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Despite its effectiveness in HIV prevention, PrEP use among Black women is suboptimal. Notably in the Deep South, Black women have the lowest PrEP uptake rates among all US regions. To increase PrEP engagement, research suggests the implementation of structural and social interventions particular to the needs of Black women. The state of Alabama is of priority to federal HIV prevention initiatives; therefore, this study conducted focus groups among 47 cis-gender Black women in rural and urban Alabama counties, with the highest statewide HIV incidence rates, to understand perceptions of PrEP and decision-making processes. Deductive coding analysis was conducted and themes were finalized based on consensus among the two coders. Four themes were identified. Findings show stigma undergirds Alabaman Black women's decisions to engage in PrEP care. Moreover, women reported stigma stifled community-level education about PrEP. Despite these experiences, education was regarded as a strategy to decrease stigma and PrEP skepticism, the latter of which emerged as a prominent theme. Medical mistrust and healthcare engagement were the other emergent themes influencing participation in PrEP care. To ensure PrEP efforts meet the needs of Black cisgender women in Alabama counties, interventions must address longstanding stigma, increase educational initiatives, and ensure interventions consider women's experiences with medical mistrust and health care engagement., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To estimate the number of women who received human immunodeficiency virus (HIV) and sexually transmitted infection (STI) testing and HIV pre-exposure prophylaxis (PrEP) services by race and ethnicity in seven THRIVE (Targeted Highly Effective Interventions to Reverse the HIV Epidemic)-funded jurisdictions and to estimate associations of age and syphilis and gonorrhea diagnoses with receipt of HIV PrEP services., Methods: We analyzed data collected from 2015 to 2020 in Birmingham, Alabama; Baltimore City, Maryland; Washington, DC, New Orleans, Louisiana; Brooklyn, New York; Philadelphia, Pennsylvania; and Hampton Roads, Virginia. We compared Black women and women of additional racial and ethnic groups by age, HIV status at enrollment, receipt of STI testing and test positivity, and steps in the PrEP continuum (screened, eligible, referred, linked, and prescribed). We also examined the association of age, syphilis, or gonorrhea with the following steps in the PrEP continuum: screened, referred, linked, and prescribed., Results: Black women made up 69.2% (8,758/12,647) of women served in THRIVE. Compared with non-Black women, Black women were more likely to have a positive test result for syphilis (3.3% vs 2.1%), gonorrhea (4.9% vs 3.5%), chlamydia (5.1% vs 1.9%), or more than one STI (1.4% vs 0.3%). Among women with negative HIV test results or unknown HIV status, Black women were more likely to be screened for PrEP eligibility (88.4% vs 64.9%). Among Black women, the proportion screened for PrEP was higher among those diagnosed with syphilis (97.3%) or gonorrhea (100%) than among those without an STI (88.1% and 87.8%, respectively). Among 219 Black women who presented with syphilis, only 10 (4.6%) were prescribed PrEP; among 407 with gonorrhea, only 11 (2.7%) were prescribed PrEP., Conclusion: Although most Black women seeking services received STI testing, the proportion of Black women who were eligible for PrEP and prescribed PrEP was low. To achieve national HIV-prevention goals, it is imperative that Black women have access to PrEP information and services., Competing Interests: Financial Disclosure Christina Schumacher reports receiving a Demonstration Project grant from the CDC. Latesha Elopre reports money paid to her institution from Merck. The other authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a disproportionate burden of rural infections. To reverse growing infection rates, the state must increase its focus on prevention efforts, including novel strategies. One such approach is to utilize dashboards that visualize real-time data on the pre-exposure prophylaxis (PrEP) care continuum to assist in prioritizing evidence-based preventative care for those most vulnerable for HIV infection., Methods: We conducted a mixed methods evaluation to ascertain stakeholders' perceptions on the acceptability, feasibility, appropriateness, and usability of a PrEP care continuum dashboard, as well as gain insight on ways to improve the activities necessary to sustain it. Clinicians, administrators, and data personnel from participating sites in Alabama completed surveys (n = 9) and participated in key informant interviews (n = 10) to better understand their experiences with the prototype data dashboard and to share feedback on how it can be modified to best fit their needs., Results: Surveys and interviews revealed that all participants find the pilot data dashboard to be an acceptable, feasible, and appropriate intervention for clinic use. Overall, stakeholders find the pilot dashboard to be usable and helpful in administrative efforts, such as report and grant writing; however, additional refining is needed in order to reduce burden and optimize usefulness. Participants voiced concerns about their site's abilities to sustain the dashboard, including the lack of systematized PrEP protocols and limited funds and staff time dedicated to PrEP data collection, cleaning, and upload., Conclusion: Study participants from clinics providing HIV prevention services, including PrEP, in Alabama voiced interest in sustaining and refining a data dashboard that tracks clients across the PrEP care continuum. Despite viewing the platform itself as an acceptable, feasible, and appropriate intervention, participants agreed that efforts need to be focused on standardizing PrEP data collection protocols in order to ensure consistent, accurate data capture and that limited funds and staff time are barriers to the sustained implementation of the dashboard in practice., (© 2024. The Author(s).)

