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One-quarter of gay, bisexual, and other men who have sex with men (GBMSM) with diagnosed HIV are not engaged in HIV care. Between 2018 and 2019, 50 GBMSM completed qualitative interviews 3 months after receiving an HIV-positive result. Interviews explored barriers to and facilitators of engagement and retention in HIV testing and care. Thematic analysis revealed five major themes: (1) reason for HIV testing (e.g., self-testing), (2) linkage to care (e.g., appointment/logistic issues and social support as encouragement), (3) barriers to engagement in care (e.g., financial burden, competing priorities, and fear/stigma), (4) facilitators of engagement (e.g., financial assistance, patient-provider relationships, auxiliary support services, and health agency), and (5) PrEP as a missed prevention opportunity. Addressing individual-, social-, and policy-level barriers could improve GBMSM's engagement in HIV care. Further, capitalizing on GBMSM's health agency through partnerships with local agencies and fostering better patient-provider relationships could optimize HIV care continuity.

Supplemental Material for Attitudes Toward Peer-Delivered Sexual-Health Services Among New York City Sexual and Gender Minority Individuals Who Have Sex with Men and Attend Collective Sex Venues by Étienne Meunier, Daniel Alohan, Stephen Tellone, Richard Silvera, Alwyn Cohall, Adam Baran, Michael Wakefield, Christian Grov, and Celia B. Fisher in Qualitative Health Research

Pre-exposure prophylaxis (PrEP) is a highly effective biobehavioral strategy for preventing HIV acquisition. Although PrEP uptake has increased steadily, discontinuation rates are high among members of key populations like gay and bisexual men (GBM). Understanding the challenges that arise for PrEP users is key to better PrEP implementation and sustained use over time. We report on barriers that arose for PrEP-using GBM, as well as facilitating factors that aided PrEP persistence, with the goal of informing PrEP implementation efforts. In 2015-2016, 103 PrEP-using GBM in NYC completed qualitative interviews about their engagement with PrEP, including their experiences navigating PrEP-related medical care. Interviews were transcribed verbatim, coded, and analyzed thematically. Over half of participants (53%) received their PrEP-related care from their primary care provider (PCP), one-third (33%) from a community-based health clinic, and 13% from multiple medical providers. Emergent themes regarding the barriers and facilitators to PrEP persistence fell into two categories: insurance- and medical appointment-related barriers and facilitators to continued PrEP use. The experiences of PrEP-using GBM can provide useful insights for providers, program developers, and policymakers aiming to improve the implementation of PrEP. To support PrEP persistence, reliable insurance coverage, cost-assistance, and easy appointment scheduling are key to maintenance. Removing insurance- and appointment-related barriers to persistence may prove essential for sustaining use among GBM.

Pre-exposure prophylaxis (PrEP) has altered the public health landscape for gay, bisexual, and other men who have sex with men (GBM) by significantly increasing protection against HIV infection. Early epidemiologic data showed GBM generally used PrEP as prescribed, i.e., as an additional protective tool over and above barrier protection, although subsequent reports have been equivocal. Irrespective of population-level trends, some GBM appear to have reevaluated their HIV risk tolerance and changed their interactions with sex partners. Scant published data have focused on factors that influence PrEP-using GBM's decisions about sexual behavior-including condom use as well as sex with HIV-positive partners-and sexual communication practices. Thus, in this study, we investigated those research concerns qualitatively via content analysis of individual interviews conducted with 103 GBM in New York City (M age 32.5 years, 50% White, 64% on PrEP > 6months). Emergent themes reflect (1) participants' strong HIV knowledge; (2) changing GBM community norms about condom use on PrEP; (3) increased focus on risk tolerance with individual differences in post-PrEP condom use; (4) appreciation for routine sexually transmitted infection (STI) screening in PrEP care concomitant with some STI knowledge deficits; (5) decreased stigma concerning, and greater comfort with, HIV-positive sex partners; and (6) increased confidence discussing HIV status and condom use preferences with partners. Findings have implications for future research as well as for clinical practice, such as enhanced STI education and provider-initiated discussions about risk compensation, serosorting, and sexual communication skills.

Pre-Exposure Prophylaxis (PrEP) has been demonstrated effective at preventing HIV among key populations like gay and bisexual men (GBM). Yet, there remains a continued need to engage GBM in PrEP behavioral and clinical research (e.g., to monitor adherence and retention in the PrEP treatment cascade). We report on the factors motivating GBM to participate in a PrEP behavioral study, with the aim of our results to inform future recruitment efforts for future PrEP research. In 2015-2016, 103 PrEP-using GBM in NYC completed qualitative interviews about their experiences on PrEP. Participants were also asked about factors that motivated them to join the study. Thematic analysis was used analyze the data. We identified five salient themes as rationale for joining the study: 58.3% cited altruistic reasons, 32% reported intellectual curiosity in the subject matter, 30.1% indicated that remuneration inspired them, 18.4% indicated that familiarity or referral to the research institute influenced their decision. Researchers attempting to enroll PrEP-using GBM may benefit from attending to the altruistic and intellectually curious nature of this population. Further, researchers may benefit from establishing familiarity among diverse communities of GBM. This in turn may contribute to the successful engagement of GBM for PrEP research.

