Peer Ambassador Stories: Formative Qualitative Research to Enhance the Reach of PrEP, HIV Testing, and Behavioral Health Treatments to LMSM in South Florida

Abstract

Existing HIV prevention interventions, such as pre-exposure prophylaxis (PrEP), and behavioral health treatments inadequately reach Latino men who have sex with men (LMSM) in the US. This study involved formative research to inform the content, design, and implementation of a scalable, low resource implementation strategy – peer ambassador stories – stories from peers to normalize using PrEP, HIV testing, and behavioral health treatment. We conducted semi-structured interviews with 20 LMSM to elucidate their content, design, and implementation preferences for peer ambassador stories. Men were asked about story prompts, story contributor characteristics, story platform features, design preferences, and recommendations for enhancing the adoption and use of the peer ambassador technology platform among LMSM. Interviews were transcribed and analyzed via rapid qualitative analysis. Qualitative analyses identified 14 themes within 4 pre-specified domains. Collectively, the themes unified around the central concept that technology-delivered peer ambassador stories require a personalized, relational, culturally relevant touch to be acceptable and appropriate for LMSM. In the acceptability and appropriateness domain, LMSM viewed peer ambassador stories as highly acceptable and appropriate. In the story content and contributor’s domain, LMSM identified influential characteristics of story contributors (e.g., experts based on training and/or lived experience, recognized local peers) and content (e.g., personal stories of seeking services). In the features and design domain, LMSM suggested delivering the stories via social media or email listservs. Finally, in the adoption and use domain, LMSM provided guidance on advertising and branding the peer ambassador stories (e.g., using a concise, bilingual name). This study suggests that disseminating peer ambassador stories using electronic platforms and audio/video formats may enhance the reach of services and if they are personalized, relational, and culturally relevant. Findings have broad implications for informing other peer-based strategies to mitigate HIV disparities among LMSM.

Background

Latino men who have sex with men (LMSM) in the United States (US) are disproportionately affected by HIV, with 20% of this population projected to be diagnosed within their lifetime (Centers for Disease Control and Prevention, 2021; Rodriguez-Diaz et al., 2021). Among Latino men in the US, 80% of new HIV cases are attributed to male-to-male sexual contact (Guilamo-Ramos et al, 2020). Within Miami-Dade County (MDC), a geographic epicenter of the US HIV epidemic (Fauci et al., 2019), LMSM experience approximately 50% of incidence (Health Council of South Florida, 2020). LMSM are therefore a priority population in MDC for the Florida Department of Health’s HIV prevention efforts, aligning with the strategic initiative in the US known as the Ending the HIV Epidemic (EHE) plan. This plan is aimed at reducing HIV incidence through prevention, testing, treatment, and support efforts (Health Council of South Florida, 2020; U.S. Department of Health and Human Services, 2021).

While evidence-based biomedical HIV-prevention interventions like pre-exposure prophylaxis (PrEP) have been expanded among MSM more broadly, they have not effectively reached LMSM (Health Council of South Florida, 2020). Among the 78,360 persons who filled prescriptions for PrEP in 2016 in the US, only 13.1% were LMSM (Huang et al., 2018). The potential of PrEP to reduce HIV transmission among LMSM can only be realized if there is increased uptake within this population.

