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In the United States, the use of pre-exposure prophylaxis (PrEP) has led to a substantial decrease in HIV prevalence and incidence. However, some populations, including young men who have sex with men (YMSM) of color, continue to be disproportionately impacted, highlighting the need for tailored interventions addressing barriers to adequate PrEP access. In collaboration with partner clinics, we recruited 19 PrEP clients and 19 PrEP providers (n = 35) to participate in hour-long in-depth interviews. Although client interviews explored personal experiences with stigma, barriers, and motivators to PrEP and information preferences, provider interviews explored providers' perceived stigma in their clinic, perceived barriers and motivators to meeting clients' PrEP needs, and rapport building with clients. Most participants were affiliated with one of the southern partner clinics. Clients and providers noted similar determinants to PrEP access, uptake, and adherence. Both recognized the impact of personal barriers such as routine adjustments and perception of need, as well as institutional barriers such as transportation and financial difficulties. Clients emphasized the role of the client–provider relationship as part of contributing to willingness to disclose information such as HIV status and sexual practices. Providers noted the importance of sexual health and LGBTQ+ topics in their training. Despite limited geographical scope and the sensitive nature of HIV-related topics, this study has several implications. PrEP clinics may benefit from hiring providers who share identities and experiences with YMSM clients of color and operating with a flexible schedule. Medical provider training should include comprehensive sexual health and LGBTQ+ competencies to reduce bias in care. [ABSTRACT FROM AUTHOR]

Doxycycline postexposure prophylaxis (doxy-PEP) reduces sexually transmitted infections (STIs) in men who have sex with men (MSM) and transgender women (TGW). In a clinical trial of doxy-PEP, we sought to assess acceptability, impact, and meaning of doxy-PEP use among MSM/TGW. We conducted semistructured, in-depth 1:1 interviews with MSM and TGW enrolled in the intervention arm of the Doxy-PEP study. We queried motivations for and meaning of use, attitudes, beliefs, adherence, effect on sexual behaviors, and partner, community, and structural factors related to use. We coded interview transcripts into content areas, followed by thematic analysis. We interviewed 44 participants (median age 38), 2% were TGW, 17% Black, 61% White, 30% Hispanic, and 45% persons with HIV. We identified three overarching themes. First, participants found doxy-PEP acceptable, and believed it was effective based on their history of STIs, easy to adhere to, and acceptable to sex partners. Second, doxy-PEP benefited their quality of life and mental health, offering "peace of mind" by reducing their anxiety about acquisition or unwitting transmission of STIs. Participants reported feeling more "in control" of preventing STIs, and positive about supporting their personal, partner, and community health. Third, impact on sexual behavior was variable, with most reporting no change or a brief initial change. Participants in a multi-site clinical trial of doxycycline for STI prevention perceived it to be efficacious, and that it provided quality-of-life benefits, including reduced anxiety and sense of control over sexual health. Doxy-PEP had limited impact on sexual behavior. Clinicaltrials.gov: NCT03980223. [ABSTRACT FROM AUTHOR]

The discovery that people with an undetectable HIV viral load are unable to transmit the virus to sex partners (U = U) has ushered in a new era in HIV care. As a result of this discovery, treatment as prevention (TasP) has become a powerful tool toward ending the epidemic. However, despite its sound scientific basis, many communities affected by HIV face barriers toward adopting TasP as a complete HIV prevention strategy. In addition, most research to date has only focused on TasP in the context of committed monogamous partnerships. To identify barriers to TasP adoption among some of those most affected by HIV, we conducted in-depth qualitative interviews with 62 sexual and gender minority individuals of varying serostatuses. Participants were identified from the results of an online survey, where those who indicated at least some awareness of TasP were invited to partake in a follow-up interview. Interviews were thematically coded to identify emergent themes relating to TasP adoption. Seven primary barriers emerged from data analysis pertaining to TasP science, internalized beliefs about HIV safety, and interactional dynamics between partners: (1) unfamiliarity with TasP science, (2) perceived limitations of TasP science, (3) difficulty changing understanding of "safe sex," (4) unwillingness to rely on partners' reports of being undetectable, (5) persistent HIV stigma, (6) less difficulty finding serosimilar partners, and (7) difficulty incorporating TasP into casual encounters. Together, these barriers confirm the existing findings about TasP adoption, and extend the literature by identifying barriers beyond a lack of education and outside of monogamous contexts. [ABSTRACT FROM AUTHOR]

