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Evidence and implication of interventions across various socioecological levels to address pre-exposure prophylaxis uptake and adherence among men who have sex with men in the United States: a systematic review

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Background Pre-exposure prophylaxis (PrEP) represents a proven biomedical strategy to prevent HIV transmissions among men who have sex with men (MSM) in the United States (US). Despite the design and implementation of various PrEP-focus interventions in the US, aggregated evidence for enhancing PrEP uptake and adherence is lacking. The objective of this systematic review is to synthesize and evaluate interventions aimed to improve PrEP uptake and adherence among MSM in the US, and identify gaps with opportunities to inform the design and implementation of future PrEP interventions for these priority populations. Methods We followed the PRISMA guidelines and conducted a systematic review of articles (published by November 28, 2021) with a focus on PrEP-related interventions by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO). Details of PrEP interventions were characterized based on their socioecological level(s), implementation modalities, and stage(s) of PrEP cascade continuum. Results Among the 1363 articles retrieved from multiple databases, 42 interventions identified from 47 publications met the inclusion criteria for this review. Most individual-level interventions were delivered via text messages and/or apps and incorporated personalized elements to tailor the intervention content on participants’ demographic characteristics or HIV risk behaviors. Interpersonal-level interventions often employed peer mentors or social network strategies to enhance PrEP adoption among MSM of minority race. However, few interventions were implemented at the community-, healthcare/institution- or multiple levels. Conclusions Interventions that incorporate multiple socioecological levels hold promise to facilitate PrEP adoption and adherence among MSM in the US given their acceptability, feasibility, efficacy and effectiveness. Future PrEP interventions that simultaneously address PrEP-related barriers/facilitators across multiple socioecological levels should be enhanced with a focus to tackle contextual and structural barriers (e.g., social determinants of health, stigma or medical mistrust) at the community- and healthcare/institution-level to effectively promote PrEP use for MSM of color.
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Wangetal. AIDS Research and Therapy (2022) 19:28
https://doi.org/10.1186/s12981-022-00456-1
REVIEW
Evidence andimplication ofinterventions
acrossvarious socioecological levels
toaddress pre-exposure prophylaxis uptake
andadherence amongmen who have sex
withmen intheUnited States: asystematic
review
Ying Wang1, Jason W. Mitchell2, Chen Zhang3 and Yu Liu1,4*
Abstract
Background: Pre-exposure prophylaxis (PrEP) represents a proven biomedical strategy to prevent HIV transmissions
among men who have sex with men (MSM) in the United States (US). Despite the design and implementation of
various PrEP-focus interventions in the US, aggregated evidence for enhancing PrEP uptake and adherence is lacking.
The objective of this systematic review is to synthesize and evaluate interventions aimed to improve PrEP uptake and
adherence among MSM in the US, and identify gaps with opportunities to inform the design and implementation of
future PrEP interventions for these priority populations.
Methods: We followed the PRISMA guidelines and conducted a systematic review of articles (published by Novem-
ber 28, 2021) with a focus on PrEP-related interventions by searching multiple databases (PubMed, MEDLINE, Web
of Science and PsycINFO). Details of PrEP interventions were characterized based on their socioecological level(s),
implementation modalities, and stage(s) of PrEP cascade continuum.
Results: Among the 1363 articles retrieved from multiple databases, 42 interventions identified from 47 publica-
tions met the inclusion criteria for this review. Most individual-level interventions were delivered via text messages
and/or apps and incorporated personalized elements to tailor the intervention content on participants’ demographic
characteristics or HIV risk behaviors. Interpersonal-level interventions often employed peer mentors or social network
strategies to enhance PrEP adoption among MSM of minority race. However, few interventions were implemented at
the community-, healthcare/institution- or multiple levels.
Conclusions: Interventions that incorporate multiple socioecological levels hold promise to facilitate PrEP adoption
and adherence among MSM in the US given their acceptability, feasibility, efficacy and effectiveness. Future PrEP inter-
ventions that simultaneously address PrEP-related barriers/facilitators across multiple socioecological levels should be
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Open Access
AIDS Research and Therapy
*Correspondence: yu_liu@urmc.rochester.edu
4 Division of Epidemiology, Department of Public Health Sciences, University
of Rochester Medical Center, 256 Crittenden Blvd, Ste. 3305, Rochester, NY
14642, USA
Full list of author information is available at the end of the article
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Wangetal. AIDS Research and Therapy (2022) 19:28
Introduction
Men who have sex with men (MSM) experience a dis-
proportionate burden of HIV in the US, accounting for
approximately 70% of the 36 thousand new HIV diagno-
ses in 2019 [1]. Particularly, MSM of color (e.g., Black and
Hispanic/Latino MSM) continue to be the priority popu-
lations most affected by HIV, representing nearly half of
the new infections among all MSM in the US [14]. e
challenges of HIV prevention in MSM are further com-
plicated by their low perception of HIV risk, the lack of
sustainable use of pre-exposure prophylaxis (PrEP), low
HIV testing uptake, and high prevalence of behaviors that
increase acquisition/transmission of HIV (e.g., condom-
less receptive/insertive anal sex, multiple anal sex part-
ners, and exchange of sex for money/drugs) [57].
Currently approved medications for PrEP, a prescrip-
tion medicine to prevent HIV infections, include Truvada
(for all people at risk for HIV) and Descovy (for peo-
ple at risk for HIV through anal sex and less impact on
kidney and bone health) [8]. When taken as prescribed,
daily oral PrEP has been shown to lower the risk of HIV
infection from sex by > 99% and from injection drug use
by > 74% [912]. Mathematical models showed that HIV
infections among people who were at high risk for HIV
while adhering to PrEP had decreased by 18% from 2016
to 2020 [13]. erefore, high-impact prevention interven-
tions to enhance PrEP uptake among MSM provide one
effective strategy to end the HIV epidemic in the US [14,
15].
PrEP care continuum is usually used to evaluate
interventions for PrEP, including (1) awareness (knowl-
edge about PrEP), (2) willingness/intention (likelihood
of initiating PrEP), (3) access (linking PrEP candidates
to healthcare system), (4) uptake (PrEP initiation),
and (5) adherence (adherence to PrEP and retention
in PrEP care) [14]. Despite the increased availability
and proven efficacy in preventing new HIV infections,
the level of engagement along the PrEP care contin-
uum remains low among MSM in the US [5, 1618].
For example, pooled analyses showed that only 13.9%
of MSM have reported ever using PrEP in their life-
time (95% confidence interval (95% CI): 8.8–21.1) [16].
Numerous observational studies with MSM in the US
have revealed important barriers across multiple socio-
ecological levels that may affect the uptake/adherence
of PrEP, including individual—(e.g., perception of low
HIV risk, insufficient PrEP knowledge and concerns
over side effects) [1921], interpersonal—(e.g., lack of
parent/peer support) [2022], healthcare system—(e.g.,
high cost and low PrEP care quality) [5, 19, 20] and
social-cultural—(e.g., stigma, discrimination and medi-
cal mistrust) levels [5, 1921, 23].
Since 2017, there has been an increasing number of
interventions to enhance the engagement in PrEP care
continuum among MSM by modifying their individ-
ual health behaviors or social networks. For example,
PrEPmate was one of the early mobile health interven-
tions that utilized daily text messages to remind young
MSM (YMSM) of PrEP medication [24]. Interventions
that leveraged peer influence to improve intentions and
willingness to use PrEP among MSM of color were also
reported in recent years [2527]. While these interven-
tions employed novel strategies (e.g., mobile health and
social network) and showed efficacy in improving PrEP
care continuum in MSM, some limitations were also
acknowledged by the authors, including sustainability
post intervention period, discrepancy between inter-
vention content and participants’ time-varying inter-
vention needs, and lack of parent/school engagement in
PrEP interventions [2426].
Despite the design and implementation of various
PrEP interventions for MSM in the US, there is a need
to systematically summarize the practical/theoreti-
cal components, modalities, strengths, and limitations
of these PrEP-focused HIV prevention interventions
for MSM. Aggregated evidence presented on different
socioecological levels (e.g., individual, interpersonal,
community and healthcare/institution levels)—via a
systematic review—enables us to compare interven-
tions across socioecological levels (e.g., acceptability,
feasibility or efficacy), informs HIV prevention sci-
entists about successful intervention strategies that
modify physical or social environments rather than
changing only individual health behaviors, as well as
reveals ways to improve current and former PrEP inter-
ventions. We conducted a systematic review of inter-
vention studies that aimed to improve one or more
aspects of the PrEP care continuum among MSM in the
US, by summarizing included studies and their socioec-
ological mechanistic levels, implementation modalities
(peer/couple-based, technology-assisted, social net-
work, etc.), and which aspects of the PrEP cascade (e.g.,
initiation, uptake, and adherence) they targeted.
enhanced with a focus to tackle contextual and structural barriers (e.g., social determinants of health, stigma or medi-
cal mistrust) at the community- and healthcare/institution-level to effectively promote PrEP use for MSM of color.