LMSM in MDC and the US are also impacted by behavioral health (BH) (i.e., mental health and substance use) disparities, which exacerbate HIV disparities (Harkness, Lozano, et al., 2022; Rodriguez-Seijas et al., 2019). Compared to their heterosexual counterparts, MSM experience higher rates of mental health concerns (e.g., anxiety, depression, suicidality) and substance use (Kipke et al., 2020; Meyer, 2003). These disparities are likely driven by the chronic stress from sexual orientation related stigma, prejudice, and discrimination (Brooks, 1981; Meyer, 2003; Meyer et al., 2021; Shenkman et al., 2021; Ventriglio et al., 2022). LMSM have lower rates of behavioral health treatment use than White MSM despite high need (Harkness et al., 2021; Loza et al., 2021). Syndemic theory suggests that behavioral health disparities synergize with HIV disparities to worsen both epidemics (Singer & Clair, 2003), which has been documented among LMSM (Martinez et al., 2016). For LMSM, the syndemic interplay between substance use disorders, mental health issues, and HIV risk behaviors (e.g., infrequent HIV testing, condomless anal sex, lack of PrEP or PEP use, having multiple sexual partners, and engaging in sexual behaviors while using substances) can be particularly pronounced (Garcia et al., 2023; Gonzalez-Guarda et al., 2023; Lee et al., 2020; Mancera et al., 2022; Quinn et al., 2020). Substance use can lead to participating in sexual activities such as condomless anal sex while under the influence of substances, and mental health challenges may exacerbate substance use, creating a cycle that increases vulnerability to HIV (Garcia et al., 2023; Mancera et al., 2022; Quinn et al., 2020). As such, addressing behavioral health, as a part of HIV prevention for LMSM, is critical.

Behavioral health disparities, as with HIV disparities, are worsened by inadequate reach (defined as the number of individuals from a given population that uses an intervention; Glasgow et al., 2019) of evidence-based behavioral health treatments to LMSM (Harkness, Lozano, et al., 2022; Phillips et al., 2021). Scaling up and disseminating evidence-based HIV-prevention and behavioral health treatments to LMSM requires identifying modifiable leverage points (i.e., elements that, when modified or leveraged, can have a significant impact on improving the implementation and outcomes of the interventions; (Wight et al., 2016)) that could improve reach. Relational factors, such as social support, normalization, and altruism, are facilitators to LMSM’s HIV-prevention and behavioral health treatment engagement (Harkness et al., 2021; Harkness, Rogers, et al., 2022). Our prior qualitative research found that peers can facilitate or impede LMSM’s service use, depending on whether peers normalize or stigmatize services (Harkness et al., 2021). Our quantitative work found that relational factors (e.g., family/friend/partner suggesting treatment, perceived norms for treatment, PrEP stigma) were highly influential on LMSM’s engagement in PrEP, and BH treatment (Harkness, Lozano, et al., 2022). Collectively, these findings highlight that peer influence is one potential modifiable leverage point for increasing LMSM’s demand for HIV prevention and BH services.

Prior research has also suggested the potential effectiveness of peer influence on HIV prevention outcomes, owing to their influential roles within communities and capacity to educate and promote safe behaviors (Cluesman et al., 2023; Tobin et al., 2022; Waterman et al., 2022; Young et al., 2022). Peers have been used to bolster both resource-efficient interventions, such as online informational campaigns, peer education forums, email newsletters, and social media campaigns, as well as more resource-intensive approaches like mobile apps with real-time monitoring and interactive educational platforms, all aimed at expanding the accessibility of interventions like PrEP to LMSM (Goldstein et al., 2023; Kudrati et al., 2021; Li et al., 2019; Mulawa et al., 2021; Mustanski et al., 2024; Nguyen et al., 2019; Reisner et al., 2021; Ronen et al., 2020). Participants in various studies have expressed a desire for peer interaction delivered through various formats, such as video testimonials and short stories (Aliabadi et al., 2015; Berkley-Patton et al., 2013). Peer narratives have been found to address gaps in HIV knowledge, motivate safer behaviors, teach behavioral skills, and instill self-efficacy for preventive behaviors through active learning, role modeling, dramatic relief, goal setting, and self-reevaluation (Li et al., 2019). As such, the goal of the current study was to conduct formative research to inform the content, design, and implementation of a scalable, low resource strategy to leverage peer influence to scale up and disseminate PrEP, HIV testing, and BH treatment to LMSM. Although the current study informed the development of one peer strategy, the findings can be used to inform other peer-based strategies that seek to achieve similar goals.

