Facilitators and Barriers to Pre-Exposure Prophylaxis (PrEP) Use Among Black Individuals in the United States: Results from the National Survey on HIV in the Black Community (NSHBC)

The Potential of Telecommunication Technology to Address Racial/Ethnic Disparities in HIV PrEP Awareness, Uptake, Adherence, and Persistence in Care: A Review

Pre-exposure prophylaxis (PrEP) is highly effective in preventing new HIV infection, but uptake remains challenging among Black and Hispanic/Latino persons. The purpose of this review was to understand how studies have used electronic telecommunication technology to increase awareness, uptake, adherence, and persistence in PrEP care among Black and Hispanic/Latino persons and how it can reduce social and structural barriers that contribute to disparities in HIV infection. Of the 1114 articles identified, 10 studies were eligible. Forty percent (40%) of studies focused on Black or Hispanic/Latino persons and 80% addressed social and structural barriers related to PrEP use such as navigation or access to PrEP. Mobile health designs were more commonly used (50%) compared to telehealth (30%) and e-health (20%) designs. There is a need to increase the development of telecommunications interventions that address the needs of Black and Hispanic/Latino persons often challenged with uptake and adherent use of PrEP.

Correlates of Homonegativity Towards Men Who Have Sex With Men Among Black Individuals in the United States

This study aims to identify the factors that are associated with homonegativity toward men who have sex with men (MSM) within Black communities since the expansion of LGBTQ rights. A survey was completed in 2016 by a nationally representative sample of 868 Black respondents, 18-50 years old, via e-mail. Demographics, perception of same-gender sexual behaviors, religiosity, experienced racism, and contact with the carceral system (CS) were assessed. 61.6% of respondents endorsed at least one homonegative belief. Being male, residing in the South, attending religious services, receiving homonegative faith messaging, and having contact with the CS were significantly associated with homonegativity toward MSM while experiencing racism, older age, and residing in a non-metropolitan area were not. Education efforts on LGBTQ identities in Black communities should engage faith communities, extend to metropolitan and non-metropolitan areas of the South, and include younger and older adults. Programs that decrease the arrest of Black individuals may also help reduce homonegativity toward MSM.

Perceived HIV Invulnerability and PrEP Knowledge and Attitudes among Black Sexual Minority Women

Black women have disproportionate rates of HIV compared to women of all other racial groups. The purpose of this analysis was to investigate perceived HIV risk, HIV and STI testing behaviors, and PrEP knowledge and attitudes among Black sexual minority women (SMW) and examine differences based on their history of male sex partners. Secondary data analysis was conducted using data from the Generations Study. This analysis used a sample of N=149 participants who identified as Black cisgender women. Results showed Black SMW with a history of male sex partners reported a higher perceived risk of contracting HIV and significantly more frequent HIV and STI testing than those without a history of male sex partners. Overall, most of the sample was not familiar with PrEP, but one-third had favorable attitudes towards it, and half felt like they did not know enough about PrEP to form an opinion. Implications for culturally relevant public health campaigns and comprehensive sexuality education that integrate PrEP are included.

Meet Me Where I Am: An Evaluation of an HIV Patient Navigation Intervention to Increase Uptake of PrEP Among Black Men Who Have Sex with Men in the Deep South

The southern region of the USA is the epicenter of the HIV epidemic. HIV disproportionately affects African Americans, particularly Black men who have sex with men (Black MSM). Given the alarming rates of new infections among Black MSM, there is an urgent need for culturally competent healthcare professionals who are trained to address the unique needs and barriers to uptake and adherence to HIV prevention, care, and treatment services. Utilizing a mixed method research approach, we conducted a process evaluation of Meet Me Where I Am, a 6-month, 6-session HIV/AIDS patient navigation training program for healthcare professionals and patient navigators working in organizations that provide HIV services to residents of central Mississippi, an area with high incidence and prevalence rates of HIV. A self-administered questionnaire after each session was given to participants to assess the acceptability, quality, and translational aspects of the training program. The overall positive feedback on the MMWIA training reflects the program's acceptability and feasibility. Participants found that the training was effective in providing the necessary knowledge and skills to deliver patient-centered HIV prevention-related navigation services. A majority (67%) of participants indicated that they felt they could apply the lessons learned within their healthcare settings to improve access to HIV prevention, care, and treatment services. If we are to reduce racial and ethnic disparities in HIV/AIDS, there is a critical need for culturally appropriate training programs designed to improve the ability of healthcare professionals and health systems to deliver culturally competent HIV prevention, care, and treatment services.

Awareness, acceptability, and intention to initiate HIV pre-exposure prophylaxis among pregnant women

HIV prevention is critically important during pregnancy, however, pre-exposure prophylaxis (PrEP) is underutilized. We conducted a survey of pregnant and non-pregnant women in a high HIV prevalence community in Washington D.C. to evaluate determinants of PrEP initiation during pregnancy. 201 pregnant women and a reference population of 1103 non-pregnant women completed the survey. Among pregnant women, mean age was 26.9 years; the majority were Black with household-incomes below the federal poverty level. Despite low perceived risk of HIV acquisition and low prior awareness of PrEP, 10.5% of respondents planned to initiate PrEP during pregnancy. Pregnant women identified safety, efficacy, and social network and medical provider support as key factors in PrEP uptake intention. The belief that PrEP will "protect (their) baby from HIV" was associated with PrEP uptake intention during pregnancy. Concerns regarding maternal/fetal side effects, and safety in pregnancy or while breastfeeding were not identified as deterrents to uptake intention. When compared to a nonpregnant sample, there were no significant differences in uptake intention between the two samples. These findings support the need for prenatal educational interventions to promote HIV prevention during pregnancy, as well as interventions that center on the role of providers in the provision of PrEP.

"We Feel Like Everybody's Going to Judge us": Black Adolescent Girls' and Young Women's Perspectives on Barriers to and Opportunities for Improving Sexual Health Care, Including PrEP, in the Southern U.S

Black adolescent girls and young women (AGYW) are disproportionately affected by HIV in the southern U.S.; however, PrEP prescriptions to Black AGYW remain scarce. We conducted in-depth interviews (IDIs) with Black AGYW ages 14-24 in Alabama to explore opportunities for and barriers to sexual health care including PrEP prescription. Twelve AGYW participated in IDIs with median age 20 (range 19-24). All reported condomless sex, 1-3 sexual partners in the past 3 months, and 6 reported prior STI. Themes included: 1) Stigma related to sex contributes to inadequate discussions with educators, healthcare providers, and parents about sexual health; 2) Intersecting stigmas around race and gender impact Black women's care-seeking behavior; 3) Many AGYW are aware of PrEP but don't perceive it as an option for them. Multifaceted interventions utilizing the perspectives, voices, and experiences of Black cisgender AGYW are needed to curb the HIV epidemic in Alabama and the U.S. South.

Building Racial and Gender Equity into a National PrEP Access Program

Transgender and gender diverse (TGD), Black, and Latinx communities have long borne a disproportionate share of the U.S. HIV epidemic, yet these same key demographics are continually underrepresented in national PrEP prescriptions. Black, Latinx, and TGD individuals are also more likely to be uninsured, meaning that a proposed federal program to cover PrEP for people without insurance could provide significant benefit to potential PrEP users from these populations. However, coverage of PrEP costs alone will not end disparities in uptake. This commentary provides additional context and recommendations to maximize effectiveness of a national PrEP program for TGD, Black, and Latinx populations in the US.

