When can get my assignment back?

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, Nationa\�l 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 Hea\�lth at Georgia State University in Atlanta.

The findings and conclusions in this report are those of the authors a\�nd 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 Clifto\�n 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, 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 participati\�ng 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 medica\�tion near to their homes or by public transportation. Frequent HIV testing wa\�s a perceived benefit. Participants differed about whether risk-reductio\�n 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, concer\�ns, and preferences of young adult African Americans that can be used to inform \� the introduction of PrEP services into HIV prevention efforts for this c\�ritical 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, 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 ar\�m 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 o\�ccurring in the United States. In 2009, there were an estimated 48,100 new HIV in\�fections (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 dru\�g use.

African Americans (14% of the U.S. population) accounted for 44% of th\�e 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 infection\�s while among heterosexually acquired infections African Americans account\�ed for 60%. While overall, HIV incidence remained stable from 2006 to 2009, by \�race and 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 an\�d atti- tudes toward the use of PrEP in U.S. populations were conducted exclusiv\�ely with men who have sex with men (MSM) (Barash & Golden, 2010; Golub, Kowalc\�zyk, 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 (Whitesi\�de, 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 PrEP and other biomedical prevention methods for a subset of 72 particip\�ants in a web-based study (Nodin, Carballo-Dieguez, Ventuneac, Balan, & Remien, 2008) of MSM Internet users who reported barebacking (intentional condomless ana\�l 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. Resul\�ts 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 includ\�ed.

The mean age of participants was 38.2 years; 30% of participants were Hi\�spanic, 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 con\�cerns 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 medication to H\�IV-un- infected persons, a well-targeted PrEP program will require: (1) outre\�ach to HIV- uninfected persons at high risk of HIV acquisition; (2) screening for \�both clinical 410 SMITH ET AL. TABLE 1. Population Characteristics in Published Surveys of PrEP Awareness and Attitudes, United States, 2004–2011 StudyHIV transmission risk group(s) Location VenueGenders included N % African-Amer - ican % Hispanic Mean or Median Age (years) HIV Status Voetsch et al. (2007) MSM MultistateMinority gay pride events M46478 11Median 32 Any Liu et al. (2008) MSM CaliforniaPublic venues, STD clinics, CBO, circuit parties M 18193–8 15–18Median 33–36 Negative, unknown (by venue) (by venue)(by venue) Koblin et al. (2008) MSM New York CityPublic venues M50323 27Median ~30 Any Mimiaga et al. (2009) MSM BostonPublic venues, Internet, health center, CBO and community referrals M 22744 10Mean 41 Negative Barash & Golden (2010) MSM SeattleGay pride event and STD clinic M 215NR NRMedian 36 Negative Golub et al. (2010) MSM New York CityBehavioral intervention trial M18021 28Mean 29 Negative, unknown Mansergh et al. (2010) MSM MultistateBehavioral intervention trial M101133 18NR Negative, positive Mehta et al. (2011) MSM New York CityBathhouses M5548% 31Mean 40 Any Kellerman et al. (2006) 62% gay, 18% bisexual, 18% heterosexual Multistate Minority gay pride events 89% M, 7% F, 3% TG 1041 43 19NR Any Whiteside et al. (2011) 90% heterosexual, 5% homosexual, 3% bisexual South Carolina STD clinic 56% M, 43% F40589% NRMedian 24 Any Notes. PrEP = preexposure prophylaxis; M = male; F = female; TG = transgender \�person; NR = not reported AFRICAN-AMERICAN PrEP ATTITUDES 411 and behavioral appropriateness of PrEP medication; (3) repeat HIV test\�ing to ensure that newly HIV–infected persons are not started or continued on an in\�adequate antiretroviral regimen; and 4) periodic counseling to reinforce continu\�ed HIV risk- reduction practices as well as adherence to PrEP medication (Centers fo\�r 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 a\�bout, 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 betw\�een June and August of 2009 using a qualitative, semi-structured interview g\�uide. A total of 10 focus groups were conducted. Eight focus groups were attende\�d 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 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 c\�ommunity- 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 Universit\�y’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 N (%) N (%) Gender Male 19 (100)23 (39.7) Female 035 (60.3) Race/Ethnicity African American 19 (100)58 (100) Mean Age, years 2121 412 SMITH ET AL.

study because (1) it involved only minimal risk of harm to participant\�s 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 b\�reach of confidentiality. DATA ANALYSIS All focus group recordings were transcribed verbatim and uploaded into N\�Vivo, a qualitative data management and analysis software (QSR International \�Pty Ltd.