Abstract: We informed women who inject drugs about different preexposure prophylaxis (PrEP) formulations; they then ranked their preferences. Daily oral PrEP was most preferred, followed by injectable PrEP and vaginal rings/gels, especially among women of color. Multiple PrEP options should be discussed with women who inject drugs to increase uptake., Competing Interests: Conflict of Interest and Sources of Funding: The authors do not have any conflicts of interest to declare. This research was funded by the American Sexually Transmitted Diseases Association Developmental Award Program and the National Institute on Drug Abuse (R21 DA043417)., (Copyright © 2023 American Sexually Transmitted Diseases Association All rights reserved.)

Background: Pre-exposure prophylaxis (PrEP) is proven to prevent HIV infection. However, PrEP uptake to date has been limited and inequitable. Analyzing the readability of existing PrEP-related information is important to understand the potential impact of available PrEP information on PrEP uptake and identify opportunities to improve PrEP-related education and communication., Objective: We examined the readability of web-based PrEP information identified using search engines and on Twitter. We investigated the readability of web-based PrEP documents, stratified by how the PrEP document was obtained on the web, information source, document format and communication method, PrEP modality, and intended audience., Methods: Web-based PrEP information in English was systematically identified using search engines and the Twitter API. We manually verified and categorized results and described the method used to obtain information, information source, document format and communication method, PrEP modality, and intended audience. Documents were converted to plain text for the analysis and readability of the collected documents was assessed using 4 readability indices. We conducted pairwise comparisons of readability based on how the PrEP document was obtained on the web, information source, document format, communication method, PrEP modality, and intended audience, then adjusted for multiple comparisons., Results: A total of 463 documents were identified. Overall, the readability of web-based PrEP information was at a higher level (10.2-grade reading level) than what is recommended for health information provided to the general public (ninth-grade reading level, as suggested by the Department of Health and Human Services). Brochures (n=33, 7% of all identified resources) were the only type of PrEP materials that achieved the target of ninth-grade reading level., Conclusions: Web-based PrEP information is often written at a complex level for potential and current PrEP users to understand. This may hinder PrEP uptake for some people who would benefit from it. The readability of PrEP-related information found on the web should be improved to align more closely with health communication guidelines for reading level to improve access to this important health information, facilitate informed decisions by those with a need for PrEP, and realize national prevention goals for PrEP uptake and reducing new HIV infections in the United States., (©Albert Park, Fatima Sayed, Patrick Robinson, Latesha Elopre, Yaorong Ge, Shaoyu Li, Christian Grov, Patrick Sean Sullivan. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 04.09.2023.)

