HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis

Although pre-exposure prophylaxis (PrEP) has been approved for primary HIV prevention for individuals aged 18 years or older since 2012, PrEP utilization has been suboptimal. To understand trends in PrEP provision from the health care providers' perspective, we systematically assessed each specific stage along the PrEP implementation cascade (i.e., awareness, willingness, consultation, and prescription) among health care professionals (HCPs) in the United States. Between June and December 2018, we conducted a systematic review of published studies on this topic. A total of 36 eligible studies were identified and included in the analyses. Random-effect models were employed to examine the pooled prevalence of each key stage along the cascade. Time trend and subgroup analyses were conducted. A thematic analysis was used to identify barriers and facilitators along the PrEP cascade. In this study, a total of 18,265 HCPs representing diverse demographics were included. The pooled prevalence of PrEP awareness was 68% [95% confidence interval (CI) = 55-80%], willingness to prescribe PrEP was 66% (95% CI = 54-77%), PrEP consultation was 37% (95% CI = 25-51%), and prescription provision was 24% (95% CI = 17-32%). Subgroup analyses revealed that PrEP provision among HCPs was lowest in the south, but has been improving annually nationwide. Infectious disease specialists [odds ratio (OR) = 4.06, 95% CI = 3.12-5.28; compared with primary care providers] and advanced practice registered nurses/physician assistants (OR = 1.51, 95% CI = 1.09-2.09; compared with physicians) had higher odds of prescribing PrEP. Barriers and facilitators regarding optimal PrEP implementation were embedded within individual, dyadic, social, and structural levels. This meta-analysis has comprehensively examined the trend and pattern of PrEP implementation among HCPs. To achieve optimal implementation of the PrEP cascade in the United States, tailored training and programs need to be provided to HCPs.

Examining the role of serostatus disclosure on unprotected sex among people living with HIV

Given the increasing prevalence of HIV, it is important to identify factors associated with safer sex behaviors between people living with HIV and their partners. Utilizing a diverse sample of 242 HIV-infected adults [n=69 men who have sex with men (MSM); n=68 men who have sex with women (MSW); n=105 women who have sex with men (WSM)], we examined the association between serostatus disclosure and unprotected anal or vaginal intercourse (UAVI) and the moderating effect of sexual behavior group on this association. Overall, 88.7% disclosed to their current partner. Approximately 18.8% of MSM, 17.7% of MSW, and 29.5% of WSM reported UAVI. Controlling for age, time since diagnosis, and partner serostatus, we found main effects on UAVI for disclosure and sexual behavior group; specifically, disclosure was inversely related to unprotected sex [AOR=0.09, 95% CI (0.02, 0.43), p<0.001], and MSM were less likely to engage in UAVI relative to WSM [AOR=0.11, 95% CI (0.17, 0.82), p<0.05]. However, the relationship between disclosure and UAVI was not moderated by sexual behavior group. Future strategies that aim to increase disclosure to partners may consider focusing on its value as a means by which to reduce sexual risk behavior.

HIV pre-exposure prophylaxis (PrEP) knowledge, familiarity, and attitudes among United States healthcare professional students: A cross-sectional study

The United States' initiative to End the HIV Epidemic by 2030 includes a primary goal to reduce new HIV infections by 90 percent. One key contributor to this plan is HIV pre-exposure prophylaxis (PrEP). While knowledge and acceptance of PrEP among clinicians is growing, few studies have assessed knowledge and awareness among future healthcare professionals in academic training programs. The present study aimed to assess and compare healthcare trainees' awareness, knowledge, and familiarity with PrEP prescribing guidelines to better understand and prevent gaps in academic training regarding PrEP. A cross-sectional web-based survey of medical, nurse practitioner, and pharmacy students enrolled at two universities was conducted between October 2017 and January 2018. The study assessed participants' awareness, knowledge, and familiarity with PrEP prescribing guidelines and willingness to prescribe PrEP and refer to another healthcare provider. The survey was completed by 744 participants (response rate = 36.2%). Overall, PrEP awareness was high though PrEP knowledge was low. There were significant differences among student groups in domains of interest. Pharmacy students had the greatest PrEP knowledge, awareness, and familiarity with prescribing guidelines. However, medical students reported the greatest comfort with performing PrEP-related clinical activities and willingness to refer a candidate to another provider. Study findings enhance our understanding of healthcare professional students' perspectives of PrEP as a biomedical prevention strategy for HIV. The gaps in students' knowledge offer opportunities for the development of educational strategies to support HIV prevention among future healthcare professionals.

