Perspectives of a peer-driven approach to improve pre-exposure prophylaxis and HIV prevention among Black/African American and Hispanic/Latino men who have sex with men

Abstract

Background:

Black/African American (B/AA) and Hispanic/Latino (H/L) men who have sex with men (MSM) are significantly less likely than white MSM to initiate pre-exposure prophylaxis (PrEP). A peer-driven intervention (PDI) may be an effective approach to addressing this disparity. In this study, we explored community member perspectives of a PDI to promote PrEP uptake among B/AA and H/L MSM.

Methods:

We conducted semi-structured interviews with B/AA and H/L HIV-negative MSM between August 2018 and October 2019 in Rhode Island, USA. Participants reported their perspectives and recommendations for a PDI. Data from participant responses were thematically analyzed.

Results:

Of 15 MSM, the median age was 25 years old (interquartile range: 22, 33). The majority identified as B/AA (53.3%), H/L (66.7%), and having a college education or above (53.3%). Most participants viewed PDI positively and were willing to learn and promote PrEP among their peers. Participants identified and supported several potential intervention components, such as education about the benefit of PrEP, emphasizing prevention-effective dosing, and clarifying no prevention effect towards other sexually transmitted infections. They preferred in-person meetings to electronic communication. Preferred characteristics of peer educators included compassion, good communication skills, and enthusiasm about PrEP.

Conclusions:

This in-depth qualitative interview suggested that a PDI approach is promising in promoting PrEP uptake, as it could deliver culturally appropriate education and encourage PrEP uptake via peer influence among B/AA and H/L MSM.

Introduction

Gay, bisexual, and other men who have sex with men (MSM) bear a disproportionate burden of the HIV epidemic in the United States (US), comprising 68% of new diagnoses in 2020.¹ B Black/African American (B/AA) and Hispanic/Latino (H/L) MSM are especially impacted. They represent less than 3.9% of the total population,² but accounted for 42% and 27%, respectively, of all new HIV diagnoses in 2020.¹ Pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention and has the potential to dramatically reduce HIV incidence among MSM in the US.³ PrEP can reduce the risk of sexual transmission of HIV by more than 90% when taken with optimal adherence (>4 pills per week).⁴ Despite proven efficacy and clinical recommendations by the Centers for Disease Control and Prevention (CDC), PrEP uptake has been slow⁵ among MSM in the US, in particular among B/AA and H/L MSM.

Significant racial and ethnic disparities exist across the PrEP care continuum, including PrEP awareness⁶, access, adherence, and retention in care.⁷ H/L MSM are significantly less aware of PrEP compared to B/AA MSM.⁸ B/AA MSM are significantly less likely to have access to healthcare or be prescribed PrEP compared to White MSM.⁸ H/L MSM are less likely to be retained in PrEP care.^9,10 Limited access to preventive care,¹¹ medical mistrust,¹² and high rates of underinsured or uninsured individuals¹³ among these vulnerable populations are some key contributors to low PrEP uptake rate in the U.S. The U.S. does not provide universal health insurance, while other Western countries (e.g. The United Kingdom, Canada, and Australia) do. Given these disparities and barriers, community-based outreach approaches that engage the social networks of B/AA and H/L may be effective for increasing PrEP uptake.

Peer-driven interventions (PDI) are modified respondent-driven sampling or snowball sampling approaches to engage hard-to-reach populations, including B/AA and H/L MSM.¹⁴ PDIs involve training an “index peer” to become a peer educator and recruiting members of their social network. Referred network members then serve as “index peers” for the following waves of recruitment. PDIs have been demonstrated to be effective in engaging hard-to-reach populations, identifying high-risk individuals, disseminating HIV education, promoting condom use, and expanding HIV testing among MSM and other populations at high risk of HIV acquisition.^15,16 PDIs are a cost-effective way to achieve a representative sample of hard-to-reach populations^17,18 and may be an effective way to engage high-risk MSM. A randomized clinical trial demonstrated that a PDI could significantly improve rates of engaging B/AA and H/L as HIV research participants.¹⁹ To our knowledge, limited research has been conducted to explore the potential of PDIs on promoting PrEP uptake among MSM.^20,21 Given the proven effect of PDIs on other aspects of HIV prevention, PDIs could be an effective, culturally appropriate, and low-cost approach for improving PrEP uptake among B/AA and H/L MSM. The goal of this study was to understand the perspectives of B/AA and H/L MSM on a PDI approach and determine elements of a PDI approach for promoting PrEP uptake in these populations most affected by HIV.

