Abstract
Patient-provider communication is a key factor affecting HIV pre-exposure prophylaxis (PrEP) awareness and access among Black sexual minority men (SMM). Optimizing patient-provider communication requires a deeper understanding of communication dynamics. In this study, we investigated the perspectives of both HIV-negative/status-unknown Black SMM and practicing community healthcare providers regarding patient-provider communication about PrEP and sexual health. We conducted eleven semi-structured qualitative focus groups (six with Black SMM; five with providers) in the Northeastern USA and thematically analyzed transcripts. A total of 36 Black SMM and 27 providers participated in the focus groups. Our analysis revealed points of alignment and divergence in the two groups’ perspectives related to patient-provider communication. Points of alignment included: (1) the importance ascribed to maximizing patients’ comfort and (2) belief in patients’ right to non-discriminatory healthcare. Points of divergence included: (1) Black SMM’s preference for sexual privacy versus providers’ preference that patients share sexual information, (2) Black SMM’s perception that providers have an ethical responsibility to initiate conversations about PrEP with patients versus providers’ perception of such conversations as being optional, and (3) Black SMM’s preference for personalized sexual health conversations versus providers’ preference for standardized conversations. Findings underscore a need for providers to offer more patient-centered sexual healthcare to Black SMM, which should entail routinely presenting all prevention options available—including PrEP—and inviting open dialogue about sex, while also respecting patients’ preferences for privacy about their sexuality. This approach could increase PrEP access and improve equity in the US healthcare system.
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Data Availability
Full interview transcripts and individual-level questionnaire data have not been made publicly available to protect the privacy of participants. All excerpts of the transcripts that are relevant to the paper (including those not quoted within the paper) are available from the corresponding author upon request.
Notes
We use the term sexual minority men (SMM) throughout this work to refer to “men whose sexual identities, orientations, or behaviors differ from the heterosexual majority” (Timmins & Duncan, 2020, p. 1667), including when referring to study samples or surveillance categories originally labeled as men who have sex with men (MSM).
Two research team members conducted a sixth group with community healthcare providers in Massachusetts, but this group was excluded from the analytic sample because it was considerably shorter (began late and terminated prematurely due to health center schedule constraints), was repeatedly interrupted, was held substantially later than the first five (summer of 2016 vs. 2015), and was considerably larger in size (n = 18).
Further inspection of questionnaire and transcript data from the three providers who reported specializing in women’s healthcare indicated that two of three had experience caring for SMM patients. The third, who did not have experience caring for SMM patients, is not quoted in the results.
References
Boone, C. A., & Bowleg, L. (2020). Structuring sexual pleasure: Equitable access to biomedical HIV prevention for Black men who have sex with men. American Journal of Public Health, 110(2), 157–158. https://doi.org/10.2105/AJPH.2019.305503
Bowleg, L. (2013). “Once you’ve blended the cake, you can’t take the parts back to the main ingredients”: Black gay and bisexual men’s descriptions and experiences of intersectionality. Sex Roles, 68, 754–767. https://doi.org/10.1007/s11199-012-0152-4
Braksmajer, A., Fedor, T. M., Chen, S. R., Corales, R., Holt, S., Valenti, W., & McMahon, J. M. (2018). Willingness to take PrEP for HIV prevention: The combined effects of race/ethnicity and provider trust. AIDS Education and Prevention, 30(1), 1–12. https://doi.org/10.1521/aeap.2018.30.1.1
