A youth-focused case management intervention to engage and retain young gay men of color in HIV care Amy Rock Wohl a *, Wendy H. Garland a , Juhua Wu b , Chi-Wai Au b , Angela Boger b , Rhodri Dierst-Davies a , Judy Carter b , Felix Carpio c and Wilbert Jordan d a Los Angeles County Department of Public Health, HIV Epidemiology Program, Los Angeles, CA, USA; b Los Angeles County Department of Public Health, Office of AIDS Programs and Policy, Los Angeles, CA, USA; c AltaMed Health Services Corporation, Daniel V. Lara Clinic, Los Angeles, CA, USA; d Los Angeles County MLK-MACC, OASIS Clinic, Los Angeles, CA, USA (Received 5 April 2010; final version received 18 November 2010) HIV-positive Latino and African-American young men who have sex with men (YMSM) have low rates of engagement and retention in HIV care. An evaluation of a youth-focused case management intervention (YCM) designed to improve retention in HIV care is presented. HIV-positive Latino and African-American YMSM, ages 18�24, who were newly diagnosed with HIV or in intermittent HIV care, were enrolled into a psychosocial case management intervention administered by Bachelor-level peer case managers at two HIV clinics in Los Angeles County, California. Participants met weekly with a case manager for the first two months and monthly for the next 22 months. Retention in HIV primary care at three and six months of follow-up was evaluated as were factors associated with retention in care. From April 2006 to April 2009, 61 HIV-positive participants were enrolled into the intervention (54% African-American, 46% Latino; mean age 21 years). At the time of enrollment into the intervention, 78% of the YMSM had a critical or immediate need for stable housing, nutrition support, substance abuse treatment, or mental health services. Among intervention participants (n �61), 90% were retained in primary HIV care at three months and 70% at six months. Among those who had previously been in intermittent care (n �33), the proportion attending all HIV primary care visits in the previous six months increased from 7% to 73% following participation in the intervention (pB0.0001). Retention in HIV care at six months was associated with increased number of intervention visits (p �0.05), more hours in the intervention (p �0.02), and prescription of HAART. These data highlight the critical needs of HIV-positive African-American and Latino YMSM and demonstrate that a clinic-based YCM can be effective in stabilizing hard-to-reach clients and retaining them in consistent HIV care. Keywords: adolescents; MSM; HIV/AIDS; Latinos; African-Americans; interventions Introduction National HIV and AIDS rates are elevated for African-American and Latino youth which is consis- tent with 2008 behavioral surveillance data in Los Angeles County in which HIV prevalence rates were 17% for African-American and 13% for Latino 18�24-year-old young men who have sex with men (YMSM) (Bingham & Sey, 2009;.

1. A youth-focused case management intervention to engage and
retain young gay men of color
in HIV care
Amy Rock Wohl
a
*, Wendy H. Garland
a
, Juhua Wu
b
, Chi-Wai Au
b
, Angela Boger
b
, Rhodri Dierst-Davies
a
,
Judy Carter
b
, Felix Carpio
c
and Wilbert Jordan
d

2. a
Los Angeles County Department of Public Health, HIV
Epidemiology Program, Los Angeles, CA, USA;
b
Los Angeles County
Department of Public Health, Office of AIDS Programs and
Policy, Los Angeles, CA, USA;
c
AltaMed Health Services
Corporation, Daniel V. Lara Clinic, Los Angeles, CA, USA;
d
Los Angeles County MLK-MACC, OASIS Clinic, Los Angeles,
CA, USA
(Received 5 April 2010; final version received 18 November
2010)
HIV-positive Latino and African-American young men who
have sex with men (YMSM) have low rates of
engagement and retention in HIV care. An evaluation of a
youth-focused case management intervention (YCM)
designed to improve retention in HIV care is presented. HIV-
positive Latino and African-American YMSM, ages
18�24, who were newly diagnosed with HIV or in intermittent
HIV care, were enrolled into a psychosocial case
management intervention administered by Bachelor-level peer
case managers at two HIV clinics in Los Angeles
County, California. Participants met weekly with a case
manager for the first two months and monthly for the

3. next 22 months. Retention in HIV primary care at three and six
months of follow-up was evaluated as were
factors associated with retention in care. From April 2006 to
April 2009, 61 HIV-positive participants were
enrolled into the intervention (54% African-American, 46%
Latino; mean age 21 years). At the time of
enrollment into the intervention, 78% of the YMSM had a
critical or immediate need for stable housing,
nutrition support, substance abuse treatment, or mental health
services. Among intervention participants
(n �61), 90% were retained in primary HIV care at three
months and 70% at six months. Among those who had
previously been in intermittent care (n �33), the proportion
attending all HIV primary care visits in the previous
six months increased from 7% to 73% following participation in
the intervention (pB0.0001). Retention in HIV
care at six months was associated with increased number of
intervention visits (p �0.05), more hours in the
intervention (p �0.02), and prescription of HAART. These data
highlight the critical needs of HIV-positive
African-American and Latino YMSM and demonstrate that a
clinic-based YCM can be effective in stabilizing
hard-to-reach clients and retaining them in consistent HIV care.
Keywords: adolescents; MSM; HIV/AIDS; Latinos; African-
Americans; interventions
Introduction
National HIV and AIDS rates are elevated for
African-American and Latino youth which is consis-
tent with 2008 behavioral surveillance data in Los

4. Angeles County in which HIV prevalence rates were
17% for African-American and 13% for Latino
18�24-year-old young men who have sex with men
(YMSM) (Bingham & Sey, 2009; Centers for Disease
Control and Prevention [CDC], 2008). Youth are also
known to test late for HIV, delay seeking care for an
HIV infection following a positive HIV test, are at high
risk for dropping out of HIV care and have poor
adherence to antiretroviral treatment regimens (Cen-
ters for Disease Control and Prevention [CDC], 2005;
Johnson, Sorvillo et al., 2003; Rao, Kekwaletswe,
Hosek, Martinez, & Rodriguez, 2007; Rudy, Murphy,
Harris, Muenz, & Ellen, for the Adolescent Trials
Network for HIV/AIDS Interventions, 2009; Valleroy
et al., 2000). In addition, among a national sample of
HIV-positive 15�22-year-old YMSM, only 15% were
receiving HIV medical care and 8% were on antire-
troviral medications (Valleroy et al., 2000).
Given the difficulties faced by HIV-positive
youth, targeted interventions are needed to help

5. YMSM access and attend regularly scheduled pri-
mary HIV care appointments. The successful man-
agement of HIV disease requires frequent lifelong
appointments with an HIV primary care provider and
uninterrupted medication use, requirements that im-
pose substantial lifestyle changes for all HIV-positive
persons (Department of Health and Human Services
[DHHS], 2008). Given the many competing chal-
lenges that HIV-positive minority YMSM face in
their daily lives including cultural and community
stigma toward their sexual orientation and HIV
status, sexual identity issues, substance abuse, mental
illness, and basic subsistence concerns regarding
employment, education, transportation, and housing,
*Corresponding author. Email: [email protected]
AIDS Care
Vol. 23, No. 8, August 2011, 988�997
ISSN 0954-0121 print/ISSN 1360-0451 online
# 2011 Taylor & Francis

6. DOI: 10.1080/09540121.2010.542125
http://www.informaworld.com
http://www.informaworld.com
it is not surprising that additional support is needed
to help them manage their HIV infection (Eastwood
& Birnbaum, 2007; Mustankski, Garafalo, Herrick, &
Donenberg, 2007; Rao et al., 2007; Swendeman,
Rotheram-Borus, Comulada, Weiss, & Ramos,
2006; Valleroy et al., 2000).
Several interventions have helped at-risk youth
access and remain in general medical care and several
models of integrated medical care for HIV-positive
youth have been developed (Harris et al., 2003; Huba
& Melchior, 1998; Johnson, Sorvillo et al., 2003;
Schneir, Kipke, Melchior, & Huba, 1998; Woods
et al., 1998). There are few quantitative evaluations
of interventions, however, that target HIV-positive
Latino and African-American YMSM with the goal of

7. improving engagement and retention in HIV care. One
intervention that included primarily HIV-negative
at-risk youth (98%) used a combination of outreach,
mental health and case management services and
reported that retention in care was correlated with
more outreach and case management contacts (Harris
et al., 2003). Another case management program
found that addressing barriers related to concrete
needs helped improve retention in HIV care for a
mostly female and young African-American sample
(Johnson, Botwinick et al., 2003).
In 2004, the Health Resource and Services Ad-
ministration (HRSA) HIV/AIDS Bureau, Special
Projects of National Significance (SPNS) program
funded eight demonstration sites to identify, imple-
ment, and evaluate new models to provide outreach
and interventions for HIV-positive Latino and Afri-
can-American YMSM (Magnus et al., 2010). As one

8. of the demonstration sites, the Los Angeles County
Department of Public Health developed and evalu-
ated a clinic-based, youth-focused case management
intervention (YCM) to engage and retain Latino and
African-American YMSM in HIV primary care
services.
Methods
Participants were recruited from April 2006 through
April 2009 from HIV testing sites, sexually trans-
mitted disease clinics, support groups, community
colleges, clubs/bars, and two predominantly African-
American or Latino public HIV clinics in Los Angeles
County. Eligibility criteria included ages 13 to 23,
confirmed HIV-positive status, African-American or
Latino race/ethnicity, and biologically male. In addi-
tion, eligible participants had to be new to HIV care
or in intermittent care with less than two HIV
primary care visits in the previous six months.

