"A Gay Man and a Doctor are Just like, a Recipe for Destruction": How Racism and Homonegativity in Healthcare Settings Influence PrEP Uptake Among Young Black MSM

Experiences of Gender and Racial/Ethnic Discrimination in Sexual Healthcare Among Transgender and Nonbinary Young Adults of Color

PURPOSE

Experiences of gender-based discrimination against transgender and nonbinary people and racial discrimination against people of color in sexual healthcare settings serve as significant barriers to care. However, the sexual healthcare experiences of transgender young adults of color (TNYAC), who face intersecting forms of discrimination, are poorly understood.

METHODS

We conducted a qualitative analysis of semi-structured interviews (n = 20) with TNYAC ages 20-30 years, residing across the United States. Interviews, conducted via Zoom from September 2021 to January 2022, focused on recent sexual healthcare experiences and potential discrimination based on gender or race. Researchers double-coded and, guided by intersectionality theory, analyzed transcripts using thematic analysis.

RESULTS

Among 20 interviewees with diverse racial/ethnic identities (Black, Latine, Asian-American and Pacific Islander, and multiracial), we identified several themes. Participants described how interpersonal and systemic interactions related to their gender and race determined their sexual healthcare experiences, specifically experiences of gender discrimination, racial stereotyping, and racial segregation. Importantly, participants noted ways their sexual healthcare experiences were shaped by intersecting systems of both racial and gender oppression. Lastly, participants developed identity-affirming protective strategies to navigate discrimination, such as independent information seeking or choosing providers with shared gender and/or racial identities.

DISCUSSION

The use of protective strategies in response to racial and gender discrimination in sexual healthcare highlights both the resilience of TNYAC and the need for equitable and inclusive healthcare services. Healthcare providers and practices can implement interventions like cultural humility training and co-located services to improve care for those who experience multiple forms of oppression.

Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV - CDC Recommendations, United States, 2025

Nonoccupational postexposure prophylaxis (nPEP) for HIV is recommended when a nonoccupational (e.g., sexual, needle, or other) exposure to nonintact skin or mucous membranes that presents a substantial risk for HIV transmission has occurred, and the source has HIV without sustained viral suppression or their viral suppression information is not known. A rapid HIV test (also referred to as point-of-care) or laboratory-based antigen/antibody combination HIV test is recommended before nPEP initiation. Health care professionals should ensure the first dose of nPEP is provided as soon as possible, and ideally within 24 hours, but no later than 72 hours after exposure. The initial nPEP dose should not be delayed due to pending results of any laboratory-based testing, and the recommended length of nPEP course is 28 days. The recommendations in these guidelines update the 2016 nPEP guidelines (CDC. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV - United States, 2016. Atlanta, GA: US Department of Health and Human Services, CDC; 2017). These 2025 nPEP guidelines update recommendations and considerations for use of HIV nPEP in the United States to include newer antiretroviral (ARV) agents, updated nPEP indication considerations, and emerging nPEP implementation strategies. The guidelines also include considerations for testing and nPEP regimens for persons exposed who have received long-acting injectable ARVs in the past. Lastly, testing recommendations for persons who experienced sexual assault were updated to align with the most recent CDC sexually transmitted infection treatment guidelines. These guidelines are divided into two sections: Recommendations and CDC Guidance. The preferred regimens for most adults and adolescents are now bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine). However, the regimen can be tailored to the clinical circumstances. Medical follow-up for persons prescribed nPEP also should be tailored to the clinical situation; recommended follow-up includes a visit at 24 hours (remote or in person) with a medical provider, and clinical follow-up 4-6 weeks and 12 weeks after exposure for laboratory testing. Persons initiating nPEP should be informed that pre-exposure prophylaxis for HIV (PrEP) can reduce their risk for acquiring HIV if they will have repeat or continuing exposure to HIV after the end of the nPEP course. Health care professionals should offer PrEP options to persons with ongoing indications for PrEP and create an nPEP-to-PrEP transition plan for persons who accept PrEP.

Pre-exposure Prophylaxis Providers in Birmingham, Alabama, and New York City, New York, Identify Critical Barriers to Newer Pre-exposure Prophylaxis Strategies: A Mixed Methods Study

ABSTRACT

Young Black and Latino men who have sex with men are disproportionately affected by the U.S. HIV Epidemic, yet pre-exposure prophylaxis (PrEP) uptake remains low. To understand barriers and facilitators to PrEP uptake and persistence, we used a concurrent mixed methods design (quantitative: online surveys, n = 19; qualitative: individual interviews, n = 15) from providers (e.g., nurse practitioners, clinicians, and social workers) at 4 clinics providing PrEP services in Birmingham, Alabama and New York City. Although all providers were comfortable prescribing daily oral PrEP, they had concerns about on-demand PrEP (e.g., complex dosing schedule) and injectable PrEP (e.g., insurance barriers). Provider training is needed to address barriers to providing PrEP modalities beyond daily oral PrEP and increase uptake among young Black and Latino men who have sex with men. Additionally, in order to increase uptake of injectable PrEP, rising PrEP costs due to changes in the 340B Drug Pricing Program will need to be addressed.

Brief Report: Potential Gains in PrEP Coverage and Effect on Racial Disparities After Introduction of On-Demand and Long-Acting Injectable PrEP: Preferences of Men Who Have Sex With Men in the United States, 2021-2022

INTRODUCTION

There are persistent race- and ethnicity-based disparities in HIV incidence among gay and bisexual men who have sex with men (GBMSM) in the United States, partially driven by inequities in distribution of pre-exposure prophylaxis (PrEP). We assessed how additional modalities of PrEP beyond daily oral might affect the uptake of PrEP and ongoing disparities in HIV incidence in the United States.

METHODS

In an online survey of GBMSM in the United States, we presented participants with descriptions of each PrEP modality. Among GBMSM not willing to use daily oral PrEP, we assessed willingness to use on-demand or long-acting injectable (LA) PrEP. Among GBMSM using daily oral PrEP, we assessed willingness to switch to on-demand or LA PrEP.

RESULTS

Among GBMSM who were not willing to use daily oral PrEP, most were also not willing to use either on-demand or LA PrEP. In adjusted analyses, Hispanic/Latino, non-Hispanic/Latino Black, and non-Hispanic/Latino GBMSM of other races were more willing to use LA PrEP than non-Hispanic/Latino White GBMSM; none of the adjusted prevalence ratios was statistically significant. Most GBMSM currently taking daily oral PrEP reported a preference for staying on that regimen. Among those interested in switching, most were interested in on-demand PrEP.

CONCLUSIONS

Most GBMSM not willing to use daily oral PrEP are also not willing to use other modalities of PrEP; most GBMSM who are currently using daily oral PrEP prefer to continue using that dosing strategy. Our results suggest that differential preferences in modalities of PrEP will not exacerbate existing disparities in PrEP distribution or HIV incidence.

"Healthcare Doesn't Care": A Mixed-Methods Study on Healthcare Stigma and PrEP Use Among Black Sexual Minority Men

BackgroundPre-exposure prophylaxis (PrEP) is a critical tool for HIV-prevention, yet PrEP uptake among Black sexual minority men (BSMM) is relatively low, despite greater HIV vulnerability. Stigma in healthcare settings can be a substantial barrier to PrEP use among BSMM, with implications for the HIV epidemic. We used a sequential explanatory mixed-methods approach to assess quantitative relationships between anticipated healthcare stigma and reduced PrEP use among BSMM, and qualitatively explore stigmatizing experiences within healthcare settings among this population.MethodsWe utilized 2 data sources. First, cross-sectional data from a pilot sample of BSMM (n = 151) was collected in late 2020 in the United States. We tested for associations between healthcare stigma and PrEP use using modified Poisson regression. Subsequently, we selected participants (n = 23) from this sample in the D.C. metropolitan area for qualitative interviews starting in 2022; we used thematic analysis to investigate forms of experienced and anticipated healthcare stigma related to PrEP use.ResultsWe found 82% lower PrEP use associated with an interquartile range increase in anticipated healthcare stigma after adjustment (aPR = 0.18, 95% CI 0.06, 0.59). Subsequently, our qualitative investigation revealed that identity-specific stigma, negative socioeconomic assumptions, and assumptions of sexual risk were prevalent themes in the healthcare stigmatization experienced by BSMM. Identity-based and socioeconomic stigma were heavily interlinked due to longstanding structural racism and homophobia. Assumptions of sexual risk were particularly complex.ConclusionWe discovered a significant negative relationship between anticipated healthcare stigma and PrEP use, further elucidated in our qualitative findings. This builds upon our previous work exploring intracommunity PrEP stigma among BSMM. Healthcare stigma serves as an additional obstacle to accessing PrEP for BSMM. This highlights its importance as a target for provider-level health equity policy and research interventions. Future research exploring this stigma in specific healthcare settings is recommended.