Introduction: African American women (AA), particularly those living in the Southeastern USA, experience disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool that may circumvent barriers to traditional HIV prevention tools, such as condom use; however, very little is known about how to improve PrEP access and uptake among AA women who may benefit from PrEP use. This project aims to understand how to increase PrEP access among AA women in the rural Southern USA, which may ultimately affect HIV incidence in this population., Methods and Analysis: The goal of the current study is to systematically adapt a patient-provider communication tool to increase PrEP uptake among AA women receiving care at a federally qualified health centre in Alabama. We will use an iterative implementation process, by assessing the feasibility, acceptability and preliminary impact of the tool on PrEP uptake, using a pilot preintervention/postintervention design (N=125). We will evaluate women's reasons for declining a referral to a PrEP provider, reasons for incomplete referrals, reasons for not initiating PrEP after a successful referral and ongoing PrEP use at 3 and 12 months after PrEP initiation among our sample. The proposed work will significantly contribute to our understanding of factors impacting PrEP uptake and use among AA women, particularly in underserved areas in the Deep South that are heavily impacted by the HIV epidemic and experience worse HIV-related health outcomes relative to other areas in the USA., Ethics and Dissemination: This protocol has been approved by the Institutional Review Board (IRB) at University of Alabama at Birmingham (Birmingham, AL; protocol 300004276). All participants will review a detailed informed consent form approved by the IRB and will provide written or verbal informed consent prior to enrolment. Results will be disseminated through peer-reviewed manuscripts, reports, and local, national and international presentations., Trial Registration Number: NCT04373551., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Adolescents are disproportionately burdened with HIV. Numerous barriers limit adolescent pre-exposure prophylaxis (PrEP) use for HIV prevention. We explored adolescent-caregiver perspectives on discussing sexual health and PrEP to inform future caregiver interventions as a possible strategy to promote PrEP use., Methods: We conducted separate in-depth interviews with adolescents aged 14-18 living in Alabama and their parent/guardian (caregiver). Interviews explored attitudes about sex, knowledge and attitudes about HIV prevention and PrEP, and attitudes about PrEP communication within adolescent-caregiver groups. Thematic analysis of adolescent and caregiver interviews was conducted independently and then triangulated to compare shared themes., Results: Nine adolescents and seven caregivers contributed to five dyads and two triads. Adolescents had a median age of 16 years (range 14-18); five were girls (55%), and five were non-Hispanic Black (55%). Most caregivers were mothers (5, 71%), non-Hispanic Black (5, 71%), with a median age of 41 (36-56) years. All adolescents expressed willingness to involve their caregiver around PrEP use. Major themes included as follows: 1) caregiver efforts to overcome cultural taboos about sex and sexuality foster adolescents' willingness to talk with caregivers about sex; 2) evolving societal norms and reflections on their own upbringings motivate caregivers to discuss and support adolescents with sexual health; and 3) caregivers desire to engage in sexual health discussions with providers and support their teens with PrEP., Discussion: As socio-cultural norms around sex evolve, adolescent-caregiver discussions about sexual health and PrEP may be an opportunity to increase PrEP use and reduce HIV infections among select adolescent sub-populations., (Published by Elsevier Inc.)

To assess PrEP service delivery preferences among Black cis-gender women living in urban and rural settings in Alabama, we conducted a cross-sectional discrete choice experiment survey. Discrete choice experiments included five attributes. Hierarchical Bayes (HB) modeling and latent class analyses (LCA) were used to evaluate attribute preferences. Among 795 Black cis-gender HIV-negative women, almost two-thirds lived in urban settings and reported having at least some college; about a third reported a household income less than $25,000 annually; and reported willingness to use PrEP. Respondents placed the greatest importance on PrEP medication formulation and healthcare facility. LCA showed the group with the highest rural proportion preferred for on-line visits. Black women in the Deep South had distinct preferences regarding PrEP service delivery. These findings can inform tailored interventions to improve PrEP uptake among Black cis-gender women across diverse settings in the South., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Ending the HIV Epidemic initiatives provide a unique opportunity to use implementation scientific methods to guide implementation of evidence-based practices and evaluate their effectiveness in real-word settings to improve HIV inequities. This report demonstrates our use of Implementation Mapping (IM) to engage participating county health departments, AIDS services organizations, and community-based organizations in the development of a data dashboard to track the PrEP care continuum for the state of Alabama, an Ending the HIV Epidemic hotspot., Methods: Our project is guided by an overarching Implementation Research Logic Model and by the tenets of IM, a 5-step approach to support researchers and community partners in the systematic selection, development, and/or tailoring of implementation strategies to increase program adoption, implementation, and sustainability., Results: Step 1, the needs assessment, established baseline data elements for a PrEP care continuum for participating community-based organizations, AIDS services organizations, and the state health department as well as investigated their desire for data visualization and willingness to share data to inform initiatives to improve PrEP access. Step 2 identified adaptability, relative advantage, and complexity as determinants of intervention adoption. Based on findings from steps 1 and 2, the investigators and community partners determined to move forward with development of a data dashboard. Step 3 identified the following implementation strategies to support a dashboard, including development of educational materials, synchronous and asynchronous training, technical assistance, and improved record systems., Discussion: Using IM supports community-engaged researchers in designing strategies to end the epidemic that are context-specific and more impactful in real-word settings., Competing Interests: L.E. is currently receiving a grant (MK8591-022) from Merck, has consulted for Black AIDS Institute, and is a speaker for MedIQ who provide CME. The remaining authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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