9. YCM combined psychosocial case management,
treatment education/adherence support and HIV risk
reduction counseling to provide a client-centered
intervention through which care was coordinated
(Garland, Wohl, Boger, Carter, & Wu, 2006). The
clinic-based intervention was administered by two
para-professional, Bachelor-level case managers who
were trained and supervised by a licensed clinical
social worker to deliver the intervention in a non-
judgmental and culturally appropriate manner. The
participants met weekly with a case manager for the
first two months and monthly for the next 22 months.
At the first meeting, the case managers conducted
a comprehensive assessment to evaluate the partici-
pant’s medical, physical, psychosocial, environmental,
and financial needs. Using the stages of change model,
the case manager evaluated whether participants were
in one of the following stages with respect to initiation
and utilization of HIV care: pre-contemplation, con-
templation, preparation, action, or maintenance
(Coury-Doniger, Levenkron, McGrath, Knox, &
Urban, 2000; Elder, Ayala, & Harris, 1999). The
case manager and the participant developed an
individualized treatment plan to address identified
barriers to engagement and retention in HIV care
corresponding to their stage of change. To reduce
barriers to care, necessary referrals for services
were identified. Participants were provided $25 quar-
terly for their participation in the evaluation totaling
$200 for the 24-month intervention.
Participants were administered a standardized
baseline survey at enrollment by the case managers
to assess demographic and psychosocial characteris-
tics, sexual risk behaviors, substance use, depression,

10. and HIV testing and care history (Magnus et al.,
2010; Radloff 1977). Data on prescribed antiretrovir-
al therapy regimens, CD4 counts, and attendance to
HIV care appointments were abstracted from medical
records.
The primary study outcome was the proportion of
YMSM retained in HIV care at six months. For the
purposes of analysis, retention in care was defined as
attending two or more HIV care appointments in the
past six months which was based on the DHHS
treatment guideline recommendation during the study
period of at least one HIV medical care visit every
three�four months (DHHS, 2008). Odds ratios
(ORs), 95% confidence intervals (CI) and t-tests
were calculated to compare demographic and beha-
vioral characteristics for Latino vs. African-American
YMSM. Data on attendance and time in the inter-
vention, referrals provided and referrals completed
were compared using a binomial test of proportions.
Referral data were used to construct a dichotomous
composite variable to indicate whether a client had a
AIDS Care 989
critical and immediate need for housing, nutrition,
substance abuse treatment, and/or mental health
services, characteristics identified in other studies of
HIV-positive youth (Eastwood & Birnbaum, 2007;
Johnson, Botwinick et al., 2003).

11. Data on mean number of HIV care visits, missed
visits, percent of scheduled visits attended, and
retention in care were compared at three and six
months for all 61 patients. The same measures were
compared at baseline and six months for the 33
patients who had been in intermittent care prior to
enrollment in the intervention. These comparisons
were conducted using paired t-tests and McNemar’s
test for paired data. Finally, logistic regression
modeling was conducted to identify factors associated
with retention in HIV care at six months and the
unadjusted ORs and 95% CIs are presented. All
statistical analyses were performed with SAS version
9.1 (SAS 2007). The study was approved by the
institutional review boards at all of the participating
organizations and all clients provided written in-
formed consent in English or Spanish.
Results

12. The majority of the 61 participants were enrolled via
referral from friends who were in the intervention
(28%); 26% were enrolled through clinic in-reach by
the case manager to re-engage patients who had been
lost to care at the clinics; 18% were enrolled by clinic
providers and staff; 16% were enrolled by referral
from local HIV testing programs; 5% through out-
reach activities, and 7% from other programs.
As shown in Table 1, 54% of the participants were
African-American, 46% were Latino, and the mean
age at enrollment was 21. Participants identified
themselves as male (91%), transgender (3%), female
(3%), or other/refused to identify (3%). Sixty-one
percent identified as homosexual, 21% as bisexual,
and 11% as heterosexual.
Almost half (43%) of the participants reported
that they were still in school and more than three
quarters (84%) reported that they had completed at
least high school. Compared to Latinos, African-

13. Americans were significantly more likely to have
completed at least high school (OR �3.5, 95%
CI �1.03, 11.8). Overall, 42% were currently em-
ployed, with no statistical differences between Afri-
can-Americans and Latinos. Most participants
reported living with their family (57%) or friends
(29%) and African-Americans were significantly
more likely to report living with friends compared
to Latinos (OR �6.4, 95% CI �1.6�25.4).
Based on the CES-D screening tool administered
at time of enrollment, 66% of participants had
depressive symptoms, with CES-D scores of 16 or
more. In addition, African-Americans were three
times more likely to have depressive symptoms at
time of enrollment compared to Latinos (OR �3.5,
95% CI �1.01, 12.4).
Among African-Americans, 52% reported life-
time drug use and 54% of Latinos reported any
lifetime drug use. Although not shown in Table 1,
46% of the overall sample reported lifetime marijua-
na use, 13% stimulant use, 8% inhalant use, and 23%
other drugs.
As shown in Table 2, one (2%) participant exited
the study early and seven (11%) were lost to follow-
up. The participant who left the study early changed
his primary HIV care to another location; the seven
participants who were lost to follow-up were also lost

14. to care at the clinic and included five who moved out
of the area, one in jail and one whose whereabouts
was unknown.
Participants attended an average of 5.1 scheduled
YCM appointments, had on average 1.1 drop-in
visits, 0.9 telephone contacts, and 2.3 missed YCM
appointments. Overall, participants attended 61% of
scheduled YCM appointments. Participants received
a mean of 7.3 hours of the intervention with
Latino YMSM receiving statistically more hours of
the intervention compared to African-Americans
(p �0.001). The average YCM appointment lasted
67 minutes and the length of the appointment was
significantly longer for Latinos compared to African-
Americans (p �0.0003).
There were 238 total referrals provided in the first
six months of the intervention. The majority of
referrals were for housing (29%), mental health
services (13%), risk reduction education (11%), and
transportation assistance (8%). By the end of
six months, 163 of the 238 (68%) referrals were
completed. Of these, 78% of the housing, 65% of the
mental health, 77% of risk reduction education, and
68% of transportation referrals were completed.
African-Americans were more likely to receive
referrals for housing (pB0.0001) and transportation
(pB0.0001) compared to Latinos, and Latinos were
more likely than African-Americans to receive refer-
rals for risk reduction services (p �0.007), support
groups (p�0.03), and substance abuse services
(p �0.03).
At time of enrollment into the intervention, 86%

15. of the African-Americans and 71% of the Latinos
had a critical need for housing, nutrition, substance
abuse treatment, or mental health services.
From months 1�3, participants attended an
average of 2.2 HIV primary care appointments,
990 A.R. Wohl et al.
Table 1. Demographic characteristics of HIV-positive 18�24-
year-old men who have sex with men who participated in a
youth-focused case management intervention (N �61).
African-
Americans
(N�33)
Latinos
(N�28)
Total
(N�61)
N (%) N (%) N (%) OR (95% CI)
Sexual orientation
Homosexual/gay 20 (61) 17 (61) 37 (61) Referent
Heterosexual 1 (3) 6 (21) 7 (11) 0.2 (0.02�1.5)
Bisexual 10 (30) 3 (11) 13 (21) 2.5 (0.7�9.2)
Other/refused 2 (6) 2 (7) 4 (7) 1.0 (0.1�7.7)
Gender identity
Male 29 (88) 26 (93) 55 (91) Referent

16. Female 2 (6) 0 (0) 2 (3) �
Transgender 1 (3) 1 (4) 2 (3) 1.0 (0.6�16.2)
Other/refused 1 (3) 1 (4) 2 (3) 1.0 (0.1�16.2)
Education
a
Less than high school 5 (16) 11 (39) 16 (27) Referent
High school or more 27 (84)* 17 (61)* 44 (84)* 3.5
(1.03�11.8)*
Currently in school
b
No 17 (55) 16 (59) 33 (57) Referent
Yes 14 (45) 11 (41) 25 (43) 1.2 (0.4�3.4)
Currently employed
c
No 20 (67) 13 (48) 33 (58) Referent
Yes 10 (33) 14 (52) 24 (42) 0.4 (0.2�1.4)
Housing status
d
Family 17 (53) 15 (63) 32 (57) Referent
Friends 13 (41)** 3 (12)** 17 (29)** 6.4 (1.6�25.4)**
On own 2 (6) 5 (21) 7 (12) 0.5 (0.1�3.1)
Homeless/shelter 0 (0) 1 (4) 1 (2) �
Depression � CES-De
No 6 (22) 10 (50) 16 (34) Referent
Yes 21 (78)*** 10 (50)*** 31 (66)*** 3.5 (1.01�12.4)***

17. History of drug use
f
No 16 (48) 13 (46) 29 (48) Referent
Yes 17 (52) 15 (54) 32 (52) 0.9 (0.3�2.5)
Mode of HIV exposure
MSM 32 (100) 22 (78) 55 (90) Referent
MSM-IDU/IDU 0 (0) 1 (4) 1 (2) �
Heterosexual 0 (0) 3 (11) 3 (5) �
Other/NIR 0 (0) 2 (7) 2 (3) �
HIV care history
Previously in care 21 (64) 13 (46) 34 (56) Referent
New to care 12 (36) 15 (54) 27 (44) 2.0 (0.7�5.6)
Disclosed HIV status to friends
g
No 7 (23) 10 (36) 17 (29) Referent
Yes 24 (77) 18 (64) 42 (71) 1.9 (0.6�5.9)
Disclosed HIV status to family
h
No 14 (44) 15 (54) 29 (48) Referent
Yes 18 (56) 13 (46) 31 (52) 1.5 (0.5�4.1)
Disclosed HIV status to no one
i
No 25 (81) 20 (71) 45 (76) Referent
Yes 6 (19) 8 (29) 14 (24) 0.6 (0.2�2.0)

18. Mean (SD) Mean (SD) Mean (SD) t-Test p
Mean age (SD) 21 (1.4) 22 (1.7) 21 (1.6) �1.67 0.10
Mean age at first sexual intercourse (SD)
j
14.2 (2.5) 14.2 (2.6) 14.3 (2.5) 0.05 0.96
Mean number of partners in past 3 months (SD)
k
2 (2.2) 2 (2.2) 2 (3.1) �0.3 0.76
AIDS Care 991
attended 76% of scheduled HIV care appointments,
and 90% were retained in care (Table 3). During
months four through six, participants attended an
average of 1.7 HIV care appointments, attended 51%
of scheduled appointments, and 70% were retained in
care. There were statistically significant decreases in
all of the HIV care measurements between three and
six months.
Among the 33 participants who had been in
intermittent care, the average number of HIV care
visits increased from 0.2 to 5.5 between baseline and
six months (pB0.0001) (Table 4). In addition, the
percentage of scheduled HIV care visits attended
increased from 7% to 73% between baseline and
six months (pB0.0001) and 82% of those who had
been in intermittent care were retained in consistent
primary HIV care at six months.

