PrEP for people who use opioids: A NIDA clinical trials network survey study in Southern U.S. cities where HIV incidence is high.

BACKGROUND: People who use opioids (PWUO) are at increased risk for HIV. Pre-exposure prophylaxis (PrEP) is effective but underutilized as HIV prevention among PWUO. This study examined predictors of willingness to take daily oral PrEP and long-acting injectable (LAI) PrEP among PWUO across eight Southern urban cities with high HIV incidence. METHODS: HIV-negative PWUO (N = 308) seeking services in community-based programs participated in this cross-sectional survey study. Measures included demographics, sexual risk behavior, substance use frequency, and awareness of and willingness to take oral and injectable PrEP. Data were analyzed using mixed-effects models. RESULTS: Willingness to take daily oral and LAI PrEP was moderately high (69.16% and 62.02%, respectively). Half had heard of PrEP, but only 4% had ever taken it. Only education and condomless vaginal sex predicted willingness to take oral PrEP. Only education predicted willingness to take LAI PrEP. Polysubstance use was prevalent, with substantial proportions of PWUO reporting frequent use of injection drugs (opioids or stimulants, 79.5%), non-injection opioids (73.3%), non-injection stimulants (71.1%), cannabis (62.6%), and hazardous drinking (29.6%). About 20% reported past-year condomless anal sex, and one-third reported past-year condomless vaginal sex. CONCLUSIONS: PWUO in this study were amenable to PrEP, particularly in light of education and condomless vaginal sex. Careful consideration for matching PrEP messaging to the PWUO audience is needed. PrEP promotion should expand beyond men who have sex with men to include groups such as these predominantly heterosexual, polysubstance-using PWUO with HIV risk who were open to both formulations of PrEP.

Adaptation of a bidirectional crisis and emergency risk communication framework by community-engaged research partnerships in rural Mississippi during the COVID-19 pandemic.

Community engagement is important for reaching populations at risk for health inequities in the coronavirus disease 2019 (COVID-19) pandemic. A community-engaged risk communication intervention implemented by a community-engaged research partnership in Southeast Minnesota to address COVID-19 prevention, testing, and socioeconomic impacts has demonstrated high acceptability, feasibility, perceived efficacy, and sustainability. In this study, we describe the adaptation of the intervention by a community-academic partnership with rural African American populations in three Mississippi counties with high COVID-19 disparities. Intervention reach was assessed by the number of messages delivered by Communication Leaders to members of their social networks. Perceived scalability of the intervention was assessed by the Intervention Scalability Assessment Tool. Bidirectional communication between Communication Leaders and community members within their social networks was used by the partnership to refine messages, meet resource needs, and advise statewide decision-makers. In the first 3 months, more than 8482 individuals were reached in the three counties. The intervention was deemed to be highly scalable by partnership members. Adaptation of a community-engaged pandemic CERC intervention is feasible and scalable, and it has the potential to reduce COVID-19 inequities across heterogeneous populations. This approach may be incorporated into current and future pandemic preparedness policies for community engagement.

Health-care providers' perspectives on an HIV patient navigation training to improve uptake of PrEP among Black sexual minority men.

This article examines implementational factors associated with an HIV patient navigation training intervention for health care professionals working with Black sexual minority men to improve access to and uptake of HIV prevention services among Black MSM. Utilizing qualitative analysis to better understand healthcare professionals' perceptions of the training program, we conducted a thematic content analysis based on constructs from Professional Network and Reach Model-Systems Model Approach (PNRSMA) framework. Data analysis revealed four major themes: 1) Knowledge and skill building, 2) Novel and Innovation, 3) Barriers to Implementation, and 4) Recommendations and Future Directions. Implementation factors such as appropriate facilitators, content, mode of delivery, learning strategies, and understanding structural barriers were important to training success. Participants highlighted innovation strategies such as the use of social media and interactive communication (e.g. role-playing and bi-directional communication) enhanced learning and skill-building. The expansion of training to include other affected groups such as women and bisexual individuals and increasing the duration of the training emerged as areas for improvement and effectiveness. Our analysis of an HIV patient navigation training revealed important findings to improve the implementation process to increase uptake of PrEP and other HIV prevention, care and treatment services.

Where's the "Everyday Black Woman"? An intersectional qualitative analysis of Black Women's decision-making regarding HIV pre-exposure prophylaxis (PrEP) in Mississippi.