Brooks, R. A., Landovitz, R. J., Regan, R., Lee, S. J., & Allen, V. C., Jr. (2015). Perceptions of and intentions to adopt HIV pre-exposure prophylaxis among Black men who have sex with men in Los Angeles. International Journal of STD & AIDS, 26(14), 1040–1048. https://doi.org/10.1177/0956462415570159
Brooks, R. A., Nieto, O., Landrian, A., Fehrenbacher, A., & Cabral, A. (2019). Experiences of pre-exposure prophylaxis (PrEP)–related stigma among Black SMM PrEP users in Los Angeles. Journal of Urban Health, 97, 679–691. https://doi.org/10.1007/s11524-019-00371-3
Burgess, D. J., Fu, S. S., & Van Ryn, M. (2004). Why do providers contribute to disparities and what can be done about it? Journal of General Internal Medicine, 19(11), 1154–1159. https://doi.org/10.1111/j.1525-1497.2004.30227.x
Burla, L., Knierim, B., Barth, J., Liewald, K., Duetz, M., & Abel, T. (2008). From text to codings: Intercoder reliability assessment in qualitative content analysis. Nursing Research, 57(2), 113–117. https://doi.org/10.1097/01.NNR.0000313482.33917.7d
Cahill, S., & Makadon, H. (2014). Sexual orientation and gender identity data collection in clinical settings and in electronic health records: A key to ending LGBT health disparities. LGBT Health, 1(1), 34–41. https://doi.org/10.1089/lgbt.2013.0001
Cahill, S., Taylor, S. W., Elsesser, S. A., Mena, L., Hickson, D., & Mayer, K. H. (2017). Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts. AIDS Care, 29(11), 1351–1358. https://doi.org/10.1080/09540121.2017.1300633
Calabrese, S. K., Tekeste, M., Mayer, K. H., Magnus, M., Krakower, D. S., Kershaw, T. S., … Betancourt, J. R. (2019). Considering stigma in the provision of HIV pre-exposure prophylaxis: Reflections from current prescribers. AIDS Patient Care and STDs, 33(2), 79–88. https://doi.org/10.1089/apc.2018.0166
Centers for Disease Control and Prevention. (2021a). Diagnoses of HIV infection in the United States and dependent areas, 2019. HIV Surveillance Report, 32. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html
Centers for Disease Control and Prevention. (2021b). Monitoring select national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2019. HIV Surveillance Supplemental Report, 26(2). https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html
Chang, E. S., Simon, M., & Dong, X. (2012). Integrating cultural humility into health care professional education and training. Advances in Health Sciences Education, 17(2), 269–278. https://doi.org/10.1007/s10459-010-9264-1
Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Sage Publications, Inc.
DESCOVY for PrEP ®. (2020). DESCOVY®. Retrieved November 10, 2020, from https://www.descovy.com/prep
Devarajan, S., Sales, J. M., Hunt, M., & Comeau, D. L. (2020). PrEP and sexual well-being: A qualitative study on PrEP, sexuality of SMM, and patient-provider relationships. AIDS Care, 32(3), 386–393. https://doi.org/10.1080/09540121.2019.1695734
Doblecki-Lewis, S., & Jones, D. (2016). Community federally qualified health centers as homes for HIV preexposure prophylaxis: Perspectives from South Florida. Journal of the International Association of Providers of AIDS Care, 15(6), 522–528. https://doi.org/10.1177/2325957416661422
Eaton, L. A., Matthews, D. D., Driffin, D. D., Bukowski, L., Wilson, P. A., Stall, R. D., & POWER Study Team. (2017). A multi-US city assessment of awareness and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among black men and transgender women who have sex with men. Prevention Science, 18(5), 505–516.https://doi.org/10.1007/s11121-017-0756-6
Elopre, L., Ott, C., Lambert, C. C., Amico, K. R., Sullivan, P. S., Marrazzo, J., … Turan, J. M. (2021). Missed prevention opportunities: Why young, Black SMM with recent HIV diagnosis did not access HIV pre-exposure prophylaxis services. AIDS and Behavior, 25, 1464–1473. https://doi.org/10.1007/s10461-020-02985-0
Fields, E., Morgan, A., & Arrington Sanders, R. (2016). The intersection of sociocultural factors and health-related behavior in lesbian, gay, bisexual, and transgender youth: Experiences among young Black gay males as an example. Pediatric Clinics of North America, 63(6), 1091–1106. https://doi.org/10.1016/j.pcl.2016.07.009