Exploring Willingness to Use Long-Acting Injectable PrEP Among Sexual and Gender Minoritized People Accessing Pharmacies

This mixed-methods study explored willingness to use long-acting injectable pre-exposure prophylaxis (LAI-PrEP) among a pharmacy-based sample of men, including sexual and gender minoritized (SGM) individuals. We conducted qualitative interviews (n = 10) with HIV-negative Black men, including Black SGM individuals, and surveys (n = 103) across three study phases with men recruited from community pharmacies in Atlanta, Georgia. Interviews explored perceived benefits and concerns related to LAI-PrEP; surveys assessed willingness and related reasons. Thematic analysis was used for interview transcripts, and descriptive statistics summarized survey responses. Participants mentioned benefits such as improved adherence and reduced stigma, but also noted concerns about medical mistrust and fear of needles. Willingness was higher in the transitional pilot phase than in the pilot phase, where concerns about side effects and comfort were more common. Findings highlight the need for tailored LAI-PrEP strategies that address barriers among Black SGM populations and promote equitable HIV prevention.

Differences Among Current Pre-exposure Prophylaxis (PrEP) Users, Former Users, and Nonusers in a Community Sample in Two Midwestern U.S. Cities: Implications for Interventions to Promote PrEP Uptake and Adherence

Disparate rates of HIV infection among Black MSM and TGW emphasize the need for interventions designed to overcome obstacles to increasing PrEP adoption within these populations. This study compared PrEP-use groups on a variety of attitudinal and behavioral factors related to PrEP adoption. Regression analysis confirmed that current and former users demonstrated greater PrEP knowledge and communicated more frequently to friends about PrEP and its benefits than nonusers. Former users exhibited more positive attitudes and perceived less stigma regarding PrEP use than other groups. Current users reported the highest prevalence of condomless anal sex and multiple partners; conversely, former users were most often in stable monogamous relationships. Our findings are consistent with the notion of prevention-effective adherence and advance our understanding of attitudinal supports for that paradigm. This research also suggests that recruitment of former PrEP users could increase the pool of effective peer behavior-change agents in future intervention efforts.

Willingness to Use Oral and Long-Acting Injectable PrEP in Substance-Using Men who have Sex with Men (SU-MSM) in High HIV Incidence Southern U.S. Cities: A NIDA Clinical Trials Network Study

In Southern U.S. states with high HIV incidence and low HIV Pre-Exposure Prophylaxis (PrEP) uptake, enhanced efforts to increase interest in and willingness to use PrEP are needed. This implementation survey examined the associations of sociodemographic background, substance use, and sexual risk behaviors with willingness to use daily oral and long-acting injectable (LAI) PrEP among substance using men who have sex with men (SU-MSM). Participants were 225 SU-MSM recruited from sexually transmitted infection (STI) clinics, syringe services programs (SSPs), and substance use treatment programs (SUTPs) in eight Southern U.S. cities. Rates of willingness were high for both daily oral PrEP (78%) and LAI PrEP (66%). In multivariable analyses, distinct factors were associated with willingness towards each. For daily oral PrEP, greater willingness was associated with condomless anal sex, less frequent non-injection opioid use, prior PrEP awareness, and past use of PrEP. For LAI PrEP, greater willingness was associated with Black race, identifying as gay, being single, and higher injection drug use frequency. Lower willingness to use LAI PrEP was associated with higher non-injection opioid use frequency. Findings about willingness to use LAI PrEP, as a relatively newer modality, and greater willingness among Black SU-MSM as a disproportionately HIV-impacted population, are especially important. These findings argue for the necessity to enhance PrEP promotion efforts that distinguish between oral and LAI PrEP and that are specifically tailored to major SU-MSM subgroups in the Southern U.S.

A Study on How Libraries Operate as Health Spaces in the United States

A health space is any physical, social, or virtual space that supports building health literacy skills, promotes health behavior, preventive health, and wellbeing, or provides health care, health information, or health or social services. To move the needle on health, especially preventive health, a focus on non-traditional health spaces is critical. Libraries serve various community needs such as food distribution, health literacy, education, immunization, and health screenings. This study explores the extent to which libraries are equipped to function as a health space. A convergent mixed-methods approach was utilized; 234 library personnel were randomly recruited using data from the 2017 Public Libraries Survey to complete a survey and 24 semi-structured follow-up interviews were conducted. Our findings support that libraries function as a health space in multiple ways including providing important health and social programming and services to patrons. They help meet patron's health information needs by leveraging the expertise of community partners and incorporating valuable input from patrons in programming decisions. However, the capacity of libraries to carry out these health initiatives varies, in particular due to limited staff expertise in health-related topics and structural issues (e.g., funding). Our research emphasizes the need to integrate organizational health literacy attributes into library operations, specifically by (1) streamlining strategic partnerships with community experts in libraries in high-need areas to extend their limited resources, and (2) incorporating health literacy into missions and operations to draw necessary financial and personnel support to overcome salient challenges (i.e., funding and staff training).

Association Between Health Care Discrimination and Medical Mistrust Among Black Assigned Female at Birth Adults with Minoritized Sexual and Gender Identities in the United States

Purpose: Black sexually and gender minoritized (SGM) people who were assigned female at birth (AFAB) experience compounding health care inequities, barriers to equitable care, and disproportionately adverse health outcomes. Given prior literature indicating that both experienced and/or anticipated reported health care discrimination and medical mistrust may shape these health care experiences of Black SGM AFAB people, we sought to investigate the specific interplay between these two factors to bolster understanding of their relationship. Methods: In January and February 2023, we conducted a cross-sectional online survey of 156 Black SGM AFAB adults in the United States (U.S.) assessing their reported lifetime experiences of all-cause and gender-, race/ethnicity-, and weight-based discrimination in health care settings, in addition to their ratings of medical mistrust on the Medical Mistrust Index (MMI). Univariate statistics, analysis of variance, post hoc pairwise tests, and multivariable linear regression were conducted to assess measures of health care discrimination, medical mistrust, and covariates and their associations among the analytic sample (n = 130). Results: Most participants reported prior experiences of health care discrimination. Adjusting for demographic, socioeconomic, and health care factors, we identified an association between experiencing any-cause-, race/ethnicity-, or weight-based discrimination and significantly higher MMI scores. The association for gender-based discrimination was not statistically significant. Conclusion: Black SGM AFAB people who experience any-cause-, race/ethnicity-, or weight-based discrimination may be more likely to experience higher levels of medical mistrust. Identifying interventions and pathways to tackle health care discrimination and the systemic and structural drivers of medical mistrust will be critical to augmenting health care outcomes and experiences of Black SGM communities.

Sexual behavior stigma among cisgender gay, bisexual, and other men who have sex with men in nine NHBS cities across the United States: Burden and associations with PrEP continuum and HIV care continuum outcomes

In the United States (US), sexuality-based stigma continues to undermine HIV prevention and care efforts. We assessed sexual behavior stigma burden across family, healthcare, and social domains and determined associations with HIV-related outcomes among cisgender gay, bisexual, and other men who have sex with men (MSM) in nine US metropolitan statistical areas. MSM (N = 4,086) recruited at places of MSM social congregation via venue-based, time-sampling procedures completed a survey on sexual behavior stigma, PrEP (pre-exposure prophylaxis) continuum and HIV care continuum outcomes, sociodemographic characteristics, and other measures. We calculated prevalence and overall mean stigma subscale scores (range: 0.00-1.00) and used logistic and mixed effects logistic regression to determine stigma-HIV outcome associations. Most participants identified as gay, were employed, and were from West Coast cities; roughly 40% were non-Hispanic white, aged 25 to 34 years, and had completed some college. One in five were living with HIV. Family stigma (prevalence = 47.5%; mean = 0.36) was associated with greater odds of healthcare engagement, PrEP awareness, and PrEP use among HIV-negative MSM. Anticipated healthcare stigma (prevalence = 14.5%; mean = 0.11) was associated with lower odds of healthcare engagement, current ART (antiretroviral therapy) use, and viral load undetectability among MSM living with HIV. General social stigma (prevalence = 49.9%; mean = 0.20) was associated with greater odds of PrEP awareness and use among HIV-negative MSM and lower odds of current ART use among MSM living with HIV. Targeted stigma-mitigation in family, healthcare, and other social contexts remains paramount to ending the HIV epidemic in the US.