BACKGROUND: Black cisgender women in the U.S. South bear a disproportionate burden of HIV compared to cisgender women in other racial and ethnic groups and in any other part of the US. Critical to decreasing new HIV infections is the improved delivery of pre-exposure prophylaxis (PrEP) for Black cisgender women as it remains underutilized in 2021. Informed by intersectionality, the study sought to characterize the sociostructural influences on Black cisgender women's deliberations about PrEP within the context of interlocking systems of oppression including racism, sexism, and classism. METHODS: Six focus groups were conducted with 37 Black women residing in Jackson, Mississippi. This sample was purposively recruited to include Black cisgender women who were eligible for PrEP but had never received a PrEP prescription. RESULTS: Six themes were identified as concerns during PrEP deliberation among Black women: 1) limited PrEP awareness, 2) low perceived HIV risk, 3) concerns about side effects, 4) concerns about costs, 5) limited marketing, and 6) distrust in the healthcare system. Three themes were identified as facilitators during PrEP deliberations: 1) women's empowerment and advocacy, 2) need for increased PrEP-specific education, and 3) the positive influence of PrEP-engaged women's testimonials. Black women shared a limited awareness of PrEP exacerbated by the lack of Black women-specific marketing. Opportunities to support Black women-specific social marketing could increase awareness and knowledge regarding PrEP's benefits and costs. Black women also shared their concerns about discrimination in healthcare and distrust, but they felt that these barriers may be addressed by patient testimonials from PrEP-engaged Black women, empowerment strategies, and directly addressing provider biases. CONCLUSIONS: An effective response to PrEP implementation among Black women in the South requires developing programs to center the needs of Black women and carry out active strategies that prioritize peer advocacy while reinforcing positive and mitigating negative influences from broader social and historical contexts.

Enhancing domestic violence advocates' ability to discuss HIV pre-exposure prophylaxis (PrEP): Feasibility and acceptability of an educational intervention.

BACKGROUND: Survivors of intimate partner violence are at elevated risk for HIV acquisition, yet there is limited research on the best strategies to optimize biomedical HIV prevention, such as pre-exposure prophylaxis among this population. Domestic violence agencies are critical collaborating partners and function as potential entry points into HIV prevention services for survivors; however, limited knowledge regarding HIV prevention has been an important barrier to advocate-led discussions. This study aimed to develop, implement, and evaluate an HIV prevention intervention for domestic violence advocates. SETTING: A nonrandomized, group-based intervention with pre-intervention, immediate post-intervention, and 3-month post-intervention periods were conducted with multiple domestic violence agencies in Mississippi. METHODS: Overall, 25 domestic violence advocates participated in the two-session intervention. Surveys were administered to assess pre-exposure prophylaxis knowledge, self-efficacy, subjective norms, and willingness to provide HIV prevention services to intimate partner violence survivors. Generalized estimating equations were conducted to assess change in behavioral outcomes over time. RESULTS: Compared to pre-intervention, there were significant increases at immediate and 3-month post-intervention in advocates' intervention acceptability, pre-exposure prophylaxis knowledge, and self-efficacy to provide HIV prevention information, discuss pre-exposure prophylaxis eligibility criteria, assist pre-exposure prophylaxis-engaged clients, and initiate pre-exposure prophylaxis counseling. CONCLUSION: This group-based intervention enhanced domestic violence advocates' acceptability, pre-exposure prophylaxis knowledge, and self-efficacy to offer HIV care information, discuss pre-exposure prophylaxis eligibility, assist pre-exposure prophylaxis-engaged survivors, and initiate pre-exposure prophylaxis counseling with intimate partner violence survivors. Efforts should focus on training domestic violence advocates in HIV prevention care for survivors and also include these agencies in collaborative strategies to reduce HIV incidence.

African American Clergy Recommendations to Enhance the Federal Plan to End the HIV Epidemic: A Qualitative Study.

African Americans in the southern United States continue to be disproportionately affected by HIV. Although faith-based organizations (FBOs) play important roles in the social fabric of African American communities, few HIV screening, care, and PrEP promotion efforts harness the power of FBOs. We conducted 11 focus groups among 57 prominent African American clergy from Arkansas, Mississippi, and Alabama. We explored clergy knowledge about the Ending the HIV Epidemic: A Plan for America (EHE); normative recommendations for how clergy can contribute to EHE; and how clergy can enhance the HIV care continua and PrEP. We explored how clergy have responded to the COVID-19 crisis, and lessons learned from pandemic experiences that are relevant for HIV programs. Clergy reported a moral obligation to participate in the response to the HIV epidemic and were willing to support efforts to expand HIV screening, treatment, PrEP and HIV care. Few clergy were familiar with EHE, U = U and TasP. Many suggested developing culturally tailored messages and were willing to lend their voices to social marketing efforts to destigmatize HIV and promote uptake of biomedical interventions. Nearly all clergy believed technical assistance with biomedical HIV prevention and care interventions would enhance their ability to create partnerships with local community health centers. Partnering with FBOs presents important and unique opportunities to reduce HIV disparities. Clergy want to participate in the EHE movement and need federal resources and technical assistance to support their efforts to bridge community activities with biomedical prevention and care programs related to HIV. The COVID-19 pandemic presents opportunities to build important infrastructure related to these goals.