19. The main factors associated with retention in HIV
care at six months was prescription of HAART,
increased number of intervention appointments and
more hours in the intervention (Table 5). A signifi-
cant dose-response trend was observed between
retention in HIV care and increasing number of
hours in the intervention (p �0.02) and increasing
number of intervention appointments (p �0.05).
Discussion
This is one of the first studies to evaluate the impact
of a youth-focused clinic-based intervention on
retention in HIV care for HIV-positive Latino and
African-American YMSM. Not only was the inter-
vention effective in engaging YMSM in consistent
HIV care, but two of the main factors associated with
retention in HIV care at six months were related to
the quantity or dose of the intervention received.
These data suggest that a time-intensive intervention
delivered by a non-judgmental and culturally compe-
tent peer is very effective in engaging at-risk Latino
and African-American YMSM in consistent HIV
care, particularly during the early months of HIV
care. Our findings are consistent with a study of
primarily HIV-negative at-risk youth that found that
more case management contact was associated with
improved retention in care (Harris et al., 2003).
The finding that YMSM who were prescribed
HAART were more likely to be retained in care is

20. a new finding as there are few similar interventions
that have been evaluated with respect to retention in
care. Given that the intervention was associated with
retention in care, intervention participants were also
probably more likely to be prescribed HAART by a
physician. Several studies have noted the difficulties
and challenges that youth face with adherence to
HAART, and it is likely that the skills needed for
YMSM to adhere to HAART are the same as those
needed to adhere to HIV care (Rao et al., 2007; Rudy
et al., 2009). It is notable that the percentage of
intervention participants on HAART (69%) was
considerably greater than that reported among
a national sample of HIV-positive YMSM (8%)
(Valleroy et al., 2000).
A large proportion of the YMSM were in a state
of crisis at time of entry into the intervention,
underscoring the strong need for youth-focused

21. interventions to help address barriers to engagement
and retention in HIV care. The severe subsistence and
psychosocial needs of the study group are consistent
with data from other studies of HIV-positive YMSM
in which a critical need for housing, substance abuse,
and mental health treatment were identified (East-
wood & Birnbaum, 2007; Johnson, Botwinick et al.,
2003; Mustankski et al., 2007; Valleroy et al., 2000).
Housing referrals were most common for the YMSM
which is consistent with other research in adolescent
and general HIV patient populations that has shown
that housing challenges are an obstacle to retention in
consistent HIV care and that housing assistance can
result in improved medical outcomes (Aidala, Lee,
Abramson, Messeri, & Siegler, 2007; Eastwood &
Birnbaum, 2007).
Table 1 (Continued )
Mean (SD) Mean (SD) Mean (SD) t-Test p

22. Average months between HIV diagnosis and
intervention enrollment (SD)
l
11.6 (19.5) 20.0 (29.9) 15.3 (24.7) �1.16 0.23
Mean CD4 cell count at enrollment (cells/mm
3
)
d
381 (180) 419 (213) 397 (194) �0.7 0.43
a
Data missing on one participant;
b
Data missing on three participants;
c
Data missing on four participants;
d
Data missing on five participants;
e
Data missing on 14 participants;
f
Includes marijuana, methamphetamine, amyl nitrate, and other
drugs;
g
Data missing on two participants;
h

23. Data missing on one participant;
i
Data missing on two participants;
j
Data missing on nine participants;
k
Data missing on six
participants; and
l
Data missing on nine participants. *p-value�0.04; **p-
value�0.009; ***p-value�0.046
Note: OR, odds ratio; CI, confidence interval; MSM, men who
have sex with men; IDU, injection drug use; NIR, no identified
risk; IQR,
interquartile range.
992 A.R. Wohl et al.
Other research has described the impact that an
HIV diagnosis can have on the mental health of gay
youth and given all of the psychosocial challenges
related to sexual identity, stigma and alienation by
friends and family, and the general vulnerabilities
attached to YMSM, it is not surprising that the

24. high rates of depression were observed (Donenberg
& Pao, 2005). The high prevalence of depression in
the African-Americans in the study group is con-
sistent with other research and underscores the
critical need for mental health interventions for
YMSM of color (Flicker et al., 2005; Johnson,
Botwinick et al., 2003; Lam, Naar-King, & Wright,
2007).
The prevalence of any lifetime drug use among
this group of YMSM was high (52%), but consistent
with the prevalence of lifetime substance use reported
in an adolescent HIV clinic population in Los Angeles
(44%) (Schneir et al., 1998). The proportion of
YMSM in the current study reporting marijuana
and methamphetamine use is also consistent with
individual drug use reported for HIV-positive YMSM
in California, however it was lower than lifetime drug
use reported from the eight sites participating in this

25. Table 2. Participation and referrals for 18�24-year-old HIV-
positive Latino and African-American MSM who participated in
a youth-focused case management intervention (YCM).
African-Americans
n �33
Latinos
n �28
Total
n�61 p-Valuea
Six month study status, n (%)
Completed 28 (85) 25 (89) 53 (87) 0.52
Exited study 1 (3) 0 (0) 1 (2) 0.32
Lost to follow-up 4 (12) 3 (11) 7 (11) 0.72
Six month YCM attendance (mean) n �33 n �28 n �61 p-
Valueb
Scheduled appointments attended 4.0 5.8 5.1 0.15
Drop-in visits 1.7 0.4 1.1 0.02
Telephone contacts 0.2 1.5 0.9 0.01
Missed appointments 1.2 3.5 2.3 0.003
Percent of scheduled appointments
attended
60% 63% 61% 0.77
Total hours of YCM received (mean) 5.1 9.7 7.3 0.001
Average duration of YCM appointment (mean

26. minutes)
52 84 67 0.0003
Total referrals provided, n (%) N�73 N�165 N�238 p-Value
b
Mental health services 6 (8) 26 (16) 32 (13) 0.12
Substance abuse services 0 (0) 10 (6) 10 (4) 0.03
Nutrition/food counselling 3 (4) 13 (8) 16 (7) 0.28
Housing 40 (55) 29 (18) 69 (29) B0.0001
Transportation 14 (20) 5 (3) 19 (8) B0.0001
Family/child related issues 0 (0) 2 (1) 2 (B1) 0.34
Financial/benefits 3 (4) 5 (3) 8 (3) 0.67
Employment assistance 0 (0) 5 (3) 5 (2) 0.13
Legal issues 0 (0) 5 (3) 5 (2) 0.13
Risk reduction education 2 (3) 24 (15) 26 (11) 0.007
Treatment advocate/pharmacy 2 (3) 12 (7) 14 (6) 0.17
Support groups 0 (1) 10 (6) 10 (4) 0.03
Dental services 1 (1) 2 (1) 3 (1) 0.92
General education 0 (0) 1 (B1) 1 (B1) 0.50
Other HIV care services 0 (0) 3 (2) 3 (1) 0.25
Other needs 2 (3) 14 (8) 16 (7) 0.23
Referrals completed at 6 months,
n (%)
55 (75) 108 (65) 163 (68) 0.13
Critical need for housing, nutrition, substance
abuse and/or mental health services at time

27. of enrollment, n (%)
30 (86) 24 (71) 54 (78) 0.13
Prescribed HAART during intervention, n (%) 25 (76) 17 (61)
42 (69) 0.21
a
Proportions compared using a binomial test of proportions.
b
Means compared using a t-tests.
AIDS Care 993
SPNS initiative (Magnus et al., 2010; Ruiz, Facer, &
Sun, 1998). Although substance use was common
among this study group of YMSM, drug use was not
associated with retention in primary HIV care once a
client was enrolled in the intervention.
The intervention was designed to include weekly
visits for the first two months followed by monthly
visits for the subsequent four months for a total of 12
case management visits. The average number of visits
was seven, however, suggesting that weekly visits are
not feasible for YMSM and that monthly visits are
more realistic for this population, given that many of
the YMSM were employed or in school. However, the
HIV care measures were statistically worse at
six months compared to three months, suggesting
that the intervention was most effective when the
contact with the case manager was most intense
during the early months of the intervention, lending
support for weekly visits up to at least six months. To

28. facilitate YCM attendance, the case managers had to
be flexible with intervention appointment times and
the clinics became flexible with HIV care visit
appointments as the YMSM would often miss
scheduled appointments and show up when no
appointment had been scheduled. Flexible scheduling
has been reported as a strategy to help YMSM
keep their appointments to clinical care and case
management (Johnson, Botwinick et al., 2003;
Magnus et al., 2010). These data suggest that clinic
scheduling flexibility will improve clinical care atten-
dance and health outcomes.
In addition to having flexible appointment times,
the case managers had multiple strategies for staying
in contact with their clients. They conducted a large
part of their communication with the YMSM using
cell phones and text messaging which was the most
effective communication strategy. While these meth-
ods of communication were not specifically evaluated
in this study, they have been found to be effective in
improving clinic attendance among general clinic
populations (Chen, Fang, Chen, & Dai, 2008; Leong
et al., 2006; O’Brien & Lazebnik, 1998). The $25
incentive was also helpful in motivating clients to
come to the appointments and incentives have been
demonstrated to improve retention in a variety of
health care interventions (Giuffrida & Torgerson,
1997).
The limitations to this study include the relatively
small sample of YMSM which prevented the calcula-
tion of adjusted OR estimates. Identification of HIV-
positive Latino and African-American YMSM both
locally and nationally for this SPNS initiative was

29. extremely challenging, even when using multiple
outreach strategies. Second, the YMSM in this study
Table 3. Retention in HIV care at 3 and 6 months among HIV-
positive 18�24-year-old MSM in a youth-focused case
management intervention (n �61).
3 months 6 months p-Value
Mean number of HIV care visits in the past
3 months
2.2 1.7 0.04
a
Mean missed HIV care visits in past 3
months
0.6 1.0 0.06
a
Percent of scheduled HIV care visits
attended in the past 3 months
76% 51% B0.0001
b
Percent retained in HIV care in past 3
months
90% 70% 0.0005
b
a
p-Value for paired t-test;

30. b
p-Value for McNemar’s test for paired data.
Table 4. Retention in HIV care at 6 months among 18�24-year-
old HIV-positive MSM in a youth-focused case
management intervention who had been in intermittent care (n
�33).
Baseline (n �33) 6 months (n �33) p-Valuea
Mean attended HIV care visits in
past 6 months
0.2 5.5 B0.0001
Mean missed HIV care visits in past
6 months
0.4 2.0 0.0001
Percent of scheduled HIV care visits
attended in past 6 months
7% 73% B0.0001
Percent retained in HIV care at
6 months
0% 82% �
a
p-Value from results of paired t-test.
994 A.R. Wohl et al.