Ford, J. V., Corona Vargas, E., Finotelli Jr, I., Fortenberry, J. D., Kismödi, E., Philpott, A., ... Coleman, E. (2019). Why pleasure matters: Its global relevance for sexual health, sexual rights and wellbeing. International Journal of Sexual Health, 31(3), 217–230. https://doi.org/10.1080/19317611.2019.1654587
Furukawa, N. W., Maksut, J. L., Zlotorzynska, M., Sanchez, T. H., Smith, D. K., & Baral, S. D. (2020). Sexuality disclosure in US gay, bisexual, and other men who have sex with men: Impact on healthcare-related stigmas and HIV pre-exposure prophylaxis denial. American Journal of Preventive Medicine, 59(2), 79–97. https://doi.org/10.1016/j.amepre.2020.02.010
Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology, 13. https://doi.org/10.1186/1471-2288-13-117
Golub, S. A. (2018). PrEP stigma: Implicit and explicit drivers of disparity. Current HIV/AIDS Reports, 15(2), 190–197. https://doi.org/10.1007/s11904-018-0385-0
Gott, M., Galena, E., Hinchliff, S., & Elford, H. (2004). “Opening a can of worms”: GP and practice nurse barriers to talking about sexual health in primary care. Family Practice, 21(5), 528–536. https://doi.org/10.1093/fampra/cmh509
Greenwald, A. G., Dasgupta, N., Dovidio, J. F., Kang, J., Moss-Racusin, C., & Teachman, B. A. (2021). Implicit bias remedies: What is known and what is not known [Unpublished manuscript]. Department of Psychology, University of Washington.
Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., ... Coyne-Beasley, T. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. American Journal of Public Health, 105(12), e60–e76. https://doi.org/10.2105/AJPH.2015.302903
Harris, N. S., Johnson, A. S., Huang, Y. L. A., Kern, D., Fulton, P., Smith, D. K., ... Hall, H. I. (2019). Vital signs: Status of human immunodeficiency virus testing, viral suppression, and HIV preexposure prophylaxis—United States, 2013–2018. Morbidity and Mortality Weekly Report, 68(48), 1117–1123. https://doi.org/10.15585/mmwr.mm6848e1
Hess, K. L., Hu, X., Lansky, A., Mermin, J., & Hall, H. I. (2017). Lifetime risk of a diagnosis of HIV infection in the United States. Annals of Epidemiology, 27(4), 238–243. https://doi.org/10.1016/j.annepidem.2017.02.003
Kanny, D., Jeffries, W. L., 4th, Chapin-Bardales, J., Denning, P., Cha, S., Finlayson, T., Wejnert, C., & National HIV Behavioral Surveillance Study Group (2019). Racial/ethnic disparities in HIV preexposure prophylaxis among men who have sex with men—23 urban areas, 2017. Morbidity and Mortality Weekly Report, 68(37), 801–806. https://doi.org/10.15585/mmwr.mm6837a2
Krakower, D. S., Ware, N. C., Maloney, K. M., Wilson, I. B., Wong, J. B., & Mayer, K. H. (2017). Differing experiences with pre-exposure prophylaxis in Boston among lesbian, gay, bisexual, and transgender specialists and generalists in primary care: Implications for scale-up. AIDS Patient Care and STDs, 31(7), 297–304. https://doi.org/10.1089/apc.2017.0031
Krakower, D., Ware, N., Mitty, J. A., Maloney, K., & Mayer, K. H. (2014). HIV providers’ perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: A qualitative study. AIDS and Behavior, 18(9), 1712–1721. https://doi.org/10.1007/s10461-014-0839-3
Krueger, R. A. (2002). Designing and conducting focus group interviews. Retrieved July 20, 2021 from https://www.eiu.edu/ihec/Krueger-FocusGroupInterviews.pdf
Lelutiu-Weinberger, C., & Golub, S. A. (2016). Enhancing PrEP access for Black and Latino men who have sex with men. Journal of Acquired Immune Deficiency Syndromes, 73(5), 547–555. https://doi.org/10.1097/QAI.0000000000001140
MacPhail, C., Khoza, N., Abler, L., & Ranganathan, M. (2016). Process guidelines for establishing intercoder reliability in qualitative studies. Qualitative Research, 16(2), 198–212. https://doi.org/10.1177/1468794115577012
Major, B., Dovidio, J. F., Link, B. G., & Calabrese, S. K. (2018). Stigma and its implications for health: Introduction and overview. In B. Major, J. F. Dovidio, & B. G. Link (Eds.), The Oxford handbook of stigma, discrimination, and health (pp. 3–28). Oxford University Press.
