This proposal responds to PA-19-050 Engaging Men in HIV Testing, Prevention, and Care and to NOT-MD-19- 001 Notice of Special Interest in Research on the Health of Sexual and Gender Minority (SGM) Populations. HIV testing is an essential first step in reducing HIV transmission rates, but the prevention counseling component has been significantly reduced in recent years and has not incorporated validated PrEP referral processes as standard of care. For those most in need of prevention services additional barriers include the cumulative impact of experiences of racial discrimination and social stigma against SGMs compounded with persistent HIV stigma. The impact of these forces on HIV testing and prevention are widely acknowledged but remain extremely difficult to intervene upon. This exploratory study combines an innovative participatory approach and intersectional stigma framework to understand how black SGM in a Southern city experience HIV/STI testing and PrEP referral. We build on existing simulated client/patient approaches to elicit, observe, and interpret interactional behaviors in health settings to capture black SGM experiences in close to real time and proximity to the environments where they receive testing and PrEP services. The goal is to understand the subjective experience of the simulated client/patient, not conduct an objective evaluation of the provider.
In Aim 1 we will (a) recruit and train eight black SGM to perform in the role of a simulated client/patient accessing HIV/STI testing and PrEP services and (b) conduct simulated walk-through exercises with providers to document and describe their standard mode of service delivery and negotiate agreements for how simulated clients/patients will access their services.
In Aim 2 simulated clients/patients will complete structured surveys immediately before and after each engagement with a provider (n=32 events) followed by a qualitative de-brief interview. We will then conduct in-depth interviews with providers to understand their perspectives on the types of experiences reported. Qualitative coding and structured survey data will be combined using a matrix-based applied thematic analysis approach, including use of frequency tables and visualization techniques to compare and contrast black SGM intersectional experiences of stigma, discrimination, empowerment, and confirmation.
Aim 3 centers on participatory intervention mapping with stakeholders including black SGM and providers to review the range of prevention experiences and collaboratively identify ways to improve (a) the referral/intake experience, (b) the capacity of providers to identify clients likely to benefit from PrEP, and (c) linkage to and uptake of PrEP by clients at highest risk. Findings will be of immediate value for local quality improvement in services, inform the expansion of HIV prevention services more broadly in North Carolina, and inform development of an equity-based provider training intervention to reduce experiences of intersectional stigma for black SGM accessing HIV prevention services.
HIV testing and PrEP are essential but underused elements of HIV prevention. For people at highest risk in the U.S.?black sexual and gender minorities in the South?multiple forms of stigma and discrimination create barriers to accessing testing and PrEP services. This study will describe black sexual and gender minority experiences and identify ways to improve the experience, and help providers better identify, refer and serve clients likely to benefit from PrEP.