Version 8, 2008). This analysis focused on participants’ responses re\�lated to PrEP. A general inductive approach was used to identify themes related to attitu\�des toward PrEP. One researcher was primarily responsible for developing the codebook a\�nd 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-occur\�ring codes were reviewed by interview question in order to identify prevalent theme\�s 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 PrE\�P; poten- tial barriers to taking PrEP; the potential effects of PrEP on sexual ri\�sk-taking; and health care access. GENERAL ACCEPTANCE OF PrEP 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 pe\�rson 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 pe\�rcep- 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 foc\�us groups.

Participants were also generally amenable to the requirement that PrEP users take AFRICAN-AMERICAN PrEP ATTITUDES 413 a rapid oral HIV test every three months. Most participants felt that th\�e 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 gro\�up felt that the quarterly testing would be an extra incentive to taking PrEP no\�ting, “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 impor\�tant fa- cilitator to potential PrEP uptake and maintenance. Most participants we\�re willing to pick up PrEP prescriptions at a variety of locations described, inclu\�ding 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 we\�re familiar, close to their normal travel routes, and could provide fast service. Man\�y participants noted the convenience of pharmacies located close to public transportati\�on 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 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 h\�ave 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 controv\�ersial.

Some participants liked the idea of having medications delivered to thei\�r 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 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 eff\�ec- 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 note\�d, “With every drug you have a down. If I’m sick or what, and if I take medici\�ne and it makes 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 o\�f 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 in\�creasing 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 o\�f $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? O\�r do I need to go get these pills? Up, I’m about to get my nails done.” 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 th\�e 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%, 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 conjunctio\�n 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. Low Perceived Susceptibility to Contracting HIV. Some participants thought they did not need PrEP because they felt their risk for acquiring HIV infecti\�on 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 questioned their ability to take a daily medication for an extended period of time. For some, recogn\�ition 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, dri\�nk 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 n\�oted 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 almost skipped the focus group because he did not want people to think h\�e 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 l\�ike, 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 ign\�orant, 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?

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 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 cu\�rrent 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 a\�nd 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 anti\�cipated 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 wh\�ile taking PrEP, the majority of participants felt that PrEP would not have any positiv\�e or negative effect on condom use: those who previously used condoms woul\�d 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 sti\�ll going to take them. Others explained that they would still want to prevent acquiring other s\�exually 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 pote\�ntial 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 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 pil\�l 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 re\�minder 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 cove\�rage 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 through \�a parent.

Although most groups had participants who utilized health departments, h\�ospital 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, y\�ou know, that’s your opportunity to get seen without…going through the process of having t\�o pay full price 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 d\�o 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 th\�is 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 P\�rEP 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- 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, severa\�l young adults felt that PrEP would either be a stimulus for or add to their cur\�rent 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 prevent\�ion, it is reassuring that there were few concerns expressed about the safety of an\�tiretroviral medications for PrEP that were of specific concern for African Americans, as has sometimes been found with respect to treatment of HIV infection. Similar\�ly, there was no expression of concerns about possible intentional harm to the com\�munity 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 ex\�pressed.

