Engagement of Latino Immigrant Men Who Have Sex with Men for HIV Prevention through eHealth: Preferences across Social Media Platforms

Abstract

Objective:

eHealth has growing potential to enhance access to HIV prevention for hard to reach populations, including young Latino immigrant men who have sex with men (MSM) in the United States. We examined the feasibility and acceptability of using eHealth tools, specifically social media platforms, to facilitate HIV testing and pre-exposure prophylaxis (PrEP) uptake among this population.

Design:

We utilized a community sensitive approach to conduct 30 in-depth interviews and five focus groups with young Latino immigrant MSM in Seattle, WA. Data were analyzed using thematic analysis with both data-driven inductive and a priori deductive approaches.

Results:

Participants were open to receiving HIV information via social media platforms. Participants recommended that social media content be tailored with their language preferences, cultural norms, and beliefs about HIV testing and PrEP in mind. Further, participants emphasized that content avoid stigmatizing HIV or Latino MSM’s complex identities.

Conclusions:

Results have implications for utilizing social media platforms and developing HIV prevention interventions for Latino immigrant MSM. Findings highlight that HIV prevention content should acknowledge how identities as an emerging adult, Latino, immigrant, and MSM, warrant unique consideration.

Introduction

In the United States (U.S.), gay, bisexual, and other men who have sex with men (MSM) accounted for 69 percent of all new HIV diagnoses in 2018, and a disproportionate share of these diagnoses occurred in racial and ethnic minority MSM (Centers for Disease Control and Prevention 2020). Notably, Latinos accounted for 30 percent of new HIV diagnoses among MSM in 2018 (Centers for Disease Control and Prevention 2020), and approximately two in three Latino MSM who were diagnosed with HIV were aged 13 to 34 (Centers for Disease Control and Prevention 2020). Increases in new HIV diagnoses were pronounced in younger age groups with Latino MSM aged 25 to 34 experiencing a 12 percent increase in new diagnoses between 2014 and 2018 (Centers for Disease Control and Prevention 2020). As foreign-born Latinos are more likely to experience delayed HIV diagnoses than their U.S.-born counterparts due to additional barriers to health and prevention services (Mizuno et al. 2015; Dennis et al. 2011; Dennis et al. 2015), these data underscore the need to focus HIV prevention efforts on young Latino immigrant MSM.

To address the prevention needs of young Latino immigrant MSM, culturally specific and tailored strategies are necessary to adequately reach this population and facilitate HIV prevention behaviors such as HIV testing and pre-exposure prophylaxis (PrEP) uptake. Extant prevention interventions, however, have tended to employ a standardized approach to HIV prevention for all Latino MSM, which overlooks the importance of tailoring prevention strategies for specific groups (Guilamo-Ramos et al. 2019). Attention to differences between U.S.-born and foreign-born young Latino MSM, for example, is particularly important as the latter may experience additional structural barriers to accessing health services, such as lack of health insurance or transportation, (Mizuno et al. 2015; Pérez, Santamaria, and Operario 2017; Melendez et al. 2013; Dennis et al. 2015). Further, Latino MSM who are born in countries with less tolerant views toward sexual minorities may be less likely to identify as gay, which may pose obstacles in reaching this group for HIV prevention (Solorio, Forehand, and Simoni 2013; Solorio et al. 2014).

The availability of eHealth, or electronically delivered health interventions (Enam, Torres-Bonilla, and Eriksson 2018), presents an opportunity to develop prevention programs for young Latino immigrant MSM and potentially overcome barriers to care. With increased access to the internet and digital tools, health information can be delivered virtually and reduce the need for physical travel. Given challenges with transportation often described by Latino populations alongside concerns regarding visiting clinics or seeing health providers due to stigma or fear (Dang, Giordano, and Kim 2012; Tanner et al. 2014), eHealth may be an appropriate mechanism for linking this community to HIV prevention services.