Characterizing Racial Differences of Mental Health Burdens, Psychosocial Determinants, and Impacts on HIV Prevention Outcomes Among Young Men Who have Sex With Men: a Community-based Study in Two U.S. Cities

Few studies examine racial differences (e.g., Black vs. White) regarding the psychosocial pathways linking mental health burdens and various HIV-related outcomes among young men who have sex with men (MSM) in the U.S. We conducted a community-based study to examine the racial differences of mental health burdens (e.g., depression, anxiety, stress), the psychosocial determinants (e.g., HIV stigma, homonegativity, resilience, social support, loneliness, housing/food security) and impact on HIV-related outcomes (e.g., event-level alcohol/drug use before sex, condomless insertive/receptive anal sex, recent HIV testing, and PrEP awareness/willingness/use) among young Black MSM (YBMSM; n = 209) and young White MSM (YWMSM; n = 109) from two cities (Nashville, TN and Buffalo, NY) in the United States. Overall, we found YBMSM were more likely (p < 0.05) to experience anxiety and depression compared to YWMSM. Among YBMSM, we found structural inequities (housing instability, food insecurity, internalized homonegativity) were positively associated with anxiety/depression/stress (p < 0.001); we also found anxiety/depression was associated with increased alcohol/drug use before sex, and stress was associated with reduced recent HIV testing and pre-exposure prophylaxis awareness/willingness/use. Among YWMSM, we found psychological buffers (perceived social support, resilience) were associated with reduced anxiety/depression/stress (p < 0.001); anxiety was associated with increased condomless insertive/receptive anal sex and recent HIV testing among this subgroup. YBMSM and YWMSM differed in psychosocial determinants and HIV-related consequences regarding their mental health. Our findings provide important implications for developing culturally and contextually tailored interventions to address mental health burdens and HIV prevention outcomes among young MSM at highest risk for HIV acquisition.

The influence of affect on HPV vaccine decision making in an HPV vaccine naïve college student population

The HPV vaccine is recommended for all adolescents starting at age 11, but coverage is low, especially in the young adult population. The CDC is prioritizing catch-up vaccination and has expanded recommendations for all young adults to age 26. College students may be ideal targets for HPV vaccine interventions as they typically have on-site clinics that offer prevention services and students are in the position to make decisions about their own healthcare. We examined the risk perceptions of 101 HPV vaccine-naïve college students, both in terms of risk cognition (beliefs about susceptibility to HPV-related cancers and genital warts) and affect (worry and fear regarding HPV-related health outcomes) as they relate to HPV vaccine intentions. Participants completed an online survey, reporting absolute and comparative risk perceptions for HPV-related cancers/genital warts, fear and worry related to getting HPV-related cancer and/or genital warts, desire for positive emotions, affective associations with the HPV vaccine, and intentions to get the HPV vaccine. More fear/worry about vaccination was directly associated with increased vaccine intentions. The perceived risk to intentions relation included an indirect effect via fear/worry. Desire for positive affect strengthened this relation. Positive affective associations with the HPV vaccine were also related to increased vaccine intentions. Given the public health impact of increasing HPV vaccine coverage for young adults, educational strategies framing the HPV vaccine positively while decreasing fear/worry related to negative health outcomes might increase interest in on-campus catch-up vaccination.