Racism, homophobia, and the sexual health of young Black men who have sex with men in the United States: A systematic review

Black gay, bisexual, and other men who have sex with men (BMSM) experience the highest rates of HIV acquisition annually out of any population in the United States, and young BMSM (YBMSM) are heavily impacted by this inequity as they enter adulthood. Despite a high annual HIV incidence, extant literature has found BMSM to engage in fewer sexual risk behaviors than White and Hispanic/Latino men who have sex with men, resulting in a gap between risk behaviors and the inequity of HIV infection. Structural factors, such as racism and homophobia, are thus being examined in order to understand this disconnect between behavior and HIV incidence. The purpose of this systematic review was to examine the discrimination experiences of YBMSM due to racism and homophobia in the United States and to evaluate the effect of these experiences on their sexual health. Four databases (MEDLINE, CINAHL Complete, APA PsycINFO, and Sociology Source Ultimate) were searched to examine the available qualitative, quantitative, and mixed method studies relevant to the research question. Out of 17 included studies, the majority were qualitative in design and were conducted in urban settings. Racism and homophobia affected YBMSM's sense of belonging, sexual identity, and sexual partnership choices. Often, masculinity would interact with these two constructs to impact how YBMSM engaged in sexual behavior, such as condomless sex, as well as their likelihood to seek sexual health care. Future research is needed to fully understand the relationships between discrimination and sexual health to develop effective structurally responsive interventions that will help decrease the inequities experienced by YBMSM.

Understanding Intentions to Discuss Long-Acting Injectable Pre-Exposure Prophylaxis with Healthcare Providers Among Black and Hispanic Gay and Bisexual Men in Texas

We examined factors influencing the intention of Black and Hispanic gay and bisexual men aged 18-34 years in Texas to discuss starting long-acting injectable pre-exposure prophylaxis (LAI-PrEP) with healthcare providers. Participants were recruited through geosocial apps and community locations, completed online surveys measuring attitudes, subjective norms, perceived behavioral control (Theory of Planned Behavior), internalized homophobia, medical mistrust, HIV risk, and medical mistrust. Among the final sample (N = 190), 63.5% intended to discuss LAI-PrEP. Poisson regression models indicated that higher attitudinal concerns [adjusted prevalence ratio (aPR): 0.80, 95% confidence interval (CI): 0.70, 0.92; P < 0.01) and higher medical mistrust (aPR: 0.98, 95% CI: 0.97, 0.99; P = 0.01) were linked to lower prevalence of intentions. Seeing a doctor in the past 12 months was associated with higher prevalence of discussing LAI-PrEP (aPR: 1.46, 95% CI: 1.00, 2.13; P = 0.05). Addressing concerns and reducing discrimination are crucial for improving LAI-PrEP uptake in this population.

Determinants of Potential HIV Vaccine Uptake Among Young Sexual Minoritized Men 17-24 Year Old

BACKGROUND

Failures in prior rollout of HIV prevention efforts have widened disparities in HIV incidence by race/ethnicity among young sexual minoritized men (YSMM). We hypothesized greater perceptions of medical mistrust would be associated with lower willingness to get an HIV vaccine, mediating the relationship between race/ethnicity and willingness to accept a future HIV vaccine.

METHODS

HIV-negative and unknown-status YSMM 17-24 years old (n = 229) recruited through social media and men-for-men networking apps completed online surveys from September 2021 to March 2022. Participants were asked about demographics, medical mistrust (health care-related sexual orientation stigma, health care-related race stigma, global medical mistrust, and trust in health care providers), and willingness to accept a future HIV vaccine.

RESULTS

Vaccine willingness was highest among White YSMM (96.0%) and lower among Black (71.0%), Latino (83.6%), and multiracial or another race/ethnicity YSMM (80.0%). Even after accounting for medical mistrust constructs as mediators, compared with White participants, Black participants had lower odds of being willing to accept a future HIV vaccine. Participants with greater trust in health care providers had higher odds of willingness to accept a future HIV vaccine.

DISCUSSION

Gaps in willingness to get an HIV vaccine are evident among YSMM by race/ethnicity, indicating potential further widening of disparities in HIV incidence when a vaccine becomes available without intervention.

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

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

Effects of Online Friendships on Safer Sex Communication and Behavior among Black Sexual Minority Men: A Study of Network Exposure

This study draws on social normative and social learning theories to examine the masspersonal safer sex communication (i.e., Facebook posts about safer sex) and safer sex behavior (i.e., condom use) in a cohort of Black sexual minority men (BSMM) (N = 340), with an eye toward understanding their relationship with the safer sex communication and behaviors of their BSMM Facebook friends. Using linear network autocorrelation regression models, results showed that BSMM's safer sex communication and condom use behavior were each associated with the communication and behavior of their online peers. Specifically, BSMM's condom use was positively associated with their friends' condom use and friends' safer sex communication, and BSMMs' safer sex communication was positively associated with friends' safer sex communication. Moreover, contrary to prior research, BSSM's safer sex communication and condom use were not related to one another, suggesting that talking about safer sex on social media should not be interpreted to be an indication of engageDment in safer sex behavior. These findings underscore an opportunity to leverage peer influence in social media networks, particularly in the form of masspersonal communication, to encourage cascades of safer sex messaging among peers and adoption of safer sex behavior.

"It's just as remarkable as being left-handed, isn't it?": exploring normativity through Australian physiotherapists' perspectives of working with LGBTQIA+ patients

INTRODUCTION

Individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual and other related identities (LGBTQIA+) experience challenges with healthcare, including physiotherapy. To understand potential contributions to poor experiences, this study explored physiotherapists' experiences and perspectives about working with members of LGBTQIA+ communities.

METHODS

This study employed a qualitative research design, suitable for exploring the experiences and perspectives of individuals within the physiotherapy context. The sample consisted of physiotherapists working in Australia who participated in a larger survey study. Data were collected via semi-structured interviews which were audio-recorded and transcribed verbatim. Data analysis was conducted using a relativistic and queer theoretical framework with a reflexive thematic approach.

RESULTS

Eighteen physiotherapists with diverse sexual orientations participated in the interviews. While all participants identified as women or men, not all used binary gender pronouns. Five key themes were developed: 1) "anti-discrimination" regarding choice of language and providing safe environments; 2) "current and historical discrimination" against LGBTQIA+ individuals; 3) "taking an equality approach" when working with LGBTQIA+ patients; 4) "knowledge of LGBTQIA+ health" in a broad sense and specifically with transgender and gender-diverse people; and 5) "managing own reactions" with respect to individual biases and discomfort.

CONCLUSION

Underpinning all themes was the overarching concept of cis/hetero/endonormativity. Assuming normativity when working with LGBTQIA+ patients, is likely to have negative effects on patients' mental health, the therapeutic relationship and quality of care. In order to improve diversity, safety, inclusion and equity of care for LGBTQIA+ individuals, it is vital that normativity within physiotherapy is challenged.

"That's My Girl; I love her": The Promise of Compassionate, Inclusive Healthcare for Black Transgender Women to Support PrEP Use

There are significant disparities in HIV pre-exposure prophylaxis (PrEP) use that disproportionately impact Black transgender women. Medical mistrust and discriminatory experiences in healthcare settings have been identified as critical barriers to equitable PrEP implementation. This qualitative study examines Black transgender women's experiences in healthcare to better understand how patient-provider relationships can help overcome the challenges brought on by medical mistrust. We interviewed 42 Black transgender women about their experiences with healthcare and PrEP access. Data were analyzed using inductive thematic content analysis to develop the following themes: (1) historical and ongoing marginalization and exclusion from healthcare remains a barrier to PrEP use; (2) Many providers continue to be unprepared to prescribe PrEP; (3) Providers can act as important advocates and sources of support; and (4) Compassionate, trusting patient-provider relationships can facilitate PrEP use. Our results highlight the importance of supportive and positive patient-provider relationships and demonstrate how providers can build trusting relationships with Black transgender women to help overcome barriers to healthcare and PrEP use.

