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Implementation of HIV pre-exposure prophylaxis PrEP programs for populations with highest incidence is critical to reducing new Black gay c in the United States. Daily oral use of anti-retroviral medications as pre-exposure prophylaxis PrEP has been demonstrated to be an extremely effective biomedical HIV prevention tool.

In an effort to shed light on these dynamics, several researchers have proposed a PrEP continuum of care, which, analogous to the treatment cascade, draws attention to the specific steps necessary for identifying, engaging, and retaining patients on PrEP.

Retention and adherence are the ultimate goal of successful PrEP implementation, but engaging highest priority individuals in PrEP programs is a necessary first step toward prevention goals. To date, this Black gay c, i.

And perhaps more concerning, early indications suggest that awareness and uptake of PrEP are lowest among Black men who have sex with men MSM11 - 14 and adherence seems to be lower among young Black MSM compared to white and Latino youth.

In addition, we know that PrEP availability Black gay c not the same as access. In order to be truly accessible, PrEP programs must be available to highest priority individuals within the settings in which they are most likely to receive care and in a manner that is financially affordable. Emerging research also points to the important "Black gay c" of providers in PrEP implementation. Many patients learn about PrEP for the first time from their medical providers, while others report that their providers have been a barrier to PrEP prescription.

These levels may be mapped onto what has been termed the social-ecological model, 29 which treats individuals as embedded within larger environments and social systems, and acknowledges that these multiple levels of influence are interactive and reinforcing. We operationalized prescription barriers at the provider-levelexamining dynamics of patient-provider interaction.

Finally, we operationalized access barriers at the systems-levelexamining the type of setting in which patients are more likely to access PrEP and the ways in which they may be able to pay for it. However, that analysis included only participants, did not include BLMSM-specific analyses, was not sufficiently powered to adjust for the role of socioeconomic status, and did not examine systems- or provider-level barriers.

These analyses build on and clarify these previous findings. A better understanding of the Black gay in which Black and Latino MSM differ from their White counterparts may allow us to identify potential targets for intervention to meaningfully increase PrEP Black gay across the continuum of care for these high priority individuals.

Between January and Juneparticipants were enrolled in a cross-sectional study examining the impact of PrEP messaging and communication strategies on PrEP knowledge and adoption intentions. Participants were recruited in the New York City area [blinded for review] using passive recruitment i.

Eligible individuals were born male regardless of current gender identity Black gay, aged 18 years or older, self-reported an HIV-negative serostatus, and reported at least one act of condomless anal sex with a male partner in the past 30 days, consistent with CDC's guidelines for PrEP eligibility for MSM.

Differences in PrEP uptake by...

If Hispanic or Latino appeared in any of these fields, these participants were classified accordingly. Finally, participants were asked whether they were currently taking PrEP; nine Black gay were excluded for this reason from the current analysis. Sexual and substance use behavior in the past 30 days was assessed with a modified version of the semi-structured Timeline Follow-Back interview.

Participants were also asked to report any substance use and heavy episodic alcohol use five or more standard drinks.

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For the current analyses, we examined total number of partners, number of condomless anal sex acts, percent of anal sex acts that were condomless, number of heavy drinking days, and number of substance use days. Participants Black gay c asked when they were last tested for HIV, and responses were dichotomized into within the past 6-months or over 6 months ago. We examined specific factors that might impact PrEP access and uptake at Black gay c levels. At a provider levelwe asked participants whether or not they: Third, we asked participants a single item 46 to assess patient preferences for participation in treatment Black gay c. Barriers included concerns that: In order to assess whether participants believe that sexual behavior is less risky on PrEP, we chose three behaviors -- condomless anal insertive sex, condomless anal receptive sex, and sex with an HIV-positive partner — and coded whether the participant believed that this behavior was less risky on PrEP i.

Finally, we asked several questions ascertaining potential factors that might catalyze PrEP adoption intentions e. These factors, which we explored previously in our work, 34 [blinded for review] were informed by literature reviews and consultation with PrEP experts; the response options were on a 5-point Likert scale which we dichotomized for analyses into low versus high scores.

As these data are drawn from a larger study of PrEP messaging factors, we first verified that there were no differences by study condition on any of the variables included in these analyses.

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Initial bivariate analyses examined demographic and behavioral differences between the Black, Latino, Black gay c, and other MSM in our sample, using chi-square for categorical variables, t-tests for continuous variables, and non-parametric tests for count variables. This analytic decision was made for parsimonious reporting; however, the limitations of this approach and the importance of further data collection on Black and Latino MSM separately are discussed below.

BLMSM were also more likely to be between the ages of 18 and 29 and were less likely to identify as gay. Black and Latino participants reported a greater number of Black gay partners in the past 30 days; however, there were no differences in the number of condomless sex acts.

Even after adjusting for education and income, BLMSM were significantly less likely to have private health insurance and more likely to have public insurance aOR. Identification as gay was included as a systems-level barrier, because many PrEP programs are being implemented through gay-focused health centers. At the patient level, BLMSM were significantly more likely to endorse stigma-related concerns related to PrEP, including concerns that others will notice they are taking a pill and want to know why aOR 2.

As such, they were "Black gay c" less likely than the rest of the sample to believe that PrEP would reduce the risk of HIV acquisition during anal condomless receptive aOR.