Meet Me Where I Am: An Evaluation of an HIV Patient Navigation Intervention to Increase Uptake of PrEP Among Black Men Who Have Sex with Men in the Deep South.

The southern region of the USA is the epicenter of the HIV epidemic. HIV disproportionately affects African Americans, particularly Black men who have sex with men (Black MSM). Given the alarming rates of new infections among Black MSM, there is an urgent need for culturally competent healthcare professionals who are trained to address the unique needs and barriers to uptake and adherence to HIV prevention, care, and treatment services. Utilizing a mixed method research approach, we conducted a process evaluation of Meet Me Where I Am, a 6-month, 6-session HIV/AIDS patient navigation training program for healthcare professionals and patient navigators working in organizations that provide HIV services to residents of central Mississippi, an area with high incidence and prevalence rates of HIV. A self-administered questionnaire after each session was given to participants to assess the acceptability, quality, and translational aspects of the training program. The overall positive feedback on the MMWIA training reflects the program's acceptability and feasibility. Participants found that the training was effective in providing the necessary knowledge and skills to deliver patient-centered HIV prevention-related navigation services. A majority (67%) of participants indicated that they felt they could apply the lessons learned within their healthcare settings to improve access to HIV prevention, care, and treatment services. If we are to reduce racial and ethnic disparities in HIV/AIDS, there is a critical need for culturally appropriate training programs designed to improve the ability of healthcare professionals and health systems to deliver culturally competent HIV prevention, care, and treatment services.

Locating the Risk: Using Participatory Mapping to Contextualize Perceived HIV Risk across Geography and Social Networks among Men Who Have Sex with Men in the Deep South.

HIV incidence among African American (AA) young men who have sex with men (YMSM) has remained stable even though they made up the largest number of new HIV diagnoses among men who have sex with men (MSM) in 2017. HIV spreads at increased rates in dense sexual networks. Identifying the location of risk behaviors "activity spaces" could inform geographically circumscribed HIV prevention interventions. Utilizing the modified social ecological model we completed five semi-structured focus groups incorporating a modified social mapping technique, based on Singer et al.'s approach. Participants included 27 AA YMSM. Focus groups explored how and where HIV transmission happens in Jackson, Mississippi. Result themes included: 1) location of sexual behaviors, 2) knowledge of geographic hotspots of HIV infection in Jackson, and 3) traveling to meet partners: at home and away. HIV transmission or "activity spaces" may be occurring outside identified HIV hot spots. Mixed geospatial and qualitative methods offered a comprehensive assessment of where HIV transmission occurs, and suggests that geographically circumscribed interventions may need to focus on where individuals living with HIV reside and in specific geographic locations where they engage in behaviors that raise their HIV acquisition risks.

"PrEP's just to secure you like insurance": a qualitative study on HIV pre-exposure prophylaxis (PrEP) adherence and retention among black cisgender women in Mississippi.

BACKGROUND: Pre-exposure prophylaxis (PrEP) has the potential to reduce transmission of HIV among Black cisgender women in the Southern United States (U.S.); however, national data suggests that PrEP initiation is lowest in the South and among Black women compared to other U.S. regions and white women. This study applied intersectionality and PrEP multilevel resilience frameworks to assess how socio-structural and clinical contexts shaped PrEP persistence among Black cisgender women in Mississippi. METHODS: Semi-structured interviews were conducted with eight Black cisgender women in Jackson, Mississippi. This sample was purposively recruited to include PrEP-initiated Black cisgender women. RESULTS: Six themes identified that shaped PrEP care among Black cisgender women: (1) internal assets, (2) sole responsibility to HIV prevention, (3) added protection in HIV serodifferent relationships, (4) financial issues, (5) trust and distrust in the medical system, and (6) side effects. Black cisgender women reported that PrEP persistence increased control over their sexual health, reduced anxiety about HIV, and promoted self-care. Black cisgender women also indicated that medication assistance programs increased PrEP affordability resulting in continued persistence. CONCLUSIONS: In addition to preventing HIV, PrEP may yield secondary positive impacts on the health and relationships of Black cisgender women. However, very few Black cisgender women in the South are using PrEP given intersectional barriers and thus necessitates adaptive strategies to support PrEP initiation and persistence. Efforts aimed at increasing the coverage of PrEP among Black cisgender women should consider implementation strategies responsive to lived realities of Black women.