Methods

We conducted qualitative interviews with 15 B/AA and H/L MSM between August 2018 and October 2019. Participants were recruited from The Miriam Hospital Sexually Transmitted Infections (STIs) and PrEP clinic and Project Weber/RENEW, a community-based organization that provides comprehensive harm reduction services to individuals with substance use disorders and who engage in sex work, including MSM. Study inclusion criteria were 1) 18 years or older; 2) self-identify as either AA or H/L; 3) assigned male sex at birth; 4) HIV negative; 5) report sex with a man in the past three months, and 6) able to speak English or Spanish. Participants identified as same-sex-loving, heterosexual, and/or LGBTQ. Interviews included questions about participants’ awareness and perspectives about PrEP, their social networks, perspectives about PDIs, and their interest and willingness to be a part of a PDI. Interviews were semi-structured and included open-ended questions to allow for flexibility in responses and opportunities for discussion. Interview guide content included questions related to how a PDI may promote PrEP uptake among B/AA and H/L MSM (e.g., discussing sexual health, attitudes towards peer intervention, PrEP educational content, and PDI design). A short questionnaire was used to collect demographics and other related information. All interviews were conducted via-in personal meetings. We conducted interviews until saturation was reached (no new data emerged). Interviews were approximately one hour long, and participants received a $50 gift card for their participation. Table 1 summarizes the main themes we explored during the interviews.

Table 1.

Summary of themes in qualitative interviews

Theme	Summary of Results
Social Networks	Diverse social networks
Cultural Influences on Sexual Health	Latino culture influenced their willingness to discuss sexuality and HIV Religious and conservative viewpoints decreased sexual health openness Latino men must be seen as masculine Latinos are reluctant to see a health care provider unless they are sick
Attitudes About Peer Driven Intervention	Positive views of a PDI to promote PrEP Willing to promote and provide PrEP education to their peers and promote
Suggested Intervention Education Content	Highlight the significance of protecting themselves from HIV and the benefits of PrEP Be clear about PrEP efficacy Educate that PrEP needs to be taken daily Emphasize that PrEP protects against HIV but not other STDs
Intervention Delivery	Preferred an in-person meeting Information could be supplemented through other avenues such as text messages or social media In person conversations are more personable and offer opportunities for questions to be answered
Preferred Interventionist	Someone easy to talk to and compassionate Someone familiar and/or culturally competent Someone knowledgeable and enthusiastic about PrEP Must have good communication skills and be sensitive to people’s needs
Suggested Intervention Incentive	Recommended amounts widely varied Providing a set payment amount rather than payment for each referral may be more beneficial Cash payment or gift cards are sufficient payment methods

Interviews were digitally recorded, professionally transcribed by an outside, HIPAA-certified transcription company, de-identified, and reviewed for accuracy by research staff. Qualitative data were deductively analyzed using reflexive thematic analysis, which is a six-step process for analyzing and reporting qualitative data: (1) familiarization with data, (2) generating codes, (3) constructing themes, and (4) reviewing, (5) defining, and (6) naming themes.²² Transcripts were coded using Dedoose software by two members of the research staff, meeting periodically to compare results and resolve discrepancies.

Results

Demographic Characteristics

Of the 15 study participants, the median age was 25 years old (interquartile range: 22, 33). The majority identified as B/AA (53.3%), H/L (66.7%), having a college education or above (53.3%), having health insurance (93.3%), identifying same-sex sexual orientation (66.7%), and being either single or having a non-monogamous relationship (80.0%). Race and ethnicity were separated into two questions, allowing us to capture two participants who identified themselves as both B/AA and H/L. Nine individuals were currently taking PrEP and six had never taken PrEP before (Table 2).