Yet, despite the growing number of eHealth HIV prevention interventions for MSM (Schnall et al. 2014; Enam, Torres-Bonilla, and Eriksson 2018; Nguyen et al. 2019), little is known about the preferences and acceptability of using eHealth strategies for young Latino immigrant MSM (Solorio, Forehand, and Simoni 2013; Solorio et al. 2014; Martinez et al. 2014; Marzan-Rodriguez, Rodriguez-Diaz, and Mustanski 2020). The few studies that have examined the use of social media or eHealth strategies specifically for this population highlight the need to assess how the community might benefit from online prevention interventions and how their multiple and complex identities necessitate nuanced information and online intervention delivery (Solorio et al. 2014; Martinez et al. 2014; Marzan-Rodriguez, Rodriguez-Diaz, and Mustanski 2020). Hence, the present study sought to examine how eHealth tools, specifically social media platforms, can facilitate HIV prevention efforts for young Latino immigrant MSM with attention to their particular barriers to care. Specifically, we examined the feasibility and cultural acceptability of using social media platforms to recruit and engage young Latino immigrant MSM for HIV testing and pre-exposure prophylaxis (PrEP) uptake. We also assessed how specific messages, images, and language used on social media platforms can address identified barriers to HIV testing and PrEP uptake among this population.

Methods

Sample and procedures

We utilized a two-phase, qualitative approach to conduct 30 in-depth interviews and five focus groups (n=24) with young Latino immigrant MSM. To be eligible for the in-depth interviews or focus groups, participants had to meet the following inclusion criteria: 1) be aged 18 to 32 years, 2) identify as Latino, 3) be an immigrant (not born in the continental U.S.), 4) report biological male sex at birth, 5) report ever having sex with men. As all study participants identified as “Latino,” we use this term to describe participants throughout the manuscript. Due to language limitations of study staff, individuals who were unable to speak Spanish or English were excluded from participation. A community-based organization in Seattle, WA that focuses on HIV prevention in the Latino lesbian, gay, bisexual, and transgender (LGBT) community supported recruitment efforts through outreach at community events, flyering, and local announcements (e.g. email list serves, radio show). All interested participants were screened for eligibility and consented to participate in the study.

The first qualitative phase of this study involved in-depth interviews (n=30) to identify individual, community, and structural level barriers to HIV testing and PrEP uptake among young Latino immigrant MSM and to assess the feasibility of using social media platforms to overcome identified barriers to facilitate HIV testing and PrEP use. The second phase involved five focus groups with approximately four to six participants in each group to identify the specific content for social media platforms that would facilitate HIV testing and PrEP use behaviors among young Latino immigrant MSM.

Focus group questions explored variable categories (normative pressures, beliefs and expectancies, self-concept/image, affect and emotions, and self-efficacy) that shape the likelihood of a behavioral intention (Jaccard, Dodge, and Dittus 2002). Specifically, questions were asked to assess how particular content on social media platforms could shape: 1) normative pressures about HIV testing or PrEP use, 2) beliefs or expectancies about the advantages and disadvantages of HIV testing or PrEP use, 3) views of how getting tested for HIV or using PrEP might affect the image they want to portray of themselves, 4) emotional and affective reactions to the prospect of HIV testing or PrEP use, and 5) perceptions of their ability to get tested for HIV or use PrEP.

In-depth interviews and focus groups were conducted in Spanish or English based on the participant’s preference and lasted approximately 1.5 hours. Participants also completed a brief demographic and risk behavior survey prior to the interview or focus group. All study participants received a $50 incentive gift card as a token of appreciation for their time. All study procedures were reviewed by the University of Washington Institutional Review Board and qualified as exempt from federal human subjects regulations.

