolve difficulties.

CONCLUSION

Addressing gaps in health care coverage, providing financial support, and improving the enrollment process in a financial assistance program may improve PrEP uptake.

Sex Workers and Syndemics: A Population Vulnerable to HIV and COVID-19

COVID-19 has disproportionately affected vulnerable populations across the U.S. Street-based sex workers are one vulnerable population whose health and impact of COVID-19 have been understudied to date. The goal of this study was to evaluate findings from a community needs assessment with street-based sex workers on impact of COVID-19 on health behaviors and social circumstances. A brief survey was developed at a community-based harm reduction and recovery services organization. Surveys were administered by peer specialists to street-based sex workers during street outreach in April and May 2020. A total of 46 surveys were analyzed. Many individuals reported continuing to do sex work and use substances during the COVID pandemic. Slightly more than a quarter of individuals (n = 13; 28.3%) indicated using personal protective equipment while doing sex work and described challenges to using precautions when working with clients. Individuals had used marijuana (n = 32, 71.1%), cocaine (n = 17, 39.5%), prescription stimulants (n = 9, 21.4%), methamphetamines (n = 5, 11.9%), prescription opioids (n = 12, 27.3%), street opioids (n = 12, 27.3%), sedatives (n = 11, 25.0%), hallucinogens (n = 3, 6.8%), inhalants (n = 3, 7.0%), or some other substance (n = 4, 8.7%) in the past 30 days. About half (48.8%) reported that COVID-19 had a major impact on their lives. This study is among the first to characterize the impact of COVID-19 on street-based sex workers. From a public health standpoint, this group also represents a high-priority population given their vulnerability and close contact with others, which increases the potential for community spread.

Benefits and Risks: A Systematic Review of Information and Communication Technology Use by Autistic People

Background

Communication via the internet is a regular feature of everyday interactions for most people, including autistic people. Researchers have investigated how autistic people use information and communication technology (ICT) since the early 2000s. However, no systematic review has been conducted to summarize findings.

Objective

This study aims to review existing evidence presented by studies about how autistic people use ICT to communicate and provide a framework for understanding contributions, gaps, and opportunities for this literature.

Methods

Guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses(PRISMA) statement, we conducted a comprehensive review across five databases, searching for studies investigating how autistic youth and adults use ICT to communicate. Authors reviewed the articles for inclusion and assessed methodological quality.

Results

Thirty-two studies met the eligibility criteria, including 19 quantitative studies, 12 qualitative studies, and 1 mixed methods study, with data from 3026 autistic youth (n = 9 studies) and adults (n = 23 studies). Ratings suggest that the evidence base is emergent. Underrepresented groups in the sample included autistic women, transgendered autistic people, non-White autistic people, low income autistic people, and minimally speaking and/or autistic adults with co-occurring intellectual disability. Three main themes emerged, including variation in ICT communication use among autistic youth and adults, benefits and drawbacks experienced during ICT communication use, and the engagement of autistic youth and adults in the online autism community.

Conclusions

Further exploration of the positive social capital that autistic people gain participating in online autism communities would allow for the development of strengths-based interventions. Additional research on how autistic people navigate sexuality and ICTs is needed to identify mechanisms for reducing vulnerability online. Additional scholarship about underrepresented groups is needed to investigate and confirm findings regarding ICT communication use for gender, racial, and socioeconomic minority groups.