Keywords: Pre-exposure prophylaxis, Intervention, Men who have sex with men, Systematic review, United States
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Wangetal. AIDS Research and Therapy (2022) 19:28
Methods
Literature search strategy
is systematic review was conducted by searching
articles via multiple databases (PubMed, MEDLINE,
Web of Science and PsycINFO) published by November
28, 2021, following the PRISMA guidelines [28]. e
final search terms included: (“gay” OR “men who have
sex with men” OR “bisexual” OR “homosexual” OR
“homosexuality” OR “same-gender-loving” OR “sexual
minority”) AND (“PrEP” OR “pre-exposure prophy-
laxis” OR “preexposure prophylaxis”) AND (“interven-
tion” OR “trial” OR “experiment” OR “randomized” OR
“pre-post”).
Inclusion/exclusion criteria
Studies were included in this systematic review if they
met the following criteria: (1) published journal articles
excluding abstracts, conference proceedings, reviews,
meta-analyses, editorials or commentaries; (2) con-
ducted in the US; (3) the current and/or the parent
study was based on an experimental or quasi-experi-
mental design (e.g., randomized controlled trial (RCT),
randomized interventional studies, and pre-post trial)
to evaluate the efficacy or effectiveness of a PrEP inter-
vention; (4) reported at least one PrEP care continuum
outcome (e.g., awareness, willingness, intention, uptake
and adherence); (5) conducted among males who self-
identified as gay, bisexual, or reported having sex with
men within a past time window; and (6) published in
English.
To achieve our goal of comprehensively summarizing
PrEP interventions for MSM in the US, we also included
the following studies for potential evaluation: (1) studies
conducted among MSM and other priority populations
(e.g., transgender women); (2) studies that used an exper-
imental design to evaluate the acceptability, feasibility,
cost-effectiveness of a PrEP intervention with reporting
PrEP-related outcomes; (3) studies using an non-experi-
mental design (e.g., qualitative or cross-sectional study)
to assess the acceptability, feasibility or cost-effectiveness
of an eligible intervention if details about its implementa-
tion to evaluate efficacy/effectiveness could be retrieved
from their published parent trials by checking the refer-
ence lists; (4) we also included protocols that elaborated
the design and implementation to supplement our sum-
mary of the PrEP interventions. We excluded studies that
used a composite measure of HIV risk with PrEP uptake
as one of the risk calculation criteria if PrEP uptake was
not explicitly reported. We also excluded papers that
described the development/adaptation of eligible inter-
ventions without reporting interested PrEP-related
outcomes.
Study screening anddata extraction
Titles and abstracts of all identified records were first
screened for duplicate removal and relevancy by two
independent reviewers (Y.W. and Y.L.). e full text
review and data extraction were then conducted indepen-
dently by one author (Y.W.), and further cross-checked
by the other author (Y.L.) for accuracy. Disagreements
were resolved by consensus-based discussion. e fol-
lowing information was extracted from eligible studies:
study location/setting, study/recruitment period, study
design, recruitment strategy, participant characteristics,
intervention content, theoretical/conceptual framework,
control group, sample size and retention, study out-
come measures (e.g., PrEP care continuum outcomes)
and major findings from the interventions (e.g., efficacy,
effectiveness, feasibility and acceptability).
We categorized all interventions into different socio-
ecological levels based on the primary barriers the inter-
ventions aimed to address. e original socioecological
model to guide HIV studies was composed of four layers:
individual, interpersonal, community and structural level
[29]. We replaced structural level with healthcare level
(i.e., interventions implemented in healthcare settings)
since we did not identify interventions that may impact
laws or policies. We additionally modified this model by
adding a layer of multiple levels to describe interventions
that address PrEP-related barriers/facilitators across
multiple socioecological levels.
Results
Search results
A total of 1363 articles were found through the initial
search of multiple databases. After removing duplicates
and ineligible articles through title/abstract screening,
66 papers were further assessed via full-text review, with
47 papers representing 42 interventions retained for the
final systematic review. Of the included studies, twenty-
three papers evaluated the acceptability (n = 8), feasibility
(n = 8), efficacy (n = 18) or effectiveness (n = 1) of inter-
ventions aimed at improving PrEP uptake and adherence
among MSM in the US. Twenty-four of the 47 articles
described the protocols for the design and implementa-
tion of relevant interventions. Study selection process is
shown in Fig.1.
Study characteristics
Forty-two interventions were categorized into 5 socio-
ecological levels and characteristics of interventions
on each level are presented in Additional file1: Tables
S1–S5, respectively. PrEP interventions for MSM were
reported to implement in the US South (Florida, Geor-
gia, Texas, Maryland, Mississippi, North Carolina and
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Page 4 of 12
Wangetal. AIDS Research and Therapy (2022) 19:28
D.C.) [3040], Northeast (Pennsylvania, New York, Mas-
sachusetts and Rhode Island) [27, 3133, 36, 38, 4149],
Midwest (Illinois, Michigan, and Wisconsin) [2426,
32, 33, 36, 47, 5052], West (California) [51, 5358]
and nationwide [5963]. irty-seven of the 42 studies
focused solely on MSM [2427, 3034, 3641, 4347,
4954, 56, 5872], with some targeting Black, Hispanic/
Latino MSM or MSM younger than 34 years old [2427,
3034, 3640, 4446, 49, 50, 52, 56, 58, 6063, 70]. Five
studies were conducted among MSM and other prior-
ity populations(e.g., transgender women or heterosex-
ual men) [35, 42, 48, 55, 57]. A RCT design was used to
evaluate 37 interventions on their effect on PrEP-related
outcomes [24, 25, 27, 3042, 4448, 50, 5256, 5863,
6672], whereas 5 interventions were evaluated using a
quasi-experimental design [26, 43, 49, 51, 57] and 4 via a
pretest-posttest design [26, 49, 51, 57].
Study outcomes acrosspre‑exposure prophylaxis care
continuum
Most interventions were evaluated by PrEP-related
outcomes across the PrEP care continuum with PrEP
uptake (n = 29) and adherence (n = 24) most commonly
reported. Awareness of PrEP was measured by partici-
pants’ knowledge about PrEP including medication pur-
pose, side effects and self-efficacy [2527, 31, 33, 39, 40,
4345, 49, 56, 60, 63, 70]. PrEP willingness/intention
focused on participants’ attitudes towards PrEP use such
as their likelihood of initiating PrEP across various con-
ditions or during a future time window (e.g., within the
next 3 or 6 months) [2527, 31, 33, 34, 39, 44, 57, 59, 60,
63, 70]. Access to PrEP was referred to participants’ link-
age to healthcare system (e.g., scheduling or attending
an appointment for PrEP consultation) [25, 27, 3335,
39, 52, 58, 6971]. PrEP uptake was measured by self-
reported PrEP initiation or a recipient of a prescription
for PrEP [25, 30, 31, 3436, 38, 39, 4346, 52, 54, 55, 57,
58, 60, 6972]. Adherence to PrEP utilized both behavio-
ral (e.g., self-reported retention in PrEP care or number
of doses missed in the past 30 days) [3033, 36, 40, 46,
4851, 58, 60, 73] or biological measurements (e.g., PrEP
concentration in dried blood spots) [24, 32, 33, 37, 4042,
53, 72]. Outcomes out of the PrEP care continuum were
also reported in a few studies, including descriptive and
subjective PrEP norms, PrEP-related stigma and barriers
to PrEP [2527].
Fig. 1 Flowchart of study selection and inclusion procedure
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Wangetal. AIDS Research and Therapy (2022) 19:28
Intervention strategies andndings
Building on the Social-ecological Model and the char-
acteristics of the reviewed interventions [29], we
categorized 42 interventions into individual-, inter-
personal-, community-, healthcare/institution-level,
and multilevel interventions. e vast majority of these
interventions were delivered at the individual or inter-
personal level. e sub-categories under individual-
level interventions were not mutually exclusive (e.g., a
technology-assisted intervention may include personal-
ized/individualized elements). Hence, the intervention
types/levels presented below were used to provide the
audience with examples of various interventions.
Individual‑level interventions
PrEP regimen interventions
PrEPare was one of the initial intervention trials that
tested the effect of daily tablets combined with a behav-
ioral intervention on adherence to PrEP in YMSM
compared to placebo pill control combined with the
behavioral intervention and behavioral intervention
alone [50]. Another trial implemented in New York City
evaluated 3 different dosing regimens of PrEP, 1 tablet
twice weekly with a post-sex dose, 1 tablet before and
after sex and 1 tablet daily [42]. Both interventions sug-
gest that daily oral PrEP was associated with a high
level of medication adherence compared to other dos-
ing recommendations [42, 50].
