PrEP for Black MSM: Community-Based Ethnography and Clinic-Based Treatment

描述(申请人提供)：在美国，男男性行为者(MSM)构成了受艾滋病毒流行影响最严重的群体：2009年所有新感染病例中有61%发生在这一人群中。黑人MSM的感染负担甚至更不成比例，患病率为28%，而白人、非拉丁裔MSM的感染率为16%。感染艾滋病毒的黑人MSM也比白人MSM更有可能在第一次检测时得到艾滋病毒诊断，这表明他们从艾滋病毒预防和控制服务中受益的可能性低于其他群体。显然，缩小黑人男男性接触者中与艾滋病毒有关的差距是一项国家卫生优先事项，对于《国家艾滋病毒/艾滋病战略》所阐明的成功控制和预防艾滋病毒/艾滋病的努力至关重要。暴露前预防(PrEP)已被证明可以减少MSM的获得率，它可能在下一代联合预防干预中发挥关键作用。然而，在PrEP在全国范围内推广之前，必须回答有关以下两个关键问题：将影响黑人MSM对PrEP的吸收和遵守的社区层面因素，以及以可扩展和有效的方式提供PrEP的最佳临床方案。此外，黑人MSM的更广泛的社会需求和认知与临床护理方案之间存在关系，因此我们提出了一项多方法研究，其中包括基于社区的人种学和社区初级保健诊所的干预。以社区为基础的人种学研究将包括机构调查、关键线人访谈、带有系统的人种学样本的人种学访谈、参与者观察和物质文化分析。借鉴社会风险、生活项目和社会网络的概念，我们将探索塑造男性健康的结构和文化因素 性关系，卫生系统的参与，以及与艾滋病毒预防有关的知识、态度和做法，特别是与预防艾滋病有关的知识和态度。人种学研究的结果将提供与设计包括PrEP在内的组合预防干预措施相关的社区背景因素的迫切需要的信息，并将为在社区诊所进行PrEP治疗黑人MSM的随机对照试验奠定基础。这项基于临床的研究将对符合条件的HIV阴性黑人MSM随机接受增强的PrEP一揽子护理，并比较它们在遵守PrEP和减少性危险行为方面的有效性。RCT将产生关于社区临床背景下黑人MSM接受PrEP的关键信息，在非实验条件下遵守PrEP的情况，卫生服务提供者使用PrEP的经验，以及PrEP对性风险实践的影响。 公共卫生相关性：在美国，男男性行为者(MSM)的新艾滋病毒感染率是所有群体中最高的，制定与这一群体合作的有效艾滋病毒预防干预措施是国家艾滋病毒/艾滋病战略的关键要素。我们建议进行以社区为基础的研究，探讨黑人男男性接触者如何参与PrEP的相关因素，然后在社区初级保健诊所进行一项研究，比较两种提供PrEP的方案。这些努力将共同为建立更有效的艾滋病毒预防干预措施或这一高危人群提供关键信息。

DESCRIPTION (provided by applicant): In the United States, men who have sex with men (MSM) comprise the group most severely affected by the HIV epidemic: 61% of all new infections in 2009 occurred in this population. Black MSM experience an even more disproportionate burden of infections, with prevalence of 28% in contrast to 16% in White, non- Latino MSM. HIV-infected Black MSM are also more likely than White MSM to receive an HIV diagnosis at their first testing experience, suggesting that they are less likely than other group to benefit from HIV prevention and control services. Clearly, the reduction of HIV-related disparities in Black MSM is a national health priority, essential to the success of efforts to contol and prevent HIV/AIDS as articulated in the National HIV/AIDS Strategy. Pre-Exposure Prophylaxis (PrEP), which has been shown to reduce acquisition among MSM, could play a critical role in the next generation of combination prevention interventions. Before PrEP is scaled up on a national level, however, critical questions must be answered regarding both the community-level factors that will shape uptake of and adherence to PrEP among Black MSM and the optimal clinical package for delivering PrEP in a way that is both scalable and effective. There is, moreover, a relationship between the broader social needs and perceptions of Black MSM and that clinical care package, and so we propose a multi-method study that incorporates community-based ethnography and an intervention in a community primary care clinic. The community-based ethnographic research will consist of institutional mapping, key informant interviews, ethnographic interviews with a systematic ethnographic sample, participant observation, and analysis of material culture. Drawing on the concepts of social risk, life projects, and social networks, we will explore the structural and cultural factors that shape men's sexual relationships, health systems engagement, and knowledge attitudes and practices related to HIV prevention in general and PrEP in particular. Findings from the ethnographic research will provide urgently needed information regarding community-contextual factors relevant to designing combination prevention interventions that include PrEP, and will lay the groundwork for the randomized controlled trial for PrEP for Black MSM in a community-based clinic. The clinic-based research will randomize eligible HIV- negative Black MSM to an enhanced versus standard PrEP package of care and compare their effectiveness on adherence with PrEP and reduction in sexual risk behaviors. The RCT will generate critical information regarding the acceptability of PrEP for Black MSM in a community clinical context, adherence to PrEP under non-experimental conditions, health providers' experiences with PrEP, and the impact of PrEP on sexual risk practices. PUBLIC HEALTH RELEVANCE: Black Men who have sex with men (MSM) have among the highest rates of new HIV infections of any group in the United States, and developing effective HIV prevention interventions that work with this group is a critical element of the National HIV/AIDS Strategy. We propose to carry out community-based research that will explore factors relevant to how Black MSM might engage with PrEP, and then to conduct a study in a community primary care clinic to compare two packages for providing PrEP. Together these efforts will provide critical information for building more effective HIV prevention interventions or this at-risk population.