Lay summary

What was the purpose of this study?: People use the internet to communicate (talk and connect) with one another. Some research has found that autistic people may prefer to communicate using the internet instead of in person. Over the past 20 years, there has been research about how autistic people use the internet. To understand what research has discovered so far, we collected published research about how autistic youth and adults use the internet to communicate.What did the researchers do?: We used scientific best practices as described in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to collect research about how autistic people us the internet to communicate. We included research that uses words (qualitative research) and numbers (quantitative research). First, we searched several places that list research studies to find research on autistic people and the internet. Then, we removed research that did not fit what we were looking for (our criteria). Finally, we then read the full articles, collected their most important findings, and looked for patterns.What do these findings add to what is already known?: Thirty-two studies met our criteria, including 19 studies that used closed-ended survey questions that tested relationships between variables, 12 studies that used open-ended interviews and looked for patterns and connections among participants, and 1 mixed methods study. In total, 3026 autistic youth of ages 10-17 years (number of participants = 9 studies) and adults (number of participants = 23 studies) participated in these 32 studies. We rated each of the 32 studies for quality and learned that the evidence base is preliminary, meaning that more rigorous high-quality studies are needed before we can be confident in the findings. We found three main themes: (1) differences in the ways that autistic youth and adults used the internet to communicate, (2) benefits and drawbacks experienced when using the internet to communicate, and (3) the engagement of autistic youth and adults in the online autism community. Some of the benefits of social media for autistic people include more control over how they talk and engage with others online and a greater sense of calm during interactions. However, findings suggest some drawbacks for autistic people, including continued feelings of loneliness and the desire for in-person friendships. Social media provides opportunities for autistic people to find others on the autism spectrum and form a stronger identity as part of the autism community. The study also showed that there is little research about autistic women, autistic transgender people, autistic racial/ethnic minorities, or autistic people from lower socioeconomic status (SES) groups.What are potential weaknesses of this study?: We only included research in scientific articles, and there may be useful information on this topic in books, student research, or online.How will these findings help young adults on the autism spectrum now or in the future?: This study can help identify gaps and opportunities for new research, support the importance of online autistic communities, and suggest possible training opportunities about how to support autistic people when they use the internet for communication.

Social Capital and Autism in Young Adulthood: Applying Social Network Methods to Measure the Social Capital of Autistic Young Adults

Social isolation is a core challenge associated with autism. Interpersonal relationships and the resources and support embedded in the social networks of autistic young adults could impact key adult outcomes, including quality of life, mental health, employment, and independence. However, little research systematically measures the networks of autistic young adults and network impact on key adult outcomes. This article demonstrates how social network analysis can be adapted for the field of autism to measure young adult networks. We provide examples as to how this approach could be implemented to yield key insights into the amount and quality of interpersonal relationships and the types of resources embedded in the networks of autistic young adults. The network protocol was feasibility tested with autistic adults during the posthigh school transition period (n = 17, 19–27 years). The parents of three of the recruited young adults also successfully completed a complementary network survey, allowing for the inclusion of the parent-reported network using duocentric network analysis, never before applied to parent–child networks. The implementation data collected from the study suggest feasibility of egocentric and duocentric approaches, with several important modifications to adapt the measure for the field of autism. The future potential of social network research for understanding autism in adulthood is discussed.

What was the purpose of this study?

Many autistic young adults are disconnected from people, communities, and organizations that could provide them with valuable social resources to support their transition to adulthood. This study tests the feasibility of using social network methods to measure the resources that autistic young adults gain from their social connections. Future studies using our social network measure might provide valuable information about possible interventions that could help autistic youth acquire the social resources needed for successful adult outcomes.

What did the researchers do?

To test the feasibility of our social network measure, 17 autistic adults, between the ages of 19 and 27 years, were recruited to complete a survey about their social connections and the resources provided to them by their social connections. The parents of three of the autistic adults were also surveyed to provide information about the social connections that they relied on to help their autistic young adult to transition successfully.

What were the results of the study?

All participants successfully completed our survey online. We analyzed the network data to illustrate what types of information the survey produced. We demonstrated how the survey captures different types of support that people gained from their networks. We also used network pictures to show how network measures characterize connections among supporters of autistic young adults. This research successfully lays the groundwork for future studies to test whether the social resources young adults on the autism spectrum receive from their networks impact their adult outcomes.

What do these findings add to what is already known?

We know very little about the social networks for young adults on the autism spectrum. Also, no studies have used duocentric network analysis to measure the social capital of youth and their parents together. This project produced new useful ways of collecting social network data from young autistic adults that will produce knowledge about how to help young adults on the autism spectrum build networks that will yield the social resources needed to support positive adult outcomes.