Technology‑assisted interventions
In recent years, text messages have become one of the
most indispensable components used in PrEP interven-
tions [33, 52]. For example, participants in LifeSteps
received text messages on a weekly basis as a motiva-
tional reminder to enhance PrEP adherence [33]. Using
the Behavioral eories and Information-Motivation-
Behavioral Skills (IMB) framework, bidirectional text
message interventions were implemented to boost
communication between participants and research
team [24, 52, 53]. For example, daily pill reminder mes-
sages were sent to participants at a personally selected
time, with study staff providing assistance to partici-
pants who did not respond to the message or reported
any difficulty with PrEP use [24, 51, 53]. Partner Ser-
vices PrEP study also used text messages to deliver
booster sessions to follow up on participants’ experi-
ences getting linked to PrEP medication [52]. Overall,
text message interventions based on mobile technol-
ogy were found to be feasible, acceptable and effica-
cious when the messages were personalized and able to
address specific needs of the target population [24, 51,
53].
e development of app-based interventions address-
ing individual level barriers/facilitators has proliferated
since 2017. Most apps were grounded in health behav-
ior change theories, such as Social Cognitive eory
(SCT), Social Learning eory and the IMB model [30,
32, 40, 45, 47, 61, 70]. e apps compiled relevant infor-
mation that may influence PrEP use (e.g., education of
correct HIV risk perception, medication efficacy, self-
efficacy and social norms) and integrated supports from
local PrEP providers to improve participants’ awareness
of PrEP and facilitate linkage to PrEP care [30, 37, 45,
47, 61, 62, 70]. Other key features that might facilitate
participants’ adherence to PrEP included medication
reminder, graphical tracking of medication adherence
and day-to-day strategies to counter relevant barriers
(e.g., PrEP stigma) [32, 49]. App-based interventions
were found to be acceptable and feasible [57, 64, 65],
but their efficacy remains unclear as most studies are
still ongoing [32, 37, 47, 61, 62, 70, 72].
Of particular note, game-based interventions have
been gaining popularity in recent years. For example,
Viral Combat is one of the early apps that used gamifica-
tion to increase adherence to PrEP among YMSM. In this
game, players gain points by engaging with healthcare
providers (HCPs), initiating and adhering to the PrEP
medication [40]. is game demonstrated that interven-
tion participants were 3.75 times more likely to engage in
optimal PrEP dosing compared to those who received a
non-PrEP related mobile game (95% CI 1.20–11.77).
Other technology-based interventions at the individual
level included interventional videos or messages deliv-
ered through open network social media platforms/web-
sites (e.g., Facebook, Instagram, Reddit, Twitter) [44, 59,
63]. For example, van den Berg etal. examined whether
SCT-based and culturally congruent social media mes-
sages would increase PrEP knowledge among Black and
Hispanic MSM [44]. is trial is ongoing and the results
have not yet been reported.
Personalized interventions
Some technology-assisted interventions often incorpo-
rate personalized/individualized elements by custom-
izing the intervention content based on participants’
demographic characteristics or HIV risk behaviors [31,
44, 47, 49, 62]. For example, M-Cubed intervention tai-
lored HIV prevention messages to participants’ self-
reported HIV status and level of HIV risk [47]. In an
intervention for MSM of color, cognitive interviewing
was used to develop HIV prevention information tailored
to participants’ serostatus and culture [44]. Most person-
alized interventions are ongoing and have not reported
their results [31, 44, 47, 62].
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Wangetal. AIDS Research and Therapy (2022) 19:28
Other individual‑level intervention strategies
e PrEPARE2 intervention tested whether provision of
objective HIV risk score to MSM had a positive impact
on their uptake of PrEP [54]. e score was generated
from a mathematic model that considered both HIV risk
behavior (e.g., condomless anal intercourse) and bio-
logical outcomes [e.g., sexually transmitted infections
(STIs)]. It is reported that PrEPARE2 did not increase
PrEP initiation among MSM (11% vs. 10%, p > 0.99) [54].
Interpersonal‑level interventions
Overall peer‑based interventions
Most peer-based interventions utilized peer interven-
tionists to enhance engagement of minority MSM in the
PrEP care continuum. In an ongoing peer-navigation
intervention, Spanish–English bilingual peer lay navi-
gators delivered PrEP-focused educational modules to
Latino MSM [58]. In a different intervention that utilized
enhanced PrEP adherence support, peer navigators led
both in-person and online groups to provide adherence
support to Black MSM [48]. However, favorable changes
in self-reported PrEP adherence were not observed for
this enhanced adherence intervention [48].
We also observed that peer-based interventions often
incorporated personalized elements [34, 38, 55, 56]. In a
culturally-tailored counseling intervention, Black MSM
interventionists helped participants identify and address
their barriers to PrEP initiation (e.g., health insurance,
mental health violence, alcohol and substance abuse)
based on their prevention needs, and referred them to
appropriate prevention resources [34]. is counseling
intervention demonstrated preliminary efficacy where
24% of participants in the intervention group initiated
PrEP compared to no one in the control group (p = 0.02)
[34].
Motivational interviewing (MI) was another common
strategy applied in peer-based interventions. Peer men-
tors would use MI to help MSM resolve their ambiva-
lence about behavioral change as they moved through
the different stages of change (e.g., contemplation, deter-
mination and action) [38, 55, 56]. In an ongoing coach-
based, mobile-enhanced intervention, participants who
reported barriers to telephonic engagement in HIV pre-
vention services would be connected with peer coaches,
who would empathize with them and assist by exploring
alternative means to help retain them in the study [38].
Couples‑based intervention
We identified one young male couple-based interven-
tion, We Prevent [60]. Guided by relationship-oriented
IMB model, We Prevent aimed to enhance MSM-spe-
cific sexual health knowledge (e.g., risk within dyads),
motivation (e.g., peer norms towards HIV prevention in
relationships) and HIV risk-reduction skills (e.g., cou-
ples HIV testing and counseling and PrEP) via two ses-
sions delivered to male couples. e intervention also
employed MI techniques to teach identification of
unhealthy relationships and communication strategies
with partners to help them prepare for engaging in HIV
prevention services as a couple [60]. is couples-based
intervention is ongoing and its efficacy is unknown.
Social network interventions
Based on the framework of IMB and SCT, three social
network interventions, E-PrEP, PrEP Chicago and one
conducted in Wisconsin, were developed for young Black
or Latino MSM [2527]. ese interventions focused on
improving participants’ knowledge about PrEP and sub-
sequent PrEP initiation, and leveraged peer influence to
scale up PrEP uptake in peers’ social networks. Partici-
pants in the E-PrEP intervention posted targeted materi-
als on social media to provide PrEP education to peers
in their existing online networks [27]. e other two peer
change agent-based interventions emphasized training
of communication skills and conversational strategies
to ensure peer change agents could advocate PrEP use
effectively. Peer change agents learned how to address
their friends’ concerns about PrEP (e.g., sigma, miscon-
ception, effectiveness and side effects) while also engag-
ing with them to help facilitate development of positive
attitudes toward PrEP [25, 26]. Social network interven-
tions exhibited high acceptability and efficacy in improv-
ing PrEP knowledge, attitudes, and self-efficacy among
young minority MSM [26, 68].
Community‑level interventions
An active PrEP patient navigation was one of the few
interventions that leveraged community engagement
in HIV prevention programs [35]. Guided by the model
of community-based case management that focused on
utilization of support and resources in the community,
patient navigators assisted participants with overcoming
barriers to PrEP linkage and identifying available sources
of support in the community [35]. For example, if partici-
pants reported administrative costs (e.g., notary services)
as a barrier to PrEP initiation, patient navigators would
then provide them with information on related commu-
nity services free of charge. e community-level inter-
vention showed preliminary efficacy to facilitate PrEP
initiation, yet no significant differences existed between
the intervention and control groups [35].
Healthcare/institution‑level interventions
Interventions at the healthcare/institution level usually
involved HCP for PrEP promotion in various health-
care settings. In most healthcare-level interventions,
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Wangetal. AIDS Research and Therapy (2022) 19:28
HCPs (e.g., nurses, STI clinic counselors) provided par-
ticipants with information on PrEP access, used MI to
encourage PrEP initiation, or taught behavioral skills to
address PrEP-related barriers (e.g., PrEP stigma coping)
[36, 41, 43, 69]. Life-Steps for PrEP and one brief behav-
ioral intervention additionally offered booster sessions to
construct/refine medication adherence plans and moni-
tor participants’ long-term adherence to PrEP [41, 69].
