Emily A. Arnold

A Qualitative Study of Provider Thoughts on Implementing Pre-Exposure Prophylaxis (PrEP) in Clinical Settings to Prevent HIV Infection

Background A recent clinical trial demonstrated that a daily dose tenofovir disoproxil fumarate and emtricitabrine (TDF-FTC) can reduce HIV acquisition among men who have sex with men (MSM) and transgender (TG) women by 44%, and up to 90% if taken daily. We explored how medical and service providers understand research results and plan to develop clinical protocols to prescribe, support and monitor adherence for patients on PrEP in the United States. Methods Using referrals from our community collaborators and snowball sampling, we recruited 22 healthcare providers in San Francisco, Oakland, and Los Angeles for in-depth interviews from May-December 2011. The providers included primary care physicians seeing high numbers of MSM and TG women, HIV specialists, community health clinic providers, and public health officials. We analyzed interviews thematically to produce recommendations for setting policy around implementing PrEP. Interview topics included: assessing clinician impressions of PrEP and CDC guidance, considerations of cost, office capacity, dosing schedules, and following patients over time. Results Little or no demand for PrEP from patients was reported at the time of the interviews. Providers did not agree on the most appropriate patients for PrEP and believed that current models of care, which do not involve routine frequent office visits, were not well suited for prescribing PrEP. Providers detailed the need to build capacity and were concerned about monitoring side effects and adherence. PrEP was seen as potentially having impact on the epidemic but providers also noted that community education campaigns needed to be tailored to effectively reach specific vulnerable populations. Conclusions While PrEP may be a novel and clinically compelling prevention intervention for MSM and TG women, it raises a number of important implementation challenges that would need to be addressed. Nonetheless, most providers expressed optimism that they eventually could prescribe and monitor PrEP in their practice.

‘Triply cursed’: racism, homophobia and HIV-related stigma are barriers to regular HIV testing, treatment adherence and disclosure among young Black gay men

In the USA, young Black gay men are disproportionately impacted upon by HIV. In this qualitative study consisting of in-depth interviews with 31 young Black gay men and nine service providers, where we used thematic analysis to guide our interpretations, we found that HIV-related stigma and homophobia, within the larger societal context of racism, were related to sexual risk behaviour, reluctance to obtain HIV testing or care, lower adherence to treatment medication, and non-disclosure of a positive HIV status to sexual partners. Participants experienced homophobia and HIV-related stigma from churches and families within the Black community and from friends within the Black gay community, which otherwise provide support in the face of racism. Vulnerability to HIV was related to strategies that young Black gay men enacted to avoid being stigmatised or as a way of coping with alienation and rejection.

Constructing Home and Family: How the Ballroom Community Supports African American GLBTQ Youth in the Face of HIV/AIDS.

This article focuses on the construction of homes and families within the ballroom community, a prominent feature of urban GLBTQ communities of color in cities across the United States. Based on two ethnographic studies with ballroom communities in the San Francisco Bay Area, California, and Detroit, Michigan, we explore the importance of gender and sexual identity in informing community practice around HIV prevention and treatment. As a community, the ballroom scene provides African American queer youth with support for same-sex desire and identity, along with multiple forms of support for HIV prevention. Our study of the ballroom community documents current forms of “intravention” occurring within the community and the importance of the gender-sex system in organizing these practices. We also offer recommendations for community-based organizations to partner with the ballroom community, making use of existing social structures within the community and the salient concepts of home and family, to provide HIV-related services and support. We argue for HIV-prevention interventions to take a more culturally appropriate, nuanced approach to reaching African American youth at risk, utilizing community and family structures, in whatever forms these may take.

‘It's my inner strength’: spirituality, religion and HIV in the lives of young African American men who have sex with men

Young black men who have sex with men account for 48% of 13–29-year-old HIV-positive men who have sex with men in the USA. It is important to develop an effective HIV prevention approach that is grounded in the context of young mens lives. Towards this goal, we conducted 31 interviews with 18–30-year-old men who have sex with men in the San Francisco-Oakland Bay Area. This paper examines the roles of religion and spirituality in men who have sex with mens lives, which is central in the lives of many African Americans. Six prominent themes emerged: (1) childhood participation in formal religious institutions, (2) the continued importance of spirituality among men who have sex with men, (3) homophobia and stigmatisation in traditional black churches, (4) tension between being a man who has sex with men and being a Christian, (5) religion and spiritualitys impact on mens sense of personal empowerment and coping abilities and (6) treatment of others and building compassion. Findings suggest that integrating spiritual practice into HIV prevention may help programmes be more culturally grounded, thereby attracting more men and resonating with their experiences and values. In addition, faith-based HIV/AIDS ministries that support HIV-positive men who have sex with men may be particularly helpful. Finally, targeting pastors and other church leaders through anti-stigma curricula is crucial.

