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. Author manuscript; available in PMC: 2021 May 1.
Published in final edited form as: AIDS Care. 2020 Mar 13;32(SUP2):40–46. doi: 10.1080/09540121.2020.1739207

AIDSImpact Special Issue Social Network Intervention to Increase Pre-Exposure Prophylaxis (PrEP) Awareness, Interest, and Use Among African American Men Who Have Sex with Men

Jeffrey A Kelly 1, Yuri A Amirkhanian 1, Jennifer L Walsh 1, Kevin D Brown 1, Katherine G Quinn 1, Andrew E Petroll 1, Broderick M Pearson 1, A Noel Rosado 1, Thom Ertl 1
PMCID: PMC7165060  NIHMSID: NIHMS1578887  PMID: 32167374

Abstract

In the United States, HIV incidence is highest among Black men who have sex with men (MSM), but their PrEP uptake is low, especially outside the country’s largest cities and in part due to lack of normative support for using PrEP. This research pilot tested a social network-level intervention designed to increase PrEP awareness, benefit perception, and norms among Black MSM in Milwaukee, a Midwestern U.S. city with large racial disparities and low PrEP uptake. Five social networks (n=40 participants) of racial minority MSM were recruited in the community and assessed at baseline with measures of PrEP knowledge, interest, attitudes, and action taking. Persons most socially interconnected with others in each network were identified as leaders, and they attended a 7-session intervention that provided training to increase knowledge about PrEP and its benefits, address misconceptions and concerns about PrEP, endorse PrEP use as a symbol of pride and health, and deliver these messages to others in their social networks between sessions. At 3-month followup, all network members were re-administered assessment measures, and changes between baseline and followup were statistically analyzed. Significant increases over time were found in network members’ knowledge about PrEP together with improved PrEP attitudes, descriptive and subjective peer norms for PrEP, PrEP use self-efficacy, and willingness to use PrEP. Participants increased in frequency of conversations with friends about HIV and reported more discussions with health care providers about PrEP. The percentage of participants who reported using PrEP increased from 3% at baseline to 11% at followup. Larger-scale evaluations of this intervention are needed in populations with high HIV incidence but low PrEP use.

Keywords: Pre-exposure prophylaxis (PrEP), social network, intervention, Black men who have sex with men (MSM)

Introduction

Most HIV infections in the United States are diagnosed among men who have sex with men (MSM). HIV incidence is higher among African American MSM than any other racial or ethnic group (CDC, 2017). With the present 4% incidence, over half of Black MSM in the US will have contracted HIV infection by age 40 (Matthews et al., 2016; Stall, 2008).

Pre-exposure prophylaxis (PrEP) use could dramatically alter this dire scenario. Uninfected persons at high risk who follow antiretroviral PrEP regimens are substantially protected from contracting the disease (Grant et al., 2010; 2016; McCormack et al., 2016), and sufficient PrEP adoption can reduce HIV incidence at a population level (Buchbinder et al., 2014; Desai et al., 2008; Juusala et al., 2012; Kessler et al., 2014; Paltiel et al., 2009). PrEP use has increased primarily among white gay men in large American cities but is much lower among racial minority MSM, especially in mid-sized cities across the center of the country and in the South (Petroll et al., 2017; Schneider et al., 2015; Siegler et al., 2018).

This limited uptake is associated with low awareness of PrEP, inaccurate under-estimation of personal risk, stigma, concerns about long-term use of a prescription medication when one is healthy, fears about side-effects, beliefs that friends or sexual partners will think that PrEP use signals that one is already HIV-infected, concerns over cost and incomplete protection, medical mistrust, and skepticism because few friends are personally known to use PrEP (Calabrese & Underhill, 2015; Golub et al., 2013; 2015; King et al., 2014; Mustanski et al., 2014; Mutchler et al., 2015; Oldenburg et al., 2015; Philbin et al., 2016; Sabari et al., 2012). Negative stereotypes about PrEP held by peers are a deterrent to its use (Ayala et al., 2013; Golub et al., 2015; Liu et al., 2014), especially among racial minority MSM (Mutchler et al., 2015).