US Black cisgender women and pre-exposure prophylaxis for human immunodeficiency virus prevention: A scoping review

BACKGROUND

Black cisgender women in the United States experience a disproportionate burden of human immunodeficiency virus acquisition. Pre-exposure prophylaxis is an effective oral daily medication that reduces the risk of human immunodeficiency virus through sex by 99% when taken as prescribed. However, less than 2% of eligible Black cisgender women take pre-exposure prophylaxis. The purpose of this scoping review was to describe the types of research studies done in this area, gaps in knowledge, and potential areas of research needed to increase pre-exposure prophylaxis use among Black cisgender women in the United States.

METHODS

We conducted our search in MEDLINE (PubMed), Embase (Elsevier), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), and Scopus (Elsevier) using a combination of keywords and database-specific subject headings for the following concepts: pre-exposure prophylaxis, African American/Black or minority, and women. We used the Joanna Briggs Institute's Reviewers' Manual process for Scoping Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews to ensure comprehensive and standardized reporting of each part of the review.

RESULTS

Fifty-nine studies were included in the final review. Results of the study were classified according to the three phases of the Human Immunodeficiency Virus Prevention Cascade-demand side, supply side, and adherence and retention. The majority of studies (n = 24, 41%) were cross-sectional quantitative surveys and 43 (34%) focused on the demand-side phase of the Human Immunodeficiency Virus Prevention Cascade. Fifty-eight percent of studies either assessed women's pre-exposure prophylaxis knowledge, attitudes, and intentions to use, or assessed perceived barriers and facilitators. Seven studies (12%) tested pre-exposure prophylaxis uptake and adherence among Black cisgender women.

CONCLUSION

This review found multiple missed opportunities to increase women's demand for pre-exposure prophylaxis and health care provider screening and referral for pre-exposure prophylaxis. Additional studies are needed to effectively assess pre-exposure prophylaxis uptake and adherence among Black cisgender women.

Knowledge of HIV and HIV pre-exposure prophylaxis among medical and pharmacy students: A national, multi-site, cross-sectional study

Pre-exposure prophylaxis (PrEP) is a highly effective strategy for preventing HIV. However, prescription of PrEP has not reached the scale that is necessary to meet the public health need of reducing HIV incidence. A factor contributing to this slow scale-up is limited healthcare practitioners' knowledge of PrEP, making PrEP education a priority. We conducted a national, cross-sectional study of medical (allopathic and osteopathic) and pharmacy students regarding knowledge of PrEP and HIV between October 2020 and February 2021. We included 28 items in our knowledge assessment. Analysis sought to identify gaps in knowledge as well as academic and demographic correlates of knowledge. A total of 2,353 students participated in the study (response rate = 17.0%). The overall mean HIV knowledge score was 79.6% correct. Regarding specific items, 68.7% of participants believed HIV treatment was difficult because it required many pills, and 61.1% incorrectly indicated a person with an undetectable HIV viral load could transmit the virus to their sexual partners. Overall mean PrEP knowledge was 84.1%. Approximately one-third of participants did not identify HIV-negative status as a requirement to be a PrEP candidate. Gay/lesbian participants and those who were in the late-phase of training reported higher knowledge of both HIV and PrEP than did heterosexual participants and those in the early-phase of training. This study identifies specific gaps in training on HIV prevention with PrEP that must be improved in health professions education to ensure PrEP reaches its full potential in ending the HIV epidemic.

Toward Greater Pre-exposure Prophylaxis Equity: Increasing Provision and Uptake for Black and Hispanic/Latino Individuals in the U.S

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition and is a critical tool in the Ending the HIV Epidemic in the U.S. initiative. However, major racial and ethnic disparities across the pre-exposure prophylaxis continuum, secondary to structural inequities and systemic racism, threaten progress. Many barriers, operating at the individual, network, healthcare, and structural levels, impede PrEP access and uptake within Black and Hispanic/Latino communities. This review provides an overview of those barriers and the innovative and collaborative solutions that health departments, healthcare organizations, and community partners have implemented to increase PrEP provision and uptake among disproportionately affected communities. Promising strategies at the individual and network levels focus on increasing patient support throughout the PrEP continuum, positioning and training community members to expand knowledge of and interest in PrEP, and leveraging mobile technologies to support PrEP uptake. Healthcare-level solutions include expanding the venues and types of healthcare professionals that can provide PrEP, and structural- and policy-level options focus on financial assistance programs and health insurance expansion. Key research gaps include demonstrating that pilot studies and interventions remain effective at scale and across varied contexts. Although the last 2 decades have provided effective tools to end the HIV epidemic, realizing this vision for the U.S. will require addressing persistent and pervasive HIV-related disparities in Black and Hispanic/Latino communities. Federal, state, and local partners should expand efforts to address longstanding health and structural inequities and partner with disproportionately affected communities to rapidly expand PrEP scale-up.

A Scoping Review Investigating Relationships between Depression, Anxiety, and the PrEP Care Continuum in the United States

Men who have sex with men and transgender women in the United States are at increased risk for HIV and may benefit from pre-exposure prophylaxis (PrEP), a once-a-day pill to prevent HIV. Due to stigma and discrimination, sexual and gender minority (SGM) populations are also at risk for depression and anxiety. This scoping review sought to identify literature addressing relationships between the PrEP care continuum, depression, and anxiety among SGM individuals and others at high risk for HIV. We conducted a systematic review of four databases (i.e., PubMed, PsycInfo, Web of Science, Google Scholar) and identified 692 unique articles that were screened for inclusion criteria, with 51 articles meeting the final inclusion criteria. Data were extracted for key study criteria (e.g., geographic location, participant demographics, study design, main findings). Results suggest that while depression and anxiety are not associated with PrEP awareness or willingness to use, they can be barriers to seeking care and to PrEP adherence. However, empirical studies show that taking PrEP is associated with reductions in anxiety. Findings suggest the need to implement mental health screenings in PrEP clinical care. In addition, addressing systemic and structural issues that contribute to mental health disorders, as well as PrEP-related barriers, is critical.

Correlates of PrEP Uptake Among Young Sexual Minority Men and Transgender Women in New York City: The Need to Reframe "Risk" Messaging and Normalize Preventative Health

Pre-exposure prophylaxis (PrEP) is an effective form of HIV prevention, but young sexual minority men face myriad barriers to PrEP uptake. Participants (n = 202) completed a survey on healthcare experiences and beliefs about HIV and PrEP. While 98% of the sample knew about PrEP, only 23.2% reported currently taking PrEP. Participants were more likely to be taking PrEP if they received PrEP information from a healthcare provider and endorsed STI-related risk compensation. Conversely, PrEP uptake was less likely among those with concerns about medication use and adherence. While there were no racial/ethnic differences in PrEP uptake, there were differences in correlates of PrEP use for White participants and participants of color. To facilitate PrEP uptake, clinicians should provide PrEP education and screen all patients for PrEP candidacy. Additionally, public health messaging must reframe HIV "risk", highlight benefits of STI testing, and emphasize the importance of preventive healthcare for SMM.

Providers PrEP: Identifying Primary Health care Providers' Biases as Barriers to Provision of Equitable PrEP Services

BACKGROUND

Despite their disparately high HIV incidence and voiced willingness to use pre-exposure prophylaxis (PrEP), Black cisgender women's knowledge and uptake of PrEP are low, especially relative to White cisgender women and men who have sex with men. Mounting evidence demonstrates that health care provider recommendations are a critical factor in women's awareness, willingness, and ability to uptake PrEP. Health care providers may make clinical judgments about who is (not) a good candidate for PrEP based on unconscious and conscious stereotypes and prejudice.