Table 2.

Demographic characteristics of interviewed study participants

	On PrEP (N=9)	Not on PrEP (N=6)
Age (Median, IQR)	23 (24,25)	32 (25, 40)
Race
Black or African American	6 (85.7%)	2 (100.0%)
White	1 (14.3%)	0 (0.0%)
American Indian or Alaska Native	0 (0.0%)	1 (25.0%)
Other	2(100.0%)	3 (75.0%)
Hispanic
Yes - Dominican	3 (33.3%)	0 (0.0%)
Yes - Puerto Rican	1 (11.1%)	3 (50.0%)
Yes - Cuban	1(11.1%)	0 (0.0%)
Yes - Guatemalan	1(11.1%)	0 (0.0%)
Yes - Other	1(11.1%)	0 (0.0%)
No	2 (22.3%)	3 (50.0%)
Sexual Orientation
Homosexual	8 (88.9%)	2 (33.3%)
Heterosexual	0 (0.0%)	1 (16.7%)
Bisexual	0 (0.0%)	2 (33.3%)
Other	1 (11.1%)	1 (16.7%)
Relationship Status
Monogamous Relationship	2 (22.2%)	1 (16.7%)
Non-Monogamous Relationship	2 (22.2%)	1 (16.7%)
Single	5 (55.6%)	4 (66.6%)
Education Level
High School	3 (33.3%)	4 (66.6%)
Some College	2 (22.3%)	0 (0.0%)
College	3 (33.3%)	1 (16.7%)
Graduate	1 (11.1%)	1 (16.7%)
Current Student
Yes	5 (55.6%)	1 (16.7%)
No	4 (44.4%)	5 (83.3%)
Employment Status
Unemployed	0 (0.0%)	3(50.0%)
Part-time	5 (55.6%)	2 (33.3%)
Full-time	4 (44.4%)	0
Disability	0 (0.0%)	1 (16.7%)
Health Insurance
None	0 (0.0%)	1 (16.7%)
Private	3 (33.3%)	1 (16.7%)
Public (Medicaid)	6 (66.7%)	4 (66.6%)

Social Networks

Participants described diverse social networks of family and friends and identified less than ten people who were considered the most important in their lives. Friends were often people they had grown up with and known for a long time or more recent friends made at college, work, or through other people. Many participants reported two to three core people who they saw or communicated with frequently, via text or in person. Several participants described their networks as diverse, such as one participant whose friend group included a wide range of different races and ethnicities.

“I have a very mixed group of friends. They all range from identifying as Latinos or Black African-Americans to white Caucasians or Asians”

[21-year-old, B/AA, H/L participant]

Most of these MSM participants reported having a group of friends who self-identified as gay or bisexual men.

“I can say I know at least ten people in my contacts right now who are gay or bisexual. I actually think they are all gay to be honest … so I think I have quite a few.”

[25-year-old, B/AA participant]

“I have a close set of 10 friends. For my Hispanic group of friends, I will say the percentage of Latinos that identify as gay or bisexual is roughly 25 percent.”

[21-year-old, B/AA, H/L participant]

Participants reported that the most influential people in their social networks were people who have similar experiences to them.

“People that influence me are people that are in recovery [Sic]. People out going through the same journey I’m going through. We want to get to the other side.”

[49-year-old, B/AA participant]

“Some of the most influential people to me are people from my background who identify as gay, who are making—I will say, who are making a brand for themselves.

[21 year old B/AA, H/L participant]

Attitudes about Peer-Driven Intervention

Of 15 participants, 14 individuals were positive about using a PDI approach to promote PrEP among B/AA and H/L MSM. Participants considered PDI a promising approach because HIV and sexual health were discussed frequently in their social network. Most were willing to provide PrEP education to their peers and promote PrEP uptake.