Data analysis

In-depth interviews and focus groups were audio recorded and transcribed verbatim for analyses. Transcripts were analyzed using thematic analysis and a multilevel framework to identify barriers at the individual, community, and structural levels to HIV testing and PrEP uptake, as well as social media engagement strategies that would help address them. A preliminary codebook was developed through a data-driven inductive approach and an a priori deductive approach (Fereday and Muir-Cochrane 2006). Prior to coding, two coders tested the codebook on a set of transcripts to ensure consistency in the application of codes. Using Dedoose Version 8.3.35, the two coders coded the transcripts independently. Throughout the coding process, the coders and the project principal investigator held group meetings to discuss disagreements in code application and to ensure accuracy. Transcripts were coded until the point of saturation when no new themes were emerging from the data.

Results

In total, there were 54 participants in the study. Overall, the average age of participants was 27 years old, and more than half of all participants (57.4%) were born in Mexico. Participants reported a mean length of 9.4 years residing in the U.S., and approximately three fourths (75.9%) of participants reported being single. Notably, nearly half (48.1%) of all participants reported not using a condom during their last sexual intercourse. The majority of participants (96.3%) reported having ever tested for HIV and less than one third (31.5%) of participants were currently using PrEP. Additional sociodemographic and risk behavior characteristics of in-depth interview and focus group participants are available in Table 1.

Table 1.

Sociodemographic and behavioral characteristics of Latino immigrant MSM participants of in-depth interview and focus groups

	In-Depth Interviews (n=30) N (%)	Focus Groups (n=24) N (%)	Total (n=54) N (%)
Age (years) M (SE)	26.5 (0.79)	27.6 (0.66)	27 (0.53)
Country of origin
Mexico	17 (56.7)	14 (58.3)	31 (57.4)
Honduras	3 (10)	2 (8.3)	5 (9.3)
El Salvador	2 (6.7)	3 (12.5)	5 (9.3)
Colombia	3 (10)	0 (0)	3 (5.6)
Othera	5 (16.7)	5 (20.8)	10 (18.5)
Time in U.S. (years) M(SE)	6.4 (1.1)	13.5 (2.2)	9.4 (1.2)
Marital status  Single	22 (73.3)	19 (79.2)	41 (75.9)
Partnered, not married	3 (10)	2 (8.3)	5 (9.3)
Married	3 (10)	2 (8.3)	5 (9.3)
Divorced	2 (6.7)	1 (4.2)	3 (5.6)
Sexual orientation
Straight	1 (3.3)	0 (0)	1 (1.9)
Gay	22 (73.3)	17 (70.8)	39 (72.2)
Bisexual	3 (10)	3 (12.5)	6 (11.1)
Other	4 (13.3)	4 (16.7)	8 (14.8)
Highest level of education completed
Less than high school	2 (6.7)	4 (16.7)	6 (11.1)
High school	14 (46.7)	5 (20.8)	19 (35.2)
College	10 (33.3)	14 (58.3)	24 (44.4)
Graduate degree	4 (13.3)	1 (4.2)	5 (9.3)
Preferred Language
Only Spanish	10 (33.3)	6 (25.0)	16 (29.6)
More Spanish than English	10 (33.3)	3 (12.5)	13 (24.1)
Both Spanish and English	6 (20)	12 (50.0)	18 (33.3)
More English than Spanish	4 (13.3)	3 (12.5)	7 (13.0)
Number of sexual partners in the last six months M (SE)	14.3 (1.1)	15.6 (5.5)	14.9 (4.4)
Sex of sexual partner(s) in last six months
Only men	26 (86.7)	21 (87.5)	47 (87)
Men and women	3 (10)	1 (4.2)	4 (7.4)
Other	0 (0)	2 (8.3)	2 (3.7)
Condom use at last sex
Yes	17 (56.7)	11 (45.8)	28 (51.9)
Ever tested for HIV
Yes	29 (96.7)	23 (95.8)	52 (96.3)
Length of time since last HIV test
Never tested	1 (3.3)	1 (4.2)	2 (3.7)
≤ 6 months	24 (80)	19 (79.2)	43 (79.6)
> 6 months, ≤ 1 year	3 (10)	0 (0)	3 (5.6)
>1 year	2 (6.7)	4 (16.7)	6 (11.1)
Current PrEP use
Yes	11 (36.7)	6 (25)	17 (31.5)
Length of time since PrEP initiation
Not on PrEP	19 (63.3)	18 (75)	37 (68.5)
≤ 6 months	3 (10)	2 (8.3)	5 (9.3)
> 6 months, ≤ 1 year	5 (16.7)	0 (0)	5 (9.3)
>1 year	3 (10)	4 (16.7)	7 (13)