What are potential weaknesses of this study?

The study was only designed to test the feasibility of the social network measure and does not provide generalizable information about how networks might impact outcomes. Also, the social network measure only allowed participants to identify five people, possibly under-reporting the actual size and composition of autistic young adult networks.

How will these findings help young adults on the autism spectrum now or in the future?

If future research suggests that social network factors help young adults on the autism spectrum to improve outcomes, then network interventions, guided by social network data, can be created.

Defining the Pre-exposure Prophylaxis Care Continuum Among Recently Incarcerated Men at High Risk for HIV Infection: Protocol for a Prospective Cohort Study

BACKGROUND

HIV disproportionately impacts criminal justice-involved individuals, including men who experience incarceration. Men make up the vast majority of those experiencing incarceration as well as those newly diagnosed with HIV infection. Pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention that significantly reduces the risk of HIV acquisition. However, implementation in criminal justice systems is limited. Little is known about effective PrEP implementation and use in this unique public health context.

OBJECTIVE

The aim of this study is to characterize the experience of implementing PrEP clinical care in a criminal justice setting for men vulnerable to HIV acquisition.

METHODS

This article describes a PrEP care continuum for men experiencing incarceration who are at increased risk of HIV acquisition, which can help conceptualize approaches to evaluating PrEP implementation.

RESULTS

The outlined study will enroll 100 men experiencing incarceration at high risk for HIV acquisition prior to release into the community. The goal is to initiate PrEP prior to release and link individuals to PrEP providers in the community, capturing barriers and facilitators to PrEP use during this uniquely vulnerable time period for HIV acquisition.

CONCLUSIONS

Based on the proposed care continuum and what is known about HIV risk and prevention efforts in the criminal justice context, we outline key future research efforts to better understand effective approaches to preventing HIV infection among this vulnerable population. The described approach presents a powerful public health opportunity to help end the HIV epidemic.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/31928.

Long-term retention in pre-exposure prophylaxis care among men who have sex with men and transgender women in the United States

INTRODUCTION

Retention in HIV pre-exposure prophylaxis (PrEP) care in real-world settings, outside of controlled trials or demonstration projects, remains poorly understood.

METHODS

We evaluated retention in PrEP care outcomes among men who have sex with men (MSM) and transgender women prescribed PrEP through March 2017 at three clinical sites in the United States (US): Jackson, Mississippi; Providence, Rhode Island; and St. Louis, Missouri. We determined retention rates by attendance of clinical visits every three months, per US Centers for Disease Control and Prevention (CDC) guidelines, as well as by the timing of patients' actual clinical visits. Multivariable analyses examined demographic and behavioural factors associated with retention.

RESULTS

From 2013 to 2015, 282 MSM and transgender women were prescribed PrEP; 82% attended a follow-up visit. Based on CDC recommendations, 56% of patients were retained in PrEP care at the first follow-up visit, having attended a visit three months after initiation. However, 76% had a follow-up visit within eight months. Thirty-percent were retained at 12 months by CDC criteria, but 62% were retained when using a 16-month endpoint. Self-reported adherence was strongly correlated with retention. In multivariable analyses, younger age was associated with decreased odds of retention at initial follow-up, and completing college was associated with increased odds of retention at 16 months. Eight participants were newly diagnosed with HIV; six were African American, and seven were under 30 years of age.

CONCLUSIONS

Measuring retention in PrEP care using three-month follow-up intervals may underestimate true retention. Nevertheless, retention in PrEP care is suboptimal in real-world settings and should be the focus of future interventions.

1271. Pre-Exposure Prophylaxis (PrEP) Awareness and Uptake Between Men Who Have Sex with Men and Men Who Have Sex with Men and Women

Background

Men who have sex with men are disproportionately impacted by HIV in the United States and may benefit most from pre-exposure prophylaxis (PrEP). However, differences may exist between men who only have sex with men (MSM) and men who have sex with both men and women (MSMW). MSMW may experience more barriers to accessing PrEP and may act as a potential bridge population for transmitting HIV to female sex partners. Differences in PrEP awareness and use between MSM and MSMW are unknown.