31. were recruited using a convenience sampling ap-
proach and the findings may not be representative
of all HIV-positive African-American and Latino
YMSM. In addition, while there was no control
group for comparison, participants served as their
own controls when the analyses of outcomes pre and
post intervention were conducted. Finally, the sus-
tainability of the intervention beyond the 6 months of
follow-up is important but has not been evaluated to
date.
Given the growing number of HIV-positive
YMSM and the challenges that they face in testing
early for HIV and accessing and staying in consistent
care, innovative, culturally appropriate care retention
interventions are necessary. The data presented here
demonstrate that it is possible to create an effective,
clinic-based intervention to address the barriers that

32. YMSM encounter in engaging in consistent HIV care.
Acknowledgements
This study was supported by the Health Resources and
Services Administration (HRSA) Special Projects of Na-
tional Significance Initiative H97HA03783-04-00 and
California HIV/AIDS Research Program grant CH05-
LAC-617. The authors would like to acknowledge the
study staff who delivered the project intervention: Amin
Lewis, Christopher Moore, and Kathy Bouch. In addition,
the authors would like to acknowledge and thank the study
participants and medical providers for their time.
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AIDS Care 997
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44. download, or email articles for individual use.
Section 1: Background Information
Across the United States, vast numbers of young children are
influenced by one or more hazard variables that have been
connected to scholastic disappointment and weakness. Among
them is a family financial hardship, which is reliably related to
negative results. Children in low-wage families have been found
to show less in psychological and behavioral improvement
contrasted with their associates in higher-pay families. There
are about 24 million children under age 6 in the United States.
Many young kids are experiencing childhood in families
encountering financial hardship. 11.4 million children live in
low-pay or low-income households. This incorporates 12
percent, almost three million children, who live with a
compelling need. Between 3 and 16 percent of young children
are influenced by destitution mixed with another dangerous
element, including guardians without a secondary school degree
(1.7 million), high schooled mother (very nearly 0.7 million)
and living in a family without English speakers (0.9 million).
Almost four million kids (16 percent) reside in families or
underneath the government destitution level and headed by a
single guardian. Scholarly difficulties are often profoundly
seeded and start in essential and optional school, which when
left unaddressed, regularly prompts remediation at the
postsecondary level. There are a few components that add to
low-pay children entering school with poor math and reading
abilities. Without a head start program, kids face many risk
factors such as school dropout, teen pregnancy, and crime. This
paper aims to focus on some of the many risk factors facing
these kids including, language barrier, socioeconomic status,
transportation, and lack of health education.
Risk Factors:
Language barrier is met when children from low-pay families
hear upwards of 30 million fewer words by the age of four than

45. their higher-wage peers. In homes where instruction is not
needed, particular requirements should set for children from
birth where dialect abilities, dialect introduction, perusing
desires, an affection for learning, and an association can make
between scholarly achievement and future performance. English
Language Learners are characterized as having English as a
second dialect and predominately a dialect other than English at
home. While there are much prosperous and advantaged English
dialect learners in schools, 66 percent of English dialect
students originate from low-wage families, and part of English
dialect learners in evaluations pre-K to fifth grade have
guardians who did not move on from secondary school. Around
8 percent of children selected in U.S. schools are English
dialect learners. Research demonstrates that English dialect
learner children are substantially less liable to score at or above
proficient levels in both math and perusing/dialect expressions.
Socioeconomic status is one factor that guarantees that
each kid has the chance to exceed expectations in both
scholastics and life. Be that as it may, many elements keep
preventing from serving this part. One of the principle variables
is the disparity of early adolescence training got by kids in
various financial status, which is to a significant degree critical
in molding a child’s prosperity scholastically and monetarily in
later years. Financial status is regularly measured as a mix of
training, wage, and occupation. This implies the individuals
who are from lower financial foundations experience the ill
effects of low-level instruction, little pay, and have low-paying
employments. Subsequently, children from lower financial
foundations don't have access to quality early youth education,
making them fall behind scholastically. Top notch early
adolescence instruction, or preschool for kids between the ages
three and five, can altogether affect a child's prosperity
scholastically and monetarily in their grown-up years.
Transportation also plays a major role in this because, in
low-wage regions of the nation, even neighborhood schools
might be a long way from children because of school

46. terminations for poor execution, low enlistment, or spending
issues. Whenever separation or wellbeing concerns block
schedule to class, it can be hard to organize exchange
transportation. The transportation itself, for example, paying for
a taxi or transport can be costly. Additionally, it can be
troublesome or outlandish for families who are tending to
family obligations to leave their homes unattended. Some low-
wage guardians penance higher-paying, longer-hour
employments with a specific end goal to set aside a few minutes
to take their children to and from school, which adds to an
absence of intergenerational versatility.
Lack of health education is where lower pay and fewer
assets imply that individuals with less instruction will probably
live in low-wage neighborhoods that do not have the assets for
good education wellbeing. These areas are regularly monetarily
underestimated and isolated and have more hazard elements for
weakness, for example, less access to general stores or different
wellsprings of solid sustenance and an oversupply of fast food
eateries and outlets that advance undesirable nourishments.
Provincial and low-pay territories, which are more populated by
individuals with less instruction, regularly experience the ill
effects of deficiencies of essential consideration doctors and
other social insurance suppliers and offices.
Other successful programs at Head Start:
The program that has managed to do this is early childhood
program what they do is they offer help for low-income
families. This program is a government supported system which
is controlled by non-benefit offices, for example, group activity
offices, neighborhood training organizations and others. It's
offered to children of 3 to 5 years of age from those families
who have little pay and can't permit themselves to pay for
instruction. Guardians are additionally required to be present
during the time spent teaching. They may act both as the
teachers and as the members in the system. The early childhood
program gives early adolescence instruction, which will help to
establish the framework of getting new information at school. It

47. is much less demanding for those children who have a few
abilities in early age to make their insight more significant in
school. To give kid’s availability for school as well as physical,
social and emotional improvement, to help guardians be better
instructors for their children. I observed this program, and I can
say that every one of the kids is separated by age from 3 to 5.
There are a few age bunches. There are a few idiosyncrasies in
the educational programs arrangement in each of the gatherings.
The staff in the Head Start Program goes about as accomplices
to guardians who take a dynamic part in the instructional
procedure of their kids. The team incorporates the instructors as
well as different experts, for example, a dialect discourse
advisor and physical preparing teachers. The guardians are
welcome to wind up Head Start volunteers with a specific end
goal to take in more about the improvement of their youngster
and to raise their fearlessness.
Family child care partners aim to help family kid care
suppliers to give brilliant child care administrations, with an
emphasis on moving them toward social accreditation models.
By satisfying this reason, it is the vision of Family child care
partners to guarantee that family child care suppliers create and
apply their insight, and get to be mindful of and use accessible
backings, in ways that cultivate the sound development and
improvement of the newborn children, babies, and preschoolers
in their consideration. They also give one-on-one, home-based
instruction and help individualized to the particular needs and
quality change objectives of the supplier. Guardians’
contribution is expected to show trustees about instructive
exercises they can do at home. Social help signifies group
outreach, referrals; family requires evaluations, giving data
about available group assets.
Section 2: Purpose of the Grant
The Administration for Children and Families (ACF)
reports the accessibility of $5,372,757 to be intensely granted
with the end goal of extending access to top notch, thorough
early learning administrations for low-salary transient and

48. occasionally qualified babies and little children and their
families. This subsidizing opportunity is being made accessible
under the Consolidated Appropriations Act, 2016 (Pub. L. 114-
113). ACF requests applications from open substances,
including states; private, non-benefit associations, including
group-based or religious associations; or revenue was driven
offices that meet the qualification for applying as expressed in
Section 645A of the Head Start Act. Particular objectives
include:
Deciding qualification, enlisting, selecting, enlisting, and
checking participation, guaranteeing the most defenseless
youngsters are served. Giving far-reaching early adolescence
instruction and advancement benefits that advance the physical,
social, passionate, intellectual, and dialect improvement of
youthful kids and families amid the early years by giving
proper: EHS bunch sizes and instructor/guardian to-youngster
proportions; Qualified and prepared staff to guarantee warm and
constant connections between guardians, kids, and families that
are vital to learning and advancement for babies and little
children; Parent contribution in their kids' learning and
advancement; Learning open doors for newborn children and
little children to develop and create in warm, sustaining, and
comprehensive situations; Culturally and phonetically
responsive administrations that bolster congruity of
consideration between the home environment of the child and
the project; Health and wellbeing of enlisted kids; Health
advancement by giving exhaustive wellbeing, psychological
wellness, and oral wellbeing administrations for kids, and
helping families to recognize and get to a therapeutic home to
guarantee continuous consideration; Nutrition, incorporating
investment in the Child and Adult Food Care Program and
courses of action for nursing moms who bosom nourish in focus
based projects and family tyke care homes; Inclusion of at-
danger kids with handicaps by guaranteeing: Services address
the issues of kids with inabilities and their families, including
the foundation and execution of methods to distinguish such

