Designing a novel peer-based decision aid to address perceived risk for HIV and PrEP interest among Black sexual minority men.

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

Black sexual minority men (SMM) are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a medication that reduces HIV acquisition. There is a gap in our understanding of the acceptability of and preference for on-demand and long-acting injectable (LAI)-PrEP among PrEP-eligible Black SMM. This study aimed to explore preference for on-demand and LAI-PrEP and reasons for those preferences among HIV-negative Black SMM of different PrEP use profiles (current PrEP users, current non-PrEP users, and PrEP discontinuers). Between March 2022 and April 2023, we conducted 17 focus group discussions (FGDs) with a total of 58 HIV-negative (current PrEP users, non-PrEP users, and PrEP discontinuers) Black SMM residing in the Washington D.C.metropolitan area. We explored acceptability and interest in on-demand and LAI-PrEP and anticipated barriers and facilitators to uptake. Two key themes emerged around interest and preferences for on-demand PrEP and LAI-PrEP: 1) lack of interest in on-demand PrEP, and 2) high acceptability of LAI-PrEP. The reasons for lack of interest in on-demand PrEP were: 1) inability to accurately anticipate and plan for sexual activity in advance, 2) uncertainty about effectiveness of on-demand PrEP, and 3) potential for unnecessary medication use, especially when anticipated sexual activity doesn't occur. Most participants finding LAI-PrEP to be highly acceptable can be attributable to: 1) LAI-PrEP being convenient, and 2) LAI-PrEP being a potential solution to suboptimal adherence to daily oral PrEP due to forgetfulness. While daily oral PrEP is the most utilized PrEP modality, some SMM-who might not be acceptable to oral PrEP-are capable of accurately identifying specific periods and circumstances for HIV infection. It is important that healthcare providers present on-demand PrEP as an option to individuals who fall into these categories. Programs to increase awareness and knowledge of LAI-PrEP among Black SMM and HCP that serve them are needed. Additionally, it is imperative that HCP who provide PrEP services receive proper training on the administration of LAI-PrEP and that there is dedicated staff to help clients navigate the insurance coverage process.

BackgroundBlack sexual minority men (SMM) are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a medication that reduces HIV acquisition. There is a gap in our understanding of the acceptability of and preference for on-demand and long-acting injectable (LAI)-PrEP among PrEP-eligible Black SMM. This study aimed to explore preference for on-demand and LAI-PrEP and reasons for those preferences among HIV-negative Black SMM of different PrEP use profiles (current PrEP users, current non-PrEP users, and PrEP discontinuers).MethodsBetween March 2022 and April 2023, we conducted 17 focus group discussions (FGDs) with a total of 58 HIV-negative (current PrEP users, non-PrEP users, and PrEP discontinuers) Black SMM residing in the Washington D.C. metropolitan area. We explored acceptability and interest in on-demand and LAI-PrEP and anticipated barriers and facilitators to uptake.ResultsTwo key themes emerged around interest and preferences for on-demand PrEP and LAI-PrEP: 1) lack of interest in on-demand PrEP, and 2) high acceptability of LAI-PrEP. The reasons for lack of interest in on-demand PrEP were: 1) inability to accurately anticipate and plan for sexual activity in advance, 2) uncertainty about effectiveness of on-demand PrEP, and 3) potential for unnecessary medication use, especially when anticipated sexual activity doesn’t occur. Most participants finding LAI-PrEP to be highly acceptable can be attributable to: 1) LAI-PrEP being convenient, and 2) LAI-PrEP being a potential solution to suboptimal adherence to daily oral PrEP due to forgetfulness.DiscussionWhile daily oral PrEP is the most utilized PrEP modality, some SMM—who might not be acceptable to oral PrEP—are capable of accurately identifying specific periods and circumstances for HIV infection. It is important that healthcare providers present on-demand PrEP as an option to individuals who fall into these categories. Programs to increase awareness and knowledge of LAI-PrEP among Black SMM and HCP that serve them are needed. Additionally, it is imperative that HCP who provide PrEP services receive proper training on the administration of LAI-PrEP and that there is dedicated staff to help clients navigate the insurance coverage process.