Methods

We evaluated all MSM and MSMW presenting to the Rhode Island Sexually Transmitted Diseases (STD) clinic and PrEP clinic from 2013–2017. Demographics and behavioral information were reviewed. Bivariate analyses were performed to present distributions of demographic and behavioral characteristics by sexual behavior. Logistic regression was conducted to explore associations between PrEP awareness/use and sexual behavior. Confounding variables were identified using the directed acyclic graphs (DAGs) and a priori.

Results

Of 1,795 male individuals, 84% (1,504) were MSM, and 16% (291) were MSMW. The median age of our study population was 29 (interquartile range [IQR]: 23–42). When compared with MSM, MSMW were more likely to be non-White (33% vs. 28%), uninsured (54% vs.46%), self-report more sexual partners in the past 12 months (median 6 [IQR: 3–9]: vs. 4 [IQR:2–10]), use intranasal cocaine (21% vs. 12%), and engage in selling (6% vs. 2%) or buying sex (12% vs. 4%, all P < 0.05). MSMW were also less likely to have a previous HIV test (77% vs. 89%) compared with MSM. MSMW were 59% (adjusted odds ratio [aOR]: 041, 95% confidence interval [CI]: 0.31–0.55) less likely to be aware of PrEP and 17% (aOR: 0.83, 95% CI: 0.41–1.66) less likely to report ever using PrEP after adjusting for age, race/ethnicity, and self-reported HIV risk.

Conclusion

Despite engaging in higher risk behaviors, MSMW were significantly less likely to be aware of or use PrEP compared with MSM. Future PrEP interventions are needed to target this potentially high-risk bridge population.

Disclosures

All authors: No reported disclosures.

963. Extragenital Chlamydia and Gonorrhea Among Females Visiting an STD Clinic

Background

Rates of chlamydia (CT) and gonorrhea (GC) are increasing in the United States. Annual screening for urogenital infection is recommended for sexually active females less than 25 years and older females at risk. CT and GC can be detected at pharyngeal and rectal sites and are commonly asymptomatic. Currently, extragenital screening is only recommended in men who have sex with men (MSM). Data among females on extragenital CT and GC are limited.

Methods

We reviewed all females presenting to a sexually transmitted diseases (STD) clinic in Providence, Rhode Island from May 2014 to December 2018. During this time, urogenital, pharyngeal, and rectal screenings were offered to all females presenting for care. We evaluated demographics, behaviors, and laboratory data on urogenital, pharyngeal and rectal CT/GC. Univariate and bivariate analyses were performed to determine the characteristics of demographic and behavioral variables associated with extragenital infection.

Results

During the study period, 2,672 females presented for STD screening. Median age was 26 years (interquartile range [IQR]: 33–22). Most patients (95%) reported engaging in sex with male partners. More than half (59%) had at least one extragenital (pharyngeal or rectal) test performed (77% pharyngeal only, 0.4% rectal only, 23% both). During the study period, there were 334 CT and 66 GC infections identified across all three anatomical sites. Of individuals with a positive CT result (N = 273), 85% (N = 233) had a positive urogenital, 19% (N = 53) a positive pharyngeal, and 18% (N = 48) a positive rectal specimen. Of individuals with a positive GC result (N = 50), 62% (N = 31) had a positive urogenital, 54% (N = 27) a positive pharyngeal, and 16% (N = 8) a positive rectal specimen. Among individuals with a positive CT or GC result, (N = 315), 17% (N = 55) had an extragenital infection in the absence of a positive urogenital result. No single risk factor was statistically associated with an extragenital CT or GC infection. Most individuals (82%) were asymptomatic at presentation.

Conclusion

In an STD clinic setting, a significant number of pharyngeal and rectal CT/GC infections may be missed in the absence of extragenital screening. Settings which engage at-risk females should consider implementation of routine CT/GC extragenital screening.