Black adolescent girls and young women (AGYW) are disproportionately affected by HIV in the United States. HIV pre-exposure prophylaxis (PrEP) is effective for HIV prevention, but prescription rates remain low. We conducted a survey of medical providers caring for Black AGYW in Alabama to explore PrEP prescription practices. While over half of the N = 36 providers reported minimal HIV testing of AGYW in clinic, most (N = 29, 81%) reported feeling confident discussing HIV prevention. Most reported willingness to prescribe PrEP to Black AGYW (58%-72%), but only 11 (31%) had prescribed PrEP to any female client. Low familiarity with CDC guidelines (N = 20, 56%) and PrEP options (N = 19, 53%) were barriers to prescription. Prescribing PrEP to AGYW was associated with provider training, with internal medicine providers being least likely to prescribe. These findings support the need to develop training tools to directly address unique training needs of providers who care for this population.

HIV disparities among Young, Black men who have sex with men (YBMSM) persist despite concerted efforts to increase uptake of prevention tools like HIV pre-exposure prophylaxis (PrEP). We conducted in-depth interviews with 25 YBMSM (aged 18-29 years old) to understand factors contributing to PrEP access in Birmingham, Alabama. We identified that one major barrier to PrEP uptake was intersectional stigma related to their multiple identities and contributed to lack of feeling able to accept their sexual identities. Facilitators of validation and acceptance of sexual identity were strong social support networks, which participants reported consisted of, not only other gay and bisexual Black men, but also Black women, an unexplored social support group among YBMSM networks. However, participants felt that internal, perceived and experienced homophobia were exacerbated in Southern, Black communities due to perceived values surrounding masculinity, which were reinforced by religious doctrine. Looking forward, public health officials will need to add additional resources to support interventions that have meso-level impact to effectively change social norms as a critical determinant of individual-level prevention practices within this at-risk group and their social networks.

In the United States, HIV infection rate inequities persist, with new infections highest among young, Black men who have sex with men (YBMSM) in the South. We conducted 23 in-depth interviews with YBMSM newly diagnosed with HIV to explore awareness of and barriers to uptake of HIV pre-exposure prophylaxis (PrEP). Participants were recruited from two university-based HIV Clinics in Alabama and were: (1) 16-29 years of age, (2) diagnosed with HIV within the prior 365 days, (3) Black race, (4) self-identified as a cis-gender male reporting sex with men AND (5) did not report prior PrEP use. Interview guides were grounded in Anderson's Behavioral Healthcare Utilization Model (ABM), with embedded constructs from the situated Information, Motivation and Behavioral Skills theoretical framework. Coding was conducted by three independent coders using thematic analysis methods. Participants (N = 23) median age was 24, more than two-thirds reported annual incomes less than $15,000 and the majority (84%) identified as gay. Major themes that emerged as barriers to accessing PrEP included low prioritization and interests in using PrEP; low perceived HIV risk due to feelings of invincibility and trust in sex partners; lack of information about accessing PrEP; negative beliefs around PrEP; and the suggestion to change PrEP messaging from only targeting YBMSM. These findings indicate that there are important missed opportunities for HIV prevention with PrEP among YBMSM in the South. In these high-risk young men, tailored interventions are needed to better inform and frame perceptions around risk, knowledge, access and prioritization of PrEP.

Purpose: Pre-exposure prophylaxis for HIV (PrEP) is an effective yet underutilized biomedical tool for adolescents and young adults' (AYA) HIV prevention due to barriers such as PrEP adherence. We assessed HIV prevention knowledge, attitudes and beliefs from adults who self-identified as a primary support person to an AYA., Methods: We surveyed AYA primary support persons at an academic hospital. Univariate and multivariate regression analyses were completed to identify factors associated with the belief AYAs engaging in HIV-associated behaviors should use PrEP and willingness to support AYAs on PrEP., Results: 200 primary support persons completed the survey. Participants were predominately female (77%) and black (56%). Nearly all primary support persons believed AYAs engaging in HIV-associated behaviors should take PrEP (94%) and 98% would support an AYA taking PrEP via transportation to appointments, assistance with refilling prescriptions, medication reminders, or encouragement., Conclusions: Primary support persons are willing to support AYAs using PrEP., Competing Interests: The authors have declared that no competing interests exist.

