Perceptions of Sexual Risk, PrEP Services, and Peer Navigation Support among HIV-Negative Latinx and Black Men who have Sex with Men (MSM) Residing in Western Washington

Abstract

Introduction:

HIV PrEP (pre-exposure prophylaxis) is underutilized among Latinx and Black men who have sex with men (MSM) in the United States. Although peer navigation approaches may increase PrEP uptake and adherence, it remains unclear what strategies work best for MSM of color.

Methods:

From July 2017 to August 2018, we conducted semi-structured in-depth interviews with 25 purposively sampled Latinx and Black cisgender MSM to evaluate how the intersectionality of race/ethnicity, sexual orientation, and other identities influenced men’s views on PrEP in general and on peer navigation specifically. Thematic analysis was used to identify and analyze emergent themes.

Results:

Emergent themes included: (1) awareness of vulnerability in intimate relationships; (2) barriers to PrEP initiation including perceived side effects, stigma, and financial concerns; (3) a wish to connect with other Latinx and Black MSM in a health and prevention space; and (4) the desire for peer matching based on identity considerations and lived experience. Younger men and Spanish-speaking Latinx men were most interested in peer navigation to access PrEP, while bisexual men had confidentiality concerns.

Conclusions:

In our study, Latinx and Black MSM viewed peer navigation services favorably, especially if they addressed men’s desire to connect with other MSM of color.

Policy Implications:

Developing culturally-congruent peer navigation programming could help improve PrEP uptake and care engagement for Latinx and Black MSM. Programs should recruit peers from the racial/ethnic minority communities most impacted by HIV and prioritize matching peers to clients based on identity concerns, needs, and preferences.

Introduction

Disparities in HIV incidence persist among Latinx and Black men who have sex with men (MSM) in the United States, despite overall progress in HIV prevention and treatment (Nosyk et al., 2020; Smith et al., 2018; Wong et al., 2020). Factors driving the HIV epidemic include a high prevalence of sexually transmitted infections (STI); sexual stigma (whether enacted, felt, or internalized); HIV stigma; and structural barriers including poverty, discrimination, residential segregation, unemployment, inadequate educational resources, and limited access to healthcare (Pellowski et al., 2013). Uptake of pre-exposure prophylaxis (PrEP) to reduce vulnerability to HIV infection remains disproportionately low among these key populations (Huang et al., 2018; Kanny et al., 2019). To address the prevention needs of those most affected by HIV, substantial efforts to reach Latinx and Black MSM with evidence-based, cost-effective, and scalable prevention strategies and interventions are needed (Kanny et al., 2019). Past reviews have identified several efficacious behavioral interventions to reduce the risk of HIV infection in Latinx and Black MSM, including peer navigation to link men to HIV testing and prevention services (Maulsby et al., 2013). Peer navigation is an umbrella term referring to a range of interventions in which nonprofessionals sharing something in common with the target population provide, among other activities, interpersonal support in the service of health care initiatives (Simoni et al., 2011).

Even as peer interventions are scaled up widely in an effort to impact the trajectory of the epidemic among Latinx and Black MSM, there are important gaps in our knowledge about the acceptability of such programs, their potential reach and effectiveness, optimal training for peers, and which approaches might work best (Rhodes et al., 2009; Simoni et al., 2011; T. Walsh et al., 2020). Outcomes of studies of peer support for HIV prevention have been mixed (Shangani et al., 2017), with some studies reporting positive results (Herbst et al., 2014; Latkin et al., 2003; Quinn et al., 2020) and others demonstrating no significant changes in sexual behavior or other outcomes between the peer intervention and control groups (Derose et al., 2016; Remy & Enriquez, 2019).