Table 3 presents results from comparisons between the two groups of interest regarding facilitators of PrEP adoption. BLMSM, even after adjusting the models for SES, differed significantly from the rest of the sample in the importance they attributed to the following facilitators of PrEP uptake at the systems level: Finally, there were no differences between the groups in how important it would be not to pay for PrEP Table 3.

At the provider-level, BLMSM were more likely to report that talking to their provider about sex is a barrier to PrEP and expressed lower agency for medical decision-making. At the systems-level, BLMSM were less likely to identify as gay, more likely to receive care at a public clinic and more likely to be publically insured. These barriers are similar to those identified for HIV treatment among individuals of color, including a lack of trust in HIV-related care 4950 and the efficacy of anti-retroviral medication in particular, 47 fueled by the awareness that optimal courses of treatment are at times not offered by racist and homophobic providers.

Not surprisingly, our BLMSM participants isolated having to talk to their doctor about their sex life as a significant barrier to PrEP compared to the rest of the sample. In fact, there is evidence that LGBT-affirmative training for medical providers has the potential to lower stigmatizing attitudes and increase cultural competency, 5758 including towards treating sexual and gender minorities equitably.

This finding leads us to suggest that public-based facilities Black gay c BLMSM may utilize for routine check-ups such as STD or primary care clinicsshould actively promote PrEP via displayed waiting and exam room brochures, pamphlets and posters, as well as during provider interactions, just as HIV testing was not long ago routinely introduced in these practices.

PrEP programs must be actively developed with redress of these problems and in response to them. The PrEP uptake facilitators suggested by our analyses align with recent encouraging findings of HPTN showing that adherence among BMSM in three cities was high when participants received client-centered care coordination.

Additionally, qualitative data on PrEP facilitator for African-American youth suggest the importance of PrEP provision in settings that are familiar and can provide services without long waits. Our findings contribute to a growing body of data suggesting that MSM of color are receptive to mobile health technologies for HIV prevention.

These findings should be considered in the context of several limitations. This lack of culturally-specific barriers is evinced by the fact that Black and Latino MSM did not differ significantly from each other in endorsement of barriers; rather they differed only from their predominately white counterparts. These analyses are not meant to suggest that the specific dynamics of PrEP engagement for Black and Latino MSM are the same, or that strategies to enhance engagement for these groups should be similar.

However, these analyses do suggest that MSM of color may face a significantly different set of barriers along the PrEP cascade, and underscore the importance of better understanding how to ameliorate these barriers with culturally-competent and specific strategies.

The systemic racism and historic discrimination encountered in medical settings may increase medical mistrust for MSM of color in general, but modes of redress must be examined with an appreciation of the unique cultural contexts in which they may be experienced for Black gay and Latino MSM separately. Second, participants in this study were enrolled on a PrEP messaging study, and therefore were interested, at some level, in learning about PrEP, and might be more open to PrEP adoption than the general population of MSM.

Third, study data were collected from toand increased knowledge about and shifting attitudes toward PrEP may influence these barriers and attempts to reduce them. However, given persistent disparities "Black gay" PrEP adoption, it seems critical to consider these differences in cascade-focused barriers as they relate to enhanced implementation efforts. Despite these limitations, this analysis informs a broader understanding of efforts to increase representation of BLMSM along the PrEP continuum of care.

Increasing interest in PrEP may involve high-quality education about PrEP efficacy, and increased engagement by trusted community members and representatives. Increasing access may require ensuring that there are multiple entry points for PrEP services, provided in the settings BLMSM already visit, rather than where we hope to recruit them. Lastly, increasing prescription may require enhancing patient-provider communication about sexual health and involving BLMSM in a meaningful way in their medical decision-making more generally.

We also thank Black gay participants who gave their time and energy to this study, and Dr. Willo Pequegnat for her support.

National Center for Biotechnology InformationU. J Acquir Immune Defic Syndr. Author manuscript; available in PMC Dec Corina Lelutiu-Weinberger 1 and Sarit A. Author information Copyright and License information Disclaimer.

Correspondence regarding this article should be addressed to Sarit A. See other articles in PMC that cite the published article. HIV Risk and Prevention Behavior Sexual and substance use behavior in the past 30 days was assessed with a modified version of Black gay semi-structured Timeline Follow-Back interview. Percent of condomless anal sex Black gay Heavy drinking days past month 3.

Open in a separate window. Footnotes Conflicts of Interest The authors have no "Black gay c" of interest to declare. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New Eng J Med. High adherence and high effectiveness observed in HIV discordant couples: Partners PrEP Study, adherence monitoring and counseling substudy.

Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. Antiretroviral pre-exposure prophylaxis implementation in the United States: Scaling Up Antiretroviral Preexposure Prophylaxis: Moving From Trials to Implementation.

The spectrum of engagement in HIV prevention: Proposal for a pre-exposure prophylaxis PrEP cascade. Community member perspectives from transgender women and men who have sex with men on pre-exposure prophylaxis as an HIV prevention strategy: Minimal awareness and stalled uptake of pre-exposure prophylaxis PrEP among at risk, HIV-negative, black men who have sex with men.

High interest in preexposure prophylaxis Black gay c men who have sex with men at risk for HIV infection: PrEP use is rising fast in the US, but large racial disparities remain.

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Gay youth PrEP study finds good retention and reasonable adherence. Awareness of and intention to use PrEP: Optimizing content for pre-exposure prophylaxis PrEP counseling for men who have sex with men: Are we prepped for preexposure prophylaxis PrEP? J Sex Transm Dis.

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