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

这项申请是对PAS-18-915艾滋病毒/艾滋病高度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中，BMSM的比例是最高的 整个世界。我们的研究团队对亚特兰大的BMSM进行了研究，发现35%的艾滋病毒 流行率和艾滋病毒年发病率超过5%。尽管PrEP在预防艾滋病毒方面非常有效 传输，它没有到达bmsm。我们让BMSM参与PrEP使用的能力有很大的失败 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，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)知晓PrEP。特别令人关切的是，物质使用作为一种障碍在 准备联动、吸收、坚持和坚持。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。关键的是，在我们最新的纵向研究中 使用BMSM，吸毒者检测艾滋病毒的可能性是非吸毒者的两倍以上 阳性，基线检测7%(n=15/205)vs.2%(n=244)，另外7%(n=13/190)vs.3% (n=8/240)1年后随访。使PrEP使用进一步复杂化的是COVID的潜在影响- 19关于卫生保健获取、卫生保健基础设施和性行为。需要更好地了解PrEP 在我们新的医疗保健环境中使用对于在PrEP使用方面取得进展至关重要。在这点上， 评估物质使用如何影响PrEP的使用是具有挑战性的，因为PrEP的执行率在 这群人。建议的研究旨在为使用BMSM提供循证的PrEP材料 参与咨询，以解决获取PrEP的障碍(不是用于干预测试，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 与PrEP的连接、摄取、坚持和持久性有关。我们建议使用艾滋病毒污名框架 作为研究柱头驱动因素和柱头的交叉途径的概念模型 与使用BMSM的物质之间使用PrEP有关的机制。目标1：招募潜在队列 在N=500名艾滋病毒检测呈阴性且测试物质使用毒理学测试呈阳性的BMSM中，并提供 循证的PrEP参与咨询，以促进PrEP护理的获得。目标2：开展社会心理活动 每两个月进行一次卫生保健获取情况评估，为期18个月，并进行艾滋病毒/性传播感染检测和干燥 TFV-DP血点检测每3个月一次，共18个月。目标3：利用从目标1和目标2收集的数据， 模拟沿着PrEP级联推进和恢复的柱头路径(即，连接、摄取、附着、 持久性)，这些途径由获得保健服务作为中介，并受到药物使用的影响。 实现这些目标将为翻译和调整干预措施以提高效力提供关键的见解 以及对感染艾滋病毒风险极高的人的耐受性。

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.