While for some there was concern about possible HIV stigma accruing to P\�rEP us- 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 ot\�hers. PrEP users will need a clear understanding of the risks posed by sharing or b\�orrowing antiretrovirals for PrEP use. These include effects on reduced adherence and effec- tiveness when medication supply is diminished by sharing or other than d\�aily use and the increased safety risk for medication use by persons without requ\�ired 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 o\�f 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 limita\�tions. Focus groups were conducted with a relatively small number of participants in \�a single large urban community (Atlanta), and interviews were 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 defici\�t in our understanding of the perceptions of a critical population that needs inc\�reased deliv- ery of intensive HIV prevention methods like PrEP. Now that trial results are avail- able and implementation is beginning in some communities, additional stu\�dies 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, especial\�ly for MSM. All the heterosexual efficacy trials are being conducted in Africa, an\�d the iPrEx efficacy trial with 2,499 MSM in six countries included 35 African Ame\�ricans from U.S. sites (Grant et al., 2010). There were two PrEP safety studies wi\�th MSM in the United States—Project Prepare (Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), 2011) and the CDC TDF saf\�ety trial (Centers for Disease Control and Prevention, 2011)—that toget\�her included ap- proximately 86 African-American MSM. Domestic PrEP surveys and qualitati\�ve in- 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 metho\�ds 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 het\�erosexuals and MSM, a population in high need of intensive HIV prevention. 420 SMITH ET AL.

REFERENCES Baeten, J., & Celum, C., on behalf of The Partners PrEP Study Team. (2011). Antiretroviral pre-exposure prophylaxis for HIV-1 Pre- vention among heterosexual African men and women: The Partners PrEP Study. Re- trieved August 29, 2011, from http://www.

hivforum.org/storage/hivforum/documents/ PREPAUG1911/006_celum.pdf Barash, E. A., & Golden, M. (2010). Awareness and use of HIV pre-exposure prophylaxis among attendees of a Seattle Gay Pride event and sexually transmitted disease clin- ic. AIDS Patient Care and STDs, 24(11), 689-691. doi: 10.1089/apc.2010.0173 Brooks, R. A., Kaplan, R. L., Lieber, E., Lando- vitz, R. J., Lee, S. J., & Leibowitz, A. A.

(2011). Motivators, concerns, and barriers to adoption of preexposure prophylaxis for HIV prevention among gay and bisexual men in HIV-serodiscordant male relation- ships. AIDS Care, 23(9), 1136-1145. doi:

10.1080/09540121.2011.554528 Centers for Disease Control and Prevention. (2011). Extended safety study of tenofovir disoproxil fumarate (TDF) among HIV-1 negative men. Retrieved November 2, 2011, from http://clinicaltrials.gov/ct2/show/NCT 00131677?term=grohskopf&rank=2 Centers for Disease Control and Prevention, Smith, D. K., Grant, R. M., Weidle, P. J., Lansky, A., Mermin, J., & Fenton, K. A. (2011).

Interim guidance: Preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. Morbidity and Mortality Weekly Reports, 60(3), 65-68.

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). (2011). Pre-exposure prophylax- is in YMSM. Retrieved November 2, 2011, from http://clinicaltrials.gov/ct2/show/ NCT01033942?term=ATN+082&rank=1 Family Health International. (2011). FEM-PrEP – Update, June 2011. Retrieved August 29, 2011, from http://www.fhi.org/NR/ rdonlyres/e7eqslera65wohq74f5qmeur - r4ohgbrofzuxlu3ulos6my24emn6qseom - 7eysom3cxrvmbesounwfd/FEMPrEPUp- dateJune2011PPT.pdf Golub, S. A., Kowalczyk, W., Weinberger, C. L., & Parsons, J. T. (2010). Preexposure pro- phylaxis and predicted condom use among high-risk men who have sex with men.

Journal of Acquired Immune Deficiency Syndromes, 54(5), 548-555. doi: 10.1097/ QAI.0b013e3181e19a54.

Grant, R. M., Lama, J. R., Anderson, P. L., Mc- Mahan, V., Liu, A. Y., Vargas, L., . . . Glid- den, D. V. (2010). Preexposure chemopro- phylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 363(27), 2587-2599. doi:

10.1056/NEJMoa1011205 Kellerman, S. E., Hutchinson, A. B., Begley, E. B., Boyett, B. C., Clark, H. A., & Sullivan, P.

(2006). Knowledge and use of HIV pre- exposure prophylaxis among attendees of minority gay pride events, 2004. Journal of Acquired Immune Deficiency Syndromes, 43(3), 376-377.

