A novel approach to HIV prevention: understanding multi-level influences on HIV pre-exposure prophylaxis (PREP) uptake and outreach among African Americans.

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This dissertation examined and provided basis for addressing factors related to HIV pre-exposure prophylaxis (PrEP) engagement, outreach, and uptake among high-risk African American youth groups in Louisville, KY. This qualitative dissertation study was designed through the lens of an interpretive framework of social constructivism which holds that multiple realities and interpretations exist and are socially constructed through the lived experiences of individuals and their interactions with others. Thus, lived experiences of various African American youth groups in Louisville as well as key informants of AIDS service organizations (ASOs) across the U.S. (including Louisville) were explored to develop a deeper understanding of the barriers and facilitators to PrEP engagement, outreach, and uptake among African American youth priority groups. Seven chapters delineate the dissertation path. Chapter one provides a background and introduces the research problem and study rationale. Chapter two presents a detailed review of the literature; provides a focused overview of the epidemiologic landscape of HIV among African Americans in the U.S. as well as in Kentucky; influences on PrEP uptake among African Americans; and gaps in the literature. Chapter three outlines the methods utilized to answer the various research questions. Chapters four, five, and six each function as distinct manuscripts addressing the various research questions. Findings revealed multi-level/multifaceted factors influencing PrEP-use among African Americans. These include intrapersonal factors (PrEP awareness/knowledge, perceived HIV risk and PrEP need, fears/reservations about PrEP, and acceptability of PrEP), interpersonal relationships, sociocultural issues (stigma, homophobia, and homonegativity), and systemic and structural factors (such as cost of PrEP medication, insurance coverage, availability and accessibility of PrEP, and responses to PrEP engagement strategies of AIDS service organizations). Strategies and lessons learned from a national sample of ASOs informed the development of a context specific framework for successfully implementing PrEP outreach among African American groups. This dissertation addresses gaps in literature by utilizing findings to create a framework that serves as recommendations for other ASOs, including Louisville ASOs, seeking to improve PrEP service delivery and outreach among African American priority groups.