Research to better understand the needs and preferences of MSM of color targeted by peer navigation programs could improve peer intervention design by identifying areas for improvement (Reback et al., 2019; Simoni et al., 2011; T. Walsh et al., 2020). The objective of the present study was to understand the individual, interpersonal, and social contexts within which condomless sex occurs for Latinx and Black MSM, perceptions about PrEP, and preferences for PrEP-related navigation services, including those related to shared or concordant identities. By describing how MSM themselves view peer navigation, we seek to fill knowledge gaps around what effective, tailored combination prevention packages including PrEP could look like for Latinx and Black MSM and elucidate the role of peer navigation as a potential component of that prevention package. An adequate understanding of men’s expectations and factors related to acceptance of peer navigation is needed to guide ongoing peer navigation programs as they expand.

Methodology

Setting and Participants.

Study participants were recruited through flyer distribution at events, Facebook posts, and word of mouth, as well as through local HIV prevention and STD clinics and from local community-based organizations for participation in an online REDCap survey as part of the “What’s PrEP?” study (Pagkas-Bather et al., 2020). Eligibility criteria included self-reporting as age 16 or over; HIV-negative; identifying as a Latinx (i.e., Chicano, Cuban, Hispanic, Latino, Mexican, Mexican American, Puerto Rican, Spanish) or Black (i.e., African American, African-born, Black, Caribbean Black, Multiethnic Black) cisgender or transgender MSM; sexually active (i.e., reporting oral or anal sex) with a man in the past 12 months; and residence in Snohomish, Thurston, Pierce, or King counties in Western Washington, which includes urban, periurban, and rural communities along the Interstate 5 corridor between Seattle and Olympia (Weinstein, 2015). The online survey collected information on demographics, HIV risk behaviors, alcohol and drug use, symptoms of depression, sexual stigma, healthcare access, PrEP use and delivery preferences, and interest in a peer navigator for the use of PrEP (Pagkas-Bather et al., 2020). At the end of the survey, participants were asked if they were willing to be contacted for an in-depth interview.

Between May 2017 and August 2018, 95 cisgender Latinx and Black men participated in the “What’s PrEP?” survey (Pagkas-Bather et al., 2020). No transgender men enrolled despite efforts to recruit this demographic. For this qualitative study, a subset of the 83 survey participants who agreed to be contacted for an in-depth interview were purposively sampled, with the aim to provide representative coverage of race/ethnicity (Latinx or Black), sexual orientation (gay or bisexual), and age (under 30 or 30 or older).

Data Collection.

Interviews were conducted between July 2017 and August 2018. A semi-structured interview guide was developed based on our prior research on HIV treatment adherence barriers and facilitators among Kenyan MSM, which employed an Information, Motivation, Behavioral Skills (IMB) model of antiretroviral therapy (ART) adherence that was situated in a context in which MSM were stigmatized, but trusted providers played an important role in access to care (Graham et al., 2018). Interviews explored men’s experiences with HIV prevention and knowledge of PrEP, access to HIV prevention, relevant social support, and provider relationships. If participants reported using PrEP, information was elicited regarding motivation to adhere, coping strategies for side effects, and disclosure of PrEP use. Participants were asked about friends, family, and providers and how they facilitate or hinder PrEP uptake and adherence. Finally, questions focused on the use of peer navigators (i.e., Latinx or Black MSM trained to provide information, encouragement, and linkage to PrEP care), eliciting feedback on acceptability of this approach and desirable attributes of a peer navigator. Men were asked to imagine their ideal peer navigator and encouraged to envision how, when, where, and how frequently contacts would happen. Men were invited to recommend peer training areas and other design features that peer intervention programs could incorporate to meet their needs. New, emergent themes were explored as they arose.

All interviews were conducted in English or Spanish by JJ or JH either in person or by telephone. Debrief notes were taken, and all conversations were digitally recorded with permission. Participant identification numbers were used to label recordings, and no identifying information was included. Participants were compensated $50 per completed interview. All participants provided written or electronic informed consent. The University of Washington institutional review board approved the research protocol (STUDY00000239).

Data Analysis.