Since FDA approval in 2012, HIV pre-exposure prophylaxis (PrEP) has been adopted by key populations, including gay and bisexual men (GBM), to reduce their HIV transmission risk. Given that PrEP is optimally effective when taken as prescribed, it is critical to understand the adherence strategies GBM use. We conducted one-on-one, semi-structured interviews with GBM taking PrEP in 2015-2016 (n = 103). Using thematic analysis, we identified six adherence strategies, with most participants (84.3%) utilizing multiple strategies to maintain adequate adherence: (1) integrating PrEP into part of a daily routine, (2) using a pillbox, (3) cognitive strategies/visual cues, (4) setting recurring smartphone alarms or reminders, (5) keeping medication on oneself at all times, and (6) partner or peer support for reminders and/or pill sharing. Overall, participants reported high PrEP adherence (M = 1.6 missed doses in the prior 30days), though nearly all described missing at least one dose unintentionally in the past. Participants credited their high levels of adherence in part to the strategies they adopted. Providers working with GBM prescribed PrEP, especially patients reporting difficulties with adherence, might consider recommending any or all of the six strategies described in this study.

HIV pre-exposure prophylaxis (PrEP) is being adopted by members of key populations, such as gay and bisexual men (GBM). Since adherence to a daily PrEP regimen ensures a maximum protection, it is critical to understand GBM's behavioral responses to having missed PrEP doses. We report on qualitative interviews with GBM taking PrEP. We identified three behavioral responses: (1) 59% continued with their next scheduled dose; (2) 49% described "making up" for a missed dose by taking medication as soon as possible; and (3) 11% reported "doubling" the next PrEP dose. Participants provided potentially contradictory narratives about their sexual behavior after a missed dose: (1) 54% described making no changes; (2) 49% described adjusting their sexual behavior to reduce HIV risk; and (3) 10% said their decision would be contingent upon how many doses were missed. For PrEP prescribers, our data provide a useful lens to understand patients' lived experiences with PrEP.

Recruitment for HIV research among gay, bisexual, and other men who have sex with men (MSM) has increasingly moved to the online sphere. However, there are limited data comparing the characteristics of clinic-based respondents versus those recruited via online survey platforms. MSM were recruited from three sampling sites (STI clinic, MTurk, and Qualtrics) to participate in a survey from March 2015 to April 2016. Respondents were compared between each of the sampling sites on demographics, sexual history, substance use, and attention filter passage. Attention filter passage was high for the online sampling sites (MTurk=93%; Qualtrics=86%), but significantly lower for the clinic-based sampling site (72%). Clinic-based respondents were significantly more racially/ethnically diverse, reported lower income, and reported more unemployment than online respondents. Clinic-based respondents reported significantly more male sexual partners in the previous 3months (M clinic-based=6; MTurk=3.6; Qualtrics=4.5), a higher proportion of gonorrhea, chlamydia, and/or syphilis in the last year, and a greater proportion of methamphetamine use (clinic-based=21%; MTurk=5%), and inhaled nitrates use (clinic-based=41%; MTurk=11%). The clinic-based sample demonstrated more demographic diversity and a greater proportion of HIV risk behaviors when compared to the online samples, but also a relatively low attention filter passage rate. We recommend the use of attention filters across all modalities to assess response validity and urge caution with online survey engines as samples may differ demographically and behaviorally when compared to clinic-based respondents.

Background: Gay, bisexual, and other men who have sex with men (GBMSM) accounted for 67% of new US human immunodeficiency virus (HIV) infections in 2012; however, less than 40% of HIV-positive GBMSM are virally suppressed. Preventing transmission from virally unsuppressed men who have condomless anal sex (CAS) with serodiscordant partners is a public health imperative. New HIV infections in GBMSM are attributed in part to online access to sex partners; therefore, low-cost eHealth interventions are a unique opportunity to reach men where they meet partners. Objective: To describe the protocol of a randomized controlled trial evaluating whether video-based messaging delivered online may lead to reductions in serodiscordant CAS and increased HIV disclosure. Methods: Sex Positive![+] is a two-arm, phase III, video-based randomized controlled trial delivered online to GBMSM living with HIV. Participants in the intervention arm receive 10 video vignettes grounded in social learning and social cognitive theories that are designed to elicit critical thinking around issues of HIV transmission and disclosure. Participants in the attention control arm receive 10 video vignettes that focus on healthy living. All videos are optimized for mobile viewing. The study protocol includes five online assessments conducted over a 1-year period among 1500 US white, black, or Hispanic/Latino GBMSM living with HIV who report suboptimal antiretroviral therapy (ART) adherence or a detectable viral load in the past 12 months and recent CAS (past 6 months) with HIV-negative or unknown status male partners. Compared to the control arm, we hypothesize that men who watch the intervention videos will report at 12-month follow-up significantly fewer serodiscordant CAS partners, increased HIV disclosure, and improved social cognition (eg, condom use self-efficacy, perceived responsibility). Results: Participant recruitment began in June 2015 and ended in December 2015. Conclusions: This protocol describes the underlying theoretical framework and measures, study design, recruitment challenges, and antifraud measures for an online, video-based randomized controlled trial that has the potential to decrease HIV transmission risk behaviors among HIV-positive GBMSM who struggle with ART adherence. The Sex Positive![+] intervention allows for participation through multiple Internet-based mediums and has the potential to reach and engage a broader population of HIV-positive GBMSM who are virally unsuppressed. ClinicalTrial: ClinicalTrials.gov NCT02023580; https://clinicaltrials.gov/ct2/show/NCT02023580 (Archived by WebCite at http://www.webcitation.org/6iHzA8wRG) [JMIR Res Protoc 2016;5(2):e125]