Methods

Participants and Procedures

We enrolled 20 HIV-negative LMSM in South Florida in this qualitative study. Recruitment efforts included contacting individuals from prior studies, word-of-mouth, and distributing flyers to a community advisory board (CAB). The CAB, composed of bilingual LMSM residing in the greater Miami area, disseminated information about the study within their social networks. Recruitment was stratified with the goal of achieving equitable representation of participants born in and outside of the US, to reflect the diversity of LMSM in MDC.

Eligible participants (1) identified as Latino/Hispanic, (2) identified as a sexual minority man (e.g., gay, bisexual) or man who has sex with men, (3) were 18–39 years old (a segment of the population where the incidence of HIV is elevated; (Health Council of South Florida, 2020)), (4) were English or Spanish speaking, (5) self-reported HIV-negative or unknown status, and (6) resided in MDC or Broward County.

Research Team

The study team included researchers in public health, medicine, psychology, and technology. Team members varied in age, race/ethnicity, sexual orientation, and previous experience with HIV and behavioral health research and service delivery. Three interviewers with LGBTQ identities or affirming perspectives conducted the interviews. The senior author provided interviewing and rapid qualitative analysis training, supplemented with weekly meetings.

Data Collection

Prospective participants completed a screener and those eligible were invited to participate. Data was collected from March to August 2022. Participants completed an informed consent and a demographic survey on REDCap before the interview via videoconference. Participants were compensated $50. The study was IRB approved by the University of Miami, with a waiver of signed consent, meaning that prospective participants reviewed consent information and checked a box to indicate their consent.

The team developed a semi-structured interview guide (Spanish/English) to identify participants’ priorities for the tool (see Supplemental Material). The guide had sections covering content, features, design, and implementation aspects of the tool, which subsequently informed the overarching ‘domains’ for the qualitative analysis within which themes were identified. Based on our earlier formative work, we conceptualized the peer ambassador stories as a consumer-facing implementation strategy (meaning that it was designed to enhance the reach of an evidence-based clinical intervention; in our case, PrEP, HIV testing, and BH treatment) by showing LMSM stories of their peers’ engagement in these services via a technology platform. This conceptualization is depicted in Figure 1. An implementation strategy is a set of actions or methods aimed at making sure that proven interventions or practices are effectively put into use in real-world settings, helping bridge the gap between research and practical application (Proctor et al., 2013). The purpose of the current study was to elucidate specific content, design, and implementation preferences from the intended recipients of this new consumer-facing implementation strategy that we are developing in this project and will evaluate in future work.

Figure 1.

Peer Ambassador Stories as an Implementation Strategy

Qualitative Analysis

Recordings were transcribed by a professional transcription service and audited by the research team. Data were analyzed via rapid qualitative analysis, a method for expediting translation to practice (Hamilton & Finley, 2019). Rapid qualitative approaches are known to yield results comparable to thematic analysis, while maximizing efficiency and maintaining rigor (Hamilton & Finley, 2019; Taylor et al., 2018). These approaches have found successful application across research contexts, including studies involving Latino populations (Harkness, Weinstein, et al., 2022; St. George et al., 2023). We followed Hamilton and colleagues’ guidelines for a rapid qualitative analysis to ensure efficiency and rigor (Burton et al., 2019; Hamilton, 2013; St. George et al., 2023). Following these guidelines, the first and senior author developed an interview summary template and guidelines. To ensure accuracy, interviewers completed summaries, which a second team member audited, and the first and senior author finalized (i.e., two audits per interview). The team used a matrix to facilitate theme identification. The matrix allowed analysts to simultaneously view and analyze each domain (i.e., acceptability and appropriateness, story content and contributors, features and design, adoption, and use) across participants. Team members identified themes independently and met with the first and senior authors to discuss new/modified themes and reach consensus. The first set of themes was based on 10 participants, which yielded 13 themes. With the addition of five more participants, we identified one additional theme. After adding another 5 participants, we reached saturation, meaning no new themes were identified (Guest et al., 2006).