Despite the national HIV and sexually transmissible infection (STI) rates growing in rural areas, rural populations—particularly men who have sex with men (MSM), have limited access to secondary (i.e., HIV/STI screening) prevention activities compared with their urban counterparts. We conducted semistructured in-depth interviews with 23 rural MSM residing in Oklahoma and Arkansas to assess their (1) experiences with HIV and STI testing; (2) perceptions of at-home testing; and (3) preferences for receiving results and care. Barriers to accessing HIV/STI screening included lack of medical providers within rural communities, privacy and confidentiality concerns, and perceived stigma from providers and community members. To overcome these barriers, all participants recognized the importance of screening paradigms that facilitated at-home screening, medical consultation, and care. This included the ability to request a testing kit and receive results online, to access affirming and competent providers utilizing telemedicine technology, as well as prompt linkage to treatment. These narratives highlight the need for systems of care that facilitate HIV and STI screening within rural communities, which do not require participants to access services at traditional physical venues. [ABSTRACT FROM AUTHOR]

Young black and Latinx men who have sex with men (YBLMSM) and transgender women (YBLTW) are disproportionately impacted by HIV. Structural and social marginalization, the social barriers, and structures that unevenly distribute benefits and burdens to different groups, may contribute to inability for youth to access prevention and treatment care services. Yet, few reports have examined the community and health care experiences of social marginalization among youth service providers who have multiple roles in the community (i.e., serve as a service provider and are a member or prior member of the YBLMSM and YBLTW population). Eighteen key informants (KIs), defined as youth, young adults, or adults who were members of or connected to the YBLMSM and young black and Latinx transgender (YBLTG) community, participated in a one-time, face-to-face, or telephone key informant interview (KII) lasting ∼45 min. KIs were defined as youth service providers because they described working with the target population and either being a member of or closely connected to the target population. KIs described key themes related to marginalization: lack of competent care among health care providers and both clinical and community spaces that left out key populations. HIV stigma and medical mistrust continues to create a barrier to care in this population and for interventions to be effective interventions will need to use an intersectional approach that simultaneously address all identities, and the social and structural needs of youth. [ABSTRACT FROM AUTHOR]

Approximately 1.1 million individuals in the United States are living with HIV/AIDS. HIV disproportionately affects young, black men who have sex with men (YBMSM). Recent biomedical advances, including the use of antiretroviral therapy as pre-exposure prophylaxis (PrEP), hold promise for preventing HIV infections. However, PrEP uptake remains slow among those most at-risk. To develop and test an intervention to address HIV disparities in YBMSM, we conducted qualitative interviews with 29 YBMSM from Jackson, Mississippi, to learn more about their views of PrEP. Twenty-nine PrEP-eligible YBMSM were enrolled and participated in either semistructured interviews or focus groups. They were asked about PrEP use, messaging, and promotion. Data were coded based on an iteratively developed coding scheme and entered into NVivo to facilitate thematic analysis. Our analysis identified the following three main themes: (1) the role of setting, context, and stigma in health care, (2) targeted PrEP messaging is further stigmatizing, and (3) recommendations for PrEP messaging and care. YBMSM in our sample felt highly stigmatized in their current environment and felt that PrEP messaging targeting YBMSM only enhanced their sense of marginalization. They concluded that broad and inclusive messaging would be just as relevant and cause less stigma. Our findings were somewhat surprising, as several prior studies benefited from using targeted materials to engage YBMSM in HIV prevention and PrEP uptake. The study's location may explain this difference in findings, which suggests the importance of considering local conditions and opinions when developing interventions for HIV prevention among minority populations. [ABSTRACT FROM AUTHOR]

Uptake of pre-exposure prophylaxis (PrEP) has dramatically increased but remains well below the estimated number of individuals who could benefit from PrEP in the United States, and uptake remains limited among young men who have sex with men (YMSM) and MSM of color. Reasons for not adopting PrEP as a prevention strategy among those at elevated risk for HIV is an important area of inquiry that could advise efforts to better position PrEP as an active part of prevention programs. As part of a mixed methods study investigating experiences with repeat HIV testing, we identified main themes emerging from in-depth interview data pertaining to reasons why YMSM report not using PrEP, among YMSM with frequent access to HIV testing services. Themes from 14 in-depth interviews with predominantly Latino MSM for not using PrEP included perceived burden of daily dosing, feeling that risk was not high enough to warrant PrEP, and beliefs that PrEP would have severe adverse events affecting the kidneys and bones. Less prominent but noteworthy themes included stigma as a PrEP user, social or provider influence on decisions not to use PrEP, and preference for current prevention strategy. No differences in PrEP discourse were noted across those at different levels of HIV risk. Results suggest that efforts are needed to engage communities and individuals around PrEP-related education, facilitate risk evaluation, and reduce PrEP stigma. New formulations and nondaily regimens may also be of particular interest to YMSM who may perceive daily PrEP regimens as highly burdensome. [ABSTRACT FROM AUTHOR]