Healthcare-level interventions were found to be effica-
cious for improving PrEP awareness, PrEP appointment
scheduling, and PrEP initiation among MSM [43, 69].
However, significant differences for PrEP adherence, via
measurement by an electronic pill storage device, were
not observed in the Life-Steps for PrEP intervention [41].
Multilevel interventions
Interventions that address PrEP determinants across
multiple socioecological levels represent an important
interventional mechanism to effectively promote PrEP
use among MSM [31, 57]. One of the few examples was
Get Connected, a web app-based intervention guided by
Integrated Behavioral Model and Self-Determination
eory, that combined both individual- and healthcare-
level strategies to help YMSM overcome multiple bar-
riers to PrEP care [31]. At the individual level, the app
delivered personalized educational materials to partici-
pants to increase their awareness of HIV risk and self-
efficacy for HIV prevention. At the healthcare/institution
level, participants were asked to rate the clinic where
they got tested for HIV or received PrEP evaluation. e
assessment used a composite measure which took into
account the clinical environment, service quality, pri-
vacy/confidentiality, perceived provider competency,
etc. Participants’ evaluations were sent to sites to help
them understand and improve their performance that
may benefit their future PrEP clients [31]. is app is still
being tested and the results have not been reported.
We Are Family represents another multilevel interven-
tion conducted in San Francisco [57]. At the individual
level, information on HIV prevention and local preven-
tion resources were delivered to participants through
in-person group sessions and the We Are Family app.
Participants were allowed to support and connect with
each other by sharing their stories of battling HIV-related
stigma. e research team also hosted or sponsored
community-level events such as prevention balls, game
nights and holiday parties to leverage community norms
to facilitate PrEP uptake in MSM. At the healthcare level,
a healthcare provider worked with the community to
provide HIV prevention services including HIV testing
or PrEP referral. is multilevel intervention was found
to be acceptable, feasible, and demonstrated preliminary
efficacy in facilitating PrEP intention, initiation and
adherence among MSM [57].
Discussion
e present systematic review provides a concise,
informative summary of what PrEP-related interventions
have occurred with MSM in the US. Most individual-
level PrEP interventions were technology-assisted and
delivered via messaging platforms and/or apps. Com-
pared with traditional venue-based interventions, tech-
nologically delivered PrEP interventions are convenient,
cost-effective, and may help overcome system-level barri-
ers to PrEP care (e.g., transportation to clinics and incon-
venient clinic locations and hours) [74, 75]. In addition,
app-based interventions included in this review provided
extensive information on PrEP, ranging from medica-
tion effectiveness, side effects, self-efficacy to local PrEP
resources—all aimed to improve participants’ aware-
ness of PrEP and help them build behavioral skills to
use PrEP [30, 32, 45, 47, 61, 70]. Some of the app-based
interventions included interactive features (e.g., quiz-
zes, exercises, discussions and games) to facilitate par-
ticipants’ continued use of the app (i.e., engagement) [32,
57, 61]. In contrast, text message interventions contained
fewer interactive features. One key strength of text mes-
sage interventions centered on them requiring fewer
resources for development and pilot testing (vs. apps).
In general, text message interventions were found to be
high acceptable by MSM [24, 48, 51, 53]. Further, partici-
pants could tailor for when and how often text messages
would be sent to accommodate their schedules for daily
PrEP intake [24, 51, 53]. Bidirectional messages may pro-
vide researchers with opportunities to better understand
participants’ medication adherence patterns and identify
when to provide assistance when necessary [24, 51, 53].
ese findings suggest text messaging interventions have
the potential to retain MSM in PrEP care.
It is also important to acknowledge the gaps in current
technology-assisted interventions. Development of apps
and platforms for interventions remain a barrier [51, 65].
Commonly reported issues regarding app design and
functions included lack of diversity in the presentation
of educational information, inability to link social media
profiles, lack of common functions (e.g., customizable
reminders), and technical glitches (e.g., slow responsive-
ness and app crashing) [30, 45, 51]. erefore, formative
studies to learn participants’ preference regarding the app
design are necessary to ensure the successful implemen-
tation of technology-based interventions. In addition,
there might be a mismatch between intervention content
and time-evolving prevention needs of MSM [24, 51].
For example, some visual/textual components used in an
intervention might only offer introductory information
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 12
Wangetal. AIDS Research and Therapy (2022) 19:28
skills to facilitate PrEP initiation, which would be less
useful to experienced PrEP users with challenges with
PrEP adherence [24]. To meet the evolving needs of
MSM, future PrEP interventions could be designed and
tailored to better align with the PrEP continuum and
men’s ongoing needs.
We observed that approximately 60% of the existing
PrEP interventions were designed for YMSM; and more
than 70% of these interventions relied on technology to
facilitate PrEP uptake. is finding aligns with the ever-
growing efforts in recent years to address the elevated
HIV epidemic among YMSM in the US [4]. Given the low
rates of PrEP use among YMSM and preference of inter-
vention modality supported by technology (e.g., social
media, networking apps, internet) [76, 77], technology-
assisted interventional components may bode well in
future PrEP interventions to enhance the PrEP care con-
tinuum among YMSM [24, 49, 52, 66].
Several interpersonal-level PrEP interventions designed
and implemented among YMSM (e.g., peer-deliver/
navigation, couple-based, social network-based inter-
ventions) met inclusion criteria for the present review.
However, interpersonal interventions that involve par-
ent or school educators to promote PrEP among YMSM
are notably missing from the current review. Substantial
evidence indicates parent’s low level of PrEP awareness,
perceived HIV and LGBTQ+ related stigma and nega-
tive reaction to PrEP, along with adolescents’ poor self-
efficacy to communicate with parents about PrEP and/
or sexual orientation were all reported barriers to PrEP
use among YMSM [22, 78, 79]. Interventions that address
parental negative attitudes towards PrEP and sexuality,
and that also promote parent-adolescent communication
may hold promise to enhance PrEP uptake and adher-
ence among YMSM. None of the included interventions
were implemented in school settings or educational
agencies. As adolescents and YMSM may spend a major-
ity of their day at school, the development and imple-
mentation of contextually appropriate interventions at
schools, by involving trusted school-based peers/counse-
lors, may offer unique opportunities to provide education
about PrEP and HIV prevention among these priority
populations.
Black and Hispanic/Latino MSM (i.e., MSM of color)
were also priority populations in the included PrEP
interventions, given their heightened HIV burden and
low rates of PrEP uptake [2, 3, 80, 81]. Findings from the
present review revealed that some of the most important
strategies in PrEP interventions for MSM of color was
the utilization of peer influence, which led to increased
cultural congruence, reduced PrEP/HIV-related stigma,
facilitated trust/access to PrEP care, and motivated con-
formity to peer norms/behaviors (i.e., social comparison)
to promote PrEP initiation/adherence [2527, 34, 38, 48,
56, 58].
However, challenges remain for PrEP interventions for
MSM of color. First, MSM of color may be less likely to
participate in online HIV interventions given the racial/
ethnic disparities in the use of technology for health-
related purposes [82, 83]. For example, almost all Black
MSM completed the face-to-face session in Partner Ser-
vices PrEP study, while only a limited number of partici-
pants completed the booster session delivered via mobile
phone [52]. Second, our aggregated evidence reflects the
lack of interventions to tackle community-level determi-
nants of PrEP care for MSM of color. Community-level
interventions that address broader contextual and struc-
tural issues by improving social determinants of health
(e.g., neighborhood environment, housing and food
insecurity) should be further strengthened [48, 84]. Last,
we identified only one intervention, Get Connected, that
overcame system- and structural-level barriers to PrEP
(e.g., stigma and medical mistrust) by providing HIV care
that is sensitive and inclusive to MSM of color. Inter-
ventions delivered to HCPs to enhance clinical experi-
ences of MSM of color are still missing from the current
literature.
We identified four interventions implemented at
the healthcare/institution level. All these interven-
tions involved educational modules delivered by HCPs
in HIV/STI clinics [36, 41, 43, 69]. One of the gaps in
the healthcare/institution-level interventions is the
lack of follow-up for long-term adherence to PrEP.