^aOther included Argentina, Brazil, Chile, Cuba, Dominican Republic, Guatemala, Peru, and Puerto Rico

We organized the salient themes that emerged from the in-depth interviews to focus on barriers to HIV testing and PrEP uptake and participants’ perceptions of social media platforms for HIV prevention. The main barriers to HIV testing and PrEP uptake that emerged among participants were 1) fear and lack of information, 2) stigma, and 3) the health care system. The themes surrounding social media platforms for HIV prevention focused on the 1) accessibility of social media and 2) social media as opportunities for HIV prevention. Results from the focus groups offer specific recommendations for developing and designing social media content and are organized by behavioral predictors of HIV prevention (Jaccard, Dodge, and Dittus 2002). All quotes that are presented were translated from Spanish to English.

Barriers to HIV testing and PrEP uptake

Fear and lack of information

The majority of participants reported having been tested for HIV, and several participants explained that HIV testing had become somewhat normalized in the Latino MSM community in the United States:

…and more recently it [HIV testing] is very normal for us [me and my friends], yes. Obviously, there’s the taboo of going to get tested and the gossip about what the result was. But, yes, it’s very normal now. You even see people who don’t see it as taboo and they get tested not because they think they have HIV but it’s like I’m going to get tested because it’s like when I go to get my blood sugar tested to see if it’s okay…it’s something that you have to do.

Despite perceptions of increased acceptability of HIV testing in the community, participants noted that they were still fearful about getting tested and receiving a positive result. One participant explained that since HIV is a disease “without a cure,” he continued to feel scared about going to get tested. Another participant noted that many Latino immigrant MSM “don’t know how it [HIV] works within the body,” and that they “don’t know what life can be like.” Resultantly, this uncertainty and lack of information about HIV treatment and disease progression posed challenges to HIV testing.

Additionally, fear of HIV testing among participants was related to concerns about immigration and immigration status. One participant said, “Like always, I’m afraid of discrimination, I fear that they will report me to certain authorities.” Others explained that their immigrant status limits their access to health care and “free HIV services,” which may influence them to not get tested for HIV or to get tested less frequently.

In addition to fear and gaps in information about HIV testing, awareness of PrEP remained limited among participants. Participants explained that they were unsure about how PrEP “works” and how one was supposed to take the medication. One participant said:

The only thing that I know is that it [PrEP] helps you if you have sex and I’m not 100 percent sure about the information, but what I have found out is that if, for example, you have sex today with a person that is infected [with HIV] or someone who has the virus, the pill helps you…

Other participants explained that information or potential misinformation about PrEP’s side effects deterred them from PrEP use. One participant noted concerns as he had heard from friends that “it [PrEP] can damage their kidneys” or affect the “density of their bones.”

Participants also mentioned that PrEP was not available in their countries of origin; hence, they did not know about the availability or cost of PrEP in the U.S. or Washington State, which added difficulties to obtaining PrEP:

…I don’t know what the cost [of PrEP] is. If the cost was very high, obviously, if I really needed it, I would buy it… I mean, I know that it is free but I don’t know if it is free. I don’t know anything.