Results

Demographics

Complete demographics are in Table 1. Briefly, most participants identified as gay (90%). Although all identified as Hispanic/Latino; some further identified White (20%), Black (5%), Asian (5%), and/or another race/ethnicity (5%). Participants on average were 31.65 years old. Participants born outside of the US had reported countries of origin including Cuba, Venezuela, Mexico, Peru, Colombia, Ecuador, and Nicaragua.

Table 1:

Participant Demographics

Demographic Characteristic	N (%) or M(SD)
Age M (SD)	31.65 (4.65)
Race/Ethnicity +
Hispanic, Latino/a/x, or Spanish	20 (100%)
Black or African American	1 (5.0%)
White	4 (20.0%)
Asian	1 (5.0%)
Another race, ethnicity	1 (5.0%)
Sexual Orientation
Gay	18 (90.0%)
Bisexual	1 (10.0%)
Pansexual	1 (10.0%)
Interview Language
English	19 (95%)
Spanish	1 (5%)
Education
High school diploma/GED	3 (15.0%)
Some college/university	4 (20.0%)
College/university degree	13 (65.0%)
Employment
Full-Time	15 (75.0%)
Part-Time	2 (10.0%)
Unemployed	3 (15.0%)
Income per Month
Less than $1000	2 (10.0%)
$1000-$1999	3 (15.0%)
$2000 or more	13 (65.0%)
Decline to answer	2 (10.0%)
Insurance
ACA (Obama Care)	2 (10.0%)
Medicare only	1 (5.0%)
PVT/HMO from work/Spouse	11 (55.0%)
Uninsured	6 (30.0%)
Nativity (country of birth)
United States	11 (55.0%)
Colombia	1 (5.0%)
Ecuador	1 (5.0%)
Peru	1 (5.0%)
Venezuela	2 (10.0%)
Mexico	1 (5.0%)
Nicaragua	1 (5.0%)
Cuba	2 (10.0%)
Years in US M(SD)*	14.22 (5.22)
Citizenship Status
US Citizen	18 (90.0%)
Resident/Awaiting Asylum	2 (10.0%)

⁺Note. Participants could endorse multiple race/ethnicities, so categories are not mutually exclusive, but all identified as Hispanic, Latino/a/x, or Spanish.

^*Note. Represent foreign-born participants only

Qualitative Findings

We identified themes within four pre-specified domains: (1) acceptability and appropriateness (1 theme), (2) story content and contributors (5 themes), (3) features and design (4 themes), and (4) adoption and use (4 themes). Collectively, the themes converged on the central notion that technology-delivered peer ambassador stories necessitated a personalized, relational, and culturally relevant approach to resonate with and suit the needs of LMSM. For instance, ‘personalized’ referred to tailoring messaging and customizing stories to address specific preferences and diverse experiences within the LMSM community, as highlighted by themes in Domain 2. ‘Relational’ aspects involved incorporating interactive features to facilitate connections with peers and health professionals, allowing users to ask questions and seek advice, as described by themes in Domain 3. Lastly, ‘culturally relevant’ elements included using bilingual names for the intervention and providing information in multiple languages to reach diverse segments of the South Florida LMSM population, as elucidated by themes in Domain 4. Themes are identified in italics below, and summarized with illustrative quotations (Q1, Q2, etc.) in Table 2. Readers are encouraged to consult the table featuring quoted material when prompted by the numbered quotations, as the quotations are essential to interpreting the results in the narrative below.