49. kids and plans to facilitate with projects giving administrations
as depicted in Section 645A(b)(11) of the Head Start Act;
Providing family organizations to guardians with
administrations that: Ensuring people group associations
Providing regulatory and budgetary administration, including
Working with families to address their transportation needs.
Guaranteeing that the focuses and family childcare homes meet
wellbeing and security prerequisites and are authorized for
newborn children and little children.
Section 3: Resources
Most of the assets spent keeping up with the brilliant
educators required by the Head Start Act. Lead instructors must
have a four-year certification and aide teachers must have an
initial learning accreditation. As the wages in the field stay
much lower than likewise credentialed positions in the K-12
framework, it is progressively testing to keep remarkable
educators on board for long not to give incremental raises or
typical cost for essential items modification. Grantees are
likewise constrained in the utilization of system dollars (topped
at 15%) to cover a large number of managerial expenses. These
costs, which are generally on the ascent, include:
· Transportation- Grantees give transport administrations to
enlisted y and families where fundamental.
· Energy costs - warming/cooling, lighting; fuel costs impact
the cost of nourishment and different products.
· Health Insurance- Employee medical coverage expenses are on
a steady and soak rise.
· Capital costs - including transports, real office hardware,
utilities, working, and keeping up structures and classroom
space
· Organization- including arranging and coordination; planning,
bookkeeping, examining; and administration of acquiring,
property, finance, and staff.
Section 4: Summary
There is different in accomplishment between low-salary
family and high-pay family. Children who originate from

50. wealthy families perform higher in school compare to lower
wage families. Around 82 percent of the secondary level
graduates who originate from high-wage families go to
universities, in contrast with 52 percent of alumni from low-pay
families. A study appeared by Ludwig, J and Phillips, D. A
demonstrated that in the course of the most recent 20 years the
percent of kids from higher pay who finished school expanded
by 21 percent, while low pay expanded by just 4 percent.
The study shows that this cycle proceeds and stays with
children in school. The rate of White graduates who were school
prepared in English was 77 percent, though 35 percent of
African American were qualified. Children who originate from
families with low-salary are going to pre-K class with
instructors who are unpracticed and do not offer the courses
expected to prep them for school. These schools do not have the
assets to prepare children for education. The percentage of 3-6-
year-olds enlisted in school is 58 percent, while Hispanic is 19
percent and black at 14 percent. Changes in the legislature and
instruction framework should be made to close the gap in
schools. It is crucial to expanding scholarly accomplishment.
All children ought to be held to the same requirements and give
the same assets and devices to help them through K-12 grade.
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52. AIDS Education and Prevention, 24(5), 408–421, 2012
© 2012 The Guilford Press
408
Dawn K. Smith and Lauren Toledo are affiliated with the
Division of HIV/AIDS Prevention, National
Center for HIV, Viral Hepatitis, STD, and TB Prevention,
Centers for Disease Control and Prevention
(CDC), Atlanta, Georgia. Lauren Toledo is also with ICF
International in Atlanta. Donna Jo Smith, Mary
Anne Adams, and Richard Rothenberg are with the Institute for
Public Health at Georgia State University
in Atlanta.
The findings and conclusions in this report are those of the
authors and do not necessarily represent the
official position of the Centers for Disease Control and
Prevention.
The authors have no financial conflicts of interest.
Address correspondence to Dr. Dawn K. Smith, Centers for
Disease Control and Prevention, 1600 Clifton
Road, Mail Stop E-45, Atlanta, GA 30333. E-mail:
[email protected]
SMITH ET AL.
AFRICAN-AMERICAN PrEP ATTITUDES
ATTITUdES ANd PROGRAM PREFERENCES
OF AFRICAN-AMERICAN URBAN
YOUNG AdULTS ABOUT PRE-EXPOSURE
PROPHYLAXIS (PrEP)
Dawn K. Smith, Lauren Toledo, Donna Jo Smith,
Mary Anne Adams, and Richard Rothenberg
We elicited attitudes about, and service access preferences for,

53. daily oral
antiretroviral pre-exposure prophylaxis (PrEP) from urban,
African-
American young men and women, ages 18–24 years, at risk for
HIV
transmission through their sexual and drug-related behaviors
participating
in eight mixed-gender and two MSM–only focus groups in
Atlanta, Geor-
gia. Participants reported substantial interest in PrEP associated
with its
perceived cost, effectiveness, and ease of accessing services and
medication
near to their homes or by public transportation. Frequent HIV
testing was
a perceived benefit. Participants differed about whether risk-
reduction be-
haviors would change, and in which direction; and whether
PrEP use would
be associated with HIV stigma or would enhance the reputation
for PrEP
users. This provides the first information about the interests,
concerns, and
preferences of young adult African Americans that can be used
to inform
the introduction of PrEP services into HIV prevention efforts
for this critical
population group.
BACKGROUNd
Recent clinical trials have demonstrated the safety and efficacy
of daily oral antiret-
roviral pre-exposure prophylaxis (PrEP) for men who have sex
with men (MSM)
(Grant et al., 2010) and heterosexual men and women (Baeten,

54. J., 2011; Thigpen
et al., 2011). An additional trial testing its efficacy for injection
drug users (IDU) is
underway. Final analyses are not yet available for two trials in
which a PrEP arm was
stopped early at an interim data safety monitoring board review
because of inability
AFRICAN-AMERICAN PrEP ATTITUDES 409
to detect efficacy of PrEP (futility) (Family Health
International, 2011; Microbicides
Trial Network, 2011).
It is timely to focus consideration of the requirements for safe
and effective
delivery of PrEP to the populations where most incident
infections are occurring
in the United States. In 2009, there were an estimated 48,100
new HIV infections
(Prejean et al., 2011) of which 64% were among MSM (2% of
the U.S. popula-
tion), 27% among heterosexuals, and 9% were attributed to
injection drug use.
African Americans (14% of the U.S. population) accounted for
44% of the new
HIV infections; Hispanics (16% of U.S. population) accounted
for 20%; and whites
for 32%. Among MSM, African Americans accounted for 37%
of new infections
while among heterosexually acquired infections African
Americans accounted for
60%. While overall, HIV incidence remained stable from 2006
to 2009, by race and

55. risk group, African-American MSM are the only group to
experience a significant
increase in new HIV infections. Specifically, among African-
American MSM aged
13–29, new infections increased 48% over that four-year period.
Although PrEP trials have shown efficacy for both MSM and
heterosexual
women and men, eight of the ten published surveys assessing
awareness and atti-
tudes toward the use of PrEP in U.S. populations were
conducted exclusively with
men who have sex with men (MSM) (Barash & Golden, 2010;
Golub, Kowalczyk,
Weinberger, & Parsons, 2010; Koblin et al., 2008; Liu et al.,
2008; Mansergh et
al., 2010; Mehta et al., 2011; Mimiaga, Case, Johnson, Safren,
& Mayer, 2009;
Voetsch, Heffelfinger, Begley, Jafa-Bhushan, & Sullivan,
2007); one with a primarily,
but not exclusively, homosexual/bisexual male population
(Kellerman et al., 2006),
and only one with a largely heterosexual STD clinic population
(Whiteside, Harris,
Scanlon, Clarkson, & Duffus, 2011). These surveys elicited
responses to discrete
choice questions about anticipated use of PrEP and awareness of
PrEP and were all
conducted while trials were underway and efficacy results were
not yet known. The
inclusion of African-American participants and younger persons
in these surveys
varied widely (Table 1).
One qualitative study conducted in New York City included
questions about

56. PrEP and other biomedical prevention methods for a subset of
72 participants in a
web-based study (Nodin, Carballo-Dieguez, Ventuneac, Balan,
& Remien, 2008) of
MSM Internet users who reported barebacking (intentional
condomless anal inter-
course). MSM of any HIV status were included, 39% of
respondents were under the
age of 30 years, 21% were African American, and 28% were
Hispanic. Results were
not analyzed by race/ethnicity. Very few had ever heard of
PrEP, and once it was
explained to them, they reported attitudes toward it that were
mixed.
Another qualitative study conducted in Los Angeles used semi-
structured in-
terviews with 25 gay and bisexual HIV-serodiscordant male
couples to learn about
motivating factors for future PrEP uptake for HIV prevention
(Brooks et al., 2011).
Couples who had been together for a minimum of twelve months
were included.
The mean age of participants was 38.2 years; 30% of
participants were Hispanic,
26% were African American. Participants identified potential
motivating factors for
adoption of PrEP as protection against HIV infection, reduced
fear about HIV in-
fection, and the opportunity to engage in unprotected sex.
Potential concerns and
barriers included the cost of PrEP, side effects, adverse effects
of intermittent use, and
accessibility of PrEP.
Because PrEP rests on the prescription of antiretroviral

57. medication to HIV-un-
infected persons, a well-targeted PrEP program will require: (1)
outreach to HIV-
uninfected persons at high risk of HIV acquisition; (2)
screening for both clinical
410 SMITH ET AL.
T
A
B
L
E
1
.
P
o
p
u
la
ti
o
n
C
h
ar
ac
te

58. ri
st
ic
s
in
P
u
b
li
sh
ed
S
u
rv
ey
s
o
f
P
rE
P
A
w
ar

59. en
es
s
an
d
A
tt
it
u
d
es
,
U
n
it
ed
S
ta
te
s,
2
0
0
4
–2

60. 0
1
1
St
u
d
y
H
IV
t
ra
n
sm
is
si
o
n
r
is
k
gr
o
u
p
(s
)