We observed improvement in behaviors that align
with the earlier stages of the PrEP continuum (e.g.,
increased PrEP awareness, scheduling and attend-
ing a PrEP appointment, and initiating PrEP care) [43,
69], but significant differences were not observed for
long-term adherence to PrEP [41]. Current models of
care in HIV/STI clinics primarily provide STI and HIV
testing services and are not well suited for transition-
ing to a longitudinal model of HIV prevention/care
due to the absence of protocols to guide clinical prac-
tice and low capacity of trained HCPs to provide PrEP
care [73]. One potential solution is to provide training
to PrEP counselors, who would then be responsible for
monitoring PrEP use among those who have initiated
the medication and providing follow-up counseling
services. Another gap is the lack of culturally trained
primary healthcare providers (PCPs) with specialty in
HIV/STI prevention/care for sexual and gender minor-
ity populations. Although HIV/STI clinics are ideal
settings to reach populations who are at elevated risk
for HIV infection [85], PCPs as the first point of con-
tact into healthcare have a unique opportunity to reach
the majority of patients who are less aware of PrEP and
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 12
Wangetal. AIDS Research and Therapy (2022) 19:28
may be in need of this preventative medication. For
example, evidence from an HIV prevention program
in Washington State showed a pronounced increase in
uptake of HIV prevention services (e.g., HIV testing)
among MSM who received healthcare from provid-
ers that were not from HIV/STI clinics, suggesting the
great potential of the entire healthcare system rather
than only HIV/STI care providers in promoting uptake
of HIV prevention services [86]. Additionally, the pre-
scription of PrEP in primary healthcare settings, where
the primary purpose is not HIV prevention and care,
may have the potential to reduce stigma surrounding
HIV among MSM and thereby may help promote PrEP
acceptance [73]. However, barriers such as insufficient
PrEP knowledge and lack of skills/motivation to discuss
PrEP with MSM clients must be addressed among PCPs
before effective structural/institution interventions can
be implemented [8789].
Our study is among the few that have systematically
summarized and evaluated PrEP interventions for
MSM in the US to inform the design and implemen-
tation of future interventions. ere are also limita-
tions to this review. First, the literature search strategy
may be not comprehensive and thus we were unable
to incorporate all relevant interventions into this sys-
tematic review. Second, the categorization of interven-
tions into each socioecological level was based on the
primary barriers the interventions aimed to address.
erefore, the intervention levels presented in this
review may be not precise and were used to provide
examples of interventions across socioecological levels
only. ird, more than 40% of the studies are ongoing.
eir effect on promoting PrEP uptake and adher-
ence is unknown. However, our primary objective is
to summarize the practical/theoretical components,
modalities, strengths, and limitations of these stud-
ies to inform the design of future PrEP interventions.
In addition, some studies with small sample size may
have low statistical power [26, 34, 35, 41, 4951, 54].
Scaled-up RCTs as well as intervention assessment in
real-world settings are further required to replicate
their results. Finally, this systematic review identi-
fies the following research opportunities based on the
gaps in existing studies: (1) expanding the spectrum of
participants (e.g., MSM with injection drug use) given
their elevated risk for HIV; (2) testing the effect of dif-
ferent regimens of PrEP (e.g., daily oral pill vs. long-
acting injectable medication) on PrEP care continuum
engagement given the evidence that reduced pill bur-
den may increase PrEP uptake/adherence among MSM
[42, 50]; and (3) taking into account different brands of
PrEP when designing and evaluating interventions in
light of the recent approval of Descovy for PrEP.
Conclusions
Low level of PrEP uptake and medication adherence
among MSM, especially young and/or those of color,
is concerning. Interventions to improve PrEP uptake
and adherence among MSM have been designed and
implemented at multiple socioecological levels (e.g.,
individual, interpersonal, community and healthcare/
institution) in recent years, with many of them cur-
rently in progress via a RCT. Fully evaluated interven-
tions, as well as those currently in progress, may hold
promise to help facilitate PrEP adoption among MSM;
mechanisms used to help improve one or more stages
of the PrEP continuum were also noted in the included
interventions. Areas for improvement were identified
and were presented as future research opportunities
to improve current and future PrEP interventions for
MSM in the US.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12981- 022- 00456-1.
Additional le1: TableS1. Summaryof study characteristics: individ-
ual-level interventions. TableS2. Summary of study characteristics:
interpersonal-levelinterventions. TableS3. Summary ofstudy charac-
teristics: community-level interventions. TableS4. Summary of study
characteristics: healthcare system-levelinterventions. TableS5. Summary
ofstudy characteristics: multilevel interventions.
Author contributions
YL designed the research study. YW led the systematic review and drafted
the first version of this manuscript. YW and YL conducted title and abstract
screening. YW conducted full text review and extracted data which was
cross-checked by YL. JM, CZ and YL reviewed and revised the manuscript.
All authors critically interpreted the results and revised the manuscript. All
authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
All data generated or analysed during this study are included in this published
article and its Additional files.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Department of Public Health Sciences, University of Rochester Medical
Center, Rochester, NY, USA. 2 Department of Health Promotion and Disease
Prevention, Stempel College of Public Health and Social Work, Florida Interna-
tional University, Miami, FL, USA. 3 School of Nursing, University of Rochester
Medical Center, Rochester, NY, USA. 4 Division of Epidemiology, Department
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 12
Wangetal. AIDS Research and Therapy (2022) 19:28
of Public Health Sciences, University of Rochester Medical Center, 256 Crit-
tenden Blvd, Ste. 3305, Rochester, NY 14642, USA.
Received: 23 February 2022 Accepted: 16 June 2022
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... 11 As part of Ending the HIV Epidemic (EHE) by 2030, the U.S. seeks to reduce inequities in access to HIV treatment and prevention and to increase access to pre-exposure prophylaxis (PrEP). 12 PrEP, in combination with safer sex practices, is indicated to reduce the risk of sexually acquired HIV in adults at high risk. 13,14 PrEP use, the behavioral characteristics of PrEP users, and differences in oral and injected PrEP 15,16 have implications for the safety of the blood supply due to the possibility of breakthrough HIV infection and window period donations that could infect a transfusion recipient. ...
... This percentage is notably lower than surveillance estimates for the overall MSM population in the U.S. 27 The lower proportion of HIV-positive MSM in this study could reflect knowledge among the participants that HIV-positive persons are not eligible to be blood donors. It could also represent self-selection based on communications among potential participants regarding the study eligibility criteria.Nearly half of the study population reported recent PrEP use, a proportion higher than reported for other studies of MSM in the U.S.12,28 In addition, high levels of educational achievement and income among study participants may indicate higher levels of access to PrEP than for all MSM. The substantial frequency of PrEP use in the study population may have directly contributed to the observed low prevalence of HIV infection. ...
Preprint
Importance: Blood donor selection policies should be evidence-based. Individual risk assessment allows potential donors to be evaluated based on their own behaviors. Objective: The Assessing Donor Variability and New Concepts in Eligibility (ADVANCE) study examined behavioral and biomarkers of HIV risk in sexually active men who have sex with men (MSM) to estimate the proportion of the study population who would not be deferred for higher risk HIV sexual behaviors and might be eligible to donate. Design: A cross-sectional assessment of sexually active MSM interested in blood donation. Setting: An 8-city study of MSM aged 18-39 years assigned male sex at birth. Interventions or Exposures: Participants completed surveys during 2 study visits to define eligibility, self-reported sexual and HIV prevention behaviors. Blood was drawn at study visit 1 and tested for HIV and the presence of tenofovir, 1 of the drugs in oral HIV pre-exposure prophylaxis (PrEP). Main Outcomes and Measures: Associations between HIV infection status or HIV PrEP use and self-reported HIV risk behaviors, including number of male sex partners, new partners, and anal sex. Results: Among 1788 screened MSM, 1593 were eligible and 1566 completed the visit 1 HIV risk questionnaire and blood draw. A median of 22 days later, 1197 completed the visit 2 follow-up questionnaire. Four individuals tested HIV positive (0.25%). Among HIV-negative participants, 789 (50.4%) reported no PrEP use in the past 3 months. The number of sex partners in the past 3 months was significantly higher among PrEP users versus non-users, as was the number reporting a new male sex partner in the same period. Among HIV-negative, non-PrEP using participants, 66.2% reported only 1 sexual partner or no anal sex and 69% reported no new sexual partners or no anal sex with a new partner in the past 3 months. Conclusion and Relevance: Among sexually active MSM, there are subgroups who self-report no new sexual partners and only 1 sexual partner within the past 3 months. These individuals are likely at lower risk of HIV infection than other MSM and would meet proposed individual risk assessment criteria for blood donation in the U.S.
... 15 The cabotegravir long-acting dosage is considered the main advantage of this PrEP modality, 35 while effectiveness of oral PrEP depends on adherence to medication, a critical factor in certain groups, such as young MSM, which are less likely to adhere to daily PrEP. 23,[36][37][38] In descriptive choice experiment (DCE) studies conducted among sexual and gender minorities in Brazil and Peru during 2020-2021, long-acting presentations and frequency of taking PrEP were important attributes in choosing PrEP modality. 20,21,39 Our findings provide additional information about preferences for alternative modalities to oral PrEP such as injectable PrEP among MSM in Latin America. ...