Table 2:

Qualitative Themes and Illustrative Quotes

Domains and Themes	Illustrative Quotations
1. Acceptability and Appropriateness
1.a. Peer Ambassador Stories Tool Is Highly Acceptable and Appropriate	Q1: “I think that it’s definitely a good one. As of like recently, I have also been kind of like looking, like this would definitely benefit me per se. Like personally, just because like I was saying, I have been looking into getting these kind of treatment, like help or like, I just don’t know where to start. So, something like this definitely seems like something that I would be interested in.” (Born in North America, late-20s) Q2: “It’s excellent because you need more principles like that, that explain, that tell you what PrEP and PEP are. I also think there is a lack of information [about PrEP and PEP] in the community, especially in people who come from Latin American countries who have emigrated to the United States.” (Born in South America, early-30s)
2. Story Content and Contributors
2.a. Experts in the Field of HIV Prevention and Care Based on Training and/or Lived Experience	Q3: “Professionals. I mean, like counselors, psychologists, so that they can share their experience... People who are untransmittable, undetectable and untransmittable, so that they feel very empowered and vocal so they can share their experiences with other people and any kind of, I mean, testimonies, people who have been diagnosed positive or even people who have been diagnosed or they have a relative who has been diagnosed with HIV.” (Born in South America, mid-30s)
2.b. Recognized Peers in the LGBTQ+ Community of South Florida	Q4: “These people or figures that are recognized by the gay community in South Florida should be our advocates to carry the message to spread the word of prevention.” (Born in North America-non-US, late-30s)
2.c. Peers from Diverse and Relatable Backgrounds	Q5: “It is important to have if it’s like Black Latino men, different shades of Latino, right? So have like White Hispanic, Black Hispanic, like having a spectrum of nationalities [...] but obviously… [have] outgoing folks that like are very open about whether it’s their status or their sex life.” (Born in North America- US, early-30s)
2.d. Personal Stories About Seeking PrEP, HIV Testing and Care, and Behavioral Health Services	Q6: “I think I like the question of what motivated you to get PrEP. I don’t know if this would be a question that would be used, but I think, what are some fears that you had with this or what were some of your hesitations.” (Born in Peru, late-20s)
2.e. Humanize the Person Behind the Stories	Q7: “Also like, I mean, I don’t know like maybe if you have someone that’s unfortunately someone that’s positive, you can ask them like how has that affected their life or like the other parts, as well as like how like their - how being part of a community has affected like their career, their journey, their personal lifestyle, or just I guess it’s like, it’s like, I would say like try to add a lot of personal questions just so that when they’re writing their stories it sounds very personal and like deep. I think heartwarming, because I think that’s a lot of like what people are looking for, it’s like, like something to open up, like this is something that will let them open up.” (Born in South America, mid-20s)
3. Features and Design
3.a. Preference for Video and Audio Story Formats Over Written Stories	Q8: “People tend to be more engaged when it’s like a video or an audio recording as opposed to reading something where people can like easily get distracted or lose interest in like whatever someone is trying to say” (Born in North America - US, late-20s)
3.b. Integrating Peer Stories Within a Social Media Platform or through an Email Listserv	Q9: “Via email, I like the idea just, because I know, I follow a few accounts and I have personal friends do a monthly newsletter that is quick, to the point, fun and engaging and it’s not endless emails, it’s not something that fills up one’s inbox. it’s just like a nice pleasant check in, so yeah, no, I think that’d be nice.” (Born in South America, mid-20s)
3.c. Bidirectionally Engaging App to Connect with Peers and Health Professionals	Q10: “Yeah, I think that’s really positive [to have the option for users to contribute their own stories]. Some people might be more than happy to do so. And I think we don’t always realize the potential that we have to touch other people’s lives or inspire people especially when we tend to think of only us like, "Oh, famous people or celebrities is having that effect." (Born in North America- US, late-30s)
3.d. Embedding an Online Locator for HIV Prevention and Behavioral Health Treatment	Q11: “I feel like if it has a locator option, I’d probably might be using that more than just looking at the stories unless you get a push notification that says “Hey, a new story had been uploaded” (Born in North America -US, early-30s)
4. Adoption and Use
4.a. Advertising the Peer Ambassador Tool in the Community to Maximize Reach	Q12: “I mean, maybe sharing those stories in different languages that we have like English, Patois, Spanish and I don’t know, I mean, depends on the demographics that you’re trying to target, but to have those in different languages. So, people can also feel more comfortable in their own language.” (Born in South America, mid-30s)
4.b. Timely Information on Relevant Resources and Community Events to Maximize Use of Tool	Q13: “Not only that events like that big but it will be cool to like have more community based events and like things that don’t get much publicity.” (Born in the Caribbean, late-20s)
4.c. Concise and Bilingual Name for the Peer Ambassador Tool	Q14: “Like it could definitely be a Spanglish word. Like how we all use Spanglish nowadays, especially in Miami, it could be something like that” (Born in South America, mid-20s)
4.d. Visual Recommendations for the Peer Ambassador Tool	Q15: It’s just, yes, it’s a look that like not just palm trees and cursive neon signs, because I feel like while that it’s South Florida, it’s now becoming the stereotypical image of South Florida and it’s, I think, much more than that. So, I think something that is clean, fresh and targeted towards the millennial, even Gen Z, more millennial in that halfway point, because it’s trendy, but not too, too much. I don’t know, but I think just a good, clean user friendly and approachable.” (Born in South America, mid-20s)