The Role of Public Health in COVID-19 Emergency Response Efforts From a Rural Health Perspective.

As the country responds to coronavirus disease 2019 (COVID-19), the role of public health in ensuring the delivery of equitable health care in rural communities has not been fully appreciated. The impact of such crises is exacerbated in rural racial/ethnic minority communities. Various elements contribute to the problems identified in rural areas, including a declining population; economic stagnation; shortages of physicians and other health care providers; a disproportionate number of older, poor, and underinsured residents; and high rates of chronic illness. This commentary describes the challenges faced by rural communities in addressing COVID-19, with a focus on the issues faced by southeastern US states. The commentary will also address how the COVID-19 Community Vulnerability Index may be used as a tool to identify communities at heightened risk for COVID-19 on the basis of 6 clearly defined indicators.

African American Clergy Perspectives About the HIV Care Continuum: Results From a Qualitative Study in Jackson, Mississippi.

Mississippi has some of the most pronounced racial disparities in HIV infection in the country; African Americans comprised 37% of the Mississippi population but represented 80% of new HIV cases in 2015. Improving outcomes along the HIV care continuum, including linking and retaining more individuals and enhancing adherence to medication, may reduce the disparities faced by African Americans in Mississippi. Little is understood about clergy's views about the HIV care continuum. We assessed knowledge of African American pastors and ministers in Jackson, Mississippi about HIV and the HIV care continuum. We also assessed their willingness to promote HIV screening and biomedical prevention technologies as well as efforts to enhance linkage and retention in care with their congregations. Four focus groups were conducted with 19 African American clergy. Clergy noted pervasive stigma associated with HIV and believed they had a moral imperative to promote HIV awareness and testing; they provided recommendations on how to normalize conversations related to HIV testing and treatment. Overall, clergy were willing to promote and help assist with linking and retaining HIV positive individuals in care but knew little about how HIV treatment can enhance prevention or new biomedical technologies such as pre-exposure prophylaxis (PrEP). Clergy underscored the importance of building coalitions to promote a collective local response to the epidemic. The results of this study highlight important public health opportunities to engage African American clergy in the HIV care continuum in order to reduce racial disparities in HIV infection.

Preexposure prophylaxis for HIV infection: healthcare providers' knowledge, perception, and willingness to adopt future implementation in the southern US.

BACKGROUND: Understanding providers' perspective on preexposure prophylaxis (PrEP) would facilitate planning for future implementation. METHODS: A survey of care providers from sexually transmitted disease and family planning clinics in South Carolina and Mississippi was conducted to assess their knowledge, perception, and willingness to adopt PrEP. Multivariable logistic and general linear regression with inverse propensity score treatment weights were used for analyses. RESULTS: Survey response rate was 360/480 (75%). Median age was 46.9 years and a majority were women (279 [78%]), non-Hispanic white (277 [78%]), nonphysicians (254 [71%]), and public health care providers (223 [62%]). Knowledge about PrEP was higher among physicians compared with nonphysicians (P = 0.001); nonpublic health care providers compared with public health care providers (P = 0.023), and non-Hispanic whites compared with non-Hispanic blacks (P = 0.034). The majority of the providers were concerned about the safety, efficacy, and cost of PrEP. Providers' perceptions about PrEP were significantly associated with their sociodemographic and occupational characteristics. The willingness to prescribe PrEP was more likely with higher PrEP knowledge scores (adjusted odds ratio [aOR] 14.94; 95% confidence interval [CI] 3.21-69.61), older age (aOR 1.14; 95% CI 1.01-1.29), and in those who agreed that "PrEP would empower women" (aOR 2.90; 95% CI 1.28-6.61); and was less likely for "other" race/ethnicity versus white (aOR 0.23; 95% CI 0.07-0.76) and in those who agreed that "PrEP, if not effective, could lead to higher HIV transmission" (aOR 0.45; 95% CI 0.27-0.75). CONCLUSIONS: To improve the acceptance of PrEP among providers, there is a need to develop tailored education/training programs to alleviate their concerns about the safety and efficacy of PrEP.