Prescribing HIV pre-exposure prophylaxis: A qualitative analysis of health care provider training needs

Increasing the number of pre-exposure prophylaxis (PrEP) prescriptions will require more health care providers to be willing and trained to prescribe the medication. The purpose of our study was to understand the training needs of clinicians who do not prescribe PrEP. From September 2017 to January 2018, qualitative interviews were conducted with providers who had no experience prescribing PrEP (N = 20). Thematic analysis revealed four themes: three emphasized the temporal nature of training requirements and one identified training preferences of providers. Study findings suggest that clinicians require specific information in order to integrate PrEP into their practices successfully.

"Shades of risk": Understanding current PrEP users' sexually transmitted infection perceptions

ABSTRACTPre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention strategy. Given the possibility of increased sexual risk-taking and acquisition of other sexually transmitted infections (STIs) following PrEP initiation, it is important to explore STI risk perceptions both before and after PrEP initiation to understand the extent to which these perceptions inform decisions to engage in condomless sex. Semi-structured qualitative interviews were conducted with men who have sex with men currently using PrEP (n = 30). Prior to analysis, PrEP users were categorized into four subgroups based on condom use behavior post-PrEP initiation: (1) condom continuers (2) condomless sex continuers, (3) condomless sex increasers, and (4) condomless sex decreasers. Thematic analysis revealed two major themes that elucidated differences in (1) the appraisal of HIV risk relative to other STIs and (2) the importance of partner communication in determining STI risk perceptions by subgroup. Most PrEP users demonstrated no behavioral change after PrEP initiation. Those engaging in condomless sex prior to PrEP initiation also continued that behavior while taking PrEP. Results of this study support a tailored approach to PrEP counseling based on individual STI risk appraisal and motivations to initiate and continue PrEP.

Factors influencing pre-exposure prophylaxis uptake among current users: A qualitative study

Daily oral pre-exposure prophylaxis is an effective strategy for HIV prevention; yet, uptake has been lower than anticipated. This study explores the factors that influenced current users' decisions to initiate PrEP in Western New York. Qualitative data from 41 semi-structured interviews were thematically analyzed. Participants' decision to initiate PrEP was based on individual, interpersonal and structural factors. PrEP users initiated when there was an increase in knowledge, risk perception, sexual health communication, and PrEP access. Findings suggest for PrEP to maximize its HIV prevention potential, public health interventions that utilize a multi-level approach may be most impactful to increase uptake.

Substance Use and Adherence to Antiretroviral Therapy among People Living with HIV in the United States

People with HIV (PWH) report substance use at higher rates than HIV-uninfected individuals. The potential negative impact of single and polysubstance use on HIV treatment among diverse samples of PWH is underexplored. PWH were recruited from the Center for Positive Living at the Montefiore Medical Center (Bronx, NY, USA) from May 2017-April 2018 and completed a cross-sectional survey with measures of substance use, antiretroviral therapy (ART) use, and ART adherence. The overall sample included 237 PWH (54.1% Black, 42.2% female, median age 53 years). Approximately half of the sample reported any current substance use with 23.1% reporting single substance use and 21.4% reporting polysubstance use. Polysubstance use was more prevalent among those with current cigarette smoking relative to those with no current smoking and among females relative to males. Alcohol and cannabis were the most commonly reported polysubstance combination; however, a sizeable proportion of PWH reported other two, three, and four-substance groupings. Single and polysubstance use were associated with lower ART adherence. A thorough understanding of substance use patterns and related adherence challenges may aid with targeted public health interventions to improve HIV care cascade goals, including the integration of substance use prevention into HIV treatment and care settings.