Demographic, socioeconomic, and health structure factors associated with the use of HIV pre-exposure prophylaxis in Brazil: A nationwide ecological study

Aims: To assess the cumulative rate of HIV Pre-Exposure Prophylaxis (PrEP) users in Brazil since its 2018 implementation and to analyze the association between PrEP usage and state-level structural factors. Methods: A nationwide ecological study from 2018 to 2022 was conducted, examining the 5-year cumulative rate of PrEP users in relation to demographic, socioeconomic, and healthcare infrastructure variables. Multiple linear regression analysis identified significant predictors of PrEP utilization. Results: Between 2018 and 2022, 124,796 individuals used PrEP, with a cumulative rate of 61.5 per 100,000 population. The highest usage was in Minas Gerais, São Paulo, and Santa Catarina, while the lowest was in Distrito Federal, Maranhão, and Alagoas. Regression analysis showed that higher PrEP usage was associated with lower population density, a younger median age, a lower male to female ratio, and reduced social vulnerability. Additionally, PrEP usage was positively associated with the density of medical doctors and the number of dispensing units. Conclusions: The study reveals significant regional disparities in PrEP usage across Brazil, influenced by socioeconomic and healthcare factors. It highlights the need for targeted public health strategies to enhance PrEP access and uptake, especially in socially vulnerable regions.

Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care

BACKGROUND

Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings.

OBJECTIVE

To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs.

DESIGN

Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018.

PARTICIPANTS

The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City.

APPROACH

Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts.

KEY RESULTS

Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers.

CONCLUSIONS

SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.

Factors associated with PrEP use in a community sample of African American men who have sex with men (MSM) and transgender women (TGW) in the United States Midwest

Black sexual minority men who have sex with men (MSM) in the United States are at disparate risk for contracting HIV infection, but pre-exposure prophylaxis (PrEP) use is suboptimal. Social network methods were used to recruit a community sample of racial minority MSM and transgender women (TGW) in two Midwestern US cities. 250 PrEP-eligible (HIV-negative) participants completed measures assessing current and intended PrEP use; demographic characteristics; PrEP knowledge, attitudes, norms, stigma, and self-efficacy; and structural barriers to PrEP. Multivariate analyses established predictors of current and intended PrEP use. Only 12% of participants reported currently using PrEP, which was associated with greater PrEP knowledge and not having a main partner, with trends for greater PrEP use by younger participants and those with partners living with HIV. Among participants not currently on PrEP, strength of PrEP use intentions was associated with higher PrEP knowledge, PrEP descriptive social norms, and PrEP use self-efficacy. This study is among few to directly compare Black who have adopted PrEP with those who have not. Its findings underscore the potential benefits of employing social network approaches for strengthening PrEP use peer norms, increasing PrEP knowledge and self-efficacy, and optimizing PrEP uptake among racial minority MSM and TGW.

Men who have sex with men experience low anxiety and few barriers to performing anal self or companion examinations: a qualitative study of the Prevent Anal Cancer Palpation Study

While rare in the larger population, anal cancer incidence is significantly higher in groups such as sexual minority men and people living with HIV. This qualitative analysis examined participants' experiences and perceptions of barriers to anal self-examination and anal companion examination through interviews completed as a part of a larger clinical trial. Interviews were conducted online with participants (n = 131) within a week of their baseline appointment between January 2020 and October 2021. Content analysis denoted participants' thoughts and perceptions about anal self-examination and anal companion examinations. Of the 131 cisgender men interviewed (mean age 49.9 years, SD 12.7), 92.4% identified as gay, 54.9% identified as white, 22.1% identified as Black, 19.9% identified as Latino, and 44.3% of participants were living with HIV. Participants did not report feelings of excessive anxiety when an abnormality was detected. However, three salient themes emerged as to why participants may not perform an anal self-examination or anal companion examination: (1) physical limitation(s), (2) potential sexualisation of the examination, and (3) level of comfort discussing anal health. Future work must continue to explore methods that not only decrease stigma surrounding anal health but also bolster feelings of accessibility to perform self and couple examinations.

A Multicomponent Intervention (POSSIBLE) to Improve Perceived Risk for HIV Among Black Sexual Minority Men: Feasibility and Preliminary Effectiveness Pilot Study

BACKGROUND

Increased pre-exposure prophylaxis (PrEP) use is urgently needed to substantially decrease HIV incidence among Black sexual minority men. Low perceived risk for HIV (PRH) is a key unaddressed PrEP barrier for Black sexual minority men. Peers and smartphone apps are popular intervention tools to promote community health behaviors, but few studies have used these together in a multicomponent strategy. Therefore, we designed a multicomponent intervention called POSSIBLE that used an existing smartphone app called PrEPme (Emocha Mobile Health, Inc) and a peer change agent (PCA) to increase PRH as a gateway to PrEP.

OBJECTIVE

This paper aims to describe the feasibility and preliminary impact of POSSIBLE on PRH and willingness to accept a PrEP referral among Black sexual minority men.

METHODS

POSSIBLE was a theoretically guided, single-group, 2-session pilot study conducted among Black sexual minority men from Baltimore, Maryland between 2019 and 2021 (N=69). POSSIBLE integrated a PCA and the PrEPme app that allows users to self-monitor sexual risk behaviors and chat with the in-app community health worker to obtain PrEP service information. PRH was assessed using the 8-item PRH scale before and after baseline and follow-up study visits. At the end of each study visit, the PCA referred interested individuals to the community health worker to learn more about PrEP service options.

RESULTS

The average age of participants was 32.5 (SD 8.1, range 19-62) years. In total, 55 (80%) participants were retained for follow-up at month 1. After baseline sessions, 29 (42%) participants were willing to be referred to PrEP services, 20 (69%) of those confirmed scheduled appointments with PrEP care teams. There were no statistically significant differences in PRH between baseline and follow-up visits (t122=-1.36; P=.17).

CONCLUSIONS

We observed no statistically significant improvement in PRH between baseline and month 1. However, given the high retention rate and acceptability, POSSIBLE may be feasible to implement. Future research should test a statistically powered peer-based approach on PrEP initiation among Black sexual minority men.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04533386; https://clinicaltrials.gov/study/NCT04533386.

A qualitative exploration of how to support PrEP adherence among young men who have sex with men

New HIV infections disproportionately affect young men who have sex with men (YMSM). PrEP is effective in preventing HIV acquisition; however, adherence is critical and is often suboptimal among YMSM. Interventions addressing the unique PrEP adherence challenges faced by YMSM are needed. We conducted qualitative interviews with 20 HIV-negative, YMSM (ages 15-24) with a PrEP indication and 11 healthcare professionals to inform adaption of a PrEP adherence intervention (Life-Steps for PrEP) for YMSM. We explored environmental, healthcare, and individual factors influencing uptake, adherence, attitudes, and perspectives (including desired modifications) on the Life-Steps intervention. Interviews were analyzed using content analysis. Of YMSM study participants (mean age 21.6) 55% were White, 15% Hispanic, and 5% Black. Most YMSM were PrEP-experienced (70%). Healthcare professionals (6 prescribers, 1 nurse, 2 health educators, 2 other/unspecified) averaged 6.9 years of experience caring for YMSM. All described stigma as a barrier to PrEP; YMSM expressed concern around being perceived as "risky" and concern about inadvertent PrEP disclosure if family/friends found their medication, or if parental insurance was used. Difficulty with planning for potential adherence challenges were identified by both groups. YMSM highlighted benefits of a nurse-led intervention (i.e., adding "legitimacy"), but stressed need for nonjudgmental, "savvy" interventionists. YMSM expressed a desire for comprehensive YMSM-specific sexual health information. These findings informed modification and expansion of Life-Steps content. Results highlight key potential barriers, many of which center around privacy. Content that addresses PrEP stigma, disclosing PrEP use, navigating insurance, and planning ahead in a nonjudgmental environment by trusted providers emerged as important components of a YMSM-focused delivery of Life-Steps for PrEP.