Recorded interviews were transcribed verbatim, reviewed, and anonymized, removing names and potentially identifying references. Data were analyzed using framework analysis, a systematic approach to organizing and elucidating themes from textual data (Gale et al., 2013). After reviewing all interview transcripts, JJ and SMG drafted an initial analytic framework (i.e., codebook) containing broad preliminary codes or descriptive categories to define concepts (e.g., disclosure, knowledge) (Fereday & Muir-Cochrane, 2006; Macqueen et al., 1998). This framework was subsequently refined through a reflexive and iterative process, whereby four team members (JJ, SMG, KW, LS) independently coded two transcripts each, after which coded transcripts were merged to reveal divergence and convergence across coders, ensure coding reliability and consistency, and add rigor to the coding process (Church et al., 2019; Ryan, 1999). JJ used the updated framework to code all transcripts; transcripts from 6 Latinx and 5 Black participant interviews were double-coded by SMG or KW. As this work progressed, the team discussed divergent coding, revised code definitions, and added emergent codes as needed. QSR NVivo 11 qualitative software was used to manage, organize, and analyze the coded transcripts.

Theoretical Framework.

We applied a socioecological model and used an intersectionality theory as the lens to analyze, interpret, and organize the interview data and compare Latinx and Black interview participants (Bauer, 2014; McLeroy et al., 1988). The socioecological model situates the individual within the larger world, where individual, interpersonal, and social structures reinforce differences in status, resources, and influence in ways that can generate health disparities (McLeroy et al., 1988). Alongside the socioecological model, an intersectional lens offers insight about the diverse needs of men of color and the identity considerations needed to optimize programming (Bauer, 2014; Larson et al., 2016; Pérez-Figueroa et al., 2015; Purdie-Vaughns & Eibach, 2008; Willis, 2012). At the individual level, the situated IMB model used to develop our interview guide framed our understanding of participants’ HIV- and PrEP-related knowledge, motivation, and behavioral skills in the context of men’s interpersonal and social supports (e.g., friends, peers, LGBTQ organizations, healthcare providers) and how these promoted or hindered men’s uptake of PrEP (Dubov et al., 2018; Graham et al., 2018).

Reflexivity.

The study team included community members representing the targeted populations and possessed experience working in service of communities affected by HIV/AIDS either through research or direct service provision. Interviews were conducted by a cisgender Latinx and cisgender Black MSM. Interactions with interviewees were on a peer-to-peer level, and participants were respected as the experts in their lived experiences.

Results

Study Population.

Between July 2017 and August 2018, twenty-five in-depth interviews were carried out before saturation was reached. Interviews lasted 90 minutes on average. Fourteen interviews were conducted with HIV-negative Latinx men, and 11 interviews were conducted with HIV-negative, non-Hispanic Black men. Ten participants (6 Latinx, 4 Black) reported that they were currently taking PrEP. Participant demographic characteristics are presented in Table 1. All participants were cisgender. Most (72%) self-reported a gay or homosexual orientation, while some identified as bisexual (20%) or queer (2%).

Table I:

Demographic Characteristics

Demographic Characteristic	Overall N = 25	Latinx N = 14	Black N = 11
Foreign-born
Yes	8 (32.0%)	7 (50%)	1 (9.1%)
No	16 (64.0%)	7 (50%)	9 (81.8%)
Missing	1 (4.0%)	0	1 (9.1%)
Self-reported PrEP use
Currently on PrEP	10 (40.0%)	6 (42.9%)	4 (36.4%)
Not currently on PrEP	15 (60.0%)	8 (57.1%)	7 (63.6%)
Age group
< 30 years of age	13 (52.0%)	4 (36.4%)	9 (64.3%)
≥ 30 years of age	12 (48.0%)	7 (63.6%)	5 (35.7%)
Educational attainment
12th grade or less	1 (4.0%)	1 (7.1%)	0
High school graduate	2 (8.0%)	1 (7.1%)	1 (9.1%)
Some college	11 (44.0%)	5 (35.7%)	6 (54.6%)
College graduate	8 (32.0%)	6 (42.9%)	2 (18.2%)
Graduate degree	3 (12.0%)	1 (7.1%)	2 (18.2%)
Sexual orientation
Gay	18 (72.0%)	12 (85.7%)	6 (54.6%)
Bisexual	5 (20.0%)	1 (7.1%)	4 (36.4%)
Queer	2 (8.0%)	1 (7.1%)	1 (9.1%)
Relationship status
Single	16 (64.0%)	10 (71.4%)	6 (54.6%)
Married/partnered	6 (24.0%)	3 (21.4%)	3 (27.3%)
Divorced/separated	3 (12.0%)	1 (7.1%)	2 (18.2%)
Residence
Seattle/King County	20 (80.0%)	11 (78.6%)	9 (81.8%)
Pierce	2 (8.0%)	1 (7.1%)	1 (9.1%)
Snohomish	3 (12.0%)	2 (14.3%)	1 (9.1%)
Thurston	0	0	0

Emergent themes.

Across interviews, key themes that emerged demonstrated Latinx and Black men’s: (1) awareness of vulnerability; (2) barriers to PrEP initiation including perceived side effects, stigma, and financial concerns; (3) wish to connect with other MSM of color in a health and prevention space; and (4) desire for peer matching based on identity considerations and lived experience.

Awareness of Vulnerability

Men’s awareness of their vulnerability to HIV infection was closely tied to intimacy in the context of relationships. Men described that they had chosen to increase condom usage or remain abstinent for a time after traumatic experiences such as condom breakage, infidelity, pressure to engage in condomless sex, or testing positive for an STI. These incidents left men in a vulnerable state, with limited social support to talk openly about these experiences. For men currently taking PrEP, this sense of heightened vulnerability was mitigated by PrEP use, given the increased agency they experienced related to PrEP’s protection. This sense of increased agency made it easier for them to disclose their PrEP status and negotiate condom use for protection from STIs.

I found out that [my ex-husband] actually cheated on me [and] it changed my perspective of what it means to live with an STD… [and] how I gotta take extra precautions… I’m conflicted now about how to go about it and as I’m aging I’m also trying to identify who I am as a person and what my beliefs are.

– Latinx gay man, age 21, not on PrEP

Any times I do hook up, I usually do say I’m on [PrEP] as a second protection layer and then usually afterwards someone goes, ‘oh so how long have you been on it or what’s going on,’ you know, so kinda [having] those minor conversations sometimes.

– Black bisexual man, age 45, on PrEP

While men openly described intimate experiences that made them feel vulnerable and needing to regain control of their health and those men taking PrEP highlighted how its protection motivated them, honest conversations about sexual health within men’s own social circles were rare and even considered taboo by some. This reticence to admit vulnerability to their friends and sexual partners meant that most frank conversations men had about sexual health occurred within the context of healthcare services, if at all.

Barriers to PrEP Initiation

Participants’ perceptions of PrEP services focused on structural barriers faced when engaging with providers. Men who were not taking PrEP but were interested in PrEP as a prevention method described challenges, such as concerns about provider reactions to their request for PrEP, rumors and fear of side effects, PrEP-related stigma, and financial burden. Younger men and men who were financially vulnerable mentioned competing priorities such as attending college or saving money for other basic needs, while Spanish-speaking men worried about communicating effectively with a language-discordant provider. Hesitation related to long-term health effects, misperceptions about PrEP, and concerns about insurance copays contributed to skepticism about why men should make PrEP a priority. This sentiment was echoed by men currently on PrEP, who alluded to their PrEP journeys, particularly their initial reactions to PrEP, their doubts about its efficacy, and uncertainty about how to bring up the topic of PrEP to their (mostly white, heterosexual) providers. Participants who reported no interest in accessing PrEP services cited PrEP’s association with gay-identifying men, side effects, perceived cost, and challenges taking a daily medication as reasons they did not want or need PrEP. These reasons kept bisexual participants in particular from engaging with the healthcare system for HIV prevention resources and having frank conversations with their providers about their sexual encounters with men.

