ABSTRACT
BACKGROUND: Increased preexposure prophylaxis (PrEP) initiation is needed to substantially decrease HIV incidence among Black sexual minority men (BSMM). However, BSMM perceive others as PrEP candidates instead of themselves and are less likely than other groups to use PrEP if prescribed. Peers and smartphone apps are popular HIV prevention intervention tools typically used independently. However, they could be useful together in a multicomponent strategy to improve perceived HIV risk and PrEP initiation for this group. Information regarding attitudes and preferences toward this multicomponent strategy is limited. OBJECTIVE: The goal of this study is to obtain attitudes and perspectives regarding the design of a multicomponent intervention that uses a smartphone app and a peer change agent (PCA) to increase perceived HIV risk and PrEP initiation. The intervention will be refined based on thematic findings for a culturally responsive approach. METHODS: Data were obtained guided by life course theory and the health belief model using 12 focus groups and 1 in-depth interview among HIV-negative BSMM from Baltimore, MD, between October 2019 and May 2020 (n=39). Groups were stratified by the following ages: 18 to 24 years, 25 to 34 years, and 35 years and older. Participants were provided details regarding an existing mobile app diary to self-monitor sexual behaviors and a hypothetical PCA with whom to review the app. Facilitators posed questions regarding perceived HIV risk, attitudes toward the app, working with a PCA, and preferences for PCA characteristics and approaches. RESULTS: Most participants identified as homosexual, gay, or same gender-loving (26/38, 68%), were employed (26/38, 69%), single (25/38, 66%), and interested in self-monitoring sexual behaviors (28/38, 68%). However, themes suggested that participants had low perceived HIV risk, that self-monitoring sexual behaviors using a mobile app diary was feasible but could trigger internalized stigma, and that an acceptable PCA should be a possible self for BSMM to aspire to but they still wanted clinicians to "do their job." CONCLUSIONS: HIV-negative BSMM have dissonant attitudes regarding perceived HIV risk and the utility of a mobile app and PCA to increase perceived HIV risk and PrEP initiation. Future research will explore the feasibility, acceptability, and preliminary impact of implementing the multicomponent intervention on perceived HIV risk and PrEP initiation among BSMM in a pilot study.
ABSTRACT
A decision analysis was conducted to evaluate the cost-effectiveness of programs in which the Amplified Mycobacterium Tuberculosis Direct test (MTD) (Gen-Probe) is used to rapidly exclude Mycobacterium tuberculosis complex as a cause of disease in smear-positive respiratory specimens. MTD sensitivity, specificity, and probability of inhibition for smear-positive specimens were estimated from literature reports. Costs and laboratory performance characteristics were determined from review of records and practices at an urban hospital in the mid-Atlantic United States. In the base case, 31.4% of smear-positive specimens were assumed to be culture positive for M. tuberculosis. Under these conditions, the marginal cost of the MTD testing program was estimated as $338 per smear-positive patient, or $494 per early exclusion of tuberculosis based on negative MTD results. By comparison, the cost of respiratory isolation ($27.77/day) and drugs ($5.66/day) averted by MTD testing was estimated at $201 per early tuberculosis exclusion. MTD testing was therefore not cost-effective in this scenario. Sensitivity analysis revealed that cost-effectiveness estimates are sensitive to the number of smear-positive specimens processed annually, the relative prevalence of M. tuberculosis in smear-positive specimens, and the marginal daily cost of respiratory isolation. A decision tool is therefore presented for assessing the cost-effectiveness of MTD under various combinations of those three variables. While routine MTD testing of smear-positive specimens is not expected to be cost-saving for most individual hospitals, centralized reference laboratories may be able to implement MTD in a cost-effective manner across a wide range of situations.