A Scripted, PrEP-Using Peer Change Agent Improves Perceived Risk for HIV and Willingness to Accept Referrals Quickly Among Black Sexual Minority Men: Preliminary Findings from POSSIBLE

PrEP use remains suboptimal among Black sexual minority men (SMM) partly due to low perceived risk for HIV (PRH). This study describes baseline results of POSSIBLE, a multicomponent pilot intervention including a peer change agent (PCA) to increase PRH among Black SMM. POSSIBLE was a theoretically guided two-session, single-group feasibility intervention in Baltimore, MD conducted between 2019 and 2021 (N = 69). Baseline study visits involved a 20-minute session with a PrEP-using PCA who used a motivational interview-based script to discuss participants' lifestyles, goals, and values, HIV risk behaviors, and PRH and tailor communication to encourage PrEP use. Bivariate analyses were conducted to assess differences in PRH before and after baseline sessions along with the correlates of PrEP referral willingness. A total of 75% of participants identified as gay; 73% were employed; 84% reported having insurance; 78% were single; 51% reported ever being diagnosed with an STI. Baseline results showed a statistically significant improvement in PRH after the first session (t=-3.09; p < .01). Additionally, 64% were willing to be referred to PrEP care after baseline; 45% of whom made a PrEP appointment. PRH was not associated with referral willingness. However, receptive anal intercourse in the previous 6 months was statistically significantly associated with referral willingness. Findings suggests that a scripted PCA could independently improve PRH among Black SMM quickly. The person-centered nature of the scripted PCA could be key to improving PrEP use among a highly marginalized and elusive community.

Willingness to Use Long-Acting Injectable PrEP Among PrEP Naïve Black and Hispanic Sexual Gender Minority Persons

In December 2021, long-acting injectable pre-exposure prophylaxis (LAI-PrEP) was approved for the prevention of HIV in at-risk adults and adolescents. LAI-PrEP may address adherence issues of daily oral daily PrEP and PrEP stigma. However, studies assessing LAI-PrEP willingness among PrEP naive Black and Hispanic sexual and gender minority (SGM) persons- a group disproportionately impacted by the HIV epidemic in the United States - is rare. To assess the extent of and characteristics of willingness to use LAI-PrEP in a national sample of Black and Hispanic SGM who are self-reported that they have never used PrEP. We analyzed data from a national sample of Black and Hispanic SGM collected between March and August 2020. We used log-binomial regression models to assess characteristics associated with willingness to use LAI-PrEP. Of the overall sample (N = 380), the mean age was 24 (SD = 2.8) and the majority of the sample (54%, n = 205) reported willingness to use LAI-PrEP. In multivariable log-binomial regression models, PrEP stigma was independently associated with less [prevalence ratio (PR) = 0.7, 95% confidence interval (CI) = 0.6, 0.9], while number of sexual partners in the past 12 months was associated with a more willingness to use LAI-PrEP (PR = 1.1, 95% CI = 1.0, 1.2). Our findings highlight the persistence of PrEP stigma as a potential barrier to willingness to use LAI-PrEP in this sample of Black and Hispanic SGM who have never used PrEP. Additional work needs to be done to reduce PrEP stigma more broadly.

Perceptions of bias in HIV prevention services, happiness with social support, and anticipated PrEP stigma among Black and Latine/x sexual and gender diverse individuals

Although pre-exposure prophylaxis (PrEP) is a highly effective preventive treatment for HIV, anticipated PrEP stigma can hinder uptake. Perceptions of bias in HIV prevention and evaluations (e.g., happiness) tied to social support among Black and Latine/x sexual and gender diverse (SGD) individuals could be important correlates of anticipated PrEP stigma. To further this line of inquiry, a national sample of 872 Black and Latine/x SGD individuals who had and had never taken PrEP (Mage = 25.1, SD = 2.8) reported how they perceived HIV prevention and how happy they were with their social support. Multivariable linear regressions revealed that greater perceptions of bias in HIV prevention services were associated with higher anticipated PrEP stigma among Black and Latine/x SGD individuals who have never taken PrEP. Greater happiness with friend support was associated with lower PrEP stigma, whereas greater happiness with family support was associated with higher PrEP stigma among individuals who have taken PrEP. Findings highlight the need for PrEP and HIV interventions to address the intersectional stigma attached to prevention and for researchers to understand how evaluations of social support may contribute to stigma among Black and Latine/x SGD individuals.

Evaluating the Impact of an Adolescent Sexuality Education Workshop on Medical Student Communication in an Objective Structured Clinical Examination

PURPOSE

Gaps still exist in medical education about the sexual health needs of sexual diverse populations, and little is known about how translatable current learning modules are to patient encounters. Efforts at an academic medical institution have been made to address this need, including a two-hour adolescent sexuality workshop during the Core Clerkship in Pediatrics. This workshop's efficacy was evaluated in an objective structured clinical examination (OSCE) given to rising fourth-year medical students, where the standardized patient case focused on an adolescent cisgender male with dysuria and in a new, same-sex relationship.

METHODS

Performance of students who completed the workshop prior to the OSCE (n = 48) were compared to those of students who did not participate in the workshop prior to the OSCE (n = 17). The encounters were recorded and transcribed, and the deidentified transcripts were scored on a rubric focusing on five domains: sexual identity disclosure, behavioral assessment, psychosocial history, counseling and anticipatory guidance, and relationship building.

RESULTS

Student's t-test comparison of the scores found significantly higher scores for the psychosocial history domain (p = .04), particularly concerning disclosure of a new boyfriend and recent sexual activity (p = .008), for students who had the workshop before the OSCE.

DISCUSSION

Students who took the adolescent sexuality workshop performed better in gathering psychosocial information in an OSCE encounter a sexual minority adolescent. These results affirm prior work that active learning on sexual diverse health in medical school curricula may prepare students for effective engagement with adolescents exploring their sexuality.

The Effects of Previous Experiences of Healthcare Discrimination on HIV Intervention Outcomes

Although several healthcare interventions have been developed to address HIV among young Black/African American men who have sex with men (YBMSM), the HIV epidemic in the United States continues to disproportionately burden this population. The current study examines previous healthcare discrimination and how it affects HIV intervention delivery. One hundred seventy-two YBMSM participated in the Peer Promotion of Wellness and Enhanced Linkage to Resources (PPOWER) project, which used a short, multi-faceted, community-level intervention based on Community Peers Reaching Out and Modeling Intervention Strategies (Community PROMISE). Data were collected at baseline, a 45-day follow up, and a 90-day follow up. Generalized Estimating Equations (GEE) were used to examine the effects of previous healthcare discrimination on outcomes related to HIV testing, alcohol and drug use, and sexual behaviors. Previous healthcare discrimination was found to moderate the relationship between time and intentions to test for HIV, perceptions of sexual risk, problem marijuana use, and problem other drug use, such that those who had experienced more healthcare discrimination showed greater improvements over time compared to those who had experienced less healthcare discrimination. The results of the current study suggest that a community-level peer intervention, in combination with a component to promote cultural competency and address prior experiences of discrimination in healthcare settings, may be highly effective for people who have experienced a barrier in their continuum of care as a result of racial discrimination.

Knowledge about HIV-Related Services Among Young Blacks with Diverse Sexual Identities: an Intra-racial Analysis

Given the disproportionate representation in HIV/AIDS cases among young Black members of the LGBTQIA community, it is important to continue to identify both their ability to assess the knowledge that can foster healthier sexual outcomes as well as dynamics that may foster or undermine their efforts. The goal of this study is to examine whether 236 young Black persons ages 18-30 years old who are members of the LGBTQIA community know where to go locally to locate healthcare services to combat HIV/AIDS and other sexually transmitted health issues. Quantitative findings show the influence of self-identified sexual identity, age, and place of residence on knowledge about HIV-related services. The implications of these results illustrate the possible effects of place and identity development on knowledge about HIV-related services that can affect life chances and quality of life for certain members of this community.

Intersectional Microaggressions, Sexual Identity Concealment, and Mental Health of Young Black Sexual Minority Men and Transgender Women

Previous research has demonstrated associations between experiences of microaggressions and negative mental and physical health outcomes, and national organizations such as the Centers for Disease Control and Prevention have acknowledged racism as a public health issue. Individuals with multiple marginalized identities, such as young Black men who have sex with men and transgender women, are commonly affected by discrimination and stigma, contributing to health disparities. One possible path by which microaggressions are linked to negative health outcomes for these groups is their impact on individuals' decisions to conceal their sexual identity, in some cases leading to increased stress and use of maladaptive coping strategies. We surveyed 280 young Black male (86%) and transgender or non-binary (14%) individuals between the ages of 16-25 years old (M = 21.68, SD = 2.73) who reported being recently sexually active with men about their experiences with intersectional microaggressions, concealment of their sexual identity, psychological distress, and substance use before and during sexual activity. Structural equation modeling revealed that experiences of microaggressions were associated with greater sexual identity concealment, and concealment partially mediated the relationship between microaggressions and psychological distress. While microaggressions were associated with greater substance use, sexual identity concealment did not mediate this relationship. Findings have implications for addressing health disparities among this population.