As a gay Latino male [and] being a low income [person] of color, medical bills are definitely a concern, especially as a student… When I realized all the screenings that I’d have to go through… and coming back every 3 months, it was just… too much for me. I brought up… PrEP [to my] provider [and]… she was like… let’s schedule another appointment and let me do my research and I’m like [sucks teeth] I already paid $25 for a copay to come here [and] you want me to pay another $25 for you to get your shit together?

– Latinx gay man, age 21, not on PrEP

[PrEP] wouldn’t be something I would consider. But if I was to more or less say, okay, I’m going to swing [or] go more gay-way, I guess?… Just a couple weeks ago [I was tested for HIV] because I had a colonoscopy, so I seen the doctor and they did the whole gamut… Sure they ask you [if I had sex with men]! [But] I generally say no.

– Black bisexual man, age 38, not taking PrEP

Latinx and Black men reported on negative experiences when accessing healthcare and structural barriers to care engagement, making it less likely for them to consider PrEP as an HIV prevention tool they would use. Men who were on the fence or uninterested in PrEP described limited interactions with their healthcare providers, among other concerns.

Wish to Connect with Other MSM of Color in a Health and Prevention Space

Many participants felt that community supports available to them were limited and concentrated in urban neighborhoods where they did not feel represented or that catered more to white MSM. Men suggested tailored community-based support, including forums to network and develop safe spaces for MSM of color to counter a sense of social, racial, and cultural alienation that many felt. Several anecdotes from men highlighted the alienation men experienced, even in organizations that served the LGBTQ community, and the need for advocacy and community mobilization to create programs and spaces that addressed the specific needs of MSM with Latinx or Black identities. A lack of community and trust also affected men’s receptiveness to HIV prevention services.

We have to be able to have those frank conversations and have programs that really talk about the complexities of our identities… like I want to build a consciousness… [because] there’s not really a sense of a united community… [and] really getting to the nitty gritty of different groups and seeing the different behavioral health outcomes… Latinx or Hispanic as an ethnicity, what is that actually capturing about the populations’ needs when our needs are so diverse and the needs of me versus my undocumented friend who for a time was couch surfing and doing sex work, are way different than… one another, right?

– Latinx queer man, age 28, on PrEP

In the space of racial communities, Seattle has a very small to non-existent… gay, lesbian, bisexual, trans community of African Americans… so when we talk about support… If I’m having a conversation with a white bisexual man in regards to my black “issues” with healthcare… they’re not really going to relate [to] any of that ‘cause they don’t have the same identity and the same understanding of where I’m coming from… I would be like “uh, yeah, NO,” because I wouldn’t trust it [peer navigation]. If there is a community of individuals that I trust, then, YES I will receive it.

– Black gay man, age 35, not on PrEP

Latinx and Black men reported difficulty in finding community resources that enable shared identity and conversations based on similar lived experiences. They suggested tailored support in the community to generate a sense of belonging.

Desire for Peer Matching Based on Identity Considerations and Lived Experience

A peer navigator who could relate to the lived experiences of Latinx and Black men was considered a priority among participants. Most men were interested in having a peer navigator with whom to discuss their sexual health and help them access PrEP. In particular, younger men and Spanish-speaking Latinx men were most interested in peer navigation to access PrEP, which they felt could help address the barriers they faced. Bisexual men had concerns over the discreetness of peers, preferring infrequent phone or online approaches rather than in-person contacts. Participants described the characteristics of their ideal peer navigator, expressing a desire for concordant identities across race/ethnicity, age, and sexual orientation. In general, men preferred a peer who was also a person of color, similar in age, also an MSM, and currently taking PrEP. When asked about the training needs of peer navigators, men alluded to their diverse lived experiences and suggested trainings focused on empathy, relationship building, communication, crisis management and trauma. Such training was considered important to support men’s mental health and to address other sexual health concerns beyond a narrow focus on PrEP uptake and adherence. There was an overall sense that men preferred a peer who delivered holistic and individualized advice and was knowledgeable about sexual health in general.