Pre-exposure prophylaxis (PrEP) has the potential to transform HIV in young Black and Latinx sexual minority men (SMM) and transgender women (TW). Addressing low PrEP uptake in this population depends on the better understanding of barriers to PrEP use. This article uses an ecological framework to explore barriers to daily oral PrEP in a sample of young Black and Latinx SMM and TW in three geographically prioritized cities in the United States. In-depth interviews were completed with 33 young Black and Latinx SMM and TW (22 at risk for and 11 recently diagnosed with HIV), aged 17-24, participating in a randomized trial aimed at increasing PrEP and antiretroviral therapy (ART) uptake and adherence. Interviews were recorded and transcribed, and then analyzed using inductive and deductive coding. Coded transcripts were organized into individual, interpersonal, community, and structural categories, by PrEP use and HIV status. Among participants, nine reported having been prescribed PrEP, with five actively or recently taking PrEP, whereas only one participant diagnosed with HIV had been prescribed PrEP. Major themes related to barriers emerged across the individual, family, community, and structural level. Limited barriers related to partners, instead partners with HIV encouraged PrEP use. Participants commonly reported low perceived HIV risk, fear of disclosure, barriers relating to insurance/cost, and medication use as reasons for nonuse of PrEP. For youth to remain on a healthy life course, HIV preventative measures will need to be adopted early in adolescence for those at risk of HIV acquisition. Interventions need to simultaneously address multilevel barriers that contribute to nonuse in adolescents. Clinical trials registry site and number: ClinicalTrials.gov Identifier: NCT03194477.

Black sexual minority men (BSMM) remain disproportionately affected by HIV, yet Pre-exposure prophylaxis (PrEP) uptake in this population remains relatively low. Informed by minority stress theory, PrEP stigma may manifest in and exacerbate societal marginalization based on sexuality and race. We used an exploratory sequential mixed-methods approach to determine if PrEP-specific stigma was associated with reduced PrEP uptake among BSMM, and qualitatively explored how PrEP use is stigmatized among BSMM. We analyzed cross-sectional data from a pilot sample of BSMM (n = 151) collected in late 2020 in the United States, testing for associations between PrEP stigma and PrEP use using modified Poisson regression. Subsequently, we selected participants (n = 23) from this sample for qualitative interviews starting in 2022. Responses to questions related to PrEP stigma were analyzed using thematic analysis. PrEP stigma was associated less than half the PrEP use (aPR = 0.43, 95% CI = 0.24, 0.75) among BSMM after adjustment. Qualitatively, we identified three major themes in how PrEP use is stigmatized among BSMM: PrEP-specific sexual stigma, intersections between PrEP and HIV stigma, and PrEP misinformation and disinformation. Aligned with minority stress theory, each theme was based in part in stigma related to sexuality or race. We found strong relationships between PrEP stigma and PrEP use independent of several sociobehavioral factors. Each of our themes were based in part in minority stressors, and underscore the importance of culturally competent PrEP promotion efforts towards BSMM. Addressing stigma is a core component of health equity efforts towards ending the HIV epidemic.

The high incidence of HIV among US Black sexual minority men is a public health crisis that pre-exposure prophylaxis (PrEP) for HIV can help address. Public health campaigns, which often include pictures of Black sexual minority men alongside PrEP-related messaging, have been developed to encourage PrEP awareness and uptake. However, the acceptability of the messaging within these campaigns among Black sexual minority men is unclear. We conducted four focus groups with 18 HIV-negative Black sexual minority men in Washington, DC to explore their perspectives regarding promotional messaging (textual elements) in PrEP visual advertisements, including their reactions to three large-scale public health campaigns. Primary themes included: (1) the need for additional information about PrEP, (2) preference for slogan simplicity, (3) the desire to normalise PrEP use, and (4) mixed views on the inclusion of condoms. Results indicated that the messaging in current PrEP visual advertisements may not sufficiently address Black sexual minority men’s questions about PrEP. Providing basic PrEP information and methods to access more information; using simple, unambiguous language; presenting PrEP use in a destigmatising, normalising fashion; and conveying the relevance of condoms if included in the advertisement could help increase the acceptability of future PrEP advertising among Black sexual minority men.