SETTING

We conducted an online experiment among N = 160 health care providers with prescribing privileges in the 48 HIV hotspot counties.

METHOD

Providers received 1 of 4 vignettes about a PrEP eligible woman. Vignettes varied by patient race and substance use status. Then, providers reported their willingness to discuss PrEP with the patient and willingness to prescribe PrEP to her.

RESULTS

We tested 2 models predicting providers (1) willingness to discuss and (2) willingness to prescribe PrEP, contingent on their racial attitudes. Providers who scored high on a modern racism measure were less willing to discuss and prescribe PrEP to the Black patient. These effects were mediated by provider perceptions of patients' abilities to adhere to PrEP, but not their expectations of risk compensatory behaviors.

CONCLUSIONS

Our findings highlight the importance of applying an intersectional lens in documenting the processes that exacerbate inequities in PrEP use. This study provides evidence to support the development of interventions that address the mechanisms that work to thwart optimal care.

The Prevalence of HIV Among Men Who Have Sex With Men (MSM) and Young MSM in Latin America and the Caribbean: A Systematic Review

Young men who have sex with men (YMSM) under 25 years old are among the few populations with increasing numbers of new HIV infections in parts of the world where HIV incidence is declining overall. In this systematic review, we synthesize the literature on HIV prevalence among MSM in Latin America and the Caribbean focusing on YMSM. Results were stratified according to study population sampling method used (probability and non-probability based). Forty-seven studies from 17 countries were published in the last 10 years. Among studies using probability-based sampling method (N = 21), HIV prevalence among MSM ranged from 1.2 to 32.6%. HIV prevalence tended to increase over time in studies sampling at different time points. HIV prevalence among YMSM exceeded 5.0% in more than a half of studies (51%; N = 22/43). Our review corroborates the high and potentially rising incidence of HIV among YMSM and characterizes the region's greatest challenge to ending the epidemic.

Community Legal Systems: Targeting PrEP and HIV Education to Decrease Risk of HIV Transmission

The southern U.S. has both high HIV and incarceration rates in comparison to its population. As in the rest of the country, HIV prevention is based on education, behavior change, and biomedical efforts, such as pre-exposure prophylaxis (PrEP). This study examined the implementation of an educational intervention and supportive services to obtain PrEP in a population of individuals (N = 218) involved in an Adult Drug Court (ADC) or on probation or parole (P-P). Nearly all ADC and P-P participants self-reported risk behaviors linked to HIV acquisition. Results supported the acceptance and usefulness of the intervention as rated by participants. Participants showed increased knowledge of HIV risks and testing post-education. In multivariate analysis, predictors of interest in using PrEP included low stigma beliefs, specifically their level of prejudice views, high depressive symptoms, and white race. The intervention shows promise. Given the high risk documented for ADC and P-P individuals, HIV prevention is a critical component for increased protective behaviors.

Pre-exposure Prophylaxis (PrEP) Information on Instagram: Content Analysis

Background

There is still an HIV epidemic in the United States, which is a substantial issue for populations bearing a disproportionate burden of HIV infections. Daily oral pre-exposure prophylaxis (PrEP) has proven to be safe and effective in reducing HIV acquisition risk. However, studies document that PrEP awareness/usage is low. There is also limited understanding of social media platforms, such as Instagram, as PrEP information sources.

Objective

Given the paucity of research on PrEP-related Instagram posts and popularity of this social media platform, the purpose of this research is to describe the source characteristics, image types, and textual contents of PrEP-related posts on Instagram.

Methods

Using Crowdtangle Search, a public insights tool owned/operated by Facebook, we retrieved publicly accessible and English-language-only Instagram posts for the 12-month period preceding April 22, 2020, using the following terms: Truvada or “pre-exposure prophylaxis” or #truvada or #truvadaprep or #truvadawhore or #truvadaforprep. We employed a qualitative coding methodology to manually extract information from posts. Using a pretested codebook, we performed content analysis on 250 posts, examining message and source characteristics (ie, organization type [eg, government, news] and individual type [eg, physician]), including information about PrEP (eg, how it works, cost), and indicated users. Frequencies and percentages were calculated for all categorical variables. A Chi-square test was conducted to determine differences between source types on a variety of message characteristics.

Results

Three-quarters of the posts (193/250, 77.2%) were posted by organizations. Of the 250 posts reviewed, approximately two-thirds (174/250, 69.6%) included a photograph, more than half (142/250, 56.8%) included an infographic, and approximately one-tenth (30/250, 12%) included a video. More than half defined PrEP (137/250, 54.8%), but fewer posts promoted PrEP use, explained how PrEP works, and included information on the effectiveness of PrEP or who can use it. The most commonly hashtagged populations among posts were men who have sex with men (MSM), but not necessarily bisexual men. Few posts contained race-/ethnicity-related hashtags (11/250, 4.4%). Fewer posts contained transgender-associated tags (eg, #transgirl; 5/250, 2%). No posts contained tags related to heterosexuals or injection drug users. We found statistical differences between source types (ie, individual versus organization). Specifically, posts from organizations more frequently contained information about who can use PrEP, whereas posts from individuals more frequently contained information describing adverse effects.

Conclusions

This study is among the first to review Instagram for PrEP-related content, and it answers the National AIDS Strategy’s call for a clearer articulation of the science surrounding HIV risk/prevention through better understanding of the current public information environment. This study offers a snapshot of how PrEP is being discussed (and by whom) on one of the most popular social media platforms and provides a foundation for developing and implementing PrEP promotion interventions on Instagram.

Association Between HIV Testing and HIV-Related Risk Behaviors Among US and Non-US Born Black Individuals Living in the US: Results From the National Survey on HIV in the Black Community (NSHBC)

Despite improvements in HIV prevention and treatment, Black individuals continue to be disproportionately affected by the HIV epidemic in the US. Using data from the National Survey on HIV in the Black Community, we examined the differences in demographic characteristics, risk behaviors, and HIV testing between US and non-US born Black adults. 868 individuals completed the survey and provided baseline data on sexual risk. Participants were grouped as US-born (N = 763) and non-US born (N = 101) based on self-reported place of birth. Amongst US-born participants, males were less likely to test for HIV, whereas those who reported a lifetime history of anal sex and sexually transmitted infections (STIs) were more likely to test for HIV. Non-US born participants who reported a single marital status were less likely to test for HIV, whereas those who reported a lifetime history of STIs were more likely to test for HIV. Some differences in predictors of HIV testing exist by place of birth. Understanding these differences is needed to develop HIV/AIDS prevention and treatment programs for US and non-US born Black individuals.

Qualitative assessment of readiness for use of HIV pre-exposure prophylaxis among men who have sex with men (MSM) in Malawi: Qualitative study using key informant interviews and focus group discussions

Background

Men who have sex with men (MSM) are a key group for HIV interventions in Malawi considering their high HIV prevalence (17.5% compared to 8.4% among men in the general population). The use of oral preexposure prophylaxis (PrEP) presents a new opportunity for MSM to be protected. We present the findings from a qualitative assessment designed to assess awareness of and willingness and barriers to using PrEP among MSM in Malawi.

Objective

The 3 main objectives of this assessment were to determine: (1) awareness of PrEP, (2) factors that influence willingness to use PrEP, and (3) potential barriers to PrEP use and adherence among MSM in order to guide the design and implementation of a PrEP program in Malawi.