61. L
o
ca
ti
o
n
V
en
u
e
G
en
d
er
s
in
cl
u
d
ed
N
%
A
fr
ic

62. an
-A
m
er
-
ic
an
%
H
is
p
an
ic
M
ea
n
o
r
M
ed
ia
n
A

63. ge
(
ye
ar
s)
H
IV
S
ta
tu
s
V
o
et
sc
h
e
t
al
.
(2
0
0
7
)

64. M
SM
M
u
lt
is
ta
te
M
in
o
ri
ty
g
ay
p
ri
d
e
ev
en
ts
M
4
6
4

65. 7
8
1
1
M
ed
ia
n
3
2
A
n
y
L
iu
e
t
al
.
(2
0
0
8
)

66. M
SM
C
al
if
o
rn
ia
P
u
b
li
c
ve
n
u
es
,
ST
D
c
li
n
ic
s,

67. C
B
O
,
ci
rc
u
it
p
ar
ti
es
M
1
8
1
9
3
–8
1
5
–1
8
M
ed
ia

68. n
3
3
–3
6
N
eg
at
iv
e,
u
n
k
n
o
w
n
(b
y
ve
n
u
e)
(b

69. y
ve
n
u
e)
(b
y
ve
n
u
e)
K
o
b
li
n
e
t
al
.
(2
0
0
8
)
M

70. SM
N
ew
Y
o
rk
C
it
y
P
u
b
li
c
ve
n
u
es
M
5
0
3
2
3
2
7

71. M
ed
ia
n
~
3
0
A
n
y
M
im
ia
ga
e
t
al
.
(2
0
0
9
)

72. M
SM
B
o
st
o
n
P
u
b
li
c
ve
n
u
es
,
In
te
rn
et
,
h
ea
lt
h

73. c
en
te
r,
C
B
O
a
n
d
co
m
m
u
n
it
y
re
fe
rr
al
s
M
2
2

74. 7
4
4
1
0
M
ea
n
4
1
N
eg
at
iv
e
B
ar
as
h
&
G
o
ld
en

75. (2
0
1
0
)
M
SM
Se
at
tl
e
G
ay
p
ri
d
e
ev
en
t
an
d
S
T
D

76. cl
in
ic
M
2
1
5
N
R
N
R
M
ed
ia
n
3
6
N
eg
at
iv
e
G

77. o
lu
b
e
t
al
.
(2
0
1
0
)
M
SM
N
ew
Y
o
rk
C
it
y
B
eh
av

78. io
ra
l
in
te
rv
en
ti
o
n
t
ri
al
M
1
8
0
2
1
2
8
M
ea
n
2

79. 9
N
eg
at
iv
e,
u
n
k
n
o
w
n
M
an
se
rg
h
e
t
al
.
(2
0

80. 1
0
)
M
SM
M
u
lt
is
ta
te
B
eh
av
io
ra
l
in
te
rv
en
ti
o
n
t

81. ri
al
M
1
0
1
1
3
3
1
8
N
R
N
eg
at
iv
e,
p
o
si
ti
ve
M
eh

82. ta
e
t
al
.
(2
0
1
1
)
M
SM
N
ew
Y
o
rk
C
it
y
B
at
h
h
o
u
se

83. s
M
5
5
4
8
%
3
1
M
ea
n
4
0
A
n
y
K
el
le
rm
an
e
t

84. al
.
(2
0
0
6
)
6
2
%
g
ay
,
1
8
%
b
is
ex
u
al
,
1
8
%
h
et

85. er
o
se
x
u
al
M
u
lt
is
ta
te
M
in
o
ri
ty
g
ay
p
ri
d
e
ev
en

86. ts
8
9
%
M
,
7
%
F
,
3
%
T
G
1
0
4
1
4
3
1
9
N
R
A
n

87. y
W
h
it
es
id
e
et
a
l.
(2
0
1
1
)
9
0
%
h
et
er
o
se
x
u

88. al
,
5
%
h
o
m
o
se
x
u
al
,
3
%
b
is
ex
u
al
So
u
th
C
ar

89. o
li
n
a
ST
D
c
li
n
ic
5
6
%
M
,
4
3
%
F
4
0
5
8
9
%
N
R

90. M
ed
ia
n
2
4
A
n
y
N
o
te
s.
P
rE
P
=
p
re
ex
p
o
su
re
p

91. ro
p
h
yl
ax
is
;
M
=
m
al
e;
F
=
f
em
al
e;
T
G
=
t
ra
n
sg

92. en
d
er
p
er
so
n
;
N
R
=
n
o
t
re
p
o
rt
ed
AFRICAN-AMERICAN PrEP ATTITUDES 411
and behavioral appropriateness of PrEP medication; (3) repeat
HIV testing to ensure
that newly HIV–infected persons are not started or continued on
an inadequate

93. antiretroviral regimen; and 4) periodic counseling to reinforce
continued HIV risk-
reduction practices as well as adherence to PrEP medication
(Centers for Disease
Control and Prevention et al., 2011). The complexity of
providing PrEP to persons
at highest risk for HIV acquisition points to the need for further
assessment of indi-
vidual and sociocultural concerns and hopes and their
incorporation into the design
and implementation of PrEP-related program services.
This is the first qualitative, focus group study to elicit attitudes
about, and pref-
erences for, PrEP services from a key group of potential users
in the United States:
inner-city, African-American young adult men and women at
risk for HIV transmis-
sion because of their sexual and drug-related behaviors.
METHOdS
PARTICIPANTS AND PROCEDURE
Three experienced social science researchers conducted focus
groups between
June and August of 2009 using a qualitative, semi-structured
interview guide. A
total of 10 focus groups were conducted. Eight focus groups
were attended by both
men and women, and two groups were composed of men who
have sex with men
(MSM) only. Focus group participants for the eight mixed-
gender focus groups were
recruited in conjunction with another ongoing study being
conducted with residents

94. of eight zip codes with high HIV and STD prevalence in
Atlanta, Georgia. Par-
ticipants for the two MSM–only focus groups were recruited
from two community-
based HIV program centers for MSM of color. To be eligible for
the study, partici-
pants must have been between the ages of 18 and 24 years and
live within one of the
eight designated zip codes. To participate in the MSM focus
group, participants had
to self-identify as MSM. Table 2 includes the demographic data
for the participants.
Outreach study staff assessed participant eligibility, described
the study, and
invited those expressing interest to a focus group session. The
focus groups were
held at a variety of locations throughout Atlanta in the
participants’ communities,
ranging from community centers to Georgia State University.
Focus groups lasted
between 1.5 and 2 hours and were audio-recorded. Georgia State
University’s Insti-
tutional Review Board granted IRB approval for the study.
Participants were asked
for verbal consent, and confidentiality was stressed at the
beginning and end of the
sessions. Waiver of signature to document informed consent
was appropriate for this
TABLE 2. Participant Demographics, PrEP Focus Group Study,
Atlanta, 2009
MSM Focus Groups Mixed Gendered Focus Groups
2 Focus Groups, N = 19 8 Focus Groups, N = 58

95. N (%) N (%)
Gender
Male 19 (100) 23 (39.7)
Female 0 35 (60.3)
Race/Ethnicity
African American 19 (100) 58 (100)
Mean Age, years 21 21
412 SMITH ET AL.
study because (1) it involved only minimal risk of harm to
participants and involved
no procedures for which written consent is normally required
outside the study, and
(2) the signature would be the only record linking the
participant to the research
and would constitute a small risk of harm resulting from an
unintended breach of
confidentiality.
DATA ANALYSIS
All focus group recordings were transcribed verbatim and
uploaded into NVivo,
a qualitative data management and analysis software (QSR

96. International Pty Ltd.
Version 8, 2008). This analysis focused on participants’
responses related to PrEP. A
general inductive approach was used to identify themes related
to attitudes toward
PrEP. One researcher was primarily responsible for developing
the codebook and
coding the transcripts. The initial codebook was reviewed by
three other researchers
familiar with the data, and all four researchers agreed upon the
final codebook. A
qualitative data analyst then applied thematic codes to the
transcribed focus group
discussions. Once coding was complete, frequently occurring
and co-occurring codes
were reviewed by interview question in order to identify
prevalent themes within
each section of the interview guide for both the mixed gendered
and MSM focus
groups. Emerging themes for the mixed gendered and MSM
focus groups were then
compared. Similar themes were discussed in all focus groups;
differences between the
MSM groups and mixed gendered groups are identified below.
RESULTS
Five main themes emerged from the discussions about PrEP:
general acceptance of
PrEP as a method of HIV prevention; potential facilitators to
taking PrEP; poten-
tial barriers to taking PrEP; the potential effects of PrEP on
sexual risk-taking; and
health care access.
GENERAL ACCEPTANCE OF PrEP

97. The majority of participants reacted positively to the idea of
taking a daily pill
to prevent HIV acquisition. One woman noted, “You might be
having sex with the
same person, you might trust them, but you’ll never know what
that person is doing,
so to be on the safe side, most definitely I’d take them pills.”
An exchange between participants in one focus group illustrates
their percep-
tion that PrEP would also be widely accepted in their
communities:
Female: I think it make a lot of people in society to come
forward to take that medicine.
Male: Yes….
Female: You’d get like everybody out here taking it.
Male: Everybody.
Female: You would have a big supply.
Female: For real. If it was free, I don’t think nobody would turn
that down.
Female: Everybody be out there trying to get them a pill.
If free, an effective pill to prevent HIV was widely accepted in
all focus groups.
Participants were also generally amenable to the requirement
that PrEP users take

98. AFRICAN-AMERICAN PrEP ATTITUDES 413
a rapid oral HIV test every three months. Most participants felt
that the testing
requirement would not be a barrier to taking PrEP, and others
mentioned that they
already participated in regular testing. One male from the MSM
focus group felt
that the quarterly testing would be an extra incentive to taking
PrEP noting, “It’d
be good because it’s good to know your status, especially if
you’re sexually active.”
FACILITATORS TO PrEP UPTAKE AND MAINTENANCE
Convenience of locations that dispense PrEP was identified as
an important fa-
cilitator to potential PrEP uptake and maintenance. Most
participants were willing
to pick up PrEP prescriptions at a variety of locations
described, including health
department clinics and community pharmacies. Some
participants were willing to go
to hospitals or hospital clinics for PrEP, but others felt the wait
time was too long at
those locations. Participants wanted to access PrEP at locations
that were familiar,
close to their normal travel routes, and could provide fast
service. Many participants
noted the convenience of pharmacies located close to public
transportation stops, as
many did not have access to cars or did not want to spend
money on gas.
Male: I’m just being honest. It’s more convenient. If it’s out of