To see, you know, another gay Black [or] Latino man… they’re on [PrEP] … of course MSM, just to see you know that they’re one of us… [and] that there’s something for us too, instead of some… white person coming to your community [to] tell you [how to] take care of yourself… they don’t understand what you’re going through, where you’re at, what barriers you face, [your] financial struggles.

– Black gay man, age 28, on PrEP

Knowledgeable about STDs and treatment [and]… trained in crisis management…. if anything bad were gonna happen they can help you… work through the crisis.

– Latinx gay man, age 30, on PrEP

Men considered the peer model relevant to their needs, and preferred peer navigators similar to them with respect to identities (e.g., race/ethnicity, age, sexual identity) and lived experiences. Peer navigators were also perceived to fill a need in the community. While Spanish-speaking Latinx men were most interested in peer navigation to access PrEP, bisexual men had confidentiality concerns.

Discussion

In this study of Latinx and Black MSM living in Western Washington, we sought to understand participants’ knowledge about HIV prevention methods including PrEP, obtain insights into perceived HIV risk and experiences with PrEP, and gauge men’s interest in peer navigation as a potential tool to link men to PrEP and other HIV prevention services. We found diverse views, assumptions, expectations, and feelings regarding PrEP. While participants had varying levels of knowledge about this prevention method, all men reported hearing of PrEP to some extent. Emergent themes included men’s awareness of personal vulnerability to HIV infection in intimate relationships and a desire for control of their sexual health; barriers to PrEP initiation including perceived side effects, stigma, and financial concerns; a wish to connect with other Latinx and Black MSM in a safe space for sexual health conversations; and a desire for matching peers based on identity considerations such as race, ethnicity, sexual orientation, and age. Peers were considered potential links between participants and the healthcare system who might be able to provide a sense of trust and intimacy that was missing in the provider space. Participants thought that peers could assist men who were considering PrEP and help men already on PrEP remain adherent and in care.

Other recent research regarding PrEP uptake has identified some of the barriers we found, including concerns about PrEP-related stigma, long-term health effects, and copays or other health-related costs, and difficulties communicating with providers, whether due to language or other barriers (Moore, 2019). Perceived financial concerns were brought up frequently by younger men, full-time students, and those with no or limited insurance coverage. Of note, the Washington State PrEP Drug Assistance Program provides financial support for costs of PrEP and related medical services (including laboratory costs, physician visits, vaccinations, etc.), but many men still face barriers related to taking time off work or traveling to clinic visits (McMahan et al., 2020). In a study of PrEP acceptability among young Latinx and Black MSM in New York City, who had fewer financial resources to access PrEP than their white peers, socioeconomic status and financial barriers similarly influenced men’s attitudes and beliefs about PrEP (Pérez-Figueroa et al., 2015). These concerns were echoed by the younger men in our study, who felt that a peer navigator could potentially guide them through the enrollment and coverage process, helping them ultimately overcome financial barriers. Other recent studies have called for removing financial and logistic barriers to PrEP uptake and retention by providing insurance coverage, financial assistance, and greater ease of appointment scheduling (D’Angelo et al., 2020; McMahan et al., 2020; Wood et al., 2018).