Initial Development and Validation of the Brief Internalized Heterosexist Racism Scale for Gay and Bisexual Black Men: A Measure of Internalized Heterosexist Racism

We introduce internalized heterosexist racism (IHR), or the internalization of damaging stereotypes, harmful beliefs, and negative attitudes about being a sexual minority person of color. We also present the initial development and validation of the Brief Internalized Heterosexist Racism Scale for gay and bisexual Black men (IHR-GBBM), a unidimensional, 10-item measure of IHR. Exploratory factor analyses on an internet-obtained sample of gay and bisexual Black men (N = 312; Mean age = 30.36 years) show that the IHR-GBBM had evidence of good internal consistency, and good convergent, discriminant, concurrent, and incremental validity. The IHR-GBBM was positively correlated with internalized racism, internalized heterosexism, and discrimination (racist, heterosexist). IHR was also negatively correlated with race stigma consciousness, weakly positively correlated with sexual identity stigma consciousness, but not correlated with either race identity, sexual identity, or social desirability. Hierarchical regressions showed that the IHR-GBBM explained an additional variance of 2.8% and 3.1% in anxiety symptoms and substance use coping, respectively, after accounting for (1) sociodemographics, (2) internalized racism and internalized heterosexism, and (3) an interaction of internalized racism and internalized heterosexism. Older participants and those who were "out" about their sexual identity reported lower IHR. Those who did not know/want to report their HIV status reported greater IHR. Results revealed no sexual identity, sexual position, relationship status, income, education, or employment status differences in IHR. We hope the development of the IHR-GBBM spurs future research on predictors and consequences of IHR. We discuss limitations and implications for the future study of internalized heterosexist racism.

Black Sexual Minority Men's Experiences in MPowerment Interventions: Implications for HIV Prevention

BACKGROUND

Black sexual minority men (BSMM) are disproportionately vulnerable to HIV acquisition; the MPowerment model is one community-based framework for preventing HIV in this population. It focuses on developing a supportive network of peers to promote health messaging, reduce stigma, and improve resilience. While these interventions have demonstrated general success, there are important challenges related to race, sexuality, and internalized stigma. Our study aimed to explore these experiences among BSMM in MPowerment models focused on HIV prevention.

METHOD

We conducted 24 qualitative interviews of BSMM attending HIV prevention-related MPowerment events in the greater D.C. Metropolitan area. In-depth interviews were conducted via phone, and interviews were analyzed using thematic analysis.

RESULTS

We identified four themes from the transcript analysis process: Black queer intersectional social support and community, HIV-related information and destigmatization, social status, and sexuality. Within each of these themes, we identified relationships with overall HIV prevention messaging, including barriers to PrEP use. Barriers related to social status were especially prevalent and described as unique to the D.C. metropolitan area.

CONCLUSION

Overall, MPowerment event spaces provide a forum for BSMM to feel safe and supported while gaining important HIV-related knowledge and prevention access. Challenges related to social status and destigmatization of sexuality are important considerations in designing and implementing this model, especially related to PrEP promotion.

Barriers to engagement with testing for sexually transmitted infections within a UK-based young adult Black Caribbean community: a qualitative study

BACKGROUND

The Black Caribbean population have a disproportionately high burden of sexually transmitted infections (STIs) compared with other ethnic groups. The aim of this study was to explore barriers to engagement with STI testing within a UK-based young adult Black Caribbean community.

METHODS

Semi-structured interviews were carried out with 14 young adults from the Black Caribbean community and six sexual healthcare professionals. Data were analysed thematically. A focus group of five young adults was conducted to refine themes.

RESULTS

Data analysis generated three themes: (1) culturally embedded stigma; (2) historically embedded mistrust; and (3) lack of knowledge. Perceived as 'dirty', particularly for females, infection with STIs was stigmatised by religious conceptions of 'purity' and shame. This presented challenges in terms of cultural acceptability of talking about STI testing with partners, friends, and family. Legacies of colonialism, medical racism and malpractice compromised young people's trust in medical intervention and confidentiality of data management. A lack of knowledge related to STIs and their treatment, and in how to access and perform STI tests further served as a barrier. Culturally tailored interventions targeting these factors and delivered by radio, podcasts and social media were highlighted as having potential to improve engagement with STI testing.

DISCUSSION

Engagement with STI testing by young adults from the Black Caribbean community is impacted by historically and culturally embedded teachings, practices and beliefs inherited through generations. Targeting these factors within culturally tailored interventions may be effective for increasing STI-testing, and thus reducing rates of STI-infection in this population.

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

AIM

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

BACKGROUND

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

DESIGN

Qualitative meta-synthesis with meta-aggregation.

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Experiences of Successful PrEP Uptake Among Adolescent Sexual Minority Men in the United States: A Qualitative Exploration

Male adolescent sexual minorities are at elevated risk of HIV acquisition yet demonstrate low rates of PrEP uptake. Understanding the experiences of adolescents who have successfully accessed PrEP may inform ways to best support adolescents seeking PrEP. Adolescent sexual minorities (N = 100) who reported utilizing PrEP responded to open-ended items asking about their initial PrEP experiences and advice for others. Qualitative analysis suggested that adolescents' ability to access PrEP is influenced by managing parental involvement and seeking culturally competent health care providers. Additionally, they reported how the benefits and drawbacks of taking PrEP played a role in their PrEP use. Findings suggest that educational PrEP interventions targeted at this population could improve uptake by incorporating discussions on side effects and mental health benefits associated with PrEP use. Structural interventions are warranted that improve adolescents' ability to seek sexual health care independently and make room for parental involvement when adolescents could benefit from their support.

The Inherent Violence of Anti-Black Racism and its Effects on HIV Care for Black Sexually Minoritized Men

The goal of this study was to examine the effects of racial discrimination, depression, and Black LGBTQ community support on HIV care outcomes among a sample of Black sexually minoritized men living with HIV. We conducted a cross-sectional survey with 107 Black sexually minoritized men living with HIV in Chicago. A path model was used to test associations between racial discrimination, Black LGBTQ community support, depressive symptoms, and missed antiretroviral medication doses and HIV care appointments. Results of the path model showed that men who had experienced more racism had more depressive symptoms and subsequently, missed more doses of HIV antiretroviral medication and had missed more HIV care appointments. Greater Black LGBTQ community support was associated with fewer missed HIV care appointments in the past year. This research shows that anti-Black racism may be a pervasive and harmful determinant of HIV inequities and a critical driver of racial disparities in ART adherence and HIV care engagement experienced by Black SMM. Black LGBTQ community support may buffer against the effects of racial discrimination on HIV care outcomes by providing safe, inclusive, supportive spaces for Black SMM.

Location Preferences for Accessing Long-Acting Injectable Pre-Exposure Prophylaxis (LA-PrEP) Among Men Who Have Sex With Men (MSM) Currently on Daily Oral PrEP

We investigated men who have sex with men's (MSM) location preferences for long-acting injectable pre-exposure prophylaxis (LA-PrEP). MSM (n = 1076) who completed the 2021 American Men's Internet Survey, were currently prescribed oral PrEP, and expressed LA-PrEP interest reported location preferences for receiving LA-PrEP: healthcare provider (HCP) setting, pharmacy, or at-home. HCP settings were preferred by 60% of participants; 26% preferred home and 14% preferred pharmacy. In adjusted models, high healthcare stigma was associated with preferring pharmacy and at-home versus HCP, while high friends/family stigma was associated with preferring HCP settings versus pharmacy. Healthcare access history was associated with preference for HCP setting versus home. Being 25 to 29 or 30 to 29 years old versus 40+ was associated with preferring HCP versus home. Private insurance was associated with location preferences. Findings support the need for multiple LA-PrEP service locations to best reach MSM and highlight multiple complex factors that influence such preferences.

COVID-19, Vaccine Hesitancy, and HIV Pre-exposure Prophylaxis Among Black Sexual Minority Men

BACKGROUND

The COVID-19 pandemic has created substantial and profound barriers to several forms of health care engagement. For Black sexual minority men, this may include engagement with pre-exposure prophylaxis (PrEP) to prevent HIV infection, with significant implications for HIV disparities. Our study explored how the COVID-19 pandemic affected Black sexual minority men, with a focus on relationships between COVID-19 and PrEP engagement.