99. the way, I’m not go-
ing bother, especially since I smoke weed…[If I had to go to]
the hospital like that, I
wouldn’t even bother because of going through all that traffic
and what you have to go
through to get there, I won’t bother.
Female: I think going to a hospital would be a disadvantage
because it would be people
waiting in line and things like that, but going to a pharmacy,
you like give them your
prescription and tell them what you need and you get out of
there. With going to a hos-
pital or a clinic, you have to wait.
Male: If it’s not within MARTA [Metropolitan Rapid Transit
Authority, public trans-
portation], I’m not going go. And if it ain’t there when I go
there, I might not come back
because I be done waste my time because I be feeling upset that
I done come down here.
Y’all know these folks want this medicine and stuff, and y’all
ain’t got it and ran out and
stuff. Y’all need to let somebody know.
Mail order prescriptions were mentioned in some groups, but
were controversial.
Some participants liked the idea of having medications
delivered to their homes
while others worried about privacy issues.
Male (MSM Group): I wouldn’t go too far because…I think they
should be able to mail
it to you. Just like these new pills like they advertise on TV,
radio—call them and they
mail it to you—[there should be] a way to call him and say “I

100. want an order of it.”
Female: Yeah, but you don’t want everybody to know, you
know what I’m saying, you
don’t want everybody to know what you get…‘cause you know,
it’s some people…they
might go in your mailbox…
BARRIERS TO PrEP UPTAKE AND MAINTENANCE
Throughout the focus groups, participants identified several
potential barriers
to taking PrEP. Barriers discussed included side effects,
medication cost, partial effec-
tiveness, low perceived personal susceptibility to contracting
HIV, burden of taking
a daily medication, reaction of peers to taking HIV medication,
and for the MSM
groups only, fear of risk compensation (decreased use of
condoms and other safer
sex practices).
414 SMITH ET AL.
Side Effects. One of the most frequently mentioned barriers to
PrEP acceptance was
possible side effects. PrEP safety studies had not been
completed at the time of the
focus groups, and moderators asked participants to assume that
PrEP would be safe
to use. Despite this, participants expressed their concern. One
man noted, “With
every drug you have a down. If I’m sick or what, and if I take
medicine and it makes

101. me feel worse than what it is and it’s supposed to make you feel
better, but if it makes
you feel weak or drowsy, or dizzy headed, I’m not going to take
it again.”
Another MSM participant shared, “I look at the TV and they
have all of these
pills for other illnesses and there’s all [of] these side effects.
That is just ridiculous
and [the side effects are] worse than…[the symptoms] you have.
Then, to make it
worse, they’ll say it could cause death. That’s what’s sticking
out in my head.”
Cost. As participants were asked about the acceptability of
taking PrEP at increasing
medication price points ($25, $50, and $75 per month), fewer
said they were willing
or able to pay for PrEP medication. Most participants felt that a
cost of $50 or more
per month would make PrEP inaccessible to them. Twenty-five
dollars was a more
acceptable price point, but would still be difficult for many of
them.
Female: If I don’t got it [the money], then no, I wouldn’t buy it
every month. I’d
probably skip a month. If I had them, I’d take them, but if I
don’t have the mon-
ey to get them, then I can’t get them, but if it’s free, of course.
I’d be the first one
in line to get them. But if I have to pay for them, I have to think
about that.
Female: And I be looking at my last $25 like, “Do I go get my
nails done? Or do I need
to go get these pills? Up, I’m about to get my nails done.”

102. Male (MSM Group): Me, personally, well, it depends on if this
was free and it wasn’t
free, if it was orderable for me because one, I don’t know if I
have insurance and ain’t
got a job, so like the money that I do get, go towards school,
but if it was free, I would
take it.
Female: Now, I can probably scrape up the 25, but I probably
couldn’t scrape up no 50
a month because the struggle is just a little too much right now.
Partial Effectiveness. Some participants doubted PrEP’s
potential to effectively pro-
tect against HIV and wanted to see the evidence before agreeing
to take PrEP. Others
wondered if PrEP would be more effective for different types of
people, or if effec-
tiveness would decline over time. When participants were asked
about the accept-
ability of PrEP at specific effectiveness rates (75% and 50%), as
the effectiveness de-
creased, fewer participants were willing to take PrEP.
Participants who rejected PrEP
at reduced effectiveness felt that the risk of failure was too
great. For example, one
female participant said, “I don’t really know, because [if you
take a 50% effective
pill], you can still get it, there’s a 50% chance to...That’s 50/50,
like, you still get it.”
A male participant shared,
Just like I said, I wouldn’t take it then because I mean, if it was
like 95% to 100%,

103. maybe [I] would. If it anything less than that, no because that’s
too big of a space, too
big of a chance of me to catch something, either way. So I
mean, I wouldn’t even put
myself at risk. Even though I said I would use protection either
way, I still wouldn’t do
it. It’d be a waste of money.
Despite reminders from moderators that PrEP should be used in
conjunction with
consistent condom use, some participants compared the
effectiveness of PrEP to that
of condoms and preferred to use the more effective method. As
one man said, “If
AFRICAN-AMERICAN PrEP ATTITUDES 415
you can’t give me the same percentage as a condom—I need that
99.9% or nothing
at all.”
In contrast, participants who were willing to take PrEP at
reduced effectiveness
rates focused on the added protection the pill would provide.
One woman explained,
However you put it…everything that they coming out with ain’t
100% anyway. The
condoms ain’t 100%, birth control, none of that…Yeah, as long
as you putting some-
thing in your body that’s helping you, regardless if it was 50
[percent effective] or 25
[percent effective], at least you trying…You got a better chance
of not catching that.

104. Low Perceived Susceptibility to Contracting HIV. Some
participants thought they
did not need PrEP because they felt their risk for acquiring HIV
infection was low,
either due to condom use or monogamy. The following quotes
illustrate this percep-
tion of low risk:
Female 1: See, I’m not in high risk, so I don’t need the pill, so I
wouldn’t take the pill
because I’m not in high risk.
Female 2: These are for girls who like all in the streets
prostituting.
Female 3: That’s what I was saying, I don’t really need them,
I’m not going to pay that
much money.
Female 2: If I’m out having sex with 25 different men every
month, then yeah, I would
take it, but right now, it’s just me and him. From what I know.
Male (MSM Group): I would not take it because I feel like…me
personally, if I’m doing
everything that I’m supposed to do and that I have to do then, I
don’t have to worry
about catching it. I feel like from using condoms or if I’m not
having sex at all or if I’m
practicing safe sex with one partner and going to the clinic and
they’re getting tested, I’m
getting tested, I won’t have to worry about anything like that,
so I wouldn’t take the pill.
Burden of Taking a Daily Medication. Many participants

105. questioned their ability to
take a daily medication for an extended period of time. For
some, recognition that
they would forget to take a pill every day discouraged them
from wanting to take
PrEP.
Female: I don’t know. I barely take my birth control every day,
so I don’t know if I could
take a pill every day. I’ll try but it’s hard to take a pill
constantly every day. Medicine for
the rest of your life? I don’t know about that.
Male: I wouldn’t take it every day…Probably like, I take it like
every week or every 2
days or something. Yeah, every day anymore can do something
else. You might drunk
and smoke and you might have a side effect, drowsiness or
something, drink or some-
thing, that too much though…I just wouldn’t feel right taking it
every day.
Reaction of Peers to Taking HIV Medication. A potential barrier
that emerged
throughout the focus group discussions was how other friends
and family members
would react to a participant taking PrEP medication. Some
participants noted that
they would avoid PrEP due to the embarrassment it could cause.
For these partici-
pants, taking PrEP could be interpreted as an admission that one
engages in risky
behaviors or lead to a perception that they have HIV.
Participants shared that HIV
stigma was prominent in their communities. One participant
even stated that he

106. almost skipped the focus group because he did not want people
to think he was
involved with AIDS research.
416 SMITH ET AL.
Male: I wasn’t going to come down here [to the focus group
today], ‘cause I’m like, shit,
someone might think that I got AIDS. I just came to show up,
but I don’t be participating
in no AIDS nothing because I don’t mean to put myself in no
category…
Male: And people are ignorant. You know what I’m saying. It’s
going put a irrelevant
stigma on you that’s not even going be there. You trying to help
yourself and help ev-
eryone else. Like say, you help that next person and if that
person get help then he’ll
help that next person and they’ll just network. But if people are
ignorant, they’ll be like,
“ooo, you taking [PrEP]. Oh, you must got it [HIV]. Why you
taking it then? You ain’t
got no reason to take [it].”
Female: I’m talking about these pills I’m a have a problem
with...these pills itself is going
to cause so much chaos…can’t nobody tell you about your
neighborhood. You going
have a problem taking them pills if everybody ain’t taking them,
[even though] you do-
ing something good. This is a positive thing. You understand
me?

