Low Self-Perceived Need for PrEP and Behavioral Indications of MSM Who Recently Refused Daily PrEP: A Mixed Methods Study in Three U.S. Cities.

Pre-exposure prophylaxis (PrEP) reduces sexual risk for HIV transmission by 99% when used appropriately, but remains underutilized among gay, bisexual, and other men who have sex with men (MSM). In this mixed-method study, we describe reasons for PrEP refusal associated with low self-perceived need for PrEP among MSM who recently declined daily oral PrEP when offered by a provider. Data are from a quantitative behavioral survey of MSM (N = 93) living in Atlanta, Chicago, and Raleigh-Durham, who also either responded to an in-depth interview (n = 51) or participated in one of 12 focus groups (n = 42). Themes of low self-perceived need for PrEP were: low self-perceived risk for HIV acquisition (33% of respondents); confidence in remaining HIV-negative (35%); using condoms (81%); limiting number of partners and choosing partners carefully (48%); asking partners about their HIV status before having sex (45%); engaging in safer sexual positions or oral sex (28%); being in a monogamous relationship or exclusivity with one partner (26%); and regular HIV testing (18%). Low self-perceived risk for HIV acquisition and high confidence in other prevention strategies were important factors related to low self-perceived need in MSM refusing daily oral PrEP when offered. Providers should continue to discuss the benefits of PrEP as a safe and highly effective option for HIV prevention.

RESUMEN: La profilaxis pre-exposición (PrEP) reduce el riesgo de transmisión sexual por el VIH en un 99% cuando se utiliza apropiadamente, pero sigue siendo subutilizada entre hombres gais, bisexuales y otros hombres que tienen sexo con hombres (HSH). En este estudio de método mixto, describimos los motivos del rechazo de la PrEP asociados a la baja necesidad autopercibida de la PrEP entre los HSH que recientemente rechazaron la PrEP oral diaria, cuando fue ofrecida por un proveedor de salud. Los datos provienen de una encuesta cuantitativa de comportamiento de los HSH (N = 93) que viven en Atlanta, Chicago y Raleigh-Durham, quienes también respondieron a una entrevista en profundidad (n = 51) o participaron en uno de los 12 grupos focales (n = 42). Los temas de baja necesidad autopercibida del uso de la PrEP fueron: el bajo riesgo auto percibido de contraer el VIH (33% de los encuestados); la confianza en seguir siendo VIH negativo (35%); utilizar condones (81%); limitar el número de parejas sexuales y elegir las parejas cuidadosamente (48%); preguntar a sus parejas sobre su estado de VIH antes de tener relaciones sexuales (45%); participar en posiciones sexuales más seguras o sexo oral (28%); estar en relación monógama o de exclusividad con una sola pareja (26%); y hacerse pruebas del VIH regularmente (18%). El bajo riesgo autopercibido de contraer el VIH y la alta confianza en otras estrategias de prevención fueron factores importantes relacionados con la baja necesidad autopercibida en los HSH que rechazaron la PrEP oral diaria cuando se les ofreció. Los proveedores de salud deben continuar el diálogo sobre los beneficios de la PrEP como una opción segura y altamente eficaz para la prevención del VIH.

"Take care of their hierarchy of needs first": strategies used by data-to-care staff to address barriers to HIV care engagement.

Data-to-Care (D2C) is a public health strategy designed to engage out-of-care (OOC) persons with HIV (PWH) in HIV care. OOC PWH are identified through review of state and local HIV data and engaged in care through individualized efforts that address barriers to HIV care. Perspectives of D2C program staff can contribute to D2C program development and sustainability. We conducted semi-structured interviews in 2017 with 20 D2C program staff from Louisiana (n = 10) and Virginia (n = 10), states with distinct D2C programs. We used content and thematic analysis to analyze interview transcripts. In both states, common barriers to care for OOC PWH include limited transportation, stigma, substance use, poverty, homelessness, and mental illness. To address these barriers and engage OOC clients in HIV care, staff and programs provided transportation vouchers and housing assistance, integrated substance use and mental health services into care engagement processes, provided empathy and compassion, and assessed and addressed basic unmet needs. Identifying and addressing social and structural barriers to HIV care is a critical and often a necessary first step in engaging OOC clients in HIV care. These findings can be used for D2C program design and implementation, facilitating engagement in HIV care for OOC PWH.