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.

Stigma often is cited as a barrier to the uptake and use of pre-exposure prophylaxis (PrEP) to prevent HIV among Black sexual minority men (SMM). Socialized gender norms (i.e., restrictive emotionality) are associated with experiences and manifestations of stigma in men. However, the association between restrictive emotionality and the stigma surrounding PrEP use has received little attention in previous research. The present study examines the association between restrictive emotionality and holding stigmatizing beliefs about PrEP use with a theoretically informed serial mediation model testing internalized homophobia and LGBT community connectedness as mediators among a sample of 455 Black SMM in the Southeastern US. Results indicate that restrictive emotionality is associated with stigmatizing beliefs about PrEP use. Further, internalized homophobia and LGBT community connectedness were found to partially mediate the proposed relationship serially. Internalized homophobia, but not LGBT community connectedness, also independently mediated the association between restrictive emotionality and stigmatizing beliefs of PrEP use. This study provides important insights into how aspects of masculinity influence the manifestation of stigmatizing beliefs about PrEP use among Black SMM. The present findings have implications for reducing these beliefs, which are known to negatively impact uptake and use of the HIV prevention tool among Black SMM at elevated risk for HIV.

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

In the United States (U.S.), Black sexual minority men (BSMM) are disproportionately burdened by HIV. Prevention advances, such as HIV pre-exposure prophylaxis (PrEP), play a key role in reducing HIV transmission and improving our understanding of sexual expression and health. Despite these advances, little is known regarding the potential link between PrEP use and positive sexuality, including the benefits that BSMM see in accessing PrEP. We conducted a thematic analysis of 32 interviews with BSMM in the Southern U.S. regarding their PrEP beliefs. We developed five themes: (1) Sexual freedom, (2) Agency and empowerment, (3) Making PrEP normative, (4) Behavioral health practices, and (5) Committed relationship tensions. Our findings suggest that BSMM are increasingly concerned about freedom of choice and invested in sexual empowerment as related to their PrEP use. Further, unanticipated benefits, community support, and relationship tensions are salient factors in considerations of PrEP use among BSMM. These findings have implications for how we might understand a broader movement toward sexual empowerment and positivity, and the pivotal role that PrEP serves in this movement.

Black sexual minority men (BSMM) are substantially less likely than White SMM to accept a clinician's recommendation to initiate HIV pre-exposure prophylaxis (PrEP). The purpose of this study is to identify PrEP messaging preferences among BSMM. Data were obtained from 12 focus groups and one in-depth interview among BSMM in Baltimore, MD (N = 39). Focus groups were stratified (18-24, 25-34, and 35 and older), and facilitators probed on ways clinicians could discuss PrEP with BSMM. An adapted pile sorting approach was used to identify themes. Most identified as homosexual, gay, or same-gender-loving (68%), were employed (69%), and single (66%). Thematic analysis revealed that BSMM wanted clinicians to explain PrEP efficacy and side effects, tailor messaging, provide prevention messaging with care, and disclose PrEP use. Clinicians could increase uptake and adherence among BSMM by implementing PrEP communication preferences. Discussing PrEP efficacy and safety is also necessary. When possible, clinicians should disclose PrEP use history to build trust.

Pre-exposure Prophylaxis Uptake, Adherence, and Persistence: A Narrative Review of Interventions in the U.S.