Stigma

In addition to individual challenges to HIV testing and PrEP use, in-depth interview participants explained that stigma remained the primary community level barrier to HIV prevention. While participants explained that their families played an important role in their lives, many noted that they were unable to share concerns about HIV or discuss issues surrounding HIV prevention due to stigma in their families and communities. One participant indicated that if people in their community knew that he had been tested for HIV, they would say “a thousand negative things…from saying that you are gay, that you sleep with whomever and that you don’t use condoms…” Another participant noted:

In general, yes, they lack more information because there still exists this, eh, I don’t know how to say it, but for our community of Latinos, it’s that someone gets tested because they have AIDS or because, I don’t know… they look at them like they’re a monster.

Participants noted that this stigma extended to PrEP use. Specifically, participants explained that there are negative beliefs and attitudes about people who use PrEP, which can prevent young Latino immigrant MSM who are interested in using PrEP from doing so. One participant exclaimed, “If you are taking PrEP, [people think] you are going around sleeping with the whole world, with the whole world, and without using a condom.”

Additionally, several participants noted that they experienced homophobia and discrimination in their countries of origin and in the U.S. These experiences exacerbated their perceptions of stigma related to behaviors that are often associated with HIV and PrEP use:

There is a stigma in the community where I’m from…that it’s part of—it [HIV] is like a punishment from God and that it’s a way of killing you. This is something that I have inside of me, I can’t get rid of this thinking because it’s a thought that has been around me in Mexico and here in the United States. And it continues in many areas—in many areas of Mexico.

Health care system

In addition to individual and community level barriers to HIV testing and PrEP uptake, participants highlighted that the overall U.S. health care system and culture perpetuate challenges for young Latino immigrant MSM to access health services. The cost of health care, for example, was a notable barrier to service utilization. Further, several participants indicated that health care was more affordable in their countries of origin compared to the U.S. Given the high cost of services and the lack of health insurance that many Latino immigrants experience, participants explained that they often decide to obtain care only for treatment when they are feeling sick and that they avoid utilizing preventive services:

Well, normally, if it is something very, very serious, they [Latino immigrants] go to the emergency room. But if it isn’t that serious, they try to cure it with at-home remedies. The people that I know, for example, because here, the majority of Latinos, we don’t have insurance and it is very, very expensive. And we will only go if it is truly, truly very serious because, well, you have to pay, and you have to pay a lot.

In addition to the cost and inaccessibility of the health care system in the U.S., participants noted that cultural factors were important in shaping HIV testing and PrEP use behaviors. Not having a doctor that speaks Spanish, for example, was frequently noted as a hurdle to discussing sensitive issues such as HIV or PrEP with providers. One participant said that he would likely have many questions for his provider prior to using PrEP; yet, without a provider who speaks Spanish, he explained that he would feel unable to engage in that conversation. Participants also noted that the inability to trust health providers in the U.S. alongside concerns about being judged for their behaviors or identities presented additional obstacles to getting tested for HIV or using PrEP. One participant noted:

Well, it really depends on the community that you’re in and the type of trust that a provider brings to these communities—a lot of people think that they will be treated poorly or that they will report them, or that they should behave a certain way.

Social media platforms and HIV prevention

In-depth interviews also explored the feasibility of using social media platforms to engage young Latino immigrant MSM and overcome identified barriers to HIV testing and PrEP use. Overall, participants expressed enthusiasm for obtaining HIV prevention information through social media and provided strong rationale for why and how social media platforms could be effective mechanisms for recruiting young Latino immigrant MSM to be tested for HIV and consider PrEP use.

Accessibility of social media

Overwhelmingly, participants indicated that social media is an essential component of their lives. Participants explained that they spend an increasing amount of time on social media and that the ability to use social media “anytime and anywhere” facilitated its use. For example, one participant noted that he might spend three to five hours a day on social media sites, and another explained that he is on social media “all day long.” Other participants concurred and described how easy it was to spend five to ten minutes on social media during natural breaks in their day such as when eating lunch or while waiting for the bus. The frequency and ease of social media usage among young Latino immigrant MSM highlight that social media platforms present an opportunity for engaging this group for HIV prevention.