Not all men in our study were interested in PrEP, nor did all participants see the peer model as relevant to their needs. For bisexual men in particular, lower levels of sexual identity disclosure relative to gay men have been attributed to lower LGBT community connectedness, less sexual identity prominence, greater religiosity, and heightened perceptions of homophobia across different interpersonal contexts (i.e., family, friends, neighbors, religious community, work, and online) (Keene et al., 2021). Non–gay-identifying MSM may be less likely to be aware of HIV/AIDS-related information and less likely to test for HIV, suggesting limited engagement with care providers (Bernstein et al., 2008). In a survey of young MSM in Chicago in which 18% of participants were bisexual, bisexual men were significantly less likely to have spoken with their provider about PrEP compared to gay individuals (Phillips et al., 2019). Researchers suggested PrEP-related stigma (i.e., PrEP’s association with gay-identifying men) may not only impact bisexual men’s willingness to use PrEP and disclose their sexual identity to providers, but providers may also be perceiving PrEP to be for and prescribing PrEP exclusively for men who report a gay identity (Phillips et al., 2019). In a study of bisexual men in San Francisco, participants preferred models of care involving discrete sexual health services such as in STD clinics, rather than those that involved enduring care relationships (Koester et al., 2013). The bisexual men we interviewed were similarly reluctant to engage with providers and also less interested in the peer model. Further research is therefore needed to identify the care preferences and the HIV prevention messages and services that are appropriate for bisexual men of color.

In support of our findings, several culturally informed PrEP interventions have successfully utilized peers to engage Latinx and Black MSM in HIV prevention services (Parisi et al., 2018; Viraj V. Patel et al., 2018; V.V. Patel, 2019; Reback et al., 2019). Preliminary findings of a social media–based, peer-led intervention to increase PrEP uptake among young Latinx and Back MSM found that compared to those assigned to the control group, participants who engaged with peers showed greater increases in knowledge, communication skills about PrEP, decreases in PrEP-stigma, and a trend towards PrEP initiations at 6 weeks (Viraj V. Patel et al., 2018; V.V. Patel, 2019). A peer navigator program designed to link transgender women and MSM to PrEP with ongoing adherence support through weekly text messages showed that 70% of MSM were still on PrEP after ninety days. Those who received adherence support through text messages delivered by peers were more likely to report that they were still on PrEP than participants who did not receive the text messages (Reback et al., 2019). In New York, the services provided by PrEP navigators have been attributed to the successful implementation of a PrEP program across five agencies, particularly for supporting PrEP candidates as well as those already on PrEP, bridging communication between medical providers and community-based organizations, guiding clients through assessment and enrollment processes, and linking clients to insurance options/drug company assistance program, food assistance, and other essential support services (Parisi et al., 2018). Interventions are also currently being developed to account for language needs and preferences, particularly in in North Carolina, where researchers are currently testing ChiCAS, a two-session Spanish-language small-group combination intervention designed to increase PrEP uptake by HIV seronegative Spanish-speaking Latinx transgender women who have sex with men (Rhodes et al., 2020). Similar approaches could be extended to Latinx MSM monolingual Spanish speakers.

As researchers strive to develop effective models of PrEP service delivery (Mayer et al., 2018), they should recognize the importance of using peer navigators who have similar life experiences to the populations they serve and consider how our findings could improve peer training and programming. A systematic review of behavioral interventions promoting PrEP engagement, which included several studies of peer-based support, concluded that these PrEP engagement interventions-at-large did not result in statistically significant increases in safer sexual behaviors, and adherence to PrEP medication declined overtime across all studies (Remy & Enriquez, 2019). Few interventions were theory-driven, which could help explain their lack of effect (Remy & Enriquez, 2019). Theoretical frameworks such as the Information, Motivation, and Behavioral Skills (IMB) model have been used to inform the development of PrEP interventions for MSM, and could be leveraged by training identity-concordant peers to provide sexual health information, motivational interviewing to promote behavior change, and specific training on the skills required to schedule appointments, use pill reminder apps, obtain refills, and enroll in insurance or other financial assistance programs (Quinn et al., 2020; J. L. Walsh, 2019). The Minority Stress Model, Empowerment Theory, and Critical Race Theory could also be used to inform model development, help address the institutional and structural barriers that ethnic and racial minorities face, and focus on strengths-based processes and resilience to bolster PrEP adherence and overall sexual health (Fisher et al., 2006; Ford & Airhihenbuwa, 2010; Meyer, 2003; Zimmerman et al., 2011). The development and testing of interventions that address multilevel barriers faced by MSM of color, use theory-driven approaches to develop peer programming and training with measurable mediators or moderators that could explain their impact or lack thereof, and promote a holistic sense of sexual health and well-being beyond a limited focus on PrEP may help reduce the HIV prevention and other health disparities faced by Latinx and Black MSM (Brooks et al., 2020; Simoni et al., 2011; Taggart et al., 2020).