Black sexual minority men (BSMM) are a priority population for HIV prevention efforts, including pre-exposure prophylaxis (PrEP) promotion. Intersectional stigma can be associated with deterrence from PrEP utilization among BSMM; this stigma has a novel context in the COVID-19 pandemic. To examine this, we investigated latent profiles of racial, sexuality-based, and related stigmas among HIV-negative BSMM in the COVID-19 pandemic and tested their association with PrEP use. We analyzed cross-sectional data from a pilot sample of HIV-negative BSMM (n = 151) collected between July 2nd and September 3rd, 2020 in the United States, primarily located on the east coast. We conducted latent profile analysis using internalized racism and homophobia, anticipated racism and homophobia, HIV stigma, healthcare stigma, and PrEP stigma. We then tested associations between latent profiles and both PrEP use (binary) and PrEP acceptability (ordinal) using modified Poisson regression and cumulative log models, respectively. We identified three latent profiles, characterized as ‘Low Internalized Stigma, High Anticipated Stigma’ (reference profile), ‘High Internalized Stigma, Low Anticipated Stigma,’ and ‘High Internalized and Anticipated Stigma.’ The ‘High Internalized and Anticipated Stigma’ profile was associated with PrEP use (aPR 0.37, 95% CI 0.17, 0.82) and acceptability (aPR 0.32, 95% CI 0.18, 0.57) nearly three times as low as the comparing profile after adjustment for confounders. The ‘High Internalized Stigma, Low Anticipated Stigma’ was also associated with PrEP acceptability nearly three times as low as the reference (aPR 0.38, 95% CI 0.22, 0.68). We identified latent profiles characterized by internalized and anticipated stigmas among BSMM during the COVID-19 pandemic and found that the profile with the highest levels of both internalized and anticipated stigma was associated with the lowest PrEP use and acceptability. Internalized stigma may be a particularly relevant intervention target in efforts to promote PrEP uptake among BSMM.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43545-022-00490-w.

Substantial advances have been made in medical technologies to reduce HIV transmission in previous decades. However, disparities regarding HIV transmission continue to persist, with Black sexual minority men (BSMM) disproportionately impacted. These disparities are driven by several different economic and socio-cultural barriers, some of which include the ongoing mistrust or distrust of medicine and science among communities of color. Furthermore, the spread of misinformation has also substantially hampered the ability to effectively communicate the importance and efficacy of a major tool that can be used to reduce HIV transmission: pre-exposure prophylaxis (PrEP). Therefore, the goal of this study was to provide an understanding of BSMM's experiences with and trust in medicine and practitioners, more broadly. The current study utilized interview data to qualitatively analyze the experiences of 32 BSMM in the United States. A thematic analysis was conducted, and we developed three different overarching themes to categorize different aspects of (a) medical mistrust, (b) medical distrust, and (c) misinformation. Results suggest that mistrust, distrust, and the spread of misinformation pertaining to medical institutions, medications (e.g., PrEP, antiretrovirals), and practitioners are present and appear to influence perceptions of HIV/AIDS and interest, access, or uptake and use of PrEP. Findings can inform ways to effectively rebuild relationships with medical providers and communicate information about PrEP uptake and HIV/AIDS by addressing medical mistrust and misinformation.

The use of preexposure prophylaxis (PrEP) to prevent HIV infection is significantly low among Black sexual minority men (BSMM), although this group experiences the greatest HIV burden in the United States. One contextual factor suggested to impact BSMM's HIV prevention efforts is the concern about, and adherence to, cultural conceptions and expectations of masculinity. The present study sought to better understand the association between masculinity and PrEP uptake by examining associations between gender-relevant beliefs and perceptions, and intentions to initiate PrEP among a sample of BSMM residing in the U.S. South. Participants (N = 114) completed assessments of precarious manhood beliefs, attitudes toward PrEP, concerns about PrEP use impacting support from social networks, projected perceptions of masculinity, and intentions to initiate PrEP. Precarious manhood beliefs were associated with greater intention to initiate PrEP; however, the indirect path of this association through attitudes toward PrEP was associated with lower intentions to initiate PrEP. In a hierarchical regression model, projected perceptions of masculinity were associated with intentions to initiate PrEP over and above other factors considered. Specifically, believing that one will be perceived as less masculine for seeking PrEP was associated with lower intentions to initiate PrEP. Findings suggest that BSMM's construal of masculinity in relation to HIV and PrEP is associated with intentions to initiate PrEP. Implications for increasing PrEP uptake among BSMM are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).