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

Despite high HIV incidence among young black men who have sex with men (YBMSM), pre-exposure prophylaxis (PrEP) uptake in this group is low. In a cohort of HIV-negative YBMSM in Atlanta, GA, all participants were offered PrEP as standard of care with free clinician visits and laboratory testing. We explored self-perceived need for PrEP among 29 in-depth interview participants by asking about reasons for PrEP uptake or refusal and factors that may lead to future reconsideration. Self-perceived need was compared to US Center for Disease Control and Prevention guidance for clinical PrEP indication using behavioral data and laboratory testing data. Self-perceived need for PrEP consistently underestimated clinical indication, primarily due to optimism for choosing other HIV prevention strategies, such as condom use, abstinence, or monogamy. Many participants cited consistent condom use and lack of sexual activity as reasons for not starting PrEP; however, follow-up survey data frequently demonstrated low condom use and high levels of sexual activity in the period after the interview. Study participants endorsed perceptions that PrEP is only for people with very high levels of sexual activity. Only one participant perceived incident sexually transmitted infection (STI) to be an indication for PrEP, despite the fact that several of the participants had a history of an STI diagnosis. These findings point to an opportunity for clinician intervention at diagnosis. Disconnect between self-perceived and guidance-based PrEP indications, as well as other factors such as medical mistrust or difficulty with access, may contribute to low PrEP uptake among YBMSM. A better understanding of the ways in which these issues manifest may be one tool for clinicians to support PrEP uptake. [ABSTRACT FROM AUTHOR]

We conducted in-depth interviews guided by the Andersen–Newman Health Service Utilization Framework to understand perceptions of pre-exposure prophylaxis (PrEP) with 25 young, black men who have sex with men (YBMSM) in the Southern United States. The mean age of participants was 24 years; 21 were insured; and 18 had a regular source of care. Five major themes emerged: (i) stigma related to being black, gay and living in the South; (ii) lack of discussion in the black community about HIV prevention and sexual health; (iii) stigma related to PrEP; (iv) medical mistrust; and (v) low perceived need to be on PrEP. This study presents formative qualitative work that underscores the need for behavioral interventions to address intersectional stigma and perceptions of risk among YBMSM in the South, so that PrEP is no longer viewed as a drastic step but rather as a routine HIV prevention strategy. [ABSTRACT FROM AUTHOR]

Young men who have sex with men (YMSM) are disproportionally impacted by HIV, and continue to lag behind other age groups in the receipt of HIV prevention and care services. To inform the development of interventions to improve pre-exposure prophylaxis and HIV care engagement outcomes among YMSM, a growing number of studies have reported the barriers and facilitators YMSM encounter when accessing HIV services. Few studies, however, have assessed how HIV service providers perceive these facilitators and barriers. In total, 21 interviews were conducted with HIV service providers in Chicago about barriers and facilitators they perceived affected YMSM's engagement in HIV services. Barriers included lack of comprehensive wraparound services, lack of trust of providers, unfamiliarity with seeking HIV services, feelings of invincibility, lack of knowledge of HIV service providers, intersectional and structural concerns (e.g., not thinking the site's services were for YMSM), geography and distance to clinic, and HIV stigma. Facilitators included presence of comprehensive wraparound services, high trust in providers, a clinic's willingness to serve uninsured patients, community engagement, word-of-mouth recommendations from lesbian, gay, bisexual, and transgender (LGBT) friends, intersectionality (e.g., offering LGBT-tailored services), geography and distance, lack of HIV stigma. Axial coding revealed that five conceptual themes cut across multiple barriers and facilitators, including health system characteristics, intersectionality, geography and transportation, community outreach, and stigma. These conceptual themes map closely onto Bronfenbrenner's ecological model. Overall, these findings highlight the importance of a multi-level approach to future intervention development to increase engagement in HIV services among YMSM. [ABSTRACT FROM AUTHOR]