Disclosures

All Authors: No reported Disclosures.

Factors associated with suboptimal retention in HIV pre-exposure prophylaxis care among men who have sex with men

Despite the efficacy of HIV pre-exposure prophylaxis (PrEP), retention in care in the United States remains suboptimal. The goal of this study was to explore factors that lead to suboptimal retention in PrEP care for men who have sex with men (MSM) in real-world clinical settings in the United States. Trained interviewers conducted semi-structured interviews with MSM (N = 49) from three clinics who had been engaged in PrEP care in the Midwest (n = 15), South (n = 15), and Northeast (n = 19) geographic regions and had experienced a lapse in PrEP use. Factors that emerged as related to suboptimal retention in PrEP care included structural factors such as transportation and out-of-pocket costs; social factors such as misinformation on media and in personal networks; clinical factors such as frequency and timing of appointments; and behavioral factors such as changes in sexual behavior and low perceived risk for HIV. Participants suggested reducing the out-of-pocket costs of medications and lab visits, having flexible appointment times, culturally responsive services, and comprehensive patient navigation to help retention in care. These findings leveraged real-world experiences and opinions of patients to inform gaps in current services and how to make changes to optimize PrEP care.

Perspectives on long-acting formulations of pre-exposure prophylaxis (PrEP) among men who have sex with men who are non-adherent to daily oral PrEP in the United States

INTRODUCTION

Pre-exposure prophylaxis (PrEP) persistence among men who have sex with men (MSM) in real world clinical settings for HIV prevention is suboptimal. New longer-acting formulations of PrEP are becoming available, including injectables, subdermal implants, and other oral medications. These longer-acting formulations have the potential to improve retention among those who have challenges remaining adherent to daily oral PrEP.

METHODS

We interviewed 49 MSM who had initiated but discontinued oral PrEP at three diverse clinics across the United States. We examined participants' perspectives about long-acting PrEP formulations and how long-acting options could affect PrEP use using thematic analysis.

RESULTS

Participants were not very knowledgeable about long-acting formulations of PrEP but were open to learning about them and considering use. Participants were concerned about safety and efficacy of products given that they were still newer and/or in development. Finally, participants had clear preferences for oral pills, injectables, and then subdermal implants and were most interested in options that reduced the number of visits to the clinic.

CONCLUSION

Long-acting formulations of PrEP are acceptable to MSM with suboptimal PrEP persistence and have the potential to improve PrEP persistence. However, many felt they needed more information on safety, efficacy, and use to consider these options. As these long-acting formulations are implemented, public health campaigns and clinical interventions to encourage may maximize uptake particularly among those who are not currently adherent to daily oral PrEP.

Facilitators for retaining men who have sex with men in pre-exposure prophylaxis care in real world clinic settings within the United States

BACKGROUND

Pre-exposure prophylaxis (PrEP) can significantly reduce HIV acquisition especially among communities with high HIV prevalence, including men who have sex with men (MSM). Much research has been finding suboptimal PrEP persistence; however, few studies examine factors that enhance PrEP persistence in real-world settings.

METHODS

We interviewed 33 patients who identified as MSM at three different PrEP clinics in three regions of the U.S. (Northeast, South, Midwest). Participants were eligible if they took PrEP and had been retained in care for a minimum of 6 months. Interviews explored social, structural, clinic-level and behavioral factors that influencing PrEP persistence.

RESULTS

Through thematic analysis we identified the following factors as promoting PrEP persistence: (1) navigation to reduce out-of-pocket costs of PrEP (structural), (2) social norms that support PrEP use (social), (3) access to LGBTQ + affirming medical providers (clinical), (4) medication as part of a daily routine (behavioral), and (5) facilitation of sexual health agency (belief).

DISCUSSION

In this sample, persistence in PrEP care was associated with structural and social supports as well as a high level of perceived internal control over protecting their health by taking PrEP. Patients might benefit from increased access, LGBTQ + affirming medical providers, and communications that emphasize PrEP can promote sexual health.