SETTING

We sampled 24 Black sexual minority men attending HIV prevention-related events in the greater D.C. Metropolitan area (D.C., Maryland, Virginia).

METHODS

We conducted qualitative phone interviews among our sample. Questions were primarily focused on the COVID-19 pandemic and how it affected engagement and considerations of PrEP use. Interviews were transcribed and qualitatively analyzed using the 6 stages of thematic analysis.

RESULTS

We identified 3 major themes from our thematic analysis: Changes in the health care system, changes in sexual and relationship contexts, and COVID-19 vaccine hesitancy and misinformation. Relationships between COVID-19 vaccine hesitancy and PrEP hesitancy were especially prevalent, with participants describing that COVID-19 hesitancy can directly deter PrEP use through eroding medical trust further.

CONCLUSIONS

We identified changes in the health care system, sexual and relationship contexts, and COVID-19 vaccine hesitancy as important issues driven by COVID-19 with significant implications for PrEP use. The COVID-19 pandemic has changed the health care and social landscape in profound ways that affect PrEP access, sexual networks, and associated HIV vulnerability. Future research further exploring relationships between specific pandemic stressors and HIV prevention among Black sexual minority men is recommended .

Acceptability and Effectiveness of a One-Hour Healthcare Provider Intervention Integrating HIV Pre-Exposure Prophylaxis and Cultural Competence Training

Enhanced provider training could improve PrEP access and equity. We conducted a pilot randomized controlled trial comparing (a) a one-hour, group-based provider intervention integrating PrEP and Cultural Competence (PCC) training with (b) a standard HIV continuing medical education session (n = 56). PCC participants favorably rated the intervention and reported increased PrEP knowledge. The PCC intervention increased their confidence performing PrEP-related clinical activities and intention to prescribe PrEP. The percentage of participants discussing PrEP with patients increased marginally in both study conditions. The percentage of participants who prescribed PrEP and self-rated cultural competence did not change in either study condition.

The impact of social connections and discrimination to HIV risk among Asian gay and bisexual men in Australia

BACKGROUND

Asian gay, bisexual, and other men who have sex with men (GBMSM) are overrepresented in new HIV diagnoses in Australia. Social engagement with other GBMSM has been associated with HIV testing and pre-exposure prophylaxis (PrEP) uptake. Asian GBMSM may be socially disconnected from LGBTQ+ people, which may increase their HIV risk. This analysis assessed the contribution of social connection on HIV risk among Asian GBMSM.

METHODS

Using an online cross-sectional survey of Asian GBMSM in Australia, we measured condomless anal intercourse (CLAI) in the last 6months without PrEP or an undetectable viral load (UVL), i.e. CLAI with a risk of HIV transmission. Bivariable and multivariable logistic regression models were performed to compare demographic characteristics and social engagement of participants who had CLAI without PrEP or UVL to those who had not. Analyses were restricted to participants who reported sex with casual partners in the last 6months.

RESULTS

Among 509 participants who had casual partners in the last 6months, 151 (29.7%) reported CLAI without PrEP or UVL. CLAI without PrEP or UVL was negatively associated with full-time employment, and recently being tested for HIV and was positively associated with experiencing discrimination based on sexual orientation. Social engagement with LGBTQ+ people was not associated with CLAI without PrEP or UVL.

CONCLUSIONS

CLAI without PrEP or UVL was not related to social connections with LGBTQ+ people but was more likely among Asian men who had experienced sexuality-related discrimination, suggesting that mitigating homophobia and biphobia may assist in improving HIV prevention among Asian GBMSM who live in Australia.

Opportunities to Increase Access to HIV Prevention: Evaluating the Implementation of Pharmacist-Initiated Pre-exposure Prophylaxis in California

Background

Pharmacies are a promising setting through which to expand access to human immunodeficiency virus (HIV) prevention, including pre-exposure and post-exposure prophylaxis (PrEP and PEP, respectively). We aimed to evaluate and inform the implementation of California's Senate Bill 159 (2019), allowing pharmacists to independently prescribe PrEP and PEP.

Methods

From October through December 2022, we conducted a cross-sectional study of 919 California pharmacists and pharmacy students, primarily recruited via the email listservs of professional organizations. Participants completed an online survey assessing the implementation of pharmacist-initiated PrEP/PEP, including knowledge, attitudes, practices, perceived barriers, and implementation preferences elicited through a discrete choice experiment.

Results

Among 919 participants (84% practicing pharmacists, 43% in community pharmacies), 11% and 13% reported that pharmacists at their pharmacy initiate PrEP and PEP, respectively. Most believed that pharmacist-initiated PrEP/PEP is important (96%) and were willing to provide PrEP (81%); fewer (27%) had PrEP/PEP training. Common implementation barriers were lack of staff/time and payment for pharmacist services. Participants preferred PrEP implementation models with in-pharmacy rapid oral HIV testing and pharmacists specifically hired to provide PrEP services.

Conclusions

Despite pharmacists' supportive attitudes, Senate Bill 159 implementation in California pharmacies remains limited, in part due to policy-level and organizational-level barriers. Ensuring PrEP/PEP-related payment for services and sufficient workforce capacity is key to leveraging pharmacists' role in HIV prevention.

Friends as Informal Educators: The Role of Peer Relationships in Promotion of Sexual Health Services among College Students

This ethnographic study of one United States university's sexual health resources explores the role of peer relationships in sexual health promotion to understand how these relationships shaped students' interactions with campus sexual health resources. Through analysis of seventeen semi-structured interviews with students, five policy interviews with providers and university personnel, and participant-observation of peer health educator training, the authors examine how trust in peer relationships can serve as a form of social capital to influence sexual health information sharing. The article introduces the term "peer administrator" to describe student actors who sit at the intersection of friend and official resource and explores the importance of these mentoring relationships for sexual health promotion. The analysis also considers how more individualistic models of public health promotion limit the impact of peer relationships and concludes with a discussion of how universities might imagine new forms of sexual health promotion among students.

HIV pre-exposure prophylaxis: It is time to consider harm reduction care for adolescents in Canada

Youth (aged 15 to 29 years) account for one quarter of new HIV cases in Canada. Of those, men-who-have-sex-with-men make up one third to one half of new cases in that age range. Moreover, Indigenous youth are over-represented in the proportion of new cases. The use of emtricitabine/tenofovir disoproxil fumarate as pre-exposure prophylaxis (PrEP) significantly reduces the risk of HIV acquisition in adults. Its use was expanded to include youth over 35 kg by the U.S. Food and Drug Administration in 2018. However, PrEP uptake remains low among adolescents. Prescriber-identified barriers include lack of experience, concerns about safety, unfamiliarity with follow-up guidelines, and costs. This article provides an overview of PrEP for youth in Canada, and its associated safety and side effect profiles. Hypothetical case vignettes highlight some of the many demographics of youth who could benefit from PrEP. We present a novel flow diagram that explains the baseline workup, prescribing guidelines, and follow-up recommendations in the Canadian context. Additional counselling points highlight some of the key discussions that should be elicited when prescribing PrEP.

Cultural discourses and HIV/AIDS activists' meanings about PrEP

Since the approval of pre-exposure prophylaxis (PrEP) for HIV prevention in 2012, research has increasingly considered how communities of men who have sex with men make sense of this prevention technology, often highlighting individual-level attitudes about PrEP. Drawing on interviews with 16 HIV activists, this study aimed to determine how activists make sense of advances in HIV prevention technology. Participants' sense-making about PrEP took the form of not merely the expression of individual attitudes, but rather reflections connected to their personal biographies and activist experience. Activists sustain seemingly contradictory discourses about PrEP, at once drawing on personal biographies and a discourse central to activist history to express scepticism about PrEP, but also other discourses to justify pharmaceutical intervention for prevention. Study findings provide evidence of the importance of attending to past and present cultural discourses when examining health advocacy groups' constructions of advances in science.