Article
Full-text available
Background Pre-exposure prophylaxis (PrEP) scale-up is urgent to reduce new HIV cases among gay, bisexual, and other men who have sex with men (MSM) in Latin America. Different PrEP modalities may increase PrEP uptake and adherence, especially among young MSM. Objectives To assess preferences for PrEP modalities among MSM from Brazil, Mexico, and Peru. Design Cross-sectional web-based study (March–May 2018) targeting MSM through advertisements on Grindr, Hornet, and Facebook. We included MSM aged ⩾ 18 years and who reported HIV-negative status. Methods We assessed preferences for PrEP modalities with the following question: ‘Considering that all following PrEP modalities were available, which one would you prefer considering a scale from 1 to 3 (1 = most preferred): daily oral PrEP, event-driven PrEP (ED-PrEP), and long-acting injectable PrEP’. We assessed factors associated with each most preferred PrEP modality per country using multivariable logistic regression models. Results A total of 19,457 MSM completed the questionnaire (Brazil: 58%; Mexico: 31%; Peru: 11%); median age was 28 years [interquartile range (IQR): 24–34]. Overall, injectable PrEP was the most preferred modality [42%; 95% confidence interval (CI): 41–43], followed by daily PrEP (35%; 95% CI: 34–35), and ED-PrEP (23%; 95% CI: 23–24). In multivariable models, preferring injectable PrEP was associated with PrEP awareness in all three countries, while PrEP eligibility only in Brazil. Preferring daily PrEP was associated with younger age and lower income in Brazil and Mexico, and lower education only in Brazil. The odds of preferring ED-PrEP were lower among MSM aware and eligible for PrEP in Brazil and Mexico. Conclusions Long-acting injectable PrEP was the preferred PrEP modality among MSM in Brazil, Mexico, and Peru, especially those aware and eligible for PrEP. Public health interventions to increase PrEP modalities literacy and availability in Latin America are urgent especially among MSM of young age, lower income, and lower education.
... When evaluating the impact of social determinants of health on knowing test results, our study identified that housing stability and social support were both positive predictors of consistent follow-up on test results among YMSM. Defined as "structural determinants and conditions in which people are born, grow, live, work, and age" [52], social determinants are thought to be the root cause of health disparities [53,54] and have been linked to lower engagement in HIV prevention behaviors, including HIV testing, follow-up on test results, and PrEP adoption [42,46,[55][56][57]. Qualitative studies further revealed that suboptimal uptake of HIV prevention services among people with negative social determinants of health could be explained by lack of transportation, shortage of HIV care providers in the neighborhood, lack of comprehensive HIV education, and poor social support [58,59]. ...
Article
Full-text available
Frequent HIV testing and knowledge of HIV serostatus is the premise before timely access to HIV prevention and treatment services, but a portion of young men who have sex with men (YMSM) do not always follow up on their HIV test results after HIV testing, which is detrimental to the implementation of HIV prevention and care among this subgroup. The comprehensive evaluation of factors associated with inconsistent follow-up on HIV test results may inform relevant interventions to address this critical issue among YMSM. To this end, we conducted a cross-sectional study in Nashville, Tennessee and Buffalo, New York from May 2019 to May 2020 to assess demographic, behavioral, and psychosocial correlates of inconsistent follow-up on HIV test results among YMSM. Of the 347 participants, 27.1% (n = 94) reported inconsistent follow-up on their HIV test results. Multivariable logistic regression showed that inconsistent follow-up on HIV test results was positively associated with condomless receptive anal sex, group sex, recreational drug use before or during sex, internalized homophobia, and stress; while negatively associated with housing stability, social support, and general resilience. Future HIV prevention intervention efforts should target these modifiable determinants to enhance the follow-up on HIV test results among YMSM.
Article
Background The Ministry of Health and Wellness of Jamaica has endorsed the use of pre-exposure prophylaxis (PrEP) as an HIV prevention strategy; however, PrEP was not included in the national HIV prevention program in 2021. Methods A cross-sectional online study involving physicians in Jamaica was conducted in 2021 to describe PrEP awareness, beliefs, attitudes, and practices. The study also assessed individual and social factors associated with discussing PrEP with patients and willingness to prescribe PrEP. Findings The mean age and standard deviation (SD) of the 69 physicians who completed the survey were 45.5 ± 13.6 years. Most of the participants (80%) reported that they were somewhat familiar with PrEP. PrEP attitude and perceived comfort in prescribing PrEP were moderate among participating physicians, with a mean and SD of 3.9 ± 0.8 and 3.6 ± 0.9 respectively. Six percent of physicians reported that they had prescribed PrEP and 17% had discussed PrEP with their patients in the past year. However, most (90%) reported that they were willing to prescribe PrEP after being informed about it. In the unadjusted model, identifying as Christian (compared to non-Christian) and reporting stronger homophobic beliefs were associated with reduced odds of discussing PrEP with patients. In the multivariable model, only homophobia remained statistically significant (OR, 0.24; 95% CI: 0.07–0.63). Conclusion The findings suggest that physicians in Jamacia may be willing to prescribe PrEP; however, homophobia is a barrier to discussions, underscoring the need for the Ministry of Health and Wellness to recognize the role that homophobia plays in the national HIV program to further reduce HIV incidence in Jamaica.
Article
Full-text available
Background Pre-exposure prophylaxis (PrEP) is a valuable tool in the response to the HIV epidemic, recommended for groups with a higher risk of HIV infection, such as men who have sex with men (MSM), particularly in the context of high-risk sexual behavior such as chemsex. Purpose This study aimed to analyze the prevalence and factors associated with the intention to use PrEP among MSM who engage in chemsex in Brazil and Portugal. Methods This was a cross-sectional study of a secondary dataset from a larger study conducted between January 2020 and May 2021 throughout Brazil and Portugal involving 1852 MSM who engage in chemsex. An initial descriptive analysis was performed to calculate the absolute and relative frequencies of independent variables related to the intention to use PrEP among MSM. A multivariate regression model was developed to identify factors independently associated with the intention to use PrEP. Results Although a high level of PrEP knowledge (85.75%) was observed among MSM who engage in chemsex, the prevalence of intention to use PrEP was only 59.07%. Five variables were associated with a higher prevalence of intention to use PrEP [engaging in double penetration – adjusted prevalence ratio (aPR): 1.56, 95% CI: 1.44–1.69; being assigned female sex at birth – aPR: 1.34, 95% CI: 1.12–1.61; cruising – aPR: 1.21, 95% CI: 1.06–1.38; not using condoms – aPR: 1.20, 95% CI: 1.05–1.36; and being an immigrant – aPR: 1.16; 95% CI: 1.07–1.25], while having knowledge of postexposure prophylaxis (aPR: 0.91; 95% CI: 0.84–0.98), having a casual sexual partner (aPR: 0.86 and 0.85; 95% CI: 0.74–0.99 and 0.74–0.98), and engaging in group sex (aPR: 0.81; 95% CI: 0.73–0.90) were associated with a lower intention to use PrEP. Conclusion The intention to use PrEP among MSM who engage in chemsex was high, and several factors were associated with this intention. Understanding the factors associated with the intention to use PrEP among MSM practicing chemsex is crucial for developing targeted interventions to increase PrEP uptake in this population. The results of this study suggest that tailored approaches are necessary to promote PrEP use in this population.
Article
Background: Advocacy is an expectation of the nursing profession. Nursing curricula should include opportunities for advocacy skills building at multiple levels of potential effect. Analyses of student performances during these advocacy exercises provide insight into how well students understand the multifactorial nature of most public health issues. Method: A socioecological model was used to evaluate nursing students' advocacy responses to food-insecurity scenarios during a guided online discussion activity aimed at advocacy skills building. Results: Student recommendations were categorized as individual, interpersonal, organizational, community, and policy interventions, with subcategories at each socioecological level. Conclusion: Recommendations are given for future educational research specific to advocacy skills building. Implications for nursing education at each socioecological level also are discussed. [J Nurs Educ. 2023;62(9):509-515.].