Methods

Ahead of the introduction of PrEP in Malawi, a qualitative study using in-depth interviews (IDIs) and focus group discussions (FGDs) was conducted in October 2018 in Blantyre, Lilongwe, and rural districts of Mzimba North and Mangochi. With support of members of the population, study participants were purposively recruited from 4 MSM-friendly drop-in centers where MSM receive a range of health services to ensure representativeness across sites and age. Participants were asked what they had heard about PrEP, their willingness to use PrEP, their barriers to PrEP use, and their preferences for service delivery. The data were analyzed using a thematic content analysis framework that was predetermined in line with objectives.

Results

A total of 109 MSM were interviewed—13 through IDIs and 96 through FGDs. Most participants were aware of PrEP as a new HIV intervention but had limited knowledge related to its use. However, the majority were willing to use it and were looking forward to having access to it. IDI participants indicated that they will be more willing to take PrEP if the dosing frequency were appropriate and MSM were involved in information giving and distribution of the drug. FGD participants emphasized that places of distribution and characteristics of the service provider are the key factors that will affect use. Knowing the benefits of PrEP emerged as a key theme in both the IDIs and FGDs. Participants highlighted barriers that would hinder them from taking PrEP such as side effects which were cited in IDIs and FGDs. Key factors from FGDs include cost, fear of being outed, drug stockouts, fear of being known as MSMs by wives, and lack of relevant information. FGDs cited stigma from health care workers, forgetfulness, and community associated factors.

Conclusions

Despite having inadequate knowledge about PrEP, study participants were largely willing to use PrEP if available. Programs should include an effective information, education, and communication component around their preferences and provide PrEP in MSM-friendly sites.

Awareness and acceptability of HIV pre-exposure prophylaxis (PrEP) among students at two historically Black universities (HBCU): a cross-sectional survey

Background

Despite young African American adults (ages 18–24) being among the highest risk groups for HIV infection, little is known about their awareness of HIV pre-exposure prophylaxis (PrEP) – a once daily pill shown to be > 90% effective in preventing HIV. To explore awareness and acceptability of PrEP among college students in this demographic, we conducted a survey of attendees at two large historically Black universities (HBCU) in North Carolina.

Methods

We administered a 14-item questionnaire to students at two HBCUs in North Carolina between February and April 2018. Questions were formatted in a yes/no or multiple choice format. Questionnaire items specifically addressed PrEP awareness and acceptability. Surveys were administered to students at a campus health fair and while transiting the campus student union via iPad. Response to all questions was optional. We fit a logistic regression model to determine association of key demographic determinants with PrEP acceptability and awareness. Statistical analyses were conducted using SAS 9.4 (SAS, Cary, NC).

Results

Overall, 210 students participated in the survey, of which 60 completed all survey items as presented. The survey cohort was 75% female, 89% heterosexual and 39% freshmen. The mean age of respondents was 19.8 years (SD: 1.8). Fifty-two percent of survey respondents reported that they were aware of PrEP prior to the time of survey administration. Only 3% of respondents reported that they were on PrEP. The most common sources of information on PrEP were campus health services (24%) and non-social media advertising (15%). Of respondents who were aware of PrEP, 61% reported that they had heard about in the 6 months prior to survey administration, while only 19% say they were aware of it for more than a year. Regarding acceptability of PrEP, 58% of respondents reported that they would take a once a day pill for HIV if they were at risk. Our logistic regression analysis found no statistically significant associations between key demographic factors and PrEP awareness. However, persons who perceived themselves to be at risk for HIV acquisition were more likely to find once daily oral PrEP (relative risk 2.66 (95% CI 1.31–5.42)) as an acceptable prevention strategy than the rest of the survey cohort.

Conclusions

African American HBCU students are becoming aware of PrEP, and generally perceive the intervention as acceptable and worth consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10996-2.

Perspectives of Black women in the United States on salon-based intervention to promote the uptake of pre-exposure prophylaxis (PrEP) for HIV

AIMS AND OBJECTIVES

To understand Black women's perspectives on a pre-exposure prophylaxis (PrEP) education intervention in a salon setting.

BACKGROUND

Black women have a significant lifetime risk of acquiring HIV. Pre-exposure prophylaxis (PrEP) is an effective prevention approach in reducing that risk. Despite this, Black women are least likely to use PrEP.

DESIGN

This was a qualitative study to identify Black women's perspectives on acceptability of a PrEP education intervention in a salon setting using hair stylists. The paper adhered to the COREQ checklist in reporting.

METHODS

Seven focus groups among Black women (n = 44) living in north-central North Carolina were conducted. Ethical approval was obtained. The interview guide included questions on knowledge of PrEP and barriers and facilitators to a PrEP promotion programme in a salon setting.

RESULTS

Conventional content analysis considered content in relation to themes of facilitators, barriers and women's preferences for intervention delivery. Facilitators included the salon characteristics, social culture and relationship with the stylist. Women noted concerns of accuracy of content from stylists and privacy as barriers.

CONCLUSIONS

Participants' trust with their stylists make a PrEP education salon-based intervention feasible. Salon-based interventions are not one-size-fits-all and researchers interested in this setting should tailor interventions to the individual salon. Interventions for PrEP in a salon setting should be culturally appropriate, confidential and consider the potential reach to the social networks of Black women in the salon.

RELEVANCE TO CLINICAL PRACTICE

The insights shared by Black women can contribute to developing a PrEP uptake intervention as a way of reducing new cases of HIV.

Sexual Subcultures and HIV Prevention Methods: An Assessment of Condom Use, PrEP, and TasP Among Gay, Bisexual, and Other Men Who Have Sex with Men Using a Social and Sexual Networking Smartphone Application

Despite being grouped together in epidemiological risk categories, gay, bisexual, and other men who have sex with men (GBM) are not a homogenous group. In addition to traditional segmentation along race, ethnicity, and socioeconomic status, many GBM also identify with sexual subcultural communities. Previous research has shown differences across a variety of health outcomes between these sexual subcultural communities. The purpose of this study was to determine whether HIV prevention practices among GBM differed according to sexual subcultural community. The study was conducted in collaboration with a popular social and sexual networking smartphone application company. A total of 23,577 GBM responded to the survey. A latent class analysis identified 6 distinct classes related to sexual subcultural community identification. We found significant differences across sociodemographic characteristics, HIV prevention practices, and condomless anal sex in the past 6 months related to sexual subculture identification. Findings suggest that sexual subcultural identity is related to decision-making around HIV prevention among GBM. Differences in HIV prevention strategies are likely a function of group norms, unique shared experiences among GBM identifying with a particular sexual subculture community, and sociodemographic characteristics associated with these groups. As such, sexual subculture identity should be considered in developing interventions and social marketing campaigns to increase uptake of biomedical HIV prevention tools among GBM. Identifying group norms and shared experiences related to HIV prevention practices among sexual subcultures is necessary to understand the role these identities play in lives of GBM, especially as it relates to their sexual health and well-being.

Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature

ABSTRACT

The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.

Hidden in Plain Sight: Identifying Women Living in the United States Who Could Benefit From HIV Preexposure Prophylaxis

HIV preexposure prophylaxis (PrEP) with oral tenofovir/emtricitabine is an effective means of decreasing human immunodeficiency virus (HIV) acquisition among women. However, few women are prescribed and are taking PrEP. This article offers perspectives on barriers to use and strategies to increase uptake among women.

HIV Risk-Related Behaviors and Willingness to Use Pre-Exposure Prophylaxis Among Black Americans with an Arrest History

OBJECTIVE

Black individuals in the USA are arrested and incarcerated at a significantly higher rate than White individuals, and incarceration is associated with increased HIV vulnerability. Pre-exposure prophylaxis (PrEP) reduces the risk for HIV transmission, but little is known about the relationship between HIV risk behavior and willingness to use PrEP among Black individuals with an arrest history.