Background: Pre-exposure prophylaxis (PrEP) for individuals at significant risk for Human Immunodeficiency Virus acquisition is approved for individuals weighing at least 35 kg by the Food and Drug Administration. This cross-sectional study analyzed indications for PrEP in a clinical setting., Methods: There were 429 charts reviewed from adolescents between 15 and 21 years old seen for preventive care visits at an adolescent primary care center in the Deep South during a 1-year timeframe. Univariate and multivariable regression analyses were completed to identify factors associated with indications for PrEP., Results: Forty-four percent of 429 adolescents (between 15 and 21 years) had a PrEP indication; 77% were women and 95% heterosexual. Significant factors associated with an indication for PrEP included living with a nonparent or nonrelative and polysubstance use. No adolescents with an indication for PrEP were prescribed PrEP. A sensitivity analysis comparing indications for PrEP between the 2014 and 2017 The Centers for Disease Control and Prevention Guidelines revealed no significant differences in percent with an indication (44.5% vs. 42.8%) or factors associated with indications., Conclusions: Pre-exposure prophylaxis as a biomedical tool for adolescents and young adults (AYAs) may remain underutilized. A key factor in improving utilization involves providers being able to recognize AYAs who may have an indication for PrEP with a specific focus on those AYAs who do not live in households with parents or a surrogate family member and those who are polysubstance users.

Purpose of Review: Seven years after TDF/FTC was approved for pre-exposure prophylaxis to reduce risks of HIV infection, there have been large increases in the number of persons using PrEP in the USA. However, recent data on pre-exposure prophylaxis (PrEP) use at the state level indicate that people living in the Southern United States are underserved by PrEP relative to their epidemic need. We sought to review possible reasons for inequitable uptake of PrEP in the South and identify implementation approaches to increase PrEP uptake in the South., Recent Findings: Published literature, data on the locations of PrEP service providers, recent data on PrEP utilization from pharmacy prescription databases, HIV surveillance data and government data on healthcare providers, and health literacy indicate a confluence of factors in the South that are likely limiting PrEP uptake. A variety of approaches are needed to address the complex challenges to PrEP implementation in the South. These include considering alternative PrEP provision strategies (e.g., pharmacy-based PrEP, telemedicine-delivered PrEP), conducting gain-based stigma-reduction campaigns, increasing capacity for reimbursement for PrEP medications and services through policy change to expand Medicaid and to preserve access to Affordable Care Act-compliant health plans, expanding STI screening programs and improving integration of PrEP offering with delivery of positive STI results, using mHealth tools to screen groups at highest risk for HIV (e.g., men who have sex with men) periodically to increase correct perception of risk, and streamlining clinical procedures to allow same-day PrEP starts for patients without obvious medical contraindications. Overcoming the structural, capacity, and policy challenges to increasing PrEP uptake in the South will require innovations in clinical approaches, leveraging technologies, and policy changes. The South has unique challenges to achieving equitable PrEP uptake, and addressing key barriers to expanded PrEP use will require multisectoral responses.

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.

Preexposure prophylaxis (PrEP) with optimal adherence has demonstrated efficacy in reducing HIV incidence in women. Black women are disproportionately burdened by the HIV epidemic, accounting for more than half of all new HIV cases in women, thereby making PrEP an ideal prevention strategy for this group. However, to date, PrEP uptake by women in the United States has been slow. Further domestic research is needed to understand the multilevel factors related to PrEP awareness, uptake, and implementation in Black women. Our purpose was to review the current status of HIV prevention in Black women. We summarize clinical trials germane to federal approval of PrEP; discuss important PrEP studies focused on women, including non-oral options; and review multilevel barriers to PrEP uptake. Lastly, we discuss the use of an integrated theoretical framework to organize multilevel factors related to PrEP uptake by Black women in order to guide intervention development., (Copyright © 2018 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.)

Disproportionate rates of HIV are observed in Black women and men, especially in the Southern United States. We observed limited uptake of preexposure prophylaxis (PrEP) services in our Southern community among these groups, particularly Black men who have sex with men relative to new HIV cases in Birmingham, AL; 18% accessed PrEP services compared with 50% of new HIV cases. Further research is needed to understand PrEP access and uptake in high-risk populations.