Article
Background: Individual risk assessment allows donors to be evaluated based on their own behaviors. Study objectives were to assess human immunodeficiency virus (HIV) risk behaviors in men who have sex with men (MSM) and estimate the proportion of the study population who would not be deferred for higher risk HIV sexual behaviors. Study design and methods: Cross-sectional survey and biomarker assessment were conducted in eight U.S. cities. Participants were sexually active MSM interested in blood donation aged 18-39 years, assigned male sex at birth. Participants completed surveys during two study visits to define eligibility, and self-reported sexual and HIV prevention behaviors. Blood was drawn at study visit 1 and tested for HIV and the presence of tenofovir, one of the drugs in oral HIV pre-exposure prophylaxis (PrEP). Associations were assessed between HIV infection status or HIV PrEP use and behaviors, including sex partners, new partners, and anal sex. Results: A total of 1566 MSM completed the visit 1 questionnaire and blood draw and 1197 completed the visit 2 questionnaire. Among 1562 persons without HIV, 789 (50.4%) were not taking PrEP. Of those not taking PrEP, 66.2% reported one sexual partner or no anal sex and 69% reported no new sexual partners or no anal sex with a new partner in the past 3 months. Conclusion: The study found that questions were able to identify sexually active, HIV-negative MSM who report lower risk sexual behaviors. About a quarter of enrolled study participants would be potentially eligible blood donors using individual risk assessment questions.
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Objectives: HIV disproportionately affects young Black men who have sex with men (YBMSM) in the Southern United States. Pre-exposure prophylaxis (PrEP) is an efficacious, biomedical approach to prevent HIV. While Mississippi (MS) has among the highest rates of new HIV infections, it also ranks among the top three states for unmet PrEP need. Thus, increasing engagement in PrEP care for YBMSM in MS is imperative. A potential method to improve psychological flexibility and promote PrEP uptake, explored by this study, is the incorporation of Acceptance and Commitment Therapy (ACT) into PrEP interventions. ACT is an evidence-based intervention used to treat a wide range of mental and physical illnesses. Methods: Twenty PrEP-eligible YBMSM and ten clinic staff working with YBMSM in MS were surveyed and interviewed between October 2021 and April 2022. The brief survey covered PrEP structural barriers, PrEP stigma, and psychological flexibility. Interview topics included internal experiences related to PrEP, existing health behaviors, PrEP related personal values, and relevant constructs from the Adaptome Model of Intervention Adaptation (service setting, target audience, mode of delivery, and cultural adaptations). Qualitative data were coded based on ACT and the Adaptome model, organized using NVivo, then thematically analyzed. Results: Patients identified side effects, costs, and taking a daily prescription as top barriers to taking PrEP. Staff reported the top barrier to PrEP for clients was concern others would believe they were living with HIV. Levels of psychological flexibility and inflexibility varied widely among participants. The resulting thematic categories derived from the interviews included 1) thoughts, emotions, associations, memories, and sensations (TEAMS) related to PrEP and HIV, 2) general health behaviors (existing coping techniques, views on medication, HIV/PrEP approach and avoidance), 3) values related to PrEP use (relationship values, health values, intimacy values, longevity values), and 4) Adaptome Model adaptations. These results informed the development of a new intervention, ACTPrEP. Conclusions: Interview data organized by the Adaptome Model of Intervention Adaptation determined appropriate ACT-informed intervention components, content, intervention adaptations, and implementation strategies. Interventions informed by ACT that help YBMSM endure short-term discomfort related to PrEP by relating it to their values and long-term health goals are promising for increasing individuals' willingness to initiate and maintain PrEP care.
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Background: Black and Latinx sexual minority youth are disproportionately affected by HIV. The House Ball and gay family communities encompass sexual and ethnic minority youth who form chosen families that promote protective HIV-related health behaviors. We conducted a small-scale trial of the We Are Family intervention, leveraging these existing social dynamics to address HIV. Methods: From September 2018 to September 2019, we enrolled N = 118 for baseline and 6-month follow-up assessments. Eligible participants were 18 years or older, San Francisco Bay Area residents, members of a house or gay family or ball attendees in the past year, smartphone users, and sexually active. The intervention included one 2-hour in-person group session, community-level events, a mobile health app, and a dedicated service provider. Results: Ninety-seven percent of our participants were people of color, 94% were retained through follow-up. 73% attended at least 1 group session, 100% used the mobile health app, and 56% attended a community-level event. Modest changes were observed baseline to follow-up: among all participants, any condomless anal intercourse past 3 months (74.6%-66.7%, P = 0.064); among HIV-negative participants (N = 82) HIV testing past 6 months (80.7%-87.2%, P = 0.166); among HIV-positive participants (N = 34) receiving HIV primary care past 6 months (64.5%-78.8%, P = 0.139), and adherent to ART past 30 days (22.6%-28.1%, P = 0.712). 86% would be willing to refer a friend to the app, and 65% found the app to be personally relevant. Conclusions: We Are Family reaches and retains its target population, is feasible, acceptable, and shows promise for improving HIV-related health behavior.
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Background The COVID-19 pandemic has resulted in a high degree of psychological distress among health care workers (HCWs). There is a need to characterize which HCWs are at an increased risk of developing psychological effects from the pandemic. Given the differences in the response of individuals to stress, an analysis of both the perceived and physiological consequences of stressors can provide a comprehensive evaluation of its impact. Objective This study aimed to determine characteristics associated with longitudinal perceived stress in HCWs and to assess whether changes in heart rate variability (HRV), a marker of autonomic nervous system function, are associated with features protective against longitudinal stress. MethodsHCWs across 7 hospitals in New York City, NY, were prospectively followed in an ongoing observational digital study using the custom Warrior Watch Study app. Participants wore an Apple Watch for the duration of the study to measure HRV throughout the follow-up period. Surveys measuring perceived stress, resilience, emotional support, quality of life, and optimism were collected at baseline and longitudinally. ResultsA total of 361 participants (mean age 36.8, SD 10.1 years; female: n=246, 69.3%) were enrolled. Multivariate analysis found New York City’s COVID-19 case count to be associated with increased longitudinal stress (P=.008). Baseline emotional support, quality of life, and resilience were associated with decreased longitudinal stress (P
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Introduction Men who have sex with men (MSM) are one of the most at-risk group for contracting HIV in the USA. However, the HIV epidemic impacts some groups of MSM disproportionately. Latino MSM comprise 25.1% of new HIV infections among MSM between the ages of 13 and 29 years. The daily medication tenofovir/emtricitabine was approved by the Food and Drug Administration for pre-exposure prophylaxis (PrEP) in 2012 and has demonstrated strong efficacy in reducing HIV acquisition. Methods and analysis Through extensive formative research, this study uses a pilot randomised controlled trial design and will examine the feasibility and acceptability of a patient navigation intervention designed to address multiple barriers to improve engagement in the PrEP continuum among 60 Latino MSM between the ages of 18 and 29 years. The patient navigation intervention will be compared with usual care plus written information to evaluate the feasibility and acceptability of the intervention and study methods and the intervention’s potential in improving PrEP continuum behaviours. The results will be reviewed for preparation for a future full-scale efficacy trial. Ethics and dissemination This study was approved by the institutional review board at San Diego State University and is registered at ClinicalTrials.gov. The intervention development process, plan and the results of this study will be shared through peer-reviewed journal publications, conference presentations and healthcare system and community presentations. Registration details Registered under the National Institutes of Health’s ClinicalTrials.gov ( NCT04048382 ) on 7 August 2019 and approved by the San Diego State University (HS-2017–0187) institutional review board. This study began on 5 August 2019 and is estimated to continue through 31 March 2021. The clinical trial is in the pre-results stage.
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Background HIV disproportionately affects young men who have sex with men (YMSM) in the United States. Uptake of evidence-based prevention strategies, including routine HIV testing and use of pre-exposure prophylaxis (PrEP), is suboptimal in this population. Novel methods for reaching YMSM are required. Objective The aim of this study is to describe the development and evaluate the feasibility and acceptability of the MyChoices app, a mobile app designed to increase HIV testing and PrEP use among YMSM in the United States. Methods Informed by the social cognitive theory, the MyChoices app was developed using an iterative process to increase HIV testing and PrEP uptake among YMSM. In 2017, beta theater testing was conducted in two US cities to garner feedback (n=4 groups; n=28 YMSM). These findings were used to refine MyChoices, which was then tested for initial acceptability and usability in a technical pilot (N=11 YMSM). Baseline and 2-month postbaseline assessments and exit interviews were completed. Transcripts were coded using a deductive approach, and thematic analysis was used to synthesize data; app acceptability and use data were also reported. Results The MyChoices app includes personalized recommendations for HIV testing frequency and PrEP use; information on types of HIV tests and PrEP; ability to search for nearby HIV testing and PrEP care sites; and ability to order free home HIV and sexually transmitted infection test kits, condoms, and lube. In theater testing, YMSM described that MyChoices appears useful and that they would recommend it to peers. Participants liked the look and feel of the app and believed that the ability to search for and be pinged when near an HIV testing site would be beneficial. Some suggested that portions of the app felt repetitive and preferred using casual language rather than formal or medicalized terms. Following theater testing, the MyChoices app was refined, and participants in the technical pilot used the app, on average, 8 (SD 5.0; range 2-18) times over 2 months, with an average duration of 28 (SD 38.9) minutes per session. At the 2-month follow-up, the mean System Usability Scale (0-100) score was 71 (ie, above average; SD 11.8). Over 80% (9/11) of the participants reported that MyChoices was useful and 91% (10/11) said that they would recommend it to a friend. In exit interviews, there was a high level of acceptability for the content, interface, and features. Conclusions These data show the initial acceptability and user engagement of the MyChoices app. If future studies demonstrate efficacy in increasing HIV testing and PrEP uptake, the app is scalable to reach YMSM across the United States. Trial Registration Clinicaltrials.gov NCT03179319; https://clinicaltrials.gov/ct2/show/NCT03179319 International Registered Report Identifier (IRRID) RR2-10.2196/10694
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Pre-exposure prophylaxis is effective in preventing HIV, but data show that its effectiveness is compromised by suboptimal adherence. This randomized controlled trial (n = 69) tested the impact of an iPhone game, Viral Combat, on PrEP adherence over 24 weeks. Tenofovir-diphosphate in red blood cells was collected as a biological outcome of adherence. At 24-weeks, intervention participants were 3.75 (95% CI: 1.20–11.77; p = 0.02) times as likely to engage in optimal PrEP dosing compared to controls. Viral Combat showed preliminary efficacy in improving PrEP adherence for diverse young men who have sex with men.