Health services interventions such as telehealth and pharmacist-prescribed approaches to PrEP distribution that don’t employ peers, could also circumvent barriers to uptake and adherence for MSM (Edeza et al., 2020). However, researchers have noted that such interventions may not be enough for MSM of color, who may also need tailored provider and peer support to enhance their motivation to engage. In our study, this was particularly relevant for Latinx Spanish-speaking men who preferred linguistic and racial concordance but were often unable to find such providers. Research has emphasized the importance of literacy, language proficiency, and patient-physician communication in establishing trust and effective patient-provider relationships (Philbin et al., 2018). Even when providers speak at least some Spanish, additional efforts are required when providers have limited fluency or are unfamiliar with the patient’s culture (Sudore et al., 2009). In other studies, Latinx and Black patients prioritized factors other than race-concordance such as education-concordance with their provider (sharing at least a college degree), site where care was received, communication style, and how well the physician knew them and their overall health status (Meghani et al., 2009). While it may not be possible for men to be matched to providers by ethnicity/race, it remains important for providers to be sensitive to their needs. One potential area of research would be to explore whether providers who work with peer navigators have increased cultural competency as a result of those interactions. Our findings suggest that approaches that consider men’s identities and unique barriers, with tailoring for men in specific sub-populations, may be critical in addressing health disparities, as others have suggested (Gafos et al., 2019; Page, 2016; Sharma et al., 2018).

This study has several limitations. First, it reflects the experiences of a convenience sample of Latinx and Black gay, bisexual, and queer men in Western Washington, United States. Several participants had previous or current roles in care organizations and high educational levels, and so had substantial knowledge of HIV and prevention methods. As such, our findings may not be generalizable to all men in the region. Second, we were unable to include the voices of transgender men in our study, despite eligibility criteria that would have allowed such participation. Inclusion of transgender men would have added yet another layer to the study findings regarding obstacles faced by sexual minority men, in addition to specific needs, and desirable attributes of a peer navigator. Our third limitation was that most interviews were conducted via phone rather than in-person, which could have affected the quality of data collected, given the absence of visual cues and nonverbal data to aid in rapport building, probing, and interpretation of responses. Lastly, many of the men interviewed were already using PrEP. However, we asked men to reflect on their PrEP journeys and what might have helped them before they started PrEP, as well as what might help them continue PrEP, and found that peer navigation was still relevant and of interest for men currently taking PrEP.

Conclusion

The increased HIV vulnerability experienced by Latinx and Black MSM underscores the urgent need for development of innovative, acceptable, and effective interventions for Latinx and Black MSM, and sub-populations including younger men, monolingual Spanish speakers, and bisexual men. For MSM of color in particular, the circumstances or contexts in which they live and the social determinants underlying access to care influence how men think about PrEP and incorporate HIV prevention into their interpersonal and community-level relationships. In particular, men’s awareness of their vulnerability to HIV infection within intimate relationships, their barriers to PrEP initiation including perceived side effects, stigma, and financial concerns, and their wish for a community space to connect meaningfully with other Latinx and Black MSM, underscore the opportunity for effective peer navigation as a bridge between Latinx and Black men and the healthcare system. Understanding the important role that identity and sense of belonging have for MSM of color is important for public health practitioners, researchers, and providers charged with increasing care engagement and reducing HIV incidence among Latinx and Black MSM.