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IntroductionPre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In the Southern United States, where young Black men who have sex with men (YBMSM) have the highest rates of new HIV infection, PrEP uptake remains low. As part of a longitudinal cohort study, YBMSM were offered optional, non-incentivized PrEP as a standard of HIV prevention care service. Among those who declined PrEP, we sought to understand their motivations, as well as their overall perceptions of PrEP as a prevention tool.MethodsThe EleMENt study is an observational HIV/STI incidence cohort of HIV-negative YBMSM aged 18–29 years in Atlanta, Georgia. We conducted 24 in-depth, semi-structured interviews with men who declined optional PrEP offered by the study. Topics included PrEP knowledge, attitudes, and intentions. We employed a phenomenological lens to identify common themes in participant accounts of the decision to forgo PrEP.ResultsParticipants fell into two categories of PrEP refusal: those who indicated no current or future interest (“nevers”) and those ambivalent about taking PrEP, but who had thus far not filled a prescription (“maybes”). YBMSM in both groups expressed mistrust of biomedical interventions, and despite being indicated for PrEP, often perceived themselves as low risk for HIV acquisition. They employed “othering” strategies, in which PrEP was described as appropriate for individuals in serodiscordant partnerships or with many casual partners. They viewed taking a daily pill as a burdensome measure only appropriate for extremely high-risk men (i.e., “the risky Other”). These perceptions were accentuated by instances of family members actively discouraged participants from taking PrEP.ConclusionWe discuss the role of future research exploring low risk estimation among YBMSM as a potential site of resistance to a public health designation of “high risk” amidst historical legacies of medical mistrust in Black communities. Such concerns must be addressed to design effective HIV and PrEP-specific interventions for this population.

Combination prevention efforts are now recommended toward reducing HIV incidence among men who have sex with men (MSM). Understanding the perceptions of both MSM and service providers is critical to informing the development of prevention packages and ultimately improving intervention effectiveness. This study assessed the preferences of MSM and health service providers in the administration of HIV-prevention efforts. Qualitative data were gathered from a series of separate MSM and health care provider focus groups in 2 South African cities. Participants discussed HIV-prevention services and MSM client experiences within South Africa and identified the 3 most important clinic characteristics and 3 most important HIVprevention services for MSM clients. Priorities indicated by both MSM and health care providers were confidentiality of visit, friendly staff, and condoms, while discrepancies existed between MSM and providers regarding provider consistency and the provision of pre-exposure prophylaxis/post-exposure prophylaxis (PrEP/PEP) and lubricant as prevention methods. Effective interventions must address these discrepancies through the design of intervention and provider training to optimally accommodate MSM.

Measurement of adherence to oral pre-exposure prophylaxis (PrEP) in real-time has been challenging. We developed DOT Diary, a smartphone application that combines automated directly observed therapy with a PrEP adherence visualization toolkit, and tested its ability to measure PrEP adherence and to increase adherence among a diverse cohort of young men who have sex with men (MSM). We enrolled 100 MSM in San Francisco and Atlanta and randomly assigned them 2:1 to DOT Diary versus standard of care. Concordance between DOT Diary measurement and drug levels in dried blood spots was substantial, with 91.0% and 85.3% concordance between DOT Diary and emtricitabine-triphosphate and tenofovir-diphosphate, respectively. There was no significant difference in the proportion of participants with detectable PrEP drug levels at 24 weeks between study arms. These results suggest DOT Diary is substantially better than self-reported measures of adherence, but additional interventions are needed to improve PrEP adherence over time.

Background The COVID-19 pandemic continues to have high caseloads in the US, with vaccines a critical component of the response. Disparities in COVID-19 morbidity and mortality have been identified across states and racial/ethnic groups, which are likely in part due to disparities in COVID-19 vaccine uptake. This study aims to better understand and contextualize COVID-19 vaccine hesitancy among persons from under-represented racial/ethnic populations in the Southern US. Methods We conducted 29 in-depth interviews with a sample of households in Atlanta, GA that were selected from an address-based sampling frame. We purposively approached households, from February 6 to June 27, 2021, that declined participation in a national COVID-19 serosurvey to gain perspectives of people who are often under-represented in research. Interviews were conducted in-person or over phone calls for participants with that preference. Thematic analysis was used to identify barriers and facilitators of COVID-19 vaccination, and to contextualize drivers of vaccine hesitancy. Results Decision-making about vaccination was described as dynamic, and was compared to the feeling of being on a roller coaster. The predominant reported sources of information were mass media and social media. Facilitators of vaccination included altruism, positive communication from trusted community members and workplace colleagues, and local vaccine provision sites. Driving reasons for vaccine hesitancy included limited trust in the government and concerns about COVID-19 vaccine safety, which one participant compared to jumping off a cliff without a tested rope. Among a subset of participants, beliefs regarding perceived intent to harm the Black community were prevalent. Opportunities to optimally address vaccine hesitancy included countering negative social media messages with positive messaging that matches the community’s vivid ways of discussing vaccines, collaborating with community stakeholders on vaccine promotion efforts, and offering workplace-based vaccine promotion efforts. Conclusions This study presents data that indicate it may be optimal to more broadly define ‘community’ in COVID-19 vaccine promotion efforts to include social media and workplace venues. To optimize vaccine and vaccine booster uptake and equity, public health must address historic racism and other concerns by using outreach that is grounded in communities.