Malebranche, D. (2020). Declaring SMM a “superior” abbreviation does not constitute a way forward in sexual health initiatives. American Journal of Public Health, 110(11), 1669–1670. https://doi.org/10.2105/AJPH.2020.305934
Maloney, K. M., Krakower, D. S., Ziobro, D., Rosenberger, J. G., Novak, D., & Mayer, K. H. (2017). Culturally competent sexual healthcare as a prerequisite for obtaining preexposure prophylaxis: Findings from a qualitative study. LGBT Health, 4(4), 310–314. https://doi.org/10.1089/lgbt.2016.0068
Millett, G. A., Peterson, J. L., Flores, S. A., et al. (2012). Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: A meta-analysis. The Lancet, 380(9839), 341–348. https://doi.org/10.1016/S0140-6736(12)60899-X
Morgan, D. L. (1996). Focus groups. Annual Review of Sociology, 22(1), 129–152.
Nowaskie, D. Z., & Sowinski, J. S. (2019). Primary care providers’ attitudes, practices, and knowledge in treating LGBTQ communities. Journal of Homosexuality, 66, 1927–1947.
O’Connell, H. R., & Criniti, S. M. (2021). The impact of HIV pre-exposure prophylaxis (PrEP) counseling on PrEP knowledge and attitudes among women seeking family planning care. Journal of Women’s Health, 30, 121–130. https://doi.org/10.1089/jwh.2019.8217
Patel, V. V., Santoro, A. F., & Chaudhry, J. (2016). Primary care providers' role in HIV prevention with pre-exposure prophylaxis: Perspectives from young men of color who have sex with men [Conference poster]. In 11th International Conference on HIV Treatment and Prevention Adherence, Fort Lauderdale, TX, United States.
Petroll, A. E., Walsh, J. L., Owczarzak, J. L., McAuliffe, T. L., Bogart, L. M., & Kelly, J. A. (2017). PrEP awareness, familiarity, comfort, and prescribing experience among US primary care providers and HIV specialists. AIDS and Behavior, 21(5), 1256–1267. https://doi.org/10.1007/s10461-016-1625-1
Philbin, M. M., Parker, C. M., Parker, R. G., Wilson, P. A., Garcia, J., & Hirsch, J. S. (2018). Gendered social institutions and preventive healthcare seeking for black men who have sex with men: The promise of biomedical HIV prevention. Archives of Sexual Behavior, 47(7), 2091–2100. https://doi.org/10.1007/s10508-018-1211-x
Pleuhs, B., Quinn, K. G., Walsh, J. L., Petroll, A. E., & John, S. A. (2020). Health care provider barriers to HIV pre-exposure prophylaxis in the United States: A systematic review. AIDS Patient Care and STDs, 34(3), 111–123. https://doi.org/10.1089/apc.2019.0189
Quinn, K., Bowleg, L., & Dickson-Gomez, J. (2019a). “The fear of being Black plus the fear of being gay”: The effects of intersectional stigma on PrEP use among young Black gay, bisexual, and other men who have sex with men. Social Science & Medicine, 232, 86–93. https://doi.org/10.1016/j.socscimed.2019.04.042
Quinn, K., Dickson-Gomez, J., Zarwell, M., Pearson, B., & Lewis, M. (2019b). “A gay man and a doctor are just like, a recipe for destruction”: How racism and homonegativity in healthcare settings influence PrEP uptake among young Black SMM. AIDS and Behavior, 23(7), 1951–1963. https://doi.org/10.1007/s10461-018-2375-z
Rogers, B. G., Whiteley, L., Haubrick, K. K., Mena, L. A., & Brown, L. K. (2019). Intervention messaging about pre-exposure prophylaxis use among young, Black sexual minority men. AIDS Patient Care and STDs, 33(11), 473–481. https://doi.org/10.1089/apc.2019.0139