Community member perspectives from transgender women and men who have sex with men on pre-exposure prophylaxis as an HIV prevention strategy: implications for implementation

BackgroundAn international randomized clinical trial (RCT) on pre-exposure prophylaxis (PrEP) as an human immunodeficiency virus (HIV)-prevention intervention found that taken on a daily basis, PrEP was safe and effective among men who have sex with men (MSM) and male-to-female transgender women. Within the context of the HIV epidemic in the United States (US), MSM and transgender women are the most appropriate groups to target for PrEP implementation at the population level; however, their perspectives on evidenced-based biomedical research and the results of this large trial remain virtually unknown. In this study, we examined the acceptability of individual daily use of PrEP and assessed potential barriers to community uptake.MethodsWe conducted semi-structured interviews with an ethnoracially diverse sample of thirty HIV-negative and unknown status MSM (n = 24) and transgender women (n = 6) in three California metropolitan areas. Given the burden of disease among ethnoracial minorities in the US, we purposefully oversampled for these groups. Thematic coding and analysis of data was conducted utilizing an approach rooted in grounded theory.ResultsWhile participants expressed general interest in PrEP availability, results demonstrate: a lack of community awareness and confusion about PrEP; reservations about PrEP utilization, even when informed of efficacious RCT results; and concerns regarding equity and the manner in which a PrEP intervention could be packaged and marketed in their communities.ConclusionsIn order to effectively reduce HIV health disparities at the population level, PrEP implementation must take into account the uptake concerns of those groups who would actually access and use this biomedical intervention as a prevention strategy. Recommendations addressing these concerns are provided.

The Bruthas Project: Evaluation of a Community-Based HIV Prevention Intervention for African American Men Who Have Sex With Men and Women

The Bruthas Project is a community-collaborative intervention to reduce HIV risk behavior among African American men who have sex with men and women (MSMW) but who do not form an identity around their same-sex behavior. The intervention was developed based on formative qualitative research with members of the population and involved four individualized risk reduction counseling sessions. Participants review general risk factors for HIV and are offered HIV testing and counseling (Session 1); discuss sexual dynamics and risk behaviors with female partners (Session 2); discuss sexual dynamics and risk behaviors with male partners (Session 3); review motivations and situational triggers for unsafe sex, and engage in role-play exercises that aim to reach personal risk reduction goals (Session 4). Community outreach and counseling are provided by African American men with whom participants can identify, and counseling is designed to respond to mens need for privacy, cultural affirmation, and masculine values. Thirty-six African American MSMW completed a pilot intervention, including baseline and 3-month follow-up assessments of sexual risk behaviors and psychosocial factors. Preanalysis and postanalysis found significant reductions in unprotected receptive and insertive anal sex with male partners, fewer numbers of female and male unsafe sex partners, and decreased sex while under the influence of drugs. Men also reported significantly increased social support, self-esteem, and reduced loneliness at follow-up. Positive outcomes suggest this is a promising approach for reducing HIV risk in this population.

‘I am not a man’: Trans-specific barriers and facilitators to PrEP acceptability among transgender women

ABSTRACT The frequent conflation of transgender (‘trans’) women with ‘men who have sex with men (MSM)’ in HIV prevention obscures trans womens unique gender identities, social and behavioural vulnerabilities, and their disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is an efficacious biomedical HIV prevention approach. However, trans women are underrepresented in PrEP research, and are often aggregated with MSM without consideration for their unique positions within sociocultural contexts. This study examined PrEP acceptability among trans women via three focus groups and nine individual interviews (total N = 30) in San Francisco. While knowledge of PrEP was low, interest was relatively high once participants were informed. Due to past negative healthcare experiences, ability to obtain PrEP from a trans-competent provider was cited as essential to PrEP uptake and adherence. Participants noted that PrEP could address situations in which trans women experience reduced power to negotiate safer sex, including sex work. Trans-specific barriers included lack of trans-inclusive marketing of PrEP, prioritisation of hormone use, and medical mistrust due to transphobia. Findings underscore the importance of disaggregating trans women from MSM in HIV prevention strategies to mitigate disparate risk among this highly vulnerable population.