METHOD

A total of 868 individuals completed a nationally representative survey and provided baseline data on sexual risk. Participants were grouped as those with a history of arrest (N = 226) and those with no history of arrest (N=619) based on self-reported arrest history. Our study examined HIV risk behaviors associated with willingness to use PrEP between those with arrest history and those without arrest history.

RESULTS

Participants with an arrest history were more likely to have a lifetime history of anal sex (p<0.0001) and sexually transmitted diseases (p=0.0007). A history of multiple sexual partners in the past 3 months was associated with PrEP willingness in individuals with an arrest history [aPR 2.61 (1.77, 3.85), p<0.0001], adjusting for other covariates in the model.

CONCLUSIONS

Differences in risk behavior and willingness to use PrEP exist by arrest history. Understanding these risk behaviors are necessary to increase access to PrEP. PrEP uptake and adherence interventions, when recommended and made available for individuals at substantive risk of HIV infection at the time of arrest and during incarceration, are essential to reducing the spread of HIV in correctional facilities and in communities to which they return.

Embedding a Linkage to Preexposure Prophylaxis Care Intervention in Social Network Strategy and Partner Notification Services: Results From a Pilot Randomized Controlled Trial

BACKGROUND

Increased preexposure prophylaxis (PrEP) uptake among black men who have sex with men and black transgender women (BMSM/TW) is needed to end the HIV epidemic. Embedding a brief intervention in network services that engage individuals in HIV transmission networks for HIV/ sexually transmitted infections testing may be an important strategy to accelerate PrEP uptake.

SETTING

Partner Services PrEP study is a pilot, randomized, control trial to improve linkage to PrEP care among BMSM/TW presenting for network services in Chicago, IL, from 2015 to 2017.

METHODS

BMSM/TW (N = 146) aged 18-40 years were recruited from network services (partners services and social network strategy services). Intervention participants developed an individualized linkage plan based on the information-motivation-behavioral skills model and received minibooster sessions. Control participants received treatment as usual. Sociodemographic, behavioral, and clinical factors were examined at baseline and 3- and 12-month postintervention. Intent-to-treat analyses examined linkage to PrEP care within 3-month postintervention (primary outcome). Secondary outcomes were PrEP initiation, time to linkage to PrEP care, and time to PrEP initiation.

RESULTS

Compared with control participants, a significantly greater proportion of the intervention participants were linked to PrEP care within 3 months (24% vs. 11%; P = 0.04) and initiated PrEP (24% vs. 11%; P = 0.05). Among those linked to PrEP care within the study period, intervention participants were linked significantly sooner than control participants [median (interquartile range) days, 26.5 (6.0-141.8) vs. 191.5 (21.5-297.0); P = 0.05].

CONCLUSION

Study results support the preliminary efficacy of Partner Services PrEP to improve linkage to PrEP care and PrEP initiation among BMSM/TW.

A Longitudinal, Qualitative Exploration of Perceived HIV Risk, Healthcare Experiences, and Social Support as Facilitators and Barriers to PrEP Adoption Among Black Women

Black women contract HIV at much higher rates than White or Hispanic women. Pre-exposure prophylaxis (PrEP) is an underutilized prevention tool among this population. We sought to determine participants' interest in PrEP and facilitators and barriers to PrEP adoption. This longitudinal, qualitative study included 30 Black women (Mage = 32.2) interviewed 4 times over 6 months. Most participants had never heard of PrEP and a majority expressed initial interest. Barriers to PrEP initiation included low perceived HIV risk, medical mistrust, provider experiences and knowledge, negative reactions from family and friends, low perceived efficacy to adherence, and transportation. This study demonstrated actual, rather than hypothetical, PrEP interest and attitudes among Black women, and the barriers that arose over time during the study. PrEP awareness needs to be promoted among Black women and medical providers. Future research should address individual risk perception, medical mistrust, increasing social support, and decreasing transportation barriers.

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

Although pre-exposure prophylaxis (PrEP) could substantially reduce the risk of HIV acquisition among adolescent cisgender men who have sex with men (cisMSM), various barriers faced by people of color, particularly within the southern region of the U.S., may lead to racial disparities in the utilization of PrEP. Few studies, however, have explored racial/ethnic differences in PrEP use by geographic setting among adolescent cisMSM. We conducted a cross-sectional analysis examining racial disparities in PrEP use among cisMSM ages 15-24 years in New Orleans, Louisiana, and Los Angeles, California recruited between May, 2017 and September, 2019. The odds of PrEP use among AA adolescents were considerably lower than White adolescents in New Orleans (OR (95% CI): 0.24 (0.10, 0.53)), although we did not find evidence of differences in Los Angeles. Our findings underscore the need for targeted interventions to promote PrEP use among adolescent MSM, particularly among AA adolescent cisMSM living in the southern region of U.S.

Longitudinal trends in PrEP familiarity, attitudes, use and discontinuation among a national probability sample of gay and bisexual men, 2016-2018

This study explored familiarity with, attitudes toward, uptake and discontinuation of PrEP (Pre-exposure prophylaxis) among a national probability sample of gay and bisexual men. PrEP is one of the most effective biomedical HIV prevention strategies; however, use among gay and bisexual men remains low within the United States. This study used a national probability sample of gay and bisexual men from three age cohorts of men (18-25, 34-41, and 52-59 years at wave 1) who completed three annual surveys between March 2016 and March 2018 (N at wave 1 = 624). Recruitment occurred through a Gallup dual-frame sampling procedure; results for this study came from eligible individuals who consented to be part of the self-administered online or mailed survey questionnaire. We used descriptive data with sampling weights to understand trends in PrEP familiarity, PrEP attitudes and PrEP use across all three time points. Next, PrEP uptake and discontinuation were assessed among men completing all three surveys and who remained eligible for PrEP at all three time points (N = 181). PrEP familiarity increased considerably between 2016 and 2018 among those eligible for PrEP (from 59.8% from wave 1 to 92.0% at wave 3). Favorable attitudes toward PrEP increased more modestly (from 68.3% at wave 1 to 72.7% at wave 3). While PrEP use increased by 90% between the two time points (from 4.1% in 2016 to 7.8% in 2018), this represented a small percentage of overall uptake among eligible participants across time (6.6%). Among respondents who reported PrEP use at wave 1 or wave 2, 33.3% subsequently discontinued PrEP use at a later wave. Findings indicate modest increases in PrEP use between 2016 and 2018 in a national probability sample of sexually-active gay and bisexual men. PrEP discontinuation was high and suggests the need for further research into gay and bisexual men's PrEP discontinuation and persistence.

Utilizing emergency departments for pre-exposure prophylaxis (PrEP)

HIV incidence and prevalence rates in emergency departments (EDs) around the nation warrant strategies to protect and sustain the HIV negative status of persons who are at risk for HIV. The ED provides a rare opportunity to serve as a vehicle for connecting pre-exposure prophylaxis (PrEP)-eligible patients with clinical settings such as an ED that are knowledgeable and well informed about PrEP. PrEP has established efficacy at preventing HIV acquisition. The greatest challenge is access to PrEP and uptake thereof among vulnerable populations. We propose recommendations to improve the functionality of EDs as access points for PrEP referrals as an HIV prevention strategy to increase PrEP availability and uptake.