Utilization of HIV Prevention, Care, and Treatment Services Among Young Men Who Have Sex With Men and Transgender Persons of Color in the U.S. South: A Qualitative Analysis.

To better understand utilization of HIV prevention, care, and treatment services by young men who have sex with men (YMSM) and young transgender persons (YTG), of Black race or Hispanic/Latino/Latina ethnicity in the U.S. South, we conducted semi-structured interviews with 127 clients at one of four community based organizations (CBOs) in Miami, Atlanta, New Orleans/Baton Rouge, or Columbia, South Carolina. Across sites, the service that most commonly drew respondents into the CBO was HIV and STD testing. Other services commonly used included HIV/STI treatment, counseling services/support groups, and PrEP services. Social/organizational/structural facilitators of service utilization include the welcoming climate/culture of the CBOs, ease of access to the services, and transportation services to reach the CBOs. Suggested service enhancements include broader range of comprehensive, navigational-type services beyond HIV testing and service co-location. Research on how to reduce stigma in the surrounding communities may help reduce health disparities experienced by these populations.

"We in This Fight Together ": HIV Treatment and Prevention Among Couples of HIV-Discordant Black and Latino Men Who Have Sex with Men.

HIV-positive Black and Latino men who have sex with men (MSM) have substantial challenges accessing and engaging in HIV care. Findings presented here are an analysis of 14 HIV-discordant couples (N = 28) from Atlanta, GA; Baltimore, MD; Chicago, IL; Los Angeles, CA; and Washington, DC. One-hour in-depth interviews were conducted. Interviews were analyzed using a qualitative content analysis approach. Most couples reported relationship fears associated with delayed disclosure, HIV care engagement instigated by the HIV-uninfected partner, and varying knowledge and concern about the impacts of HIV infection and risk reduction. Findings suggest an opportunity to jointly educate and treat MSM of color in HIV-discordant relationships to improve engagement in ART and PrEP care and adherence.

HIV Testing Program Activities and Challenges in Four U.S. Urban Areas.

The national "Ending the HIV Epidemic: A Plan for America" supports expanded testing in jurisdictions and groups with disproportionate HIV burden. Public health planners benefit from learning HIV testing service (HTS) strengths, challenges, and innovations. We conducted semistructured interviews with 120 HTS staff from local health departments, community-based organizations, and community members in Houston, Texas; Miami, Florida; New Orleans, Louisiana; and Washington, DC. We coded interview transcripts using qualitative methods to identify themes. Program strengths include HIV testing integration with other client services; prioritized testing and tailored incentives; multiple advertising methods; and partnerships among HTS providers. Challenges include stigma, fear, and disparities; funding requirements that create competition between providers; and service accessibility, unnecessary repeat testing, and insufficient innovation. The four jurisdictions addressed some, but not all, of these challenges. Cross-jurisdictional collaboration, together with state and federal partners plus program data may help identify additional strategies for strengthening HTS.

"To Me, Everybody Is infected": Understanding Narratives about HIV Risk among HIV-negative Black Men Who Have Sex with Men in the Deep South.

For black MSM living in the Deep South, the intersection of sexuality, race, and geography impacts HIV risk substantially. Between July and September 2016, we conducted a qualitative study among HIV-negative black MSM in five southern cities in the US with elevated HIV prevalence. Analysis included assessment of interrater reliability, cluster analysis, and descriptive statistics. We enrolled 99 black MSM (mean age: 33.6; SD = 12.8; range: 17-68 years). Four overarching themes emerged: harboring fear of HIV and the internalization of HIV stigma; scrutinizing potential partners to assess riskiness and HIV status; embracing distance and isolation from those perceived as a threat to HIV status; and exhibiting self-efficacy toward HIV prevention and utilizing risk reduction strategies. Future HIV prevention efforts may benefit by balancing risk and deficit based strategies with those that emphasize resilience, address disenfranchisement via structural interventions, and assess and treat inherent trauma(s).