Rucker, A. J., Murray, A., Gaul, Z., Sutton, M. Y., & Wilson, P. A. (2018). The role of patient–provider sexual health communication in understanding the uptake of HIV prevention services among Black men who have sex with men. Culture, Health & Sexuality, 20(7), 761–771. https://doi.org/10.1080/13691058.2017.1375156
Russ, S., Zhang, C., & Liu, Y. (2021). Pre-exposure prophylaxis care continuum, barriers, and facilitators among Black men who have sex with men in the United States: A systematic review and meta-analysis. AIDS and Behavior, 25, 2278–2288. https://doi.org/10.1007/s10461-020-03156-x
Schwartz, J., & Grimm, J. (2022). Communication strategies for discussing PrEP with men who have sex with men. Journal of Homosexuality, 69, 61–74. https://doi.org/10.1080/00918369.2020.1813509
Sekoni, A. O., Gale, N. K., Manga-Atangana, B., Bhadhuri, A., & Jolly, K. (2017). The effects of educational curricula and training on LGBT-specific health issues for healthcare students and professionals: A mixed-method systematic review. Journal of the International AIDS Society, 20(1), 21624.
Sewell, W. C., Solleveld, P., Seidman, D., Dehlendorf, C., Marcus, J. L., & Krakower, D. S. (2021). Patient-led decision-making for HIV preexposure prophylaxis. Current HIV/AIDS Reports, 18, 48–56. https://doi.org/10.1007/s11904-020-00535-w
Shindel, A. W., Ando, K. A., Nelson, C. J., Breyer, B. N., Lue, T. F., & Smith, J. F. (2010). Medical student sexuality: How sexual experience and sexuality training impact US and Canadian medical students’ comfort in dealing with patients’ sexuality in clinical practice. Academic Medicine, 85(8), 1321–1330. https://doi.org/10.1097/ACM.0b013e3181e6c4a0
Skolnik, A. A., Bokhour, B. G., Gifford, A. L., Wilson, B. M., & Van Epps, P. (2019). Roadblocks to PrEP: What medical records reveal about access to HIV pre-exposure prophylaxis. Journal of General Internal Medicine, 35(3), 832–838. https://doi.org/10.1007/s11606-019-05475-9
St. Vil, N. M., Przybyla, S., & LaValley, S. (2019). Barriers and facilitators to initiating PrEP conversations: Perspectives and experiences of health care providers. Journal of HIV/AIDS & Social Services, 18(2), 166–179. https://doi.org/10.1080/15381501.2019.1616027
Sullivan, M. C., & Eaton, L. A. (2021). Intersecting barriers to PrEP awareness and uptake in Black men who have sex with men in Atlanta, GA: A syndemic perspective. International Journal of Behavioral Medicine, 28, 349–359. https://doi.org/10.1007/s12529-020-09925-1
Sullivan, P. S., Sanchez, T. H., Zlotorzynska, M., Chandler, C. J., Sineath, R. C., Kahle, E., & Tregear, S. (2020). National trends in HIV pre-exposure prophylaxis awareness, willingness and use among United States men who have sex with men recruited online, 2013 through 2017. Journal of the International AIDS Society, 23(3). https://doi.org/10.1002/jia2.25461
Thomann, M., Grosso, A., Zapata, R., & Chiasson, M. A. (2018). ‘WTF is PrEP?’: Attitudes towards pre-exposure prophylaxis among men who have sex with men and transgender women in New York City. Culture, Health & Sexuality, 20(7), 772–786. https://doi.org/10.1080/13691058.2017.1380230
Timmins, L., & Duncan, D. T. It's raining MSM: The continued ubiquity of contentious terminology in research on sexual minority men's health. American Journal of Public Health, 110(11), 1666–1668. https://doi.org/10.2105/AJPH.2020.305870.