“Yeah. I would be like a campaign spokesperson for PrEP or how to get on PrEP—how would you go about bein’ on PrEP? That’s what I would—be like the poster boy. “Look, I’m here if you need advice, you need someone to talk to. Don’t be by the stigma, ‘Oh, you’ll be labeled out,’ because whatever you tell me is confidentiality. I’m not gonna spread your personal information. I would socialize and have them come to my house and talk to them one on one.”

[56-year-old, B/AA participant]

“I’m very interested. I think a lot of people don’t know about PrEP right now. It’s not fair to a bunch of people that could be benefiting and not knowing it, so I’d love to be a part of the program.”

[22-year-old, B/AA, H/L participant]

The individual who opposed this approach indicated a preference for healthcare professionals to deliver PrEP information and argued that he made significant decisions independently and was minimally influenced by the suggestions of others.

I’d be amazed if my friends approached me about this. “Wow, okay,” I’d prefer a doctor…because I’d be scared for people on the street to approach me like that “Why are you approaching’ me like this, bro? What’s going on?” I’d be worried…No, I wouldn’t trust [the information my friends tell me].

[31 year-old, B/AA and American Indian participant ]

Most participants liked the idea of being educated by a community member rather than a clinician. Although most participants were favorable about a PDI approach, some did have concerns about confidentiality and would like to conduct conversations about HIV and sexual health privately.

“The fact that I could get it delivered discreetly. The fact that there were no violations of the HIPAA law for confidentiality. It would help that if my significant other did find out, an outreach worker could explain to them what was going on. That way they wouldn’t think they were more at risk or less at risk.”

[37-year-old, H/L participant]

Suggested Intervention Content

Participants emphasized that the high efficacy of PrEP in preventing HIV should be highlighted in a PDI approach, as this information would likely arouse people’s interest.

“The most important thing. I guess, that it could potentially save their life.”

[23-year-old, H/L participant]

Participants also emphasized the importance of highlighting the need for daily adherence to PrEP to maximize its effectiveness as a protective measure, and the importance of clarifying that while PrEP offers protection against HIV, it does not protect against other sexually transmitted diseases (STDs).

“The most important thing that you got to slip in there somehow is that it doesn’t prevent STDs, but you have a whole list of things that are good about PrEP, that 96 percent compared to the 70-somethin’ percent. That’s big, and just let them know it’s daily.”

[31-year-old, B/AA participant]

Methods to Deliver Intervention

Most participants preferred an in-person intervention rather than electronic communication. However, communication with a peer educator and delivery of PrEP information could be supplemented through other avenues such as email, text messages, or social media. Several participants highlighted how in-person conversations can be more casual and personable.

“I think I would want to do it face-to-face, over coffee ‘cause they would probably have questions and it would be easier to answer their questions face-to-face.”

[23-year-old, H/L participant]

“I think in-person contact is, of course, the best form of communication, though you can get your same point across in written communication. Being clear from the beginning, I think, is very important for that communication to be heard or said or read firsthand.”

[25-year-old, B/AA participant]

Participants also mentioned that social media would be an effective way to engage them in PDIs.

“Social media, ads, flyers, posters, Twitter, Facebook, Instagram, and emails, Instagram, Facebook would be the best ways to reach me about PrEP.”

[31-year-old, B/AA participant]

Characteristics of an ideal peer educator

Participants described an ideal peer educator as an individual who is easy to talk to, familiar to them, knowledgeable and enthusiastic about PrEP, compassionate, and confident in themselves. They emphasized the importance of a peer educator having good communication skills and being sensitive to people’s needs.

“You gotta be a person that shows compassion to let the person be able to speak to you and express how they feel.”

[56-year-old, B/AA participant]

“I feel like the biggest issue would be probably going back to the way that you deliver, the way that you communicate this- to take PrEP. I think it’s just the delivery of that message. I feel like that’s gonna be the biggest problem, or it’s having the educator feel confident with themselves, to educate somebody else. Again, it’s that whole issue of the stigmatism [sic] against HIV in general.”