Social media as opportunities for HIV prevention

While Latino immigrant MSM indicated active participation on social media platforms, they noted that there were a vast array of platforms with different reasons for why they used each platform. Hence, when asked about receiving HIV prevention information on social media, Latino immigrant MSM indicated that some platforms would be more suitable for such information than others. Specifically, participants explained that they would be open to receiving information about HIV testing and PrEP on social media platforms used for social networking, such as Instagram and Facebook.

Several participants agreed that social networking platforms such as Instagram would be an effective strategy to disseminate information about HIV because of the ease in which people consume the information and content delivered through them. One participant explained, “…because it is much easier to quickly read [on social media] than go to an agency or something where they hand you a bunch of papers that you become too lazy to read.”

As participants demonstrated openness to recruitment and engagement via social media platforms for HIV prevention, they described how content on platforms could overcome barriers to testing and PrEP use among Latino immigrant MSM. For example, participants suggested that content could relay information about the cost of testing and PrEP in order to address the common concern about how much individuals have to pay to access such services. Additionally, participants recommended that messages and images used to recruit and inform young Latino immigrant MSM about HIV prevention strategies be general and concise to address the barrier of stigma that may deter individuals from accessing services. For example, participants explained that images that scare people or present negative depictions of people who have HIV would deter them from engaging in prevention behaviors. Another participant explained, “Don’t try to make it so that it is only for gay people but that it is universal, that all people should have access…” Hence, while participants desired images on social media platforms that were culturally tailored and specific, they did not want the images to further stigmatize their complex identities.

Taken together, in-depth interview participants highlighted that social media platforms were a feasible strategy to engage young Latino immigrant MSM for HIV testing and PrEP uptake. They further demonstrated that the messaging and content used to engage them could potentially address barriers that can often deter HIV prevention behaviors.

Focus groups

Recommendations for social media design and content

Based on the in-depth interview findings that social media platforms were feasible mechanisms through which we can address barriers to HIV testing and PrEP uptake, we conducted focus groups to elicit specific information about desired content and messaging on social media that would engage young Latino immigrant MSM to get tested for HIV and facilitate PrEP use. Table 2 presents the results from the focus groups and describes how specific images, design elements, language, or text can shape behavioral predictors of HIV testing and PrEP uptake.

Table 2.

Recommendations for social media design/content and linkages to behavioral predictors of HIV prevention: Summaries and themes from young Latino immigrant MSM focus group participants

	Social Media Design and Content Recommendations
Behavioral Predictors	Images	Colors/Layout/Design	Language/Messaging
Social norms	Use pictures of people that reflect our race/ethnicity Present images that reflect our diverse sexual preferences as MSM Present Seattle relevant images that associate HIV testing and PrEP to our local context	Use illustrations and graphics instead of photos to make the content more inclusive of everyone Create realistic designs that include everyday behaviors to make the content relatable and believable Make the content colorful to reflect the colorful parties and celebrations that Latinos have	Present information in Spanish so that they we know it is for us Do not use complex words to avoid creating language barriers
Beliefs/expectancies	Present HIV prevention as something that will help us have the lifestyle we desire Demonstrate that HIV prevention services will be discreet and confidential	Include logos and highlight local partnerships to demonstrate that we can trust the source of the content	Avoid messages that will make us think something bad will happen if we get tested or use PrEP Prompt us to ask or answer questions so that we think we should act with regards to HIV prevention
Self-concept/image	Present images of men that are attractive so that we see ourselves as attractive Present images that imply a monogamous relationship to avoid suggesting that we are promiscuous Use images that promote us as super heroes so that we can envision taking care of ourselves	Use eye-catching layouts and designs that will make us interesting and interested	Avoid language that describes us as being bad or doing something wrong
Emotions/affect	Present cheeky images and humor to make us laugh and draw us in	Use bright colors to elicit happy emotions and feelings about HIV	Use relaxed verbiage or slang words to make us feel relaxed and comfortable
Self-efficacy	Use images that demonstrate that we have the ability engage in HIV prevention behaviors	Include contact information and affiliations to allow us to take next steps Show that the services will be free so that we know we can afford them	Use messages that show that we will be supported in the process of getting tested or using PrEP Include a hashtag so that we can search for more information