Barriers and Facilitators for Antiretroviral Treatment Adherence Among HIV-Positive African American and Latino Men Who Have Sex With Men.

Some Black/African American and Hispanic/Latino men who have sex with men (MSM) living with HIV do not take antiretroviral therapy (ART). We conducted semistructured interviews with 84 adult, Black/African American and Hispanic/Latino MSM with HIV to understand ART barriers and facilitators. We used chi-square statistics to identify factors associated with ART use (p ≤ .05), and selected illustrative quotes. Over half (51.2%) said they followed their doctor's instructions; however, only 27.4% reported consistently taking ART. Some men delayed ART until overcoming diagnosis denial or becoming very sick. ART use was facilitated by encouragement from others, treatment plans, side effect management, lab test improvements, pill-taking reminders, and convenient care facilities that provide "one-stop shop" services. Men were more likely to take ART when having providers who communicated effectively and were perceived to treat them with respect. Healthcare personnel can use our findings to strengthen services for MSM of color.

Barriers and Facilitators for Clinical Care Engagement Among HIV-Positive African American and Latino Men Who Have Sex with Men.

Achieving optimal health among people living with HIV (PLWH) requires linkage to clinical care upon diagnosis, followed by ongoing engagement in HIV clinical care. A disproportionate number of black/African American and Hispanic/Latino men who have sex with men (MSM) living with HIV do not, however, achieve ongoing care. We conducted semistructured interviews in 2014 with 84 urban black/African American and Hispanic/Latino MSM living with HIV to understand their barriers and facilitators to engagement. We classified men as care-engaged or not at the time of the interview, and conducted content analysis of the interview transcripts to identify barriers and facilitators to engagement. Respondent mean age was 42.4 years (range, 20-59). Over half (59.5%, n = 50) were black/African American. Slightly more than a third (38.1%, n = 32) reported not being continuously care-engaged since diagnosis, and 17.9% (n = 15) delayed entry, although they have subsequently entered and remained in care. Sustained engagement began with overcoming denial after diagnosis and having treatment plans, as well as having conveniently located care facilities. Engagement also was facilitated by services tailored to meet multiple patient needs, effective patient-provider communication, and providers who show empathy and respect for their patients. Respondents were less likely to be care-engaged when these factors were absent. It can be difficult for racial and ethnic minority MSM living with HIV to begin and sustain care engagement. To optimize care engagement, our findings underscore the value of (1) convenient multipurpose HIV care facilities that meet patient needs; (2) excellent provider-patient communication that reinforces respect, trust, and HIV treatment literacy; and (3) assisting PLWH to create personalized treatment plans and overcome possible challenges such as diagnosis denial.

Preparing to measure health coverage in federal surveys post-reform: lessons from Massachusetts.

In preparation for health reform in 2014, qualitative research was conducted with Massachusetts residents to explore how to adapt surveys to accommodate reporting information about health exchanges. Questions about exchange participation were effective when state-specific exchange program names were offered, but generic terms such as "marketplace" and "exchange" did not resonate with respondents. However, respondents were able to understand new questions about premiums and subsidies and to answer with a high degree of accuracy. These questions, taken in tandem with answers on plan type, were sufficient to distinguish among Medicaid, subsidized exchange coverage, and unsubsidized coverage, even without the benefit of state-specific exchange program names.

Developing multilingual prescription instructions for patients with limited english proficiency.

This article describes the development of a set of patient-centered prescription medication instructions and their translation into Chinese, Korean, Russian, Spanish, and Vietnamese. Challenges and lessons learned from this process are reported to inform future efforts to develop easy-to-understand, multilingual materials for use in health care settings.