Since the early years of the epidemic, social network interventions have been successfully used for HIV prevention to deliver credible prevention messages to persons who are hidden in the community and hard to reach (Kelly et al., 1997). Recent studies have recruited social networks of high-risk MSM in the community, identified network members who are most trusted and most interconnected with others in the network, and trained and engaged network leaders to communicate HIV prevention messages to friends. Social network interventions have been shown to produce reductions in high-risk sexual behavior practices (Amirkhanian et al., 2005; 2015; Kelly et al., 2006).

Network approaches also hold promise for increasing uptake of biomedical HIV prevention approaches such as PrEP (Latkin et al., 2013). Interventions that engage credible, trusted, and personally-known individuals to raise the topic of PrEP with others in their social networks could strengthen interest in PrEP, increase perceptions of PrEP benefits, counter PrEP stigma, and create peer group norms favorable towards PrEP adoption. Given the disproportionate risk of African American MSM for contracting HIV infection and lower PrEP use among racial minorities than non-minorities (Huang et al., 2018), these efforts especially need to reach high-risk racial minority MSM in the community (Kelly, 2019).

This research reports on the feasibility and potential effectiveness of an intervention designed to increase PrEP awareness, attitudes, and intentions in a community sample of social networks of African American MSM. The intervention’s components were guided by the frameworks of reasoned action and social cognitive theories (Bandura, 1986; Fishbein & Ajzen, 2010). Our approach identified the most highly interconnected members of each network, invited network leaders to attend sessions that provided PrEP education and skills training in how to endorse PrEP to friends, and explored change in PrEP-related characteristics among members of the networks between baseline and 3-month followup.

Materials and Methods

This research was undertaken in 2016–2017 in Milwaukee, Wisconsin, USA, a Midwestern U.S. city with a metropolitan population of 1.2 million where Black MSM account for a disproportionate percentage of new HIV infections (MMWR, 2011). The study protocol was approved by the Medical College of Wisconsin IRB. Written informed consent was provided by all study participants.

Recruitment of Social Networks

Five social networks were enrolled in the study. Recruitment of each network began by identifying and enrolling an initial “seed” in a community venue frequented by Black MSM including clubs, hangout places, and drop-in centers for racial minority LBGT youth. Study outreach field staff identified an individual observed to be actively interacting with others in the venue, approached the individual, briefly explained the study, and determined if the individual met entry criteria as a seed: reporting male gender at birth; describing oneself as African American, Black, or multi-racial; being age 18 or older; and reporting sex with males in the past year. Because PrEP is used by HIV-negative MSM, seeds were individuals who did not report knowledge that they were HIV-infected. After completing the baseline assessment, seeds were asked to give MSM friends study invitation packets. Friends of the seed who responded to the invitation were scheduled for a baseline assessment. Each “first ring” friend surrounding the seed then gave invitation packets to his friends. The recruited networks of the five seeds included 40 unique members (mean network size=8, range=4–12 participating members). Smaller networks were generally those in which participants named one another as friends rather than extending to unique new people. Entry criteria for network members were the same as criteria for seeds, although—to preserve network structural integrity and to avoid breaching serostatus confidentiality—we did not restrict study eligibility based on serostatus self-knowledge or race.

Baseline Assessment Measures

Assessment measures were completed by a self-administered questionnaire during individual sessions at the time of the baseline visit:

Demographic characteristics included age, gender at present, race, years of education completed, employment situation, self-defined sexual orientation, history of HIV testing, and—if tested—self-report of the most recent HIV test result.

Use of PrEP and discussion about PrEP with a health care provider

PrEP was first described to participants as a pill that people can take daily to reduce their risk for getting HIV. Participants were then asked whether or not they had heard of PrEP, had ever talked with a health care provider about PrEP, or were currently taking PrEP.

