Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care.

BACKGROUND: Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings. OBJECTIVE: To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs. DESIGN: Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018. PARTICIPANTS: The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City. APPROACH: Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts. KEY RESULTS: Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers. CONCLUSIONS: SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.

Challenges to Providing Integrated HIV Prevention in Substance Use Treatment Settings: Frontline Staff Perspectives on HIV and Sex-Related, Education, Communication and Stigma.

INTRODUCTION: Substance use treatment settings can play a critical role in ending the HIV epidemic. Community-based methadone clinics are potentially useful sites to offer biomedical HIV prevention, but little is known about how clinicians and other clinic staff communicate with patients about sexual behavior and HIV-related topics. METHODS: Thirty semi-structured interviews were conducted at two methadone clinics in Northern New Jersey. Participants included medical providers (physicians, RNs, DNPs), methadone counselors, intake coordinators, lab technicians, and other auxiliary staff members. Results: Three major themes were identified: (1) HIV education is primarily provided by external organizations, (2) there is limited staff-patient communication around HIV and sexual behaviors, and (3) HIV stigma is prevalent among staff and patients. CONCLUSION: To implement PrEP in methadone treatment settings, clinic staff must be able to engage in non-judgmental communication about HIV and sex with patients. Additionally, federal and state funding for HIV prevention in substance use treatment settings must be prioritized to enable clinics to access the necessary training and resources.

'Why aren't you on PrEP? You're a gay man': reification of HIV 'risk' influences perception and behaviour of young sexual minority men and medical providers.

Public health models and medical interventions have often failed to consider the impact of reductionist HIV 'risk' discourse on how sexual minority men interpret, enact and embody biomedical knowledge in the context of sexual encounters. The aim of this study was to use an anthropological lens to examine sexual minority men's perception of HIV risk and experience within the medical system in order to examine the influence of risk discourse on their health, behaviour and social norms. In-depth interviews (n = 43) were conducted with a racially, ethnically and socioeconomically diverse sample of young sexual minority men and explored HIV-related beliefs and experiences, as well as their interactions with healthcare providers. Findings suggest that the stigmatisation of behaviours associated with HIV appears to be shaped by three key forces: healthcare provider perceptions of sexual minority men as inherently 'risky', community slut-shaming, and perceptions of risk related to anal sex positioning. Stigmatising notions of risk appear to be embodied through sexual health practices and identities vis-à-vis preferred anal sex positions and appear to influence condom use and PrEP initiation.

Logistical Facilitators and Barriers to PrEP Implementation in Methadone Clinic Settings: Provider and Staff Perspectives.

OBJECTIVES: The purpose of this study was to examine the feasibility of implementing pre-exposure prophylaxis (PrEP), a daily oral medication for human immunodeficiency virus (HIV) prevention, in methadone clinics. METHODS: Medical and nonmedical staff (n = 30) at 2 methadone clinics in Northern New Jersey were qualitatively interviewed about various aspects of substance use treatment, clinical operations, and HIV risk and prevention among their patient populations. Audio-recorded interviews were professionally transcribed, then coded and analyzed by the research team. RESULTS: Themes surrounding the viability of PrEP implementation emerged for both logistical facilitators and barriers. Facilitators included availability of prescribing clinicians, ability to conduct lab testing on-site, and availability of existing hepatitis C programs as a blueprint for PrEP management. Barriers included increased provider burden, financial concerns, and perceptions that PrEP provision is outside the clinic's treatment scope. CONCLUSIONS: Although staff expressed willingness and potential ability to provide PrEP, they identified barriers regarding insurance reimbursement, limited funding, and concerns that PrEP would extend the clinic's treatment scope. However, given the enabling factors such as availability of providers and existing clinical infrastructure, providing PrEP could increase clinic revenue through insurance reimbursement and federal funding for PrEP-related services. Clinic-level education is needed for clinical and nonclinical staff to better understand the logistics of implementing PrEP, particularly regarding prescribing practices, billing and insurance concerns, and the essential nature of HIV prevention as a critical component of substance use treatment.