Design and Analysis of Cognitive Interviews for Comparative Multinational Testing.

This article summarizes the work of the Comparative Cognitive Testing Workgroup, an international coalition of survey methodologists interested in developing an evidence-based methodology for examining the comparability of survey questions within cross-cultural or multinational contexts. To meet this objective, it was necessary to ensure that the cognitive interviewing (CI) method itself did not introduce method bias. Therefore, the workgroup first identified specific characteristics inherent in CI methodology that could undermine the comparability of CI evidence. The group then developed and implemented a protocol addressing those issues. In total, 135 cognitive interviews were conducted by participating countries. Through the process, the group identified various interpretive patterns resulting from sociocultural and language-related differences among countries as well as other patterns of error that would impede comparability of survey data.

Cognitive evaluation of self-report questions for surveillance of periodontitis.

This paper describes the cognitive testing of eight self-report questions as part of a broader effort to evaluate and validate the use of these questions in estimating the prevalence of periodontitis in the United States population. This study examined how United States respondents understood and processed the proposed questions in English and Spanish, as well as identifying and correcting for possible response errors. The set of eight questions was selected by the Centers for Disease Control and Prevention Periodontal Disease Surveillance Workgroup for further testing after analytical assessments and field testing of an array of potential questions. Evaluation of these eight oral health questions was based on 40 in-depth, semi-structured cognitive interviews in English and Spanish. Results of this cognitive test study are presented. The recommendations from this cognitive testing evaluation served as the basis to improve the original questions in English and Spanish to be more inclusive and consistent and improve the estimation of periodontal disease in the United States population.

Cognitive Evaluation of Self-Report Questions for Surveillance of Periodontitis.

This paper describes the cognitive testing of eight self-report questions as part of a broader effort to evaluate and validate the use of these questions in estimating the prevalence of periodontitis in the United States population. This study examined how United States respondents understood and processed the proposed questions in English and Spanish, as well as identifying and correcting for possible response errors. The set of eight questions was selected by the Centers for Disease Control and Prevention Periodontal Disease Surveillance Workgroup for further testing after analytical assessments and field testing of an array of potential questions. Evaluation of these eight oral health questions was based on 40 in-depth, semi-structured cognitive interviews in English and Spanish. Results of this cognitive test study are presented. The recommendations from this cognitive testing evaluation served as the basis to improve the original questions in English and Spanish to be more inclusive and consistent and improve the estimation of periodontal disease in the United States population.

Using focus groups to develop a culturally sensitive methodology for epidemiological surveys in a Latino population: findings from the Los Angeles Latino Eye Study (LALES).

BACKGROUND: Many standardized survey instruments are initially developed in English-speaking populations. These instruments may not be culturally appropriate for other ethnic groups, such as Latinos. METHODS: The Los Angeles Latino Eye Study (LALES) was designed to determine the prevalence of blindness, visual impairment, and ocular diseases; risk factors for these diseases; and general and ocular healthcare use among non-institutionalized adult Latinos in suburban Los Angeles County, California. The LALES investigators used focus groups to develop questionnaires and to devise culturally sensitive methods for implementing this epidemiologic study in a Latino population. Eighty-four respondents were administered the in-home questionnaire and then scheduled into one of 6 in-home focus groups, allowing participants to reflect in groups about the study, their participation, and the state of the instruments and the translations. FINDINGS: Overall, respondents reported that the questionnaire was well written, easy to understand, and very clear. Recommendations from participants included: 1) keep questions brief; 2) minimize the number of response choices; 3) keep phrasing clear; 4) simplify technical terms; 5) provide test results immediately after the clinical examination; and 6) hire Spanish-speaking staff to increase participants' trust and confidence. CONCLUSION: Focus groups assisted in yielding a culturally appropriate survey research tool and methodology for this population-based study in a Latino community.