Racial Variations in Psychosocial Vulnerabilities Linked to Differential Poppers Use and Associated HIV-Related Outcomes among Young Men Who Have Sex with Men: A Study in Two U.S. Metropolitan Areas

Background: Poppers use has become increasingly prevalent and is associated with elevated HIV risk among young men who have sex with men (YMSM) in urban settings. However, knowledge regarding racial variations of poppers use and their psychosocial determinants to inform culturally-targeted interventions remain limited. Methods: We conducted a cross-sectional study among YMSM recruited from two US metropolitan areas (Nashville, TN and Buffalo, NY) to investigate the differences of socio-environmental and mental health factors associated with poppers use and important HIV-related outcomes [e.g., HIV testing, pre-exposure prophylaxis (PrEP, substance use, and risky sexual behaviors] among White and Black YMSM (i.e., YWMSM and YBMSM). Results: Among 347 YMSM aged 18-35 years, 32.3% reported poppers use. Notably, poppers-using YWMSM were more likely (p < 0.05) to report mental health burdens (e.g., depression, anxiety, loneliness), while poppers-using YBMSM were more likely (p < 0.05) to experience adverse social-environmental events (e.g., unstable housing, food insecurity, no health insurance, perceived HIV stigma, internalized homonegativity). Poppers-using YMSM showed a higher prevalence of sexual risk behaviors (e.g., event-level alcohol/drug use, condomless insertive/receptive anal sex, group sex) compared to their non-user counterparts, with YWMSM showing the highest likelihood to engage in these risk behaviors. Compared to poppers-using YBMSM, poppers-using YWMSM were associated with a higher likelihood of ever testing for HIV, ever using PrEP and willingness to use PrEP in the next 12 months. Conclusion: Given the distinctive patterns of psychosocial determinants of poppers use between YWMSM and YBMSM, culturally-tailored poppers reduction programs should be designed to tackle the associated HIV risks among YMSM with effectivenes.

Factors correlated with pre-exposure prophylaxis (PrEP) awareness and use among black adults in the United States: implications for improving HIV prevention

HIV remains a significant public health concern for Black adults (BA) in the United States. Pre-exposure prophylaxis (PrEP) is a highly effective prevention tool prescribed to protect the health of HIV-uninfected individuals. Yet, low rates of PrEP awareness and utilization persist among BA. Less is understood about the pathways that may promote PrEP uptake. The present study explored factors associated with PrEP awareness and use among BA. Using a cross-sectional sample of 666 BA, we employed multivariable logistic regression models to examine the relationship between PrEP and several covariates. Most participants were unaware of PrEP (71%). Reporting history of incarceration and lifetime sexually transmitted infection testing [aOR 1.76 (1.19, 2.59), p < 0.05] had greater odds of PrEP awareness. Only 6% of respondents had ever taken PrEP. Reports of incarceration history [aOR 9.96 (2.82, 35.14), p < 0.05], concurrent sexual partners [aOR 1.09 (1.00, 1.18), p < 0.05], and substance use during sex [aOR 4.23 (1.02, 17.48), p < 0.05] had greater odds of PrEP use. Interventions aiming to improve PrEP uptake among BA must consider the individual, social, and structural contexts associated with its awareness and use. Enhanced efforts by healthcare providers and institutions may better facilitate access to PrEP for HIV prevention and control transmission.

An Analysis of Sex Practices and Behaviors Among African Americans in Sexually Concurrent and Sexually Exclusive Relationships

Historically, sexually concurrent relationships have been associated with increased risk for sexually transmitted infections (STIs), including HIV. Due to socio-structural factors, African Americans (AAs) have higher rates of STIs compared to other racial groups and are more likely to engage in sexually concurrent (SC) relationships. Current research has challenged the assumption that SC is the only risky relationship type, suggesting that both SC and sexually exclusive (SE) relationships are at equal risk of STI and HIV acquisition and that both relationship types should engage in safer sex practices. This study aimed to compare sex practices and behaviors among AA men and women in SC and SE relationships (N = 652). Results demonstrate differences in sexual practices and behaviors between SC and SE men and women. Overall, SC and SE women report condom use with male partners less frequently than SC and SE men. SC men were more likely to report substance use during sex compared to SC and SE women. Pre-exposure prophylaxis (PrEP) use did not differ across groups. SE men were less likely to report STI testing and diagnosis compared to SC women. Findings support the need to focus on culturally and gender-specific safer sex interventions among AAs.