Perspectives of a peer-driven approach to improve pre-exposure prophylaxis and HIV prevention among Black/African American and Hispanic/Latino men who have sex with men

BACKGROUND

Black/African American (B/AA) and Hispanic/Latino (H/L) men who have sex with men (MSM) are significantly less likely than white MSM to initiate pre-exposure prophylaxis (PrEP). A peer-driven intervention (PDI) may be an effective approach to addressing this disparity. In this study, we explored community member perspectives of a PDI to promote PrEP uptake among B/AA and H/L MSM.

METHODS

We conducted semi-structured interviews with B/AA and H/L HIV-negative MSM between August 2018 and October 2019 in Rhode Island, USA. Participants reported their perspectives and recommendations for a PDI. Data from participant responses were thematically analysed.

RESULTS

Of 15 MSM, the median age was 25years (interquartile range: 22, 33). The majority identified as B/AA (53.3%), H/L (66.7%), and having a college education or above (53.3%). Most participants viewed a PDI positively and were willing to learn and promote PrEP among their peers. Participants identified and supported several potential intervention components, such as education about the benefit of PrEP, emphasising prevention-effective dosing, and clarifying no prevention effect towards other sexually transmitted infections. They preferred in-person meetings to electronic communication. Preferred characteristics of peer educators included compassion, good communication skills, and enthusiasm about PrEP.

CONCLUSIONS

This in-depth qualitative interview suggested that a PDI approach is promising in promoting PrEP uptake, as it could deliver culturally appropriate education and encourage PrEP uptake via peer influence among B/AA and H/L MSM.

Acceptability of HIV Prevention Approaches Among USA Faith-Based Leaders

HIV/AIDS disproportionately impacts underserved communities in the USA. This study evaluated the acceptability of partnering with faith communities to improve HIV prevention, screening, and engagement in care with a focus on Hispanic/Latinx (H/L) communities. We engaged faith-based leaders to identify how the cultural competence and foundations of trust within these communities may be leveraged to improve HIV-related healthcare access for underserved groups including H/L individuals. Using a semi-structured qualitative interview approach, we interviewed N = 20 faith-based leaders in Providence County, Rhode Island (RI). Data were analyzed using the framework approach which utilized inductive generation of themes and systematic grouping into predetermined categories. Seven of the 20 interviewees self-identified as H/L faith leaders and discussed needs specific to H/L communities including destigmatization of HIV, increased access to care, and partnerships founded on mutual respect. The other 13 faith leaders did not personally identify as H/L but all served communities with significant H/L populations. We included these individuals given their communities already performed HIV and/or other health outreach and could provide insight into what approaches could be adapted to the needs expressed by H/L leaders. All interviewees were accepting of developing partnerships with outside organizations to engage in HIV prevention, and all identified potential solutions to identified barriers. Results suggested that faith-based outreach should be further investigated as a method of improving HIV prevention in the general and H/L populations.

Characterizing substance use among men who have sex with men presenting to a sexually transmitted infection clinic

Illicit substance use poses a significant public health challenge in the United States. Certain populations are disproportionately impacted by substance use disorders. Men who have sex with men (MSM) have been shown to be three to four times more likely to report substance use compared to the general population. MSM also make up a disproportionate number of new cases of STIs. The impact of substance use disorders on STI and HIV infection risk has been well documented among this vulnerable population. Understanding the intersection of substance use and sexual risk is important to design effective interventions to reduce substance use and risk of STIs. However, little is known about the relationship between venues used to arrange sexual encounters including hook-up apps and substance use. This study describes the demographics and social network characteristics of MSM who presented to an STI clinic in Rhode Island including reported substance use and the primary hook-up venues used for meeting sexual partners. The results show that individuals using online venues to meet sexual partners were more likely to report substance use, indicating the possible utility of interventions using social media to address the unique vulnerability of STI and HIV infection for substance using MSM.