Stigma and Substance Use as Barriers to PrEP Linkage, Uptake, Adherence, and Persistence among BMSM

本申请是对PAS-18-915艾滋病毒/艾滋病高优先药物滥用研究的回应。艾滋病毒发病率 在美国东南部，与男性发生性关系的黑人男性（BMSM）是美国最高的男性之一。 世界我们的研究团队在亚特兰大对BMSM进行了研究，结果显示35%的人感染了艾滋病毒。 艾滋病毒感染率和年发病率超过5%。虽然PrEP对预防艾滋病毒非常有效， 传输，它没有到达BMSM。在我们的能力，从事BMSM在PrEP使用的失败是高度 鉴于艾滋病毒在这一群体中的传播率令人震惊，这是一个问题。在我们最近的工作中， 在亚特兰大的BMSM中，我们发现只有4%（n=19/474）的BMSM目前正在服用PrEP，尽管 90%（n=428/474）知道PrEP。特别值得关注的是物质使用作为障碍的影响， PrEP链接，摄取，坚持和持久性。在我们的研究中，物质使用在BMSM中很常见， 43%（n=204/474）报告最近使用药物。而且，关键的是，在我们最近的纵向研究中， 在BMSM中，物质使用者检测HIV的可能性是非物质使用者的两倍多 基线检测时阳性，7%（n=15/205）vs 2%（n=4/244），另外7%（n=13/190）vs 3% （n=8/240）在一年后的研究随访时。使PrEP使用进一步复杂化的是COVID的潜在影响- 19关于卫生保健获得、卫生保健基础设施和性行为。需要更好地了解PrEP 在我们新的卫生保健环境中使用是在PrEP使用的进步至关重要。在这一点上， 评估物质使用如何影响PrEP的使用是具有挑战性的，因为PrEP的实施率很低， 这个团体。拟议的研究旨在提供物质使用BMSM与循证PrEP 参与咨询，以解决获得PrEP的障碍（不是干预测试，而是 促进PrEP的使用），并评估耻辱和物质使用的多种形式和途径，因为它们 与PrEP连接、摄取、依从性和持久性有关。我们建议使用艾滋病毒污名框架 作为一个概念模型，用于调查污名驱动因素和污名的交叉途径， 机制，因为它们与使用BMSM的物质之间的PrEP使用有关。目标1：招募前瞻性队列 的N=500 BMSM，其在毒理学测试中检测HIV阴性且测试物质使用阳性，并提供 以证据为基础的PrEP参与咨询，以促进获得PrEP护理。目标2：开展社会心理活动 每两个月进行一次卫生保健获得情况评估，持续18个月，并进行艾滋病毒/性传播感染检测， 每3个月进行一次TFV-DP血斑检测，持续18个月。目标3：利用从目标1和2收集的数据， 沿着PrEP级联沿着推进和逆转的模型柱头途径（即，联系、吸收、坚持， 持久性），这些途径由医疗保健的获得和物质的使用调节。 实现这些目标将为翻译和调整干预措施以提高效力提供重要的见解 和持久性的个人在极高的风险艾滋病毒。

This application is in response to PAS-18-915 HIV/AIDS High Priority Drug Abuse Research. HIV incidence among Black men who have sex with men (BMSM) in the southeastern United States is one of the highest in the world. Our research team has conducted studies with BMSM in Atlanta that have demonstrated 35% HIV prevalence and over 5% annual HIV incidence. Although PrEP is highly effective for preventing HIV transmission, it is not reaching BMSM. The failures in our ability to engage BMSM in PrEP use are highly problematic given the alarming rates of HIV transmission among this group. In our most recent work with BMSM in Atlanta, we found that only 4% (n=19/474) of BMSM are currently taking PrEP even though 90% (n=428/474) are aware of PrEP. Of particular concern is the impact of substance use as a barrier in PrEP linkage, uptake, adherence, and persistence. Substance use is common among BMSM in our study, with 43% (n=204/474) reporting recent substance use. And, critically, in our most recent longitudinal study with BMSM, substance users were more than twice as likely than non-substance users to test HIV positive, 7% (n=15/205) vs. 2% (n=4/244) at baseline testing, and an additional 7% (n=13/190) vs 3% (n=8/240) at study follow up one year later. Further complicating PrEP use is the potential impact of COVID- 19 on health care access, health care infrastructure, and sex behavior. The need to better understand PrEP use in the context of our new health care landscape is critical to making advances in PrEP use. At this point, assessing how substance use impacts PrEP use is challenging because PrEP implementation is so low among this group. The proposed research aims to provide substance using BMSM with evidence-based PrEP engagement counseling to address barriers to accessing PrEP (not for intervention testing, but for facilitating PrEP use) and to assess the multiple forms and paths of stigma and substance use as they relate to PrEP linkage, uptake, adherence, and persistence. We propose using the HIV Stigma Framework as a conceptual model for investigating the intersecting pathways of stigma drivers and stigma mechanisms as they relate to PrEP use among substance using BMSM. Aim 1: Enroll a prospective cohort of N=500 BMSM who test HIV negative and test substance use positive on toxicology testing, and provide evidence-based PrEP engagement counseling to facilitate access to PrEP care. Aim 2: Conduct psychosocial and health care access assessments every 2-months for 18-months, and conduct HIV/STI testing and dried blood spot testing for TFV-DP every 3-months for 18-months. Aim 3: Using data collected from Aims 1 and 2, model stigma pathways of advancing and reverting along the PrEP cascade (i.e., linkage, uptake, adherence, persistence), with these pathways mediated by health care access and moderated by substance use. Achieving the aims will provide critical insight for translating and adapting interventions to enhance potency and durability for individuals at exceedingly elevated risk for HIV.