Koblin, B. A., Murrill, C., Xu, G., Camacho, M., Liu, K. L., Raj-Singh, S., & Torian, L. (2008). Awareness of HIV prevention strategies under development: Word on the street. Journal of Acquired Immune De- ficiency Syndromes, 48(2), 232-234. doi:

10.1097/QAI.0b013e318174391e Liu, A. Y., Kittredge, P. V., Vittinghoff, E., Ray- mond, H. F., Ahrens, K., Matheson, T., . .

. Buchbinder, S. P. (2008). Limited knowl- edge and use of HIV post- and pre-exposure prophylaxis among gay and bisexual men.

Journal of Acquired Immune Deficiency Syndromes, 47(2), 241-247.

Mansergh, G., Koblin, B. A., Colfax, G. N., McK- irnan, D. J., Flores, S. A., & Hudson, S. M.

(2010). Preefficacy use and sharing of an- tiretroviral medications to prevent sexually transmitted HIV infection among US men who have sex with men. Journal of Acquired Immune Deficiency Syndromes, 55(2), e14- 16. doi: 10.1097/QAI.0b013e3181f27616 Mehta, S. A., Silvera, R., Bernstein, K., Holzman, R. S., Aberg, J. A., & Daskalakis, D. C.

(2011). Awareness of post-exposure HIV prophylaxis in high-risk men who have sex with men in New York City. Sexually Transmitted Infections, 87(4), 344-348.

doi: 10.1136/sti.2010.046284 Microbicides Trial Network. (2011). MTN state- ment on decision to discontinue use of oral tenofovir tablets in VOICE, a major HIV prevention study in women. Retrieved Sep- tember 29, 2011, from http://www.mtn- stopshiv.org/node/3619 Mimiaga, M. J., Case, P., Johnson, C. V., Safren, S. A., & Mayer, K. H. (2009). Preexposure antiretroviral prophylaxis attitudes in high- risk Boston area men who report having sex with men: Limited knowledge and experi- ence but potential for increased utilization after education. Journal of Acquired Im- mune Deficiency Syndromes, 50(1), 77-83.

doi: 10.1097/QAI.0b013e31818d5a27 Nodin, N., Carballo-Dieguez, A., Ventu- neac, A. M., Balan, I. C., & Remien, R. (2008). Knowledge and acceptabil- ity of alternative HIV prevention bio- medical products among MSM who bare- AFRICAN-AMERICAN PrEP ATTITUDES 421 back. AIDS Care, 20(1), 106-115. doi:

10.1080/09540120701449096 Prejean, J., Song, R., Hernandez, A., Ziebell, R., Green, T., Walker, F., . . . Group, H. I. V. I.

S. (2011). Estimated HIV incidence in the United States, 2006–2009. [Research Sup- port, Non-U.S. Gov’t Research Support, U.S. Gov’t, P.H.S.]. PLoS One, 6(8), e17502.

doi: 10.1371/journal.pone.0017502 Thigpen, M.C., Kebaabetswe, P. M., Smith, D.K., Segolodi, T.M., Soud, F.A., Chillag, K., Chirwa, L.I., Kasonde, M., …& Paxton, L.A., for the TDF2 Study Group. (2011).

Daily oral antiretroviral use for the preven- tion of HIV infection in heterosexually ac- tive young adults in Botswana: Results from the TDF2 study. Retrieved August 29, 2011, from http://www.hivforum.org/storage/ hivforum/documents/PREPAUG1911/004_ paxton.pdf Voetsch, A. C., Heffelfinger, J. D., Begley, E. B., Jafa-Bhushan, K., & Sullivan, P. S. (2007).

Knowledge and use of preexposure and postexposure prophylaxis among attendees of Minority Gay Pride events, 2005 through 2006. Journal of Acquired Immune De- ficiency Syndromes, 46(3), 378-380. doi:

10.1097/QAI.0b013e3181576874 Whiteside, Y. O., Harris, T., Scanlon, C., Clarkson, S., & Duffus, W. (2011). Self-perceived risk of HIV infection and attitudes about preex- posure prophylaxis among sexually trans- mitted disease clinic attendees in South Car - olina. Aids Patient Care and STDs, 25(6), 365-370. doi: 10.1089/apc.2010.0224 This article has been cited by:

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