While participants had diverse perspectives and opinions about the specific content on social media that would facilitate HIV testing and PrEP use, they indicated that content that elicited positivity and hopefulness regarding HIV prevention was key. One participant explained that the content should not have a negative focus; rather, “it has to make you happy…or something that shows that this [content] will help you move forward.” Hence, participants noted that images of people dying or of people who were sick would bring about unwanted memories of friends who had died from the disease. Another participant agreed that negative images would not motivate him to consider HIV testing or PrEP use, and that messages that promoted fatalistic ideas would not be engaging.

Therefore, participants suggested using bright colors to elicit feelings of happiness surrounding HIV prevention. Further, they explained that the use of colorful and lively images would remind them of the fun parties and celebrations that they enjoy and would present HIV prevention in a more positive light. Further, participants explained that dark colors have negative connotations. One participant said that, “[Using] black [colors], is like saying ‘you are going to die,’ or like mourning. It will make the person feel sad and it will make them scared about reading the content.”

In addition to desiring positive imagery and content that would elicit happy emotions, participants indicated that the content should be “relatable.” Participants indicated that relatable content involved images that “look like us.” Hence, using pictures of people who are Latino in lieu of “generic” or stock images was important. Another participant explicitly said not to use photos “that are of gringos or Americans.” Focus groups also elicited that presenting text in Spanish rather than English would also suggest that the content and messages were for them.

Notably, participants discussed the diversity within the Latino population and suggested trying to capture this within the social media content. One participant described the diversity of Latino bodies, explaining that they can be “fat, skinny, black, white.” Other participants agreed that the content should aim to acknowledge the different communities within the Latino community:

… that it touches different aspects of all… of all that the community is, no? Like in my case, trans people, gay people, those who are sexually active…that each of these people feel identified… that it is of Latinos of diverse colors…

I would like to see the conversation surrounding prevention involve different intersections of identity, likely trying to combat the stigma that exists if I don’t have documents, don’t have citizenship…

Hence, participants described how information that was relatable and that addressed different aspects of their identities had potential to address the stigma that often deters them from engaging with HIV prevention content. While several focus group participants highlighted the importance of seeing real images and photographs of people they could relate to, others suggested that delivering content using cartoons, illustrations, and graphics in lieu of real photographs could prevent excluding certain communities of Latino immigrant MSM.

In addition to wanting content that was attractive and felt relatable, participants indicated that it should empower them to act. One participant explained that the content should include “something that shows that we can do something about it [HIV],” while another said that the message should relay “hope.” Another participant indicated that, “people still don’t know how much power we have as individuals.” These statements highlighted the importance of demonstrating that young Latino immigrant MSM have or can obtain the ability and skills to prevent HIV.

Participants also desired content that would relay to young Latino immigrant MSM that they would be supported in the process of engaging in HIV prevention behaviors. One participant indicated that he wanted content that showed that people would be there to help him find resources and that he would feel supported and welcome. This desire for supportive content was linked to the importance of building community. Specifically, one participant indicated that the content “should make me feel part of the community.” Another participant explained that since “we are still a minority within a minority,” support and community were essential to combating stigma and normalizing HIV testing and PrEP uptake.

Additional summaries and themes from the focus groups alongside recommendations for social media design content that are linked to behavioral predictors of HIV prevention are presented in Table 2.

Discussion

The results from the in-depth interviews demonstrated that social media platforms are a feasible mechanism for engaging young Latino immigrant MSM and for addressing barriers to HIV prevention. While participants described individual, community, and structural barriers to HIV testing and PrEP use, these barriers often overlapped and interacted with each other. The inaccessibility of the U.S. health care system and high costs of health care services, for example, contributed to the lack of information among participants about PrEP. Hence, interviews highlighted that acknowledging the complexity of barriers to HIV prevention is important for developing content that can address them.