Racial Differences of Psychosocial Characteristics, HIV Risk-Taking and HIV Prevention Uptake between Men Who Have Sex with Men Only and Men Who Have Sex with Men and Women: A Community-Based Study in Two US Cities

Bisexual behavior preference plays an important role in shaping HIV risks among men who have sex with men (MSM), yet few studies have examined the racial differences in the patterns of sexual risk and HIV prevention uptake between men who have sex with men and women (MSMW) and men who have sex with men only (MSMO). We conducted a community-based study to identify and compare psychosocial characteristics, sexual risks, HIV testing frequency, and pre-exposure prophylaxis (PrEP) engagement between Black and White MSMW and MSMO in two US cities. Findings indicate that White MSMW were most likely to engage in HIV risk-taking behaviors (e.g., alcohol/drug use before sex, condomless/group sex), while Black MSMW were least likely to recently test for HIV or report awareness (aPR: 0.32, 95% CI: 0.17-0.61), willingness (aPR: 0.58, 95% CI: 0.30-0.98), and use (aPR: 0.59, 95% CI: 0.31-0.93) of PrEP. Findings from our study supplement salient information for designing culturally tailored HIV prevention interventions for specific MSM subgroups in the US.

Suboptimal Follow-Up on HIV Test Results among Young Men Who Have Sex with Men: A Community-Based Study in Two U.S. Cities

Frequent HIV testing and knowledge of HIV serostatus is the premise before timely access to HIV prevention and treatment services, but a portion of young men who have sex with men (YMSM) do not always follow up on their HIV test results after HIV testing, which is detrimental to the implementation of HIV prevention and care among this subgroup. The comprehensive evaluation of factors associated with inconsistent follow-up on HIV test results may inform relevant interventions to address this critical issue among YMSM. To this end, we conducted a cross-sectional study in Nashville, Tennessee and Buffalo, New York from May 2019 to May 2020 to assess demographic, behavioral, and psychosocial correlates of inconsistent follow-up on HIV test results among YMSM. Of the 347 participants, 27.1% (n = 94) reported inconsistent follow-up on their HIV test results. Multivariable logistic regression showed that inconsistent follow-up on HIV test results was positively associated with condomless receptive anal sex, group sex, recreational drug use before or during sex, internalized homophobia, and stress; while negatively associated with housing stability, social support, and general resilience. Future HIV prevention intervention efforts should target these modifiable determinants to enhance the follow-up on HIV test results among YMSM.

Addressing food insecurity in HIV care: perspectives from healthcare and social service providers in New York state

Ending the HIV epidemic in the United States will require addressing social determinants contributing to poor care engagement among people living with HIV (PLH), such as food insecurity. Food insecurity is associated with poor care engagement among PLH. Yet, few studies have examined the perspectives of healthcare and social services providers on addressing food insecurity in HIV care. Guided by the Social Ecological Model, we conducted semi-structured interviews with 18 providers in New York State to understand barriers and facilitators to addressing food insecurity in HIV care. Thematic analysis illustrated eight themes across various levels of the Social Ecological Model. At the patient-level, providers perceived patients' feelings of embarrassment, shame, and judgement, and low health literacy as barriers. At the provider-level, challenges included limited time. Facilitators included fostering strong, patient-provider relationships. Barriers at the clinic-level included limited funding, while clinic resources served as facilitators. At the community-level, challenges included intersecting stigmas arising from community norms towards PLH and people who receive food assistance and limited access to healthy food. Findings suggest the need to incorporate their insights into the development of interventions that address food insecurity in HIV care.