Domain 1: Acceptability and Appropriateness

In general, a peer ambassador stories tool is acceptable and appropriate, according to participants who expressed positive feedback and considered it as something beneficial for the community. Acceptability refers to feeling that something is satisfactory and appropriateness refers to something being a good perceived fit, relevant, or compatible (Proctor et al., 2011). Aligned with these definitions, participants expressed that the peer intervention was a fresh and innovative approach, a powerful tool for disseminating crucial messages about HIV prevention, and a good initiative to reach the LMSM community. They described its potential to inspire action among individuals to access HIV testing, PrEP, or behavioral health treatment (Q1). Participants also indicated that the tool aligned with cultural needs, particularly among immigrant LMSM (Q2).

Domain 2: Contributors and Story Content

Participants reported it would be beneficial to show stories from peers who are experts in the field of HIV prevention and care based on training and/or lived experience. They felt that individuals with direct experience delivering and/or receiving HIV prevention and care services, such as healthcare experts, individuals living with HIV, and current users of PrEP would be highly influential (Q3).

Participants also recommended obtaining stories from those who are recognized peers in the LGBTQ+ community of South Florida. They suggested that inviting well-known, admired, or trusted LGBTQ community members such as bartenders, entertainers, and local social media influencers to be peer ambassadors would increase interest and engagement (Q4). Participants also suggested that peers from diverse and relatable backgrounds contribute stories. They indicated that LMSM would be more receptive to the stories if peers represented the diverse LGBTQ+ community across different demographics (e.g., age, sexual orientation, HIV-status, race) (Q5).

Participants were interested in contributors sharing their personal stories about seeking PrEP, HIV testing and care, and behavioral health services including direct experiences with PrEP (e.g., obtaining and staying on PrEP, hesitations and motivations for PrEP use, side effects, adherence, navigating health insurance), HIV testing (e.g., testing frequency, testing motivations, locations), and access to behavioral health services (e.g., motivations for seeking treatment). These story prompts were considered useful for alleviating concerns LMSM may have about seeking services (Q6).

Beyond questions related to health, participants felt it was important to humanize the person behind the stories, meaning they wanted the people sharing their healthcare experiences to also share who they are as a person, such as upbringing, dating experiences, and socioeconomic factors (Q7).

Domain 3: Features and Design

In the third domain, we also received feedback on the features and design of the technology platform that would host the peer stories. In terms of the stories themselves within this platform, participants generally preferred video and audio recordings over written stories. They felt that video and audio recordings would engage LMSM more (Q8); however, some recognized the benefit of all three formats as written stories would allow LMSM to share their stories anonymously. Once collected, participants recommended integrating peer stories within a social media platform or through an email listserv to distribute the stories to LMSM consumers. Recommended social media platforms included Instagram, Facebook, or TikTok, or, alternatively, sending the stories through email messages or newsletters (Q9).