Mental Health Among Parents of Children With Critical Congenital Heart Defects: A Systematic Review

Background Parents of children with critical congenital heart defects (PCCHDs) may be at high risk for mental health morbidity; however, the literature is not well characterized. Given that compromised parental mental health can lead to long‐term cognitive, health‐related, and behavioral problems in children, a systematic review of this literature could provide informed recommendations for continued research and enhance the care of families of children living with critical congenital heart defects. Methods and Results We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines that resulted in 30 studies on the mental health of PCCHDs. The literature revealed that PCCHDs are at an elevated risk for psychological problems, particularly in the immediate weeks and months following cardiac surgery. Up to 30% of PCCHDs have symptoms consistent with a diagnosis of posttraumatic stress disorder, with over 80% presenting with clinically significant symptoms of trauma; 25% to 50% of PCCHDs reported clinically elevated symptoms of depression and/or anxiety, and 30% to 80% reported experiencing severe psychological distress. There was high variability in measurements used to assess study outcomes, methodological quality, and sociocultural composition of the parents included in the studies. Conclusions There is an urgent need for additional research on the severity, course, persistence, and moderators of these mental health problems over time, and for the development and testing of screening approaches and interventions that can be feasibly delivered in the context of ongoing pediatric cardiac care.

Facilitators and barriers to effective scale-up of an evidence-based multilevel HIV prevention intervention

BackgroundSince the scale-up of HIV/AIDS prevention evidence-based interventions (EBIs) has not been simple, it is important to examine processes that occur in the translation of the EBIs into practice that affect successful implementation. The goal of this paper is to examine facilitators and barriers to effective implementation that arose among 72 community-based organizations as they moved into practice a multilevel HIV prevention intervention EBI, the Mpowerment Project, for young gay and bisexual men.MethodsCBOs that were implementing the Mpowerment Project participated in this study and were assessed at baseline, and 6-months, 1 year, and 2 years post-baseline. Semi-structured telephone interviews were conducted separately with individuals at each CBO. Study data came from 647 semi-structured interviews and extensive notes and commentaries from technical assistance providers. Framework Analysis guided the analytic process. Barriers and facilitators to implementation was the overarching thematic framework used across all the cases in our analysis.ResultsThirteen themes emerged regarding factors that influence the successful implementation of the MP. These were organized into three overarching themes: HIV Prevention System Factors, Community Factors, and Intervention Factors. The entire HIV Prevention System, including coordinators, supervisors, executive directors, funders, and national HIV prevention policies, all influenced implementation success. Other Prevention System Factors that affected the effective translation of the EBI into practice include Knowledge About Intervention, Belief in the Efficacy of the Intervention, Desire to Change Existing Prevention Approach, Planning for Intervention Before Implementation, Accountability, Appropriateness of Individuals for Coordinator Positions, Evaluation of Intervention, and Organizational Stability. Community Factors included Geography and Sociopolitical Climate. Intervention Factors included Intervention Characteristics and Adaptation Issues.ConclusionsThe entire ecological system in which an EBI occurs affects implementation. It is imperative to focus capacity-building efforts on getting individuals at different levels of the HIV Prevention System into alignment regarding understanding and believing in the program’s goals and methods. For a Prevention Support System to be maximally useful, it must address facilitators or barriers to implementation, address the right people, and use modalities to convey information that are acceptable for users of the system.

California's “Bridge to Reform”: Identifying Challenges and Defining Strategies for Providers and Policymakers Implementing the Affordable Care Act in Low-Income HIV/AIDS Care and Treatment Settings

Background In preparation for full Affordable Care Act implementation, California has instituted two healthcare initiatives that provide comprehensive coverage for previously uninsured or underinsured individuals. For many people living with HIV, this has required transition either from the HIV-specific coverage of the Ryan White program to the more comprehensive coverage provided by the county-run Low-Income Health Programs or from Medicaid fee-for-service to Medicaid managed care. Patient advocates have expressed concern that these transitions may present implementation challenges that will need to be addressed if ambitious HIV prevention and treatment goals are to be achieved. Methods 30 semi-structured, in-depth interviews were conducted between October, 2012, and February, 2013, with policymakers and providers in 10 urban, suburban, and rural California counties. Interview topics included: continuity of patient care, capacity to handle payer source transitions, and preparations for healthcare reform implementation. Study team members reviewed interview transcripts to produce emergent themes, develop a codebook, build inter-rater reliability, and conduct analyses. Results Respondents supported the goals of the ACA, but reported clinic and policy-level challenges to maintaining patient continuity of care during the payer source transitions. They also identified strategies for addressing these challenges. Areas of focus included: gaps in communication to reach patients and develop partnerships between providers and policymakers, perceived inadequacy in new provider networks for delivering quality HIV care, the potential for clinics to become financially insolvent due to lower reimbursement rates, and increased administrative burdens for clinic staff and patients. Conclusions Californias new healthcare initiatives represent ambitious attempts to expand and improve health coverage for low-income individuals. The states challenges in maintaining quality care and treatment for people living with HIV experiencing these transitions demonstrate the importance of setting effective policies in anticipation of full ACA implementation in 2014.