Effectiveness, Acceptability, and Feasibility of a Telehealth HIV Pre-Exposure Prophylaxis Care Intervention Among Young Cisgender Men and Transgender Women Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Despite its promise for HIV prevention, the uptake of pre-exposure prophylaxis (PrEP) has been slow, and there have been substantial inequities in PrEP access. Young men who have sex with men and transgender women of color are most in need of PrEP and least likely to have that need fulfilled. PrEP telehealth care, which provides remote PrEP care via electronic communication, seems well suited to address several of the challenges of PrEP provision, including discomfort with stigmatizing and difficult-to-access health care systems, transportation challenges, and privacy concerns, and address disparities in PrEP access. Research suggests that PrEP telehealth care has promise and is a favored option for many prospective recipients of PrEP. However, despite growing attention to telehealth approaches as an avenue for increasing access to PrEP amidst the COVID-19 pandemic, there have been no published randomized controlled trials (RCTs) on PrEP telehealth care to date, making it difficult to draw strong conclusions about the advantages or disadvantages of telehealth compared with usual PrEP care. We developed PrEPTECH, a telehealth intervention that focuses specifically on alleviating issues of stigma, access, cost, and confidentiality for young people with risk factors for HIV infection who are seeking PrEP care. Leveraging data from the 2017 observational pilot study, we redesigned and enhanced PrEPTECH.

OBJECTIVE

This study aims to assess the effectiveness, acceptability, and feasibility of a telehealth HIV PrEP care intervention, PrEPTECH, in increasing PrEP uptake.

METHODS

This is the protocol for an RCT of young cisgender men and transgender women who have sex with men in 4 regions within the United States: the San Francisco Bay Area, California; Los Angeles County, California; Miami-Dade County, Florida; and Broward County, Florida. Participants in the intervention arm received access to a web-based telehealth program, PrEPTECH, which offers a fully web-based pathway to PrEP, whereas those in the control arm received access to a dynamic web page containing publicly available informational resources about PrEP. Follow-up data collection occurred at 3 and 6 months. An analysis will be conducted on outcomes, including PrEP initiation, persistence, adherence, coverage, and medication prescription, as well as PrEPTECH acceptability and feasibility.

RESULTS

The study was funded in 2019 and received institutional review board approval in 2020. The PrEPTECH intervention was developed over the next 1.5 years. Study recruitment was launched in February 2022 and completed in September 2022, with 229 participants recruited in total. Data collection was completed in April 2023.

CONCLUSIONS

The results of this RCT will offer valuable evidence regarding the effectiveness, acceptability, and feasibility of telehealth HIV PrEP care interventions among young cisgender men and transgender women who have sex with men.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04902820; https://clinicaltrials.gov/ct2/show/NCT04902820.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47932.

Are we ready for a sustainable approach? A qualitative study of the readiness of the public health system to provide STI services to the key populations at risk of HIV in Bangladesh

INTRODUCTION

In Bangladesh, sexually transmitted infection (STI) services are available for all populations in public health facilities. However, STI services for key populations (KPs) at risk of HIV need specifically designed approaches that are predominantly administered to KPs through donor-supported service centers operated by non-government organizations (NGOs) and community-based organisations (CBOs). However, the steady decline in donor funding warrants a sustainable transition of STI services for the KPs into public health facilities. This article aimed to explore the service availability and readiness of public health facilities to provide STI services for the KPs.

METHODS

This qualitative study explored the service availability and readiness of public health facilities in three districts of Bangladesh by adapting the Service Availability and Readiness Assessment tool. We conducted 34 in-depth interviews,11 focus group discussions with KPs, and 29 key-informant interviews with healthcare providers, researchers, programme implementers and policy planners, in addition to series of direct observations at the public healthcare facilities. Data were analysed through thematic analysis, and categorised in relation to the WHO building blocks.

RESULTS

This study revealed that the public health system was generally not ready to serve the KPs' needs in terms of providing them with quality STI services. The 'service delivery' component, which is the most crucial facet of the public health system, was not ready to provide STI services to KPs. Findings also indicated that health workforce availability was limited in the primary and secondary healthcare layers but adequate in the tertiary layer, but needed to be oriented on providing culturally sensitised treatment. Counseling, an essential component of STI services, was neither ready nor available. However, health information systems and a few other components were partially ready, although this warrants systematic approaches to address these challenges.

CONCLUSION

The findings show that public health facilities are yet to be fully ready to render STI services to KPs, especially in terms of service delivery and human and health resources. Therefore, it is not only integral to mobilize communities towards the uptake of public health services, but health systems need to be prepared to cater to their needs.

Individual and Health System Factors for Uptake of Pre-exposure Prophylaxis Among Young Black and Latino Gay Men

BACKGROUND

Young Black and Latino men who have sex with men (YBLMSM) have the highest rates of new HIV infections in the USA and use PrEP at lower rates than White MSM.

OBJECTIVE

To explore YBLMSM's perspectives and experiences of PrEP use to identify factors enabling or impeding uptake.

DESIGN

Qualitative study using semi-structured interviews conducted between August 2015 and April 2016.

PARTICIPANTS

Black and Latino MSM, 18-20 years of age, who live, socialize, or work in the Bronx, and were fluent in English or Spanish.

APPROACH

We used a thematic analysis to identify themes related to not taking PrEP and PrEP uptake.

KEY RESULTS

Half the participants (n = 9) were currently using PrEP, a majority had Medicaid (n = 13), all reported having a PCP, all identified English as their primary language (n = 15), and all identified as gay. Salient themes included concerns over-side effects, stigma related to HIV and sexuality, mistrust of medical providers, provider's refusal to prescribe PrEP, and insurance and cost.

CONCLUSIONS

Modifiable barriers for PrEP uptake and persistence were reported by most participants, with an emphasis on PrEP misinformation and the pervasiveness of intersectional stigma, providers' low awareness, and hesitant attitudes towards PrEP and barriers created by insurance companies. Supportive infrastructures for PrEP providers and patients are needed.

Use of geofencing interventions in population health research: a scoping review

OBJECTIVES

Technological advancements that use global positioning system (GPS), such as geofencing, provide the opportunity to examine place-based context in population health research. This review aimed to systematically identify, assess and synthesise the existing evidence on geofencing intervention design, acceptability, feasibility and/or impact.

DESIGN

Scoping review, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance for reporting.

DATA SOURCES

PubMed, CINAHL, EMBASE, Web of Science, Cochrane and PsycINFO for articles in English published up to 31 December 2021.

ELIGIBILITY CRITERIA

Articles were included if geofencing was used as a mechanism for intervention delivery.

EXCLUSION CRITERIA

(1) a component or combination of GPS, geographical information system or ecological momentary assessment was used without delivery of an intervention; (2) did not include a health or health-related outcome from the geofencing intervention; or (3) was not a peer-reviewed study.

DATA EXTRACTION AND SYNTHESIS

Several researchers independently reviewed all abstracts and full-text articles for final inclusion.

RESULTS

A total of 2171 articles were found; after exclusions, nine studies were included in the review. The majority were published in 5 years preceding the search (89%). Geofences in most studies (n=5) were fixed and programmed in the mobile application carried by participants without their input. Mechanisms of geofencing interventions were classified as direct or indirect, with five studies (56%) using direct interventions. There were several different health outcomes (from smoking to problematic alcohol use) across the five studies that used a direct geofencing intervention.

CONCLUSIONS

This scoping review found geofencing to be an emerging technology that is an acceptable and feasible intervention applied to several different populations and health outcomes. Future studies should specify the rationale for the locations that are geofenced and user input. Moreover, attention to mechanisms of actions will enable scientists to understand not only whether geofencing is an appropriate and effective intervention but why it works to achieve the outcomes observed.

Sexual Orientation, HIV Vulnerability-Enhancing Behaviors and HIV Status Neutral Care Among Black Cisgender Sexual Minority Men in the Deep South: The N2 Cohort Study

Black sexual minority men (SMM) in the Deep South are heavily impacted by HIV; yet studies fail to consider discordance across aspects of sexual orientation (i.e., identity, attraction, behavior) or how a lack of concordance enhances vulnerability to HIV. We sought to explore the overlap across aspects of sexual orientation and examine associations between each aspect and the number of sexual partners who engaged in HIV vulnerability-enhancing behaviors, and HIV prevention and care outcomes. A total of 204 Black SMM completed surveys, reporting their sexual identity, attraction, and behavior (i.e., sex with men only vs. sex with men and women), number of condomless sex or transactional sex (e.g., buyers vs. sellers) partners in the past 6 months, and adherence to pre-exposure prophylaxis (PrEP) or antiretroviral therapy (ART) among users. Less than one in four participants (22.5%) reported overlap in same-sex sexual orientations, while 17.1% of bisexual men reported overlap across aspects. In multivariable models, differences were found in how aspects of sexual orientation were associated with the number of partners who bought or sold sex; as well as how often participants tested for HIV in the past 12 months. Results suggest different aspects of sexual orientation have implications for addressing HIV among Black SMM in the Deep South.