Participants completed a set of eight scales found reliable and valid in prior research with community samples of MSM (Cronbach’s alphas of all scales between .79 and .94) (Walsh, 2018). PrEP knowledge was measured by asking the respondent to indicate whether each of 13 statements was true, false, or unknown (sample item: “Daily PrEP use can lower the risk of getting HIV by more than 90%”; scale range=0–13). PrEP attitudes were measured with five items on which respondents used 5-point Likert scales (strongly disagree to strongly agree) to indicate their strength of endorsement (sample item: “Taking PrEP is safe”). Scores were the mean on the 1 to 5 scale. PrEP stigma was measured with five Likert scale items (strongly disagree to strongly agree) to indicate their strength of endorsement (sample item: “Taking PrEP is safe”; score range=1–5). PrEP descriptive norms were measured with three items reflecting how participants believe their friends would feel about using pre-exposure prophylaxis (sample item: “My friends would consider using PrEP”; score range=1–5). PrEP subjective norms were measured with a 3-item scale of how participants believe their friends would feel about them using PrEP (sample item: “My friends would think it was responsible if I used PrEP”; score range=1–5). PrEP self-efficacy was assessed with eight items in which participants used 4-point scales to indicate how difficult—from very hard to very easy—it would be to engage in an action (sample item: “How difficult or easy would it be for you to visit a doctor who can provide PrEP?”; range=1–4). PrEP behavioral intentions were measured with three items that asked participants to use 4-point scales to indicate the likelihood (from definitely will not do to definitely will do) that they will talk with a health care provider about PrEP, seek out more information about PrEP, or get a prescription for PrEP (score range=1–4). To assess willingness to use PrEP, participants used Likert scales to indicate their strength of agreement with three statements (sample item: “I would be willing to go on PrEP if I had a casual sex partner who was HIV-positive”; score range=1–5). On all scales, higher scores reflect greater level of the construct being measured.

Number of times talked with friends about HIV/AIDS, PrEP, and safer sex

Participants were asked how many times in the past three months they talked with friends about HIV/AIDS, about PrEP, and about safer sex or condoms.

Acceptability of the Planned Intervention

Participants were asked at baseline if they would be willing to attend sessions that provided information about PrEP and addressed their PrEP-related concerns, and also if they would be willing to attend sessions that provided training in how to comfortably talk with others about PrEP. Respectively, 97% and 95% responded that they probably or would definitely do so, indicating high interest in the intervention.

Identification of Network Leaders

Maps of the study’s five social networks were visually inspected to identify those members most socially interconnected with others in the same network or linked with network members who would not otherwise be reached. A total of 11 members of the five networks (29% of network members) were designated as leaders and invited to attend the intervention.

Network Leader Intervention Procedures

The network leader intervention consisted of five weekly group sessions lasting approximately two hours, followed by two biweekly booster sessions. To allow for interactive discussion and skills building exercises, leaders were divided into two smaller groups that received the same intervention. Sessions were facilitated by two project staff experienced in conducting HIV prevention interventions for racial minority MSM. Network leaders received modest incentive payments for attending intervention sessions, and leader attendance at sessions exceeded 93%.

The intervention followed a topic and format guide, although facilitators had latitude to address any issues raised by network leaders. Session 1 sought to inspire and energize network leaders by emphasizing how they can help friends avoid contracting HIV infection by learning about PrEP. Because network leaders themselves were often unaware of PrEP or themselves held misconceptions about it, sessions always addressed the leaders’ own beliefs and concerns, guiding leaders in sharing what they learned in each session with their friends. Session 1 provided background about PrEP, explained for whom it is useful, and provided information about its protective benefits.

Beginning with Session 2, network leaders planned and role-played conversations to have with friends around PrEP-related topics. Session 2 focused on countering misconceptions, stigma, medical mistrust, or negative stereotypes held by friends about PrEP, and what leaders would say to address concerns held by friends. In Session 3, the facilitation team was joined by staff from a local PrEP clinic who described its services, the process of initiating and maintaining PrEP, and how the agency assists in making PrEP affordable. The third and fourth sessions focused on instilling positive expectations and attitudes about PrEP benefits; linking PrEP use with positive themes of pride, health, and the protection of oneself and one’s community; and assisting network leaders in communicating messages that emphasize PrEP as a growing social norm that can protect the health of MSM of color and that men who look into PrEP are at the vanguard of the community. Session 5 helped leaders develop plans to assist friends in overcoming personal barriers to PrEP, increasing PrEP use self-efficacy, and tailoring messages to each friend. Two biweekly booster sessions reinforced and supported leaders’ efforts to function as PrEP advocates in their networks. Because some network members were HIV-positive and not PrEP candidates, network leaders also encouraged linkage and adherence with medical care. Central to the intervention model is that network leaders not only learn about PrEP but also diffuse PrEP awareness and benefit perception to their friends. Network leaders were given grid monitoring forms with the first names of others within their networks and asked to talk with them in person and by social media prior between sessions. Facilitators problem-solved difficulties that arose and reinforced leader efforts.