The Internet is a common tool for gay, bisexual, and other men who have sex with men (MSM) to find sexual partners and sexual health information. Given persistently high human immunodeficiency virus (HIV) infection rates among MSM, it is important to examine the role of online outreach for MSM as part of HIV prevention and care. We provide an overview of the unique perspectives of online sexual health outreach, delivered through AIDS Service Organizations (ASOs) through sociosexual Internet sites and mobile applications. Data were drawn from the qualitative arm of the community-based Cruising Counts study conducted across Ontario from December 2013 to January 2014. ASO online outreach providers and managers ( n = 22) were recruited to complete a 1-h in-person/telephone interview to explore in-depth their experiences with, and perspectives on, delivering online outreach services for MSM in Ontario. Thematic analyses were conducted inductively using NVivo 10. Service providers suggested a high demand for online outreach services for MSM. Strengths and advantages of online outreach over face-to-face outreach included anonymity, instant access to services, peer model, and accessing hard-to-reach populations of MSM. Barriers included consistent quality of service, collaborations between companies that own online technologies and outreach service agencies, budgetary and staff capacity issues, and uncertainty of best practices and evaluation parameters for online outreach. Findings from these interviews can inform service providers, policy makers, and researchers on how online sexual health outreach can play a greater role in HIV prevention by better acknowledging and addressing the opportunities and barriers experienced by service providers working with MSM communities online. [ABSTRACT FROM AUTHOR]

The Centers for Disease Control and Prevention estimates that one in four sexually active men who have sex with men (MSM) could decrease their HIV risk by using HIV pre-exposure prophylaxis (PrEP). Because many MSM access healthcare from primary care providers (PCPs), these clinicians could play an important role in providing access to PrEP. Semistructured qualitative interviews were conducted with 31 PCPs in Boston, MA, to explore how they approach decisions about prescribing PrEP to MSM and their experiences with PrEP provision. Purposive sampling included 12 PCPs from an urban community health center specializing in the care of lesbian, gay, bisexual, and transgender persons ('LGBT specialists') and 19 PCPs from a general academic medical center ('generalists'). Analyses utilized an inductive approach to identify emergent themes. Both groups of PCPs approached prescribing decisions about PrEP as a process of informed decision-making with patients. Providers would defer to patients' preferences if they were unsure about the appropriateness of PrEP. LGBT specialists and generalists were at vastly different stages of adopting PrEP into practice. For LGBT specialists, PrEP was a disruptive innovation that rapidly became normative in practice. Generalists had limited experience with PrEP; however, they desired succinct decision-support tools to help them achieve proficiency, because they considered preventive medicine to be central to their professional role. As generalists vastly outnumber LGBT specialists in the United States, interventions to support PrEP provision by generalists could accelerate the scale-up of PrEP for MSM nationally, which could in turn decrease HIV incidence for this priority population. [ABSTRACT FROM AUTHOR]

Conversations about HIV prevention before engaging in sex may result in safer sex practices and decreased HIV transmission. However, partner communication for HIV prevention has been understudied among black/African American men who have sex with men (BMSM), a group that is disproportionately affected by HIV. We explored and described encounters and perceptions about HIV prevention conversations among BMSM and their sex partner(s) in New York City. We conducted an inductive thematic analysis of semi-structured interviews with BMSM who reported sex with a man in the previous 3 months. Interviews were professionally transcribed; Nvivo was used for data analysis. Twenty-two BMSM were included in this analysis; median age = 29.1 years; 71.4% self-identified as MSM; 85.7% were ever HIV tested; and 52.6% reported no disclosure or discussion about HIV status with their previous sex partner. The main themes were: (1) missed opportunities for HIV prevention conversations (e.g., no HIV prevention conversations or HIV prevention conversations after sex had occurred); (2) barriers to HIV prevention conversations (e.g., being in the moment; not wanting to pause); (3) emotional thoughts after sex (e.g., feeling worried about possible HIV exposure); and (4) rethinking relationships and sexual health (e.g., changed sex practices by asking partners' HIV status before sex; started using condoms). These findings offer insight into HIV prevention conversations by BMSM around the time of or during sexual encounters and may inform and strengthen partner-level HIV prevention communication interventions for BMSM. [ABSTRACT FROM AUTHOR]