Participants suggested that the platform for the peer stories have additional features, other than just hosting the stories. They proposed that the tool be bidirectionally engaging to connect with peers and health professionals which could be operationalized as a moderated chat, having an option for recipients to contribute their own stories, or sharing community news and events. However, participants also recognized the need to monitor online behavior (e.g., ensure appropriate content is shared among individuals) and enforce rules related to confidentiality, respect, and accurate information sharing (Q10). They also recommended embedding an online locator for HIV prevention and behavioral health treatment so that the comfort LMSM may feel in seeking services after viewing the peer stories would be immediately actionable (Q11). They suggested the online locator have an interactive map or be a service directory for PrEP, HIV/STI testing, behavioral health, and other local resources such as crises hotlines and shelters.

Domain 4: Adoption and Use

Participants suggested advertising the peer ambassador tool in the community such as LGBTQ+ community spaces and events and social media platforms in various languages to reach South Florida LMSM (Q12). To maximize consistent platform use, participants recommended the tool show timely information on relevant resources and community events (Q13). When asked for suggestions on the name for the peer ambassador tool, men recommended using a concise and bilingual name (Q14). Participants also provided visual recommendations for the peer ambassador tool, such as fresh and clean colors, and creative images that can portray South Florida (Q15).

Discussion

This formative study to shape the content and design of a consumer-facing implementation strategy to enhance the reach of PrEP, HIV testing, and behavioral health treatment revealed that a peer ambassador approach was perceived to be highly acceptable and appropriate for LMSM in South Florida. We identified key elements to engage peer ambassadors for story development by leveraging their credibility and rapport with the community, and to disseminate the peer ambassador stories to LMSM using electronic platforms and through audio/video formats for enhanced reach. We also learned that men preferred an electronic platform that was bidirectionally engaging, for example, using features that would allow them to interact with peers and health professionals or being able to share their own stories.

Our study findings suggest that having relatable peers from diverse backgrounds share their stories of HIV prevention and BH treatment use could help generate trust and credibility among potential recipients of these services. Participants consistently expressed the desire for relatability among contributors, recommending local influencers, entertainers, bartenders, or peers from diverse LGBTQ backgrounds. They emphasized the importance of contributors not only sharing their experiences accessing services but also their personality and identity. These preferences can inform the selection and training of peer story contributors to use in HIV prevention with LMSM. For instance, our findings suggest that coaching peers to align with these priorities may be helpful (Goldstein et al., 2023; Neuhaus et al., 2022).

These study findings are consistent with prior studies of peer-led programs where researchers observed that by leveraging similar social identities or lived experiences, peers were able to (1) build and strengthen trust and (2) widen the reach of the program to subgroups who providers struggle to link to prevailing HIV prevention efforts and routine HIV testing (Freestone et al., 2022; Shangani et al., 2017). Another advantage to leveraging peers for HIV prevention efforts documented in prior literature is their ability to connect with participants on numerous intersecting social identities (Freestone et al., 2022). For example, programs that incorporated peer mentoring helped LMSM navigate the complicated HIV-related healthcare terrain and discuss sensitive topics such as immigration status and fears of HIV testing due to immigration enforcement (Wang et al., 2022). Though emerging evidence indicates that peer interventions and implementation strategies can be effective (Shangani et al., 2017; Tobin et al., 2022), scalable strategies that leverage peer influence are needed to meet the needs of LMSM.