Student Education About Pre-exposure Prophylaxis (PrEP) Varies Between Regions of the United States

BACKGROUND

Daily, oral pre-exposure prophylaxis (PrEP) is an effective and safe prevention strategy for people at risk for HIV. However, prescription of PrEP has been limited for patients at the highest risk. Disparities in PrEP prescription are pronounced among racial and gender minority patients. A significant body of literature indicates that practicing healthcare providers have little awareness and knowledge of PrEP. Very little work has investigated the education about PrEP among health professionals in training.

OBJECTIVE

The objective of this study was to compare health professions students' awareness of PrEP and education about PrEP between regions of the US, and to determine if correlations between regional HIV incidence and PrEP use were present.

DESIGN

Survey study.

PARTICIPANTS

A cross-sectional sample of health professions students (N = 1859) representing future prescribers (MD, DO, PA), pharmacists, and nurses in the US.

KEY RESULTS

Overall, 83.4% of students were aware of PrEP, but only 62.2% of fourth-year students indicated they had been taught about PrEP at any time during their training. Education about PrEP was most comprehensive in the Northeastern US, the area with the highest PrEP to need ratio (4.7). In all regions, transgender patients and heterosexual men and women were least likely to be presented in education as PrEP candidates, and men who have sex with men were the most frequently presented.

CONCLUSIONS

There are marked differences in education regarding PrEP both between academic programs and regions of the USA.

Experiences of Pre-Exposure Prophylaxis (PrEP)-Related Stigma among Black MSM PrEP Users in Los Angeles

Black men who have sex with men (BMSM) are disproportionately affected by HIV infection in the USA. Pre-exposure prophylaxis (PrEP) is a proven efficacious biomedical prevention strategy with the potential to alter significantly the course of the epidemic in this population. However, the social stigma attached to PrEP and those who use it may act as a barrier to the uptake and continuation of PrEP among high-risk BMSM. In-depth, semi-structured qualitative interviews were conducted with 26 BMSM PrEP users to explore their experiences of stigma related to their PrEP use. BMSM reported multiple experiences or manifestations of PrEP-related stigma, which included (1) perception that PrEP users engage in elevated sexual risk behaviors; (2) conflicts in relationships attributed to PrEP; (3) experiences of discomfort or judgment from medical providers; (4) assumption that PrEP users are HIV-positive; and (5) gay stigma in families limiting PrEP disclosure. The experiences of stigma typically occur within the context of PrEP disclosure and have significant personal and social consequences for PrEP users. Efforts to address PrEP and other social-stigmas within the Black community may help facilitate PrEP uptake and continuation with BMSM.

HIV-Related Mistrust (or HIV Conspiracy Theories) and Willingness to Use PrEP Among Black Women in the United States

Uptake of pre-exposure prophylaxis (PrEP) among Black women living in the US is suboptimal. We sought to determine the association between HIV-related medical mistrust (or belief in HIV conspiracy theories) and willingness to use PrEP among Black women. We analyzed data from the 2016 National Survey on HIV in the Black Community (NSHBC), a nationally representative cross-sectional survey. Among NSHBC participants, 522 were women and 347 (69.0%) reported HIV risk factors. Only 14.1% were aware that PrEP exists; 30.8% reported willingness to use PrEP. HIV-related medical mistrust was reported by 60.4% of women. In multivariable analysis, controlling for income, education, marital status and health care engagement, belief in conspiracy theories was significantly associated with higher willingness to use PrEP. The HIV-Related Medical Mistrust Scale item: "there is a cure for HIV, but the government is withholding it from the poor" was independently associated with higher PrEP willingness. This finding speaks to the need for an improved understanding of the role of HIV-related medical mistrust among Black women to improve uptake of biomedical HIV prevention.

Role of Social and Sexual Network Factors in PrEP Utilization Among YMSM and Transgender Women in Chicago

Despite demonstrated efficacy, uptake of HIV pre-exposure prophylaxis (PrEP) remains low, particularly among high-risk demographics such as transgender women, Black men who have sex with men (BMSM), and young MSM (YMSM). Research thus far has largely focused on individual factors that may impede PrEP uptake in these demographics, leaving social network factors relatively unexplored. The present study used data collected from participants within RADAR, a longitudinal cohort study in Chicago focused on understanding the individual, dyadic, network, social, and biologic factors associated with HIV infection within YMSM. Of the 906 study participants who did not report an HIV diagnosis at baseline, 7.0% reported using PrEP in the prior 6 months. Recent PrEP use was associated with both individual-level (age and gender) and network-level factors (mean relationship strength, sexual network degree, etc.). These findings highlight the need to expand beyond focusing on individual-level drivers of PrEP uptake, as well as changing our understanding of who is most important within a network (centrality vs. strength of weak ties). Future work is needed to determine whether variables associated with PrEP uptake are similarly connected to PrEP adherence.

Intersectional social control: The roles of incarceration and police discrimination in psychological and HIV-related outcomes for Black sexual minority men

RATIONALE

Although Black gay, bisexual, and other sexual minority men face disproportionately high levels of incarceration and police discrimination, little research examines how these stressors may drive HIV and psychological health inequities among these men.

OBJECTIVE

In this study we examined associations between incarceration history, police and law enforcement discrimination, and recent arrest with sexual HIV risk, Pre-Exposure Prophylaxis (PrEP) willingness, and psychological distress among Black sexual minority men.

METHOD

Participants were a U.S. national sample of 1172 Black sexual minority men who responded in 2017-2018 to self-report measures of incarceration history, past year police and law enforcement discrimination, recent arrests, sexual HIV risk, PrEP willingness, and psychological distress. We used structural equation modeling to examine direct and indirect pathways from incarceration, police and law enforcement discrimination, and arrests to sexual HIV risk, PrEP willingness, and psychological distress.

RESULTS

Past-year police and law enforcement discrimination prevalence was 43%. Incarceration history was positively associated with later police and law enforcement discrimination, which, in turn, was positively associated with recent arrest. Incarceration and recent arrest and were associated with greater sexual HIV risk; incarceration and police and law enforcement discrimination were associated with lower PrEP willingness; and police and law enforcement discrimination was associated with higher psychological distress. Mediation analyses showed that the effects of incarceration were partially mediated by police and law enforcement discrimination.

CONCLUSION

Findings suggest police discrimination may be a mechanism of mass incarceration and fundamental driver of health inequities among Black sexual minority men.

The pre-exposure prophylaxis (PrEP) consciousness of black college women and the perceived hesitancy of public health institutions to curtail HIV in black women

BACKGROUND

Consistent use of Pre-Exposure Prophylaxis (PrEP), a biomedical intervention for HIV seronegative persons, has been shown to significantly decrease HIV acquisition. Black women are a viable population segment to consider for PrEP use as their HIV incidence is overwhelmingly higher than all other women groups.

METHODS

We developed and piloted a cultural- and age- appropriate PrEP education intervention to determine Black college women's: 1) perceptions of and receptivity to PrEP use; and 2) preferences for PrEP information delivery.

RESULTS

We recruited N = 43 Black college women. Most of our sample were sophomore and Juniors of whom identified as heterosexual (83%) and single (67%). Over 50% of young women had never been HIV tested and only 28% had been tested in the last 6 months; however, 100% of the women believed their HIV status was negative. Prior to participating in the study, most Black college women (67%) had not heard about PrEP and were unsure or apprehensive (72%) to initiate PrEP. The Black college women indicated that our educational intervention was extremely helpful (67%) for understanding and learning about PrEP. Post participating in our PrEP education module, regardless of delivery modality, participants reported being likely (62.55-70%) to initiate PrEP in the future.