[29-year-old, H/L participant]

Suggested Intervention Incentive

Participants discussed using incentives, such as cash or gift cards, to compensate people for being peer educators and referring members of their social network for PrEP uptake. The majority thought $25-$30 would be an acceptable amount for compensation. Some participants expressed a preference for fixed payment amounts rather than commission-based payments for each referral, as fixed payment compensation would not be contingent upon the number of individuals reached.

“Almost the $25 per person thing, to me, it turns me off, because it seems like you’re almost working a retail. More of a set amount, rather than a referral every time someone comes in.”

[23-year-old, H/L participant]

“I’ll say a $30 gift card or anything, pretty much, but mostly either Amazon, or just a regular gift card, or just a gift card for Target or something like that.”

[21-year-old, B/AA, H/L participant]

Cultural Influences

Some H/L participants described the influences of Latino culture on their willingness to discuss sexuality and HIV, particularly with family. Due to the importance of religion and conservative viewpoints on sexuality, they chose not to discuss sex or sexual health with their families.

“Culturally it’s the way that some of us have grown up. Our parents are very religious. They have taught us that there’s either a man or a woman, and they also have taught us that there’s only one thing that can be happening in this world, and that is that you need to be married to a woman; things like that. It’s very the norm, and of how society views things, and also telling us that there are certain—there is forbidden conversations, and one of those is sex, and sexuality, as well.”

[21-year-old B/AA, H/L participant]

Another participant described how Latino men feel pressure to act with the concept of machismo, creating a barrier for H/L MSM to talk about their sexuality or HIV within their community.

“My thing is because it’s like you said, it’s conservative or a lot of Latino men feel like they have to be macho. They have to be a macho guy or they’re very, very stubborn in their ways. They don’t like to really talk about stuff. I think that is definitely a big barrier when it comes to Latino men even taking—or even going on HIV—even taking a pill that prevents them from HIV, ‘cause they feel like they don’t need something like that. They should just be able to do it themselves. I think that the problem is that they’re too—their ego. Their ego is definitely an issue.”

[29-year-old, H/L participant]

Participants also described the reluctance among Latinos to see a healthcare provider unless they are sick, meaning there is a tendency among H/L populations to avoid seeking preventative care.

“Latinos have this thing with doctors, that you only go to doctors if you’re sick. It’s a cultural mentality toward the healthcare system. That’s why I feel like they don’t take it as seriously as they should.”

[24-year-old, H/L participant]

For one Muslim participant, conservative religious beliefs impacted his sexual identity, which he kept disclosing from his family, negatively impacted his self-image, and limited opportunities to discuss HIV.

“I can’t talk about this with my mother and brothers. They’ll stop hanging around me. None of the Muslims I hang around and even myself—even when I do it, I feel disgusted with myself. I hate doin’ it, which is why I do it so little now. I try and pray five times a day, every day, as long as I can make the prayer, and I’m not traveling.”

[37-year-old, H/L participant]

Minority participants expected that peer educators should have the same sexual identities and race/ethnicity due to the shared culture and experience, especially cultural barriers to disclosing their sexual identity and seeking prevention care.

I think it’s best that you send brown, gay men into brown, gay men areas to talk to brown, gay men about being brown, gay men.”

[21-year-old B/AA, H/L participant]

Discussion

This study is among a few qualitative studies exploring the acceptability and potential components of a PDI for PrEP among B/AA and H/L MSM (See Table 1 for summarization of our study findings). In our study, almost all participants had favorable viewpoints about a PDI for PrEP and were either willing to educate or be educated by peers. This study finding was concordant with other studies that explored PDIs for other HIV prevention outcomes, including ART adherence, and increased condom use among high-risk populations.^17–19 Given our study findings and the supportive evidence in the literature, a PDI approach has the potential to promote PrEP uptake among B/AA and H/L MSM who are disproportionally impacted by HIV and could benefit from PrEP.²³