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Background Methamphetamine (meth) use among men who have sex with men (MSM) is associated with increased HIV prevalence and transmission and substandard advancement along the HIV prevention and care continuum. Given the growth of mobile health (mHealth) technologies, it is no longer necessary to limit meth treatment options to physical, brick-and-mortar sites, and administration using generic, nontailored content. Objective In a 2-arm randomized controlled trial (RCT; N=300), we aim to evaluate the use of an mHealth intervention (Getting Off) to assess the impact and noninferiority of a cross-platform app (developed from a manualized meth treatment intervention) to help MSM reduce meth use and HIV sexual risk behaviors and improve their advancement along the HIV prevention and care continuum (HIV testing, pre-exposure prophylaxis uptake and persistence, and antiretroviral therapy uptake and adherence). Methods Participants will be randomized into 2 arms: arm A, with immediate access to the app (immediate delivery: n=150), or arm B, with delayed access to the app after a 30-day period (delayed delivery: n=150). Participants in both arms will use the same Getting Off app and will have 30 days to complete the 24 sessions. Participants will be assessed at the 1-, 2- (delayed delivery arm only), 3-, 6-, and 9-month timepoints to determine observed treatment effects and will be compared with a historical matched sample of participants (n=~600) who received the brick-and-mortar group-based Getting Off intervention. ResultsRecruitment began in January 2019 for phase 1, the formative phase. In January and February 2019, 4 focus groups (N=36) were formed to provide input on the adaptation of the group-based manual intervention to a mobile app. Data collection for phase 2, the RCT, is expected to be completed in January 2023. The final results are anticipated in April 2023. Conclusions By creating a culturally responsive mobile app, Getting Off aims to reduce meth use and improve sexual health outcomes among meth-using MSM. The Getting Off app could have significant public health impact by greatly expanding access to effective, affordable, private, culturally competent, and highly scalable meth treatment for MSM. Trial RegistrationClinicaltrials.gov NCT03884946; https://clinicaltrials.gov/ct2/show/NCT03884946 International Registered Report Identifier (IRRID)DERR1-10.2196/22572
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Pre-exposure prophylaxis (PrEP) represents a viable HIV prevention tool for black men who have sex with men (BMSM). However, aggregated evidence regarding the presentations and determinants of the PrEP continuum (e.g., awareness, willingness, intention, uptake and adherence) remains absent to empirically inform future intervention efforts. We meta-analytically summarized the prevalence and qualitatively synthesized key barriers/facilitators of the stages of the PrEP continuum among a pooled sample of 42,870 BMSM aggregated from 56 published studies. Our random-effect models indicated a pooled prevalence of PrEP awareness (50.8%, 95% CI: 43.6–58.0%, willingness/intention (58.2%, 95% CI: 52.0–68.1%) and uptake (15.5%, 95% CI: 12.8–18.2%). Qualitative summary revealed that perception of HIV risk, intersectional/PrEP-related stigma and medical mistrust were among the most quoted factors that influence PrEP use. BMSM remain underrepresented in key stages of the PrEP continuum. Futures interventions are continuously needed to target multilevel barriers/facilitators to enhance the PrEP continuum among BMSM.
Article
Introduction: Preexposure prophylaxis (PrEP) is effective in preventing HIV among adherent users. However, PrEP uptake among transgender women is low, and current prescribing guidelines from the Centers for Disease Control and Prevention (CDC) are not specific to transgender women. Self-perceived risk of HIV among those who are PrEP-indicated is not well understood. Methods: This cross-sectional analysis included 1293 transgender women screened at baseline from March 2018 to May 2020 for a multisite, prospective cohort study. We compared the prevalence of PrEP indication using current CDC prescribing criteria versus transgender women-specific criteria developed by study investigators with community input. We identified factors associated with study-specific PrEP indication and factors associated with self-perceived low to no HIV risk among those who were PrEP-indicated. We also calculated descriptive statistics to depict the PrEP care continuum. Results: PrEP indication prevalence using transgender women-specific criteria was 47% (611), 155 more than who were identified using the CDC criteria. Eighty-three percent were aware of PrEP, among whom 38% had ever used PrEP. Among PrEP ever users, 63% were using PrEP at the time of the study. There were 66% of current PrEP users who reported 100% adherence within the previous 7 days. Among those who were PrEP-indicated, 13% were using and adherent to PrEP at the time of the study. More than half (55%) of PrEP-indicated participants had low or no self-perceived HIV risk. Conclusions: These findings suggest that further guidance is needed for health care providers in prescribing PrEP to transgender women. Greater uptake and adherence are also needed for optimal effectiveness.
Article
Background: Young adult men who have sex with men (YMSM) are at increased risk for HIV, especially minority YMSM. Pre-exposure prophylaxis (PrEP) is a breakthrough daily pill to prevent HIV. Consistent adherence is key to PrEP effectiveness, which is why the CDC recommends adherence support be provided to all PrEP patients. Mobile health can overcome barriers to the delivery of adherence support, particularly for YMSM who may be most in need of it due, at least in part, to their young age. Methods: We created a culturally- and developmentally-sensitive PrEP adherence mobile app (called "Dot") that was tailored for culturally-diverse young adult MSM. After formative research and usability testing, we conducted a 6-week pre-post study to evaluate the impact of Dot on self-reported PrEP adherence, PrEP treatment self-efficacy, PrEP knowledge, and intention to practice safe sex among culturally-diverse YMSM, age 20-29. Results: At 6 weeks, there were significant improvements in PrEP adherence, PrEP self-efficacy, and intention to practice safe sex. PrEP knowledge scores did not significantly change. Conclusions: The Dot app proved feasible and effective at improving PrEP adherence among culturally-diverse YMSM. Moreover, the app had a high-degree of user appeal, which is foundational to success of an mhealth intervention.
Article
Background: The aim of this study was to evaluate the efficacy of a novel, brief two-session behavioral intervention to promote HIV pre-exposure prophylaxis (PrEP) uptake among men who have sex with men (MSM) who are behaviorally at risk for HIV. Setting: A pilot randomized controlled trial (RCT) was conducted at a sexually transmitted infection (STI) clinic to compare a brief motivational interviewing (MI) intervention to passive referral only for PrEP uptake. Methods: MSM who scored as "high-risk" on the HIV Incidence Risk Index for MSM (HIRI-MSM) were offered a brief (15-20 minutes) MI-based intervention at the time of STI testing to address barriers to PrEP uptake, including low risk perception, stigma, side-effects, and cost. The initial session was followed by a brief, telephone booster session that lasted <10 minutes. The primary outcome was attending a clinical PrEP appointment and accepting a prescription for PrEP. Results: Participants were recruited from an urban STI clinic in the USA. A total of 86 MSM who were behaviorally at risk for HIV were enrolled in the study (N=43 intervention; N=43 treatment-as-usual, "TAU"). Participants randomized to the intervention were significantly more likely to attend a clinical appointment and accept a prescription for PrEP, compared to TAU (52.3% versus 27.9%, respectively; OR=3.6; 95%CI: 1.5, 8.9; p=.005). Conclusion: A brief behavioral intervention focused on the initial steps in the PrEP care cascade demonstrated preliminary efficacy in promoting uptake among MSM who are behaviorally at risk for HIV.