CONCLUSIONS

Results indicate that Black college women would strongly consider PrEP when provided with basic knowledge, regardless of delivery modality. Participants also showed greater appreciation for in-person delivery and found it to be significantly more helpful and of greater quality for learning about PrEP; comprehension or perceived usefulness of PrEP-related content was relatively the same between groups. PrEP content delivery -- via in-person or online methods - is contingent on learning style and presentation.

TRIAL REGISTRATION

This study has been registered under the ISRCTN Registry as of July 6, 2020. The trial registration number is ISRCTN14792715 . This study was retrospectively registered.

Attitudes about community pharmacy access to HIV prevention medications in California

OBJECTIVE

Increasing access to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) is a high priority for the Ending the HIV Epidemic Initiative. Expanding access to PrEP and PEP through a variety of health care settings, including community pharmacies, may increase access in communities most in need. California is the first state to allow community pharmacists to furnish PrEP and PEP directly to consumers. Our objective was to assess attitudes among key stakeholders about a California policy to allow community pharmacists to furnish HIV PrEP and PEP.

METHODS

We conducted a qualitative case study with key pharmacy stakeholders. Semistructured phone interviews were audio-recorded and transcribed verbatim. We generated analytical memos for each interview and working with these analytical memos, we conducted a constant comparison across cases to identify commonalities and differences.

RESULTS

We launched the study in October 2018 and interviewed pharmacists (n = 7) working in a variety of settings, including retail-, clinic-, and community-based pharmacies. We also interviewed medical providers (n = 2) working in high-volume PrEP clinics and sought input from representatives of large retail chain pharmacies (n = 2). Overall, pharmacists and medical provider informants shared similar opinions about the central benefits as well as the key challenges related to pharmacist-delivered PrEP and PEP services. Benefits included: community pharmacists are widely accessible, PrEP and PEP protocols are similar to other preventative medications, policy may lead to efficiencies in the health care workforce, and community pharmacists are authorities on medication adherence. Challenges included: implementation issues may limit pharmacist involvement, and missed opportunities to diagnose and treat other health conditions.

CONCLUSION

This study characterizes the types of benefits and challenges that can be expected when PrEP and PEP prescribing privileges are extended to community pharmacists. This information may be useful to policymakers and other stakeholders considering legislation to permit direct prescription of PrEP and PEP by pharmacists.

Masculine ideology and Black men who have sex with men's interest in HIV pre-exposure prophylaxis (PrEP)

We examined how traditional masculinity and stigma surrounding HIV pre-exposure prophylaxis (PrEP) affect PrEP interest among Black men who have sex with men (BMSM). One hundred twenty-three men attending a Black Gay Pride event completed measures assessing traditional masculinity, PrEP stigma, and PrEP interest along with two behavioral measures of interest in PrEP. Results demonstrated that avoidance of femininity directly related to interest in PrEP and indirectly through conformity to heterosexual self-presentation. Further, PrEP stigma differentially moderated both of these relationships. Interventions designed to improve engagement of PrEP for BMSM should be attentive to traditional masculinity as a barrier.

Pre-Exposure Prophylaxis (PrEP) Awareness Is Low Among Heterosexual People of Color Who Might Benefit From PrEP in Philadelphia

Introduction: We assessed awareness of pre-exposure prophylaxis (PrEP) among HIV-negative Black and Latinx persons living in the Philadelphia Metropolitan Statistical Area. Methods: Using chi-square and Wilcoxon rank-sum tests, we analyzed data from the 2016 heterosexual cycle of the National HIV Behavioral Surveillance system to assess how sociodemographic factors, health care utilization, and risk behaviors affected PrEP awareness. Results: Participants (n = 472) were predominately Black, non-Hispanic (88.1%) with a median age of 41.5 years. Most participants reported having a usual source of medical care (92.1%) and seeing a medical provider within 12 months (87.0%). However, PrEP awareness was low in this sample (4.9%) and was lower among those who had a medical visit compared with those who had not (P < .01). Conclusion: Current Centers for Disease Control and Prevention clinical guidelines suggest that providers counsel high-risk patients about PrEP. Our data suggest that this is not happening with people of color in Philadelphia. Interventions targeting medical providers working with HIV-risk people of color may be appropriate.

The Impact of HIV Pre-Exposure Prophylaxis (PrEP) Counseling on PrEP Knowledge and Attitudes Among Women Seeking Family Planning Care

Background: Adult women account for >19% of all new HIV diagnoses in the United States, but receive only 7%-8% of new prescriptions for HIV pre-exposure prophylaxis (PrEP), and report low awareness of PrEP even within communities with high risk of HIV transmission. Family planning (FP) programs are a promising, underutilized setting for the provision of PrEP counseling to women, especially the 40% of women FP clients who receive no other form of health care. This study tested the feasibility of integrating routine PrEP counseling in a high-volume FP clinic with no previous PrEP experience. Materials and Methods: Trained FP counselors at a FP clinic in Philadelphia surveyed women about knowledge and attitudes related to PrEP, then provided a brief PrEP counseling intervention. After counseling, knowledge and attitudes were reassessed. In response to counselor requests, we developed the Women's PrEP Counseling Checklist (WPCC) tool to structure and standardize each counseling session. We then compared baseline and postintervention data among participants overall and in two cohorts: those receiving unguided counseling (initial design) and those receiving WPCC-guided counseling (enhanced design). Results: Both cohorts displayed significant (p < 0.0001) gains in PrEP knowledge and acceptability after counseling. Participants receiving WPCC-guided counseling reported higher knowledge scores postintervention (p = 0.031) and greater gains in PrEP acceptability (p = 0.000) than their peers receiving unguided counseling. Conclusions: Introducing PrEP counseling into routine FP care is feasible, and effectively improves knowledge and attitudes about PrEP within a large population of women, broadening access to PrEP on individual and population levels. The WPCC tool both enhances the impact of counseling on patients and reduces the work burden on providers.

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

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

The Relationship Between Perception of HIV Susceptibility and Willingness to Discuss PrEP With a Health Care Provider: A Pilot Study

HIV continues to be a significant public health concern and despite recent reductions in new HIV diagnoses, certain demographics continue to be disproportionality affected. Men who have sex with other men (MSM) account for the largest percentage of new HIV diagnoses; however, 24% of new diagnoses can be attributed to male-to-female sex, highlighting the need to explore the HIV epidemic beyond the narrow scope of MSM. A multivariate linear regression model was used to explore the perception of HIV susceptibility and level of comfort discussing pre-exposure prophylaxis (PrEP) with a health care provider among a sample of men living in the United States (n = 377). Men who had an increased perception of HIV susceptibility were significantly more likely to feel comfortable discussing PrEP with a health care provider. Men who distinguish themselves to be at increased risk of acquiring HIV were significantly more likely to report having either insertive or receptive condomless anal intercourse within the previous 3 months, while men who reported condomless vaginal intercourse perceived low HIV susceptibility. Never being screened for HIV was significantly associated with a perception of low HIV susceptibility compared to those men who had been screened in the previous year. Understanding how men perceive HIV susceptibility and engage with HIV prevention may help to improve HIV prevention efforts such as PrEP.

Associations Between Relationship Power and Pre-Exposure Prophylaxis (PrEP) Use Among Men Who Have Sex With Men

Few studies have attempted to understand relationship-level factors impacting PrEP utilization among men who have sex with men (MSM). This study examined associations between relationship power and PrEP use among 826 MSM participating in a cross-sectional, Internet-based survey. The results of our analysis indicate that decision-making dominance was positively associated with PrEP use among MSM, but the association between relationship control/overall relationship power and PrEP use was inconclusive. Furthermore, when examining specific types of decision-making dominance, equal and greater dominance compared to one's partner regarding types of sexual activity engaged in, as well as dominance more generally, were positively associated with PrEP use. However, the relationships between decision-making dominance related to condom use/sexual initiation and PrEP use were inconclusive. This study suggests that the promotion of egalitarian relationships-as well as other relationship-level determinants-should be an essential component of biobehavioral interventions targeting this population.