In this qualitative study, we explored potential components for a successful PDI for PrEP uptake, including desired characteristics of peer educators, quality of social networks, the need for formal training about HIV and PrEP, incentives for referrals, and culturally competent approaches. Participants felt that peer educators should be outgoing and personable, have good communication skills, be knowledgeable and enthusiastic about PrEP, be able to educate and recruit people they know, and share experiences or backgrounds with participants. Participants felt that a prominent community member should lead this intervention, which is consistent with research showing peers at the center of their social network have more influence over others’ health behavior.^24,25 Most participants also noted that peer educators should share the same identity (e.g. race, ethnicity, and sexual orientation) as the targeted population, which was also reported by other HIV research.²⁶ Recruitment efforts should focus on those most likely to commit to serving as peer educators, with large social networks, who are B/AA and H/L, and who can reach high-risk B/AA and H/L MSM who are otherwise difficult to engage in PrEP education and care.

Most participants preferred in-person meetings for HIV and PrEP education. The risks of HIV and PrEP benefits were identified as the most important information to deliver. Participants also believed it is critical to emphasize PrEP as a daily medication to prevent HIV acquisition, and that PrEP usage is not protective against other STIs. Additionally, the intervention should include culturally appropriate content due to the cultural barriers mentioned by Latino participants that they’ve experienced within their community.

Most study participants reported having close LGBTQ-identifying friends and felt more comfortable discussing sex and HIV with them. However, participants noted stigma towards HIV and PrEP within MSM communities, which might hinder communication and discussion. H/L MSM described how cultural beliefs about sexuality in the Latino community prevented conversations about HIV. B/AA, non-H/L MSM who participated in the current study did not report cultural barriers to HIV and PrEP discussions, although previous research has documented similar religious and cultural barriers to HIV and PrEP conversations within the B/AA community.^27,28

Incentives could be used to compensate peer educators’ efforts to disseminate HIV and PrEP knowledge to members of their social networks. Study participants considered a $25-$30 amount acceptable. Several participants were passionate about educating their peers about PrEP and considered incentives as a bonus, potentially indicating a willingness to educate others without compensation. Identifying potential peer educators who are committed to providing formal educational training is crucial to a PDI to promote PrEP.

Our study has limitations. First, we conducted interviews in Rhode Island. Results may be different for B/AA and H/L MSM in other locations and cultural settings. We conducted purposeful sampling to include diverse perspectives, but the viewpoints expressed here may not be reflective of the larger MSM population. For example, the finding that B/AA MSM did not report cultural barriers does not align with the findings of several studies conducted in the Deep South which found that stigma was a major barrier.^29,30 Thus, the experiences of B/AA MSM in Rhode Island may be different from other communities. Also, while we recruited through a clinic with a diverse patient population and a community-based organization that serves hard-to-reach MSM, the perspectives of MSM who were not engaged in services and were harder to reach are missing. This study was conducted before the onset of the Coronavirus Diseases 2019 (COVID-19) pandemic, and it is important to note that the preference for in-person meetings may have changed since then. The COVID-19 pandemic has had a significant impact on how people socialize, and as a result, attitudes toward in-person meetings may have shifted. As on-demand and long-acting PrEP were either not recommended or not approved during the study period, the intervention should include information about these in the education content, ensuring participants are aware of all available PrEP options. This study could be biased due to social desirability, as participants were aware that this study was a formative phase of a larger project developing a PDI approach. However, individuals were assured that there were no right or wrong answers to any questions during the discussion and that the study team would like to hear their true thoughts about a PDI approach and their experience as an MSM. Therefore, social desirability likely had a minimized effect on the study findings. Nevertheless, this qualitative study contributes important information for developing a unique intervention to promote PrEP among a vulnerable population.

Conclusions

This in-depth qualitative interview explored B/AA and H/L MSM’s perspectives on a PDI approach to promoting PrEP uptake. A successful PDI should select good candidates as peer educators, provide extensive training about HIV and PrEP, disseminate HIV and PrEP knowledge and encourage PrEP uptake through index peers’ social networks, and contain culturally appropriate content. This study sheds light on designing a PDI approach for PrEP promotion among B/AA and H/L MSM.