It is essential to consider the content, delivery, and design of implementation strategies to reach LMSM. Technology platforms may be an effective tool to reach MSM through cost-effective means, given evidence that they can be timesaving, convenient, and, thereby, cost-effective (Horvath et al., 2020). For example, social media platforms such as Grindr have been used to support HIV self-testing among MSM (LeGrand et al., 2017). Our study showed that LMSM favored stories being integrated within social media platforms and emails due to easy access. We also learned that interactive features, such as an online forum to communicate with peers and the option to contribute one’s own story, may optimize engagement. Previous research has demonstrated the role peer support plays in fostering resilience among online community members (Veronese et al., 2020; Young & Schneider, 2021). Including interactive features with a peer story technology platform could encourage health-promoting behaviors among participants such as modeling sex positive norms through experience sharing (Barry et al., 2018). However, to prevent and address offensive messaging, or misinformation, moderation is needed as expressed by participants in our study.

Although we conducted this research to inform our development of a peer ambassador technology tool, our findings also have implications outside of this purpose. To end the US HIV epidemic, specific efforts that serve diverse LMSM communities are necessary (Fauci et al., 2019; Harrison et al., 2022; Rodriguez-Diaz et al., 2021). Our formative findings suggest that designing appropriate strategies that leverage peer influence requires exploring the local context and needs of LMSM. Although our aim was to develop a low-cost strategy centered on publicly available peer stories, participant feedback highlighted preferences for more resource-intensive activities like chat rooms and service locators, which may pose challenges in terms of intervention implementation, community preferences, and financial constraints (Li et al., 2019). Considering these limitations, researchers have suggested incorporating contingencies, including time, resources, and processes, into the implementation plan and considering technology options that align with available resources and long-term sustainability to maximize the scalability and effectiveness of eHealth interventions (Kudrati et al., 2021; Li et al., 2019). Strategies that are cost-effective, inexpensive, and resource-efficient may be more sustainable (Brennan et al., 2022; Swendeman et al., 2019; Tsuyuki et al., 2022), which is consistent with our findings that videos recorded by peers and made available online and stored for little to no cost could fit within this sustainable model. Participants also highlighted additional low-resource activities, such as text messages and email newsletters to distribute the stories. These approaches are consistent with the findings in existing literature, which emphasize cost-effective strategies such as social media campaigns, online peer education forums, and email newsletters. These strategies may be more economical than individual-level or in-person interventions, primarily due to reduced personnel costs and their capacity for efficient scalability (Goldstein et al., 2023; Kudrati et al., 2021). Given the emergence of technology-delivered interventions for HIV prevention among MSM, our findings meet the need for more studies evaluating their relevance and potential effects on LMSM (Wang et al., 2022).

Despite its strengths, this study had some limitations. As the data from this qualitative research was part of a formative study to inform the development content, design, and implementation of a low-resource, scalable strategy to leverage peer influence to disseminate PrEP, HIV testing, and behavioral health treatment to LMSM, study findings are not applicable to all LMSM. Another limitation is that we could not evaluate themes across subgroups of LMSM based on sample size. Further qualitative research is needed to assess the consistency of our findings across subgroups. However, our process of collecting formative data to inform the design considerations for the tool can serve as a valuable model for other populations where peer influence plays a role in HIV prevention and treatment engagement.

Conclusion

This formative qualitative research informs the development of a scalable consumer-facing implementation strategy to increase the uptake of PrEP, HIV testing and behavioral health treatment to LMSM in South Florida that ranges in costs. For instance, a cost-effective way to implement the recommendations from participants would be to share stories through text messages and email newsletters. However, with increased financial resources, a more robust implementation could involve the development of a website with bidirectional features such as chatrooms, moderated forums where users can communicate with peers and health professionals, and a service locator for HIV prevention and care resources. Engaging LMSM in design decisions helps to ensure that the ultimate product will be acceptable, appropriate, and responsive to their needs. Their feedback and suggestions were varied but unified around the fundamental idea that for technology-delivered peer ambassador stories to be acceptable and appropriate for LMSM, the approach must be personalized, relational, and culturally relevant. There is promising potential for similar consumer-facing implementation strategies that leverage peer influence and incorporate scalable technology to be expanded and further developed to achieve EHE goals.