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

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

Barriers to linking high-risk jail detainees to HIV pre-exposure prophylaxis

Individuals involved in the criminal justice (CJ) system continue to be at disproportionate risk for HIV infection, and often have a greater prevalence of substance use and sexual related risk behaviors relative to their non-CJ involved peers. Pre-exposure prophylaxis (PrEP), a once daily antiretroviral medicine, is an evidence-based approach for reducing the risk of contracting HIV but limited data exist regarding the use of PrEP among CJ populations, especially in the U.S. South. This study was conducted at the Pulaski County Regional Detention Facility (PCRDF) in Little Rock, Arkansas (AR), the largest county jail in the state. We explored knowledge about PrEP and HIV, perceptions about PrEP feasibility in both the jail and community settings and barriers to PrEP program implementation, through in-depth qualitative interviews with 21 jail detainees. We purposively sampled individuals based on specific self-reported risk behavior, including sexual risk (both heterosexual and same-sex) and drug related risk (e.g. IDU), among all eligible individuals. We identified five primary themes from the interviews: 1) accessing healthcare during community reentry was a low priority; 2) perception of risk and interaction with people with HIV was low; 3) there are many barriers to disclosing HIV risk behaviors in jail settings; 4) knowledge of PrEP is low but willingness to use is high; and 5) multiple barriers exist to PrEP uptake post-release. Our findings are contextually unique and therefore have important implications for future implementation of PrEP access either within jail settings or linkage to PrEP post release.

Low Awareness of and Access to Pre-exposure Prophylaxis But High Interest Among Heterosexual Women in Cleveland, Ohio

Women received <5% of all US pre-exposure prophylaxis (PrEP) prescriptions in 2016. Among 351 heterosexual women surveyed in Cleveland, Ohio, 14.5% were aware of PrEP, 20.5% knew where to access PrEP, 75.9% were willing to try PrEP, and 50.9% expressed interest in more information.

Key barriers and enablers associated with uptake and continuation of oral pre-exposure prophylaxis (PrEP) in the public sector in Zimbabwe: Qualitative perspectives of general population clients at high risk for HIV

Background

Understanding the perspectives and preferences of clients eligible for pre-exposure prophylaxis (PrEP) is essential to designing programs that meet clients’ needs. To date, most PrEP programs in limited-resource settings have been implemented by partner organizations for specific target populations, but the government of Zimbabwe aims to make PrEP available to the broader population at substantial risk in public sector clinics. However, there is limited information on general population perspectives about PrEP in Zimbabwe.

Methods

A qualitative study was conducted to explore clients’ motivation to take or decline PrEP and continue or discontinue PrEP. Through a PrEP pilot in one urban family planning clinic and one rural youth center in Zimbabwe, 150 HIV-negative clients screened as being at high risk of HIV and were offered PrEP between January and June 2018. Sixty semi-structured interviews were conducted with clients who agreed to follow-up (including 5 decliners, all from the rural youth center, and 55 accepters, with 42 from the rural youth center and 13 from the urban family planning clinic). Interviews were conducted after either the first or second PrEP follow-up appointment or after the client declined PrEP. Interviews were audio recorded, de-identified, transcribed, and coded thematically.

Results

PrEP uptake was driven by risk perception for HIV, and in many cases, that risk was introduced by the unsafe behavior or HIV-positive status of a partner. Among sero-discordant couples (SDCs), the desire to safely conceive a child was also cited as a factor in taking PrEP. Clients who opted for PrEP preferred it to other forms of HIV prevention. SDCs reported decreased condom use after PrEP initiation and in some cases were using PrEP while trying to conceive a child. After initiating PrEP, clients had more confidence in their sexual relationships and less stress associated with negotiating condom use. Family and partner support was critical to starting and continuing PrEP, but some clients stopped PrEP or missed appointments due to side effects or logistical challenges such as transportation.

Conclusions

Results of this study can be used to provide operational guidance for national public sector roll-out of PrEP as part of combination HIV prevention in Zimbabwe. Based on feedback and experiences of clients, the training materials for health workers can be refined to ensure that health workers are prepared to counsel clients on the decision to start and/or continue PrEP and answer common client questions. Program advertisements should also be targeted with key messages that speak to client experiences.

Trial registration

Clinical Trial Registry Number: PACTR201710002651160.

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.

Area-level HIV risk and socioeconomic factors associated with willingness to use PrEP among Black people in the U.S. South

Purpose:

In the United States (U.S.), southern states have the highest HIV incidence. Uptake of pre-exposure prophylaxis (PrEP) has been slow among Black people, particularly in the South. We know little about how area-level HIV risk influences one's willingness to use PrEP.

Methods:

169 Black participants across 142 ZIP codes in the South completed the 2016 National Survey on HIV in the Black Community. We performed log-binomial regression to estimate the prevalence risk associated with residing in the upper 25th percentile of increases in new HIV diagnosis (2014–2015) within ZIP code and an individual's willingness to use PrEP, adjusting for individual and area-level covariates.

Results:

Participants were 68% female, mean age of 36 years, and 24% willing to use PrEP. Among the ZIP codes, 23% were within Atlanta, GA. The median increase in new HIV diagnoses was 25 per 100,000 population from 2014 to 2015 (IQR, 14–49). Participants living in ZIP codes within the upper 25th (compared-to-lower 75th) percentile of new HIV diagnoses were more willing to use PrEP (adjusted prevalence ratio (aPR) = 2.02, 95% CI = 1.06–3.86, P = .03). Area-level socioeconomic factors attenuated that association (aPR = 1.63, 95% CI = 0.78–3.39, P = .19).

Conclusions:

Area-level factors may influence PrEP uptake among Black people in the South.

Using HIV Risk Prediction Tools to Identify Candidates for Pre-Exposure Prophylaxis: Perspectives from Patients and Primary Care Providers

Clinical guidelines for HIV pre-exposure prophylaxis (PrEP) include risk prediction tools to identify appropriate candidates. We conducted a qualitative interview study to explore the potential acceptability, interpretation, and anticipated impact of such tools from the perspectives of men who have sex with men (MSM) and primary care providers (PCPs). Our purposive sample of English-speaking participants included: (1) MSM reporting HIV risk behaviors (n = 32; median age = 38 years; 53% non-Hispanic white; 22% high school degree or less education); (2) PCPs specializing in health care for MSM (n = 12); and (3) PCPs in general practice (n = 19). MSM participants questioned the ability of risk tools to predict HIV acquisition, and their perceptions of what might constitute a high HIV risk score varied widely. Many MSM participants believed that receiving a high score would prompt them to consider PrEP or other risk reduction strategies. Some believed that the data would be useful, particularly if discussed with their providers, whereas others anticipated feeling fear, anxiety, or mistrust. PCPs expressed more confidence in HIV risk prediction and imagined integrating tools with medical histories and their clinical judgment to assess risk. PCPs were most enthusiastic about adopting HIV risk prediction as a teaching tool to help patients visualize and reduce risk, their concerns about time constraints notwithstanding. In conclusion, our findings suggest that PCPs' views of HIV risk prediction tools are generally positive, whereas MSM participants' are more mixed. Given that both groups emphasized the value of contextualizing risk, shared decision making may be needed to implement HIV risk prediction tools effectively.