107. Female: They will flip the whole story. You understand me?
Prevention don’t mean noth-
ing.
Female: [People will say,] “Oh, that girl got AIDS.”
Other participants, however, felt that taking PrEP would be a
source of pride. These
participants said they would not have a problem letting others
know they were tak-
ing PrEP because it would make them cool or because they felt
they were doing a
service to the community by preventing HIV spread.
Female: I want to say this. If I was taking the pill…I wouldn’t
be ashamed to take one.
I give [it to] my friend, hey man, like “take this” because I want
to help everybody out
around me. Especially if they ain’t got it and it going protect
them. I’m fixing to give my
friend, “Hey, y’all better take this!”
Female: You know what? I’d probably sit [my PrEP pills] on the
dresser, so those who
come can see…”This is what I’m taking so I can make sure that
I don’t get…something
bad”…Those who come in…should know. “This is what I’m
doing to make sure I don’t
get those kind of germs.”
Male: It’s sav[ing] my life. It’s pimping. I’m cool for taking
this.
Specific Fear of Risk Compensation. Although there were
participants in all groups
who anticipated some risk compensation as a result of taking

108. PrEP, only participants
in the MSM focus groups mentioned this as a reason to not take
PrEP. Some MSM
participants felt that taking PrEP would negatively influence
their current risk reduc-
tion practices and as a result wished to avoid using the pill.
Male (MSM Group): No, I wouldn’t take it to prevent myself
from getting HIV. Some
people get a little risky with it…because y’all explain it to us,
how it helps us in the long
run, but most people would use that as an excuse to say, if they
have something, we
don’t have to worry about it.
Male (MSM Group): My concern is, it might make me kind of
lax about my safe sex
practices, to be honest with you…I might just get into it one
night and be like, “oh, I
took that pill.” I’m just being honest.
EFFECTS OF PrEP ON SEXUAL RISK TAKING
In the broader context of possible changes in sexual risk
behaviors anticipated
while taking PrEP, across all focus groups, participants had
differing opinions about
whether change would occur and, if so, in which direction.
AFRICAN-AMERICAN PrEP ATTITUDES 417
When directly asked if they would be able to consistently use
condoms while
taking PrEP, the majority of participants felt that PrEP would

109. not have any positive
or negative effect on condom use: those who previously used
condoms would con-
tinue condom use and those who did not use condoms would not
start using them
as a result of using PrEP.
Female: You just asked if we participated in the program [to
take PrEP], how easy would
it be to use a condom? It’s the same, it’s no different. If we
already used the condoms
before we started taking the pill, it’s no different. It wouldn’t
be difficult. It would just
be like, I already used them before, now I have this pill and I’m
still going to take them.
Others explained that they would still want to prevent acquiring
other sexually
transmitted infections or becoming pregnant. One woman said,
“I would still use
condoms because the pill is for HIV, it’s not for trichomoniasis
and herpes and geni-
tal warts and any other STD that you could get it from. So I
would still use protec-
tion.”
A minority of participants felt that taking PrEP, especially if
highly effective,
would result in risk compensation, such as having sex without
condoms or increas-
ing their number of sexual partners. Some of these participants
saw potential simi-
larities between taking hormonal birth control and taking PrEP
and said that it
would be difficult to continue using condoms while taking
PrEP, especially if they

110. had one monogamous or primary partner.
Female: I don’t know because, that I don’t know. If you taking
a pill that’s saying you
ain’t going [to get] HIV and then you got one boyfriend. Every
time ya’ll ain’t going use
no condom, because that pill going kick in. That’s just like that
same way people feel
about birth control. When a girl on birth control, a boy don’t
want to use no condom
because they feel like you on birth control. So I think it, I don’t
know, it be easy for me
though ‘cause I still use a condom, but then again, it probably
be a little difficult.
Male: It be hard. It be more difficult because I’m taking a pill
that’s 100% effective, I’m
taking it every day, so what’s the use of a condom? ‘Cause a
condom, they say kind of
take away from the pleasure when you doing it, so if I can take
this pill to prevent what
this condom prevent, why am I even going deal with the
condom?
Only one participant expressed the belief that taking PrEP
would be a reminder
about HIV that would encourage her to use condoms more
frequently.
HEALTH CARE ACCESS
A majority of participants shared that they either had no
insurance coverage or
had some form of public insurance for themselves or their
family. Very few partici-
pants said they had private insurance through their employer or

111. through a parent.
Although most groups had participants who utilized health
departments, hospital
clinics, or community health centers for health care, a few
participants said they
consulted private physicians for health concerns. The majority
of participants said
they went to emergency rooms when ill or injured. Reasons
discussed for choosing
emergency rooms included the ability to be seen by a doctor
without having to pay
up front, proximity to one’s home, and the perception that
emergency rooms provide
high quality care and offer services not provided by health
clinics. The following
quotes represent what many participants shared about accessing
emergency rooms:
418 SMITH ET AL.
Female: I don’t get no kind of Medicaid or anything. I get like a
reduced fee if I go to a
public health center or something like that. But since I been 18,
uh-uh, nothing free. So
that’s my reasoning for going close by home, you know, or
anywhere in the area, but
[County Hospital A] is closer than anything around me.
Female: Ain’t nothing in life free. If you go to the emergency
room, they’ll see you.
They’re going to send you a bill, you know what I’m saying?
But, you know, that’s your
opportunity to get seen without…going through the process of
having to pay full price

112. to go for an appointment. That’s just your other way of getting
around, to do what
you’ve got to do. Because you’ve got to do what you’ve got to
do for yourself.
Male: They [County Hospital B] got the best doctors. They got
everything…They might
be a little slow, but they make sure you get took care of.
Infrequently, concerns about the interests for pharmaceutical
companies were ex-
pressed.
Male: I probably would try to be against it [PrEP] because if
they going get their folks
to coming up with a pill to prevent it, they pretty much have a
cure for it…they got that
close to making a pill that prevents you from getting HIV, they
damn well can have some
type of pill that can cure…I mean, y’all just need to come on
and come out with it. I
don’t advocate it. I be like, “y’all just trying to make money
with this mess.”
dISCUSSION
In these focus groups of young African-American men and
women, substantial inter-
est in PrEP was reported among both heterosexuals and MSM.
Interest in PrEP was
associated with its cost, effectiveness, and ease of accessing
services and medication
near to their homes or by public transportation.
In this young, socio-demographically disadvantaged population,
reported ac-

113. cess to private or employer health insurance was minimal while
use of publicly
funded insurance and health service providers was common.
Concerns about the
cost of PrEP were raised although some felt they could afford to
contribute a mod-
est amount (e.g., $25) as might be required for a medication or
clinic visit co-pay or
sliding-fee charge.
Rather than viewing frequent HIV testing as a barrier to its use,
several young
adults felt that PrEP would either be a stimulus for or add to
their current practice
of repeated HIV testing.
In light of the severity of the HIV epidemic among younger
African Ameri-
cans and the resulting need for expanded access to intensive
HIV prevention, it is
reassuring that there were few concerns expressed about the
safety of antiretroviral
medications for PrEP that were of specific concern for African
Americans, as has
sometimes been found with respect to treatment of HIV
infection. Similarly, there
was no expression of concerns about possible intentional harm
to the community by
making PrEP available (e.g., “conspiracy theories”).
This group may have an information network relatively distinct
from others in
which concerns about the intent of pharmaceutical companies
have been expressed.
While for some there was concern about possible HIV stigma
accruing to PrEP us-

114. ers, others felt that acknowledged PrEP use would provide a
reputational advantage.
AFRICAN-AMERICAN PrEP ATTITUDES 419
However, some reports raised serious issues that need to be
addressed in educa-
tion and counseling efforts that will accompany the introduction
of PrEP. Some par-
ticipants expressed a willingness to share their PrEP medication
with others. PrEP
users will need a clear understanding of the risks posed by
sharing or borrowing
antiretrovirals for PrEP use. These include effects on reduced
adherence and effec-
tiveness when medication supply is diminished by sharing or
other than daily use
and the increased safety risk for medication use by persons
without required screen-
ing (e.g., HIV status, renal function). In addition, for some
focus group participants,
there was overestimation of the efficacy of condoms, the
efficacy of PrEP, and the
expected duration of PrEP use (e.g., “rest of my life”)—all of
which will need to be
clarified before a fully informed decision about whether to take
PrEP can be ob-
tained by a clinical provider.
The findings of this study should be considered in light of its
limitations. Focus
groups were conducted with a relatively small number of
participants in a single
large urban community (Atlanta), and interviews were

115. completed before any efficacy
trial results were known, so participants were considering
hypothetical levels of ef-
ficacy, safety, and cost. However, the selection of African-
American young adults
from neighborhoods with high HIV and STD prevalence
addresses a deficit in our
understanding of the perceptions of a critical population that
needs increased deliv-
ery of intensive HIV prevention methods like PrEP. Now that
trial results are avail-
able and implementation is beginning in some communities,
additional studies of the
interests, concerns, and preferences of African-American young
adults in a wider set
of communities is warranted. New studies are needed to identify
the broad range of
concerns, program preferences, and opportunities that should
inform the introduc-
tion and scale-up of PrEP services into HIV prevention efforts,
especially for MSM.
All the heterosexual efficacy trials are being conducted in
Africa, and the iPrEx
efficacy trial with 2,499 MSM in six countries included 35
African Americans from
U.S. sites (Grant et al., 2010). There were two PrEP safety
studies with MSM in
the United States—Project Prepare (Eunice Kennedy Shriver
National Institute of
Child Health and Human Development (NICHD), 2011) and the
CDC TDF safety
trial (Centers for Disease Control and Prevention, 2011)—that
together included ap-
proximately 86 African-American MSM. Domestic PrEP surveys
and qualitative in-

116. terview studies underrepresent African-American MSM and
heterosexuals (see Table
1) when compared to the racial/ethnic composition of the U.S.
epidemic. This under-
representation restricts what we can know now about
acceptability, adherence, risk
behavior, and PrEP program preferences among African-
American heterosexuals
and MSM, two critical populations for reducing HIV incidence
in the United States.
The successful introduction of clinically delivered HIV
prevention methods for
African-American young adults at risk of HIV acquisition
requires an understanding
not only of their current beliefs about HIV acquisition and its
related sexual risk and
protective behaviors, but also their beliefs about medication use
and challenges and
opportunities related to their access to health care. This study
begins to inform PrEP
education and delivery strategies tailored to young African-
American heterosexuals
and MSM, a population in high need of intensive HIV
prevention.
420 SMITH ET AL.
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