3-Month Followup Assessments

Three months after the intervention, individual followup assessment sessions with the same measures administered at baseline were scheduled with all study participants. Three participants who reported that they were HIV-positive at baseline were excluded from outcome analyses. Of the 37 HIV-negative participants assessed at baseline, 33 (89%) completed followup assessments. Chi-square tests and Mann-Whitney U tests showed no significant demographic differences between those who did and did not complete followup, although those who did not complete followup reported fewer male sexual partners in the past 6 months, p < .05.

Statistical Methods

Descriptive statistics were used to evaluate characteristics of the sample. To assess changes over time in PrEP outcomes, we used multilevel models with time (0=baseline, 1=3-month followup) as a predictor. A change following intervention was indicated by a significant effect of time. These models included network as a fixed factor (McNeish & Stapleton, 2016). Models were fit in Mplus 8 using an FIML estimator robust to non-normality, the MLR estimator (Muthén & Muthén, 1998–2019). This approach allowed us to maintain the maximum sample size and avoid biases associated with complete case analysis (Graham, 2009). A sensitivity analysis took an intent-to-treat approach by carrying forward baseline values on all outcomes for participants without followup data. Exploratory analyses assessed changes among network members who were not leaders and thus did not personally attend the intervention. We report linear, logistic, or negative binomial regression coefficients (for continuous, categorical, and count outcomes, respectively) indicating impact of time on outcomes.

Results

Participant Characteristics

Participants were 27 years old on average. 89% identified as African American/Black and 11% as multiracial or of another race. 8% were Latino, 73% of participants had a high school education or less, and 38% were unemployed.

Changes in PrEP Outcomes from Baseline to 3-Month Followup

Changes in PrEP outcomes are summarized in Table 1. Multilevel models showed significant increases in PrEP knowledge following the intervention (p<.001) and significant improvement in attitudes toward PrEP (p<.01). Both descriptive norms (p<.05) and subjective norms (p<.01) significantly improved from baseline to 3-month followup, and participants gained in self-efficacy for PrEP use (p<.05) and in willingness to use PrEP following the intervention (p<.05). The number of conversations participants had with friends about HIV/AIDS increased over time, (p<.05). Participants were more likely to have discussed PrEP with a health care provider following the intervention (p<.05). Finally, although low counts precluded statistical testing, 3 participants initiated PrEP use between baseline and followup, increasing the percentage using PrEP from 3% (n=1) to 11% (n=4).

Table 1.

Changes in PrEP Outcomes from Baseline to 3-Month Followup Among African American MSM Participating in a Social Network Intervention

Change Over Time (N = 37) ITT Analysis (N = 37)
PrEP Outcome Baseline (N = 37) M (SD) / % FollowUp (N = 33) M (SD) / % B (SE) p B (SE) p
Knowledge 0.48 (0.22) 0.73 (0.19) 0.24 (0.04)*** <.001 0.20 (0.04)*** <.001
Attitudes 4.04 (0.60) 4.41 (0.55) 0.33 (0.11)** .002 0.27 (0.10)** .005
Stigma 1.81 (0.56) 1.76 (0.49) −0.01 (0.11) .946 0.03 (0.10) .753
Descriptive Norms 3.88 (0.78) 4.14 (0.89) 0.25 (0.12)* .040 0.23 (0.11)* .041
Subjective Norms 4.19 (0.88) 4.59 (0.62) 0.37 (0.12)** .002 0.23 (0.11)** .003
Self-Efficacy 3.59 (0.36) 3.71 (0.27) 0.12 (0.06)* .050 0.11 (0.05)+ .051
Intentions 3.22 (0.80) 3.43 (0.54) 0.17 (0.14) .228 0.16 (0.13) .228
Willingness 4.40 (1.01) 4.78 (0.41) 0.37 (0.15)* .014 0.37 (0.15)* .014
HIV/AIDS Conversationsa 7.73 (8.83) 11.91 (12.87) 0.40 (0.20)* .041 0.33 (0.18)+ .072
PrEP Conversationsa 3.19 (3.72) 5.45 (7.38) 0.51 (0.30)+ .090 0.39 (0.30) .188
Discussion with Providerb 38% (n = 14) 67% (n = 22) 2.27 (1.04)* .029 2.40 (1.04)* .021
OR = 9.69* OR = 11.02*
PrEP Useb 3% (n = 1) 12% (n = 4) -- -- -- --
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*

p<.05

**

p<.01

***

p<.001.