Participants also mentioned how misinformation about PrEP or information about side effects also posed barriers to PrEP use, which aligns with findings from a recent study that documented how an increase in ads about lawsuits for PrEP on social media sites may negatively impact PrEP use among Latino MSM (Grov et al. 2020). These data underscore the importance of delivering accurate and reliable information about PrEP and HIV prevention to young Latino immigrant MSM to facilitate informed decision-making among this population.

Further, findings from the in-depth interviews reflect much of what has been previously reported about social media use among Latino men generally, which suggest that there is an opportunity to take advantage of the online environment in which young Latino immigrant MSM inhabit. Specifically, by engaging young Latino immigrant MSM through social media platforms, results highlight that we can support early adoption of HIV prevention behaviors and increase knowledge about HIV prevention to reduce HIV transmission in the Latino community.

Focus groups furthered the discussion on HIV prevention and social media platforms as they provided specific recommendations for the content used on social media. While there were diverse opinions about the particular images and design elements that participants felt would facilitate HIV testing or PrEP uptake, they overwhelmingly agreed that content should be tailored to their specific needs. This tailoring required awareness of young Latino immigrant MSM’s language preferences, cultural expectations and norms, and beliefs about HIV prevention. Overall, the summary of findings and themes from the focus groups (Table 2) emphasize that content and messaging should be inclusive, positive, and motivational. These findings align with prior research that have established the critical need to tailor HIV/AIDS prevention programs for specific groups (McKleroy et al. 2006). These efforts require understanding and addressing not only the needs and preferences of target racial/ethnic groups, but also those of specific subpopulations that may be further marginalized (Raj, Amaro, and Reed 2001).

There are important limitations that should be considered alongside study findings. As more than half of the study’s participants were from Mexico and 72 percent identified as gay, the study’s findings may be reflect the perceptions of a particular segment of the young Latino immigrant MSM community. Given the diverse perceptions of gender, sexuality, and HIV in Latin America, future studies may focus on Latinos from specific countries or regions to capture more nuanced social media preferences for HIV prevention. While all participants reported male sex at birth, we did not collect information on participants’ gender identity. Hence, we were unable to capture nuances between participants who identify as cisgender, non-binary, or transgender. Further, participants were recruited through a community-based organization that serves the Latino LGBT community; hence, Latino immigrant MSM who are less likely to be connected to community-based organizations and services may not have been reached. At the same time, less than a third of participants were currently using PrEP and about half had not used a condom at last sex, suggesting that we were able to reach Latino immigrant MSM who could benefit from interventions to increase HIV prevention behaviors.

Notably, study participants indicated that the social media content should avoid ostracizing the Latino immigrant MSM community, which underscores the importance of addressing intersectional stigma associated with HIV and Latino immigrant MSM’s complex identities. Hence, findings highlight that HIV prevention content should acknowledge the implications of identities as an emerging adult, Latino, immigrant, and MSM. Further, additional factors including language, socioeconomic status, skin tone, and time residing in the U.S., may shape the identities and experiences of Latino immigrant MSM and warrant attention in HIV prevention intervention development.

This study has implications for future efforts that seek to engage young Latino immigrant MSM for HIV prevention through eHealth and social media platforms. Given elevated risk among this population as well their specific cultural and social priorities and needs, appropriate and community-directed strategies to reach Latino immigrant MSM for HIV prevention is necessary. The findings from this formative research will inform the development of social media content that will be used to engage young Latino immigrant MSM for HIV prevention. The content will align with behavioral predictors of HIV testing and PrEP uptake and address multilevel barriers to prevention. As such, this study is our first step in developing culturally sensitive and theoretically informed social media content to enhance HIV prevention among Latino immigrant MSM.