Notes: Linear, logistic, and negative binomial multilevel regression coefficients are reported. ITT=intention to treat; PrEP=pre-exposure prophylaxis.

a

Negative binomial regressions (count outcomes).

b

Logistic regressions (categorical outcomes).

Changes in PrEP use were not tested in logistic regression due to low counts.

Sensitivity analyses

An intent-to-treat (ITT) analysis carried forward baseline values for those with missing followup data, presuming no change in their outcomes over time. As shown in Table 1, this ITT analysis showed significant change in PrEP-related knowledge (p<.001), attitudes (p=.005), descriptive and subjective norms (p=.04 and p=.003 respectively), willingness to take PrEP (p=.02), and discussing PrEP with a provider (p=.02).

Exploratory analyses

We explored whether effects of the intervention spread from leaders to the 27 other network members who did not attend intervention sessions. Excluding network leaders, there were significant increases in PrEP knowledge (B=0.19 (0.04), p<.001) and descriptive norms (B=0.37 (0.11), p<.001) from baseline to followup, with trends for being more willing to use PrEP (B=0.29 (0.17), p=.09) and more likely to have discussed PrEP with a health care provider at followup (B=1.90 (1.04), OR = 6.68, p=.07).

Discussion

PrEP use in the United States has increased, but primarily among white gay men in the country’s largest cities. Uptake remains much lower among racial minority MSM in mid-sized cities. This pilot study explored the feasibility and potential effectiveness of a social network intervention to reach African American MSM in the community and enlist network leaders to play roles as PrEP advocates to others in their social networks. Changes between baseline and followup demonstrated significant improvement over time on PrEP-related knowledge, attitudes, normative perceptions, self-efficacy, and willingness to use PrEP among members of the five social networks enrolled in the study. Participants talked more often with peers about HIV and more often reported discussing PrEP with their health care providers. Social norms influence HIV preventive behavior, and among the most important normative influences is what individuals believe their friends do, especially those who are liked, trusted, and seen as being like themselves (Kelly et al., 1997). Personally-known network leaders can by engaged to discuss PrEP, countering stigma associated with its use.

The study’s chief limitations are its modest sample size and limited statistical power, and that causal inferences cannot be drawn nor effectiveness established with a pre-post single group design. This concern could potentially have been lessened by if we had repeated the baseline assessment before intervention to establish stability. It is possible that external factors could have produced the changes observed over time. With respect to the latter concern, we obtained records for the number of Truvada prescriptions written by providers in central Milwaukee zip codes during the periods before and after the study (AIDSVu, 2019). There was no increase in number of prescriptions written, making it unlikely that change in study participants was part of a secular trend. A larger trial is needed to definitively establish the effects of the intervention, including with biological confirmation of PrEP use beyond self-report.

PrEP can protect individuals at high-risk from contracting HIV infection. Just as in other HIV prevention areas, making persons aware of PrEP is an important but insufficient step. Interventions that create peer norms, attitudes, benefit perceptions, and plans supportive of PrEP use are also critical, and social network approaches have high potential for reaching at-risk persons and increasing informed decision-making about PrEP use. The intervention studied here is well-suited for implementation by community-based organizations and is especially needed for populations where HIV incidence is high but PrEP use is low.

Acknowledgments

This research was supported by the Research and Education Program Fund of the Advancing a Healthier Wisconsin endowment at the Medical College of Wisconsin and by grants R01-NR017574 from the U.S. National Institute of Nursing Research and P30-MH52776 from the U.S. National Institute of Mental Health.

Footnotes

The authors declare no conflicts of interest.

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