U.S. Bureau of Labor Statistics. (2021). Employment status of the civilian population by race, sex, and age. Economic News Release. Retrieved March 11, 2021 from https://www.bls.gov/news.release/empsit.t02.htm
Wilkinson, S. (2015). Focus groups. In J. A. Smith (Ed.), Qualitative psychology: A practical guide to research methods (3rd ed., pp. 199–221). Sage Publications.
Wilson, K., Bleasdale, J., & Przybyla, S. M. (2021). Provider-patient communication on pre-exposure prophylaxis (Prep) for HIV prevention: An exploration of healthcare provider challenges. Health Communication, 36, 1677–1686. https://doi.org/10.1080/10410236.2020.1787927
Wong, L. P. (2008). Focus group discussion: A tool for health and medical research. Singapore Medical Journal, 49(3), 256–260.
World Health Organization (WHO). (2017). Sexual health and its linkages to reproductive health: An operational approach. Retrieved from: https://www.who.int/reproductivehealth/publications/sexual_health/sh-linkages-rh/en/
Zhang, C., McMahon, J., Fiscella, K., Przybyla, S., Braksmajer, A., LeBlanc, N., & Liu, Y. (2019). HIV pre-exposure prophylaxis implementation cascade among health care professionals in the United States: Implications from a systematic review and meta-analysis. AIDS Patient Care and STDs, 33(12), 507–527. https://doi.org/10.1089/apc.2019.0119
Zhang, X., Sherman, L., & Foster, M. (2020). Patients’ and providers’ perspectives on sexual health discussion in the United States: A scoping review. Patient Education and Counselling, 103(11), 2205–2213. https://doi.org/10.1016/j.pec.2020.06.019
Acknowledgements
The authors thank the focus group participants who generously dedicated their time and effort to study participation. We are also grateful to those who assisted with study recruitment, including community health center leaders who helped to disseminate study recruitment materials and coordinate focus group logistics.
Funding
This study was funded by the National Institutes of Health (NIH; K01-MH103080; PI: Sarah K. Calabrese). Resources were contributed by the Yale University Center for Interdisciplinary Research on AIDS, which is funded by the NIH (P30-MH062294). Support was also received from the District of Columbia Center for AIDS Research, which is funded by the NIH (P30-AI117970). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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Study conceptualization was led by SKC and SR with support from all co-authors. Data were collected by SKC, AIE, and DD. Formal analyses were led by SR with support from SKC, DM, and MT. The first draft of the manuscript was written by SKC and SR. All authors provided feedback on the drafted manuscript and approved the final version of the manuscript.
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Sarah K. Calabrese received partial support from Gilead Sciences to attend a research conference. Douglas S. Krakower has been a consultant to Fenway Health for research studies funded by Gilead Sciences, has a pending grant with unrestricted project support from Merck, and has received personal fees to develop medical education content for Medscape, MED-IQ, DKBMed, and UpToDate, Inc. Kenneth H. Mayer has conducted research with unrestricted project support from Gilead Sciences and Merck and is a member of the faculty and advisory board of the National LGBTQIA + Health Education Center, which the paper references in the discussion as a source of health education resources.
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All study procedures were approved by the Yale University Human Subjects Committee (#HSC-1308012487) prior to implementation. Verbal informed consent was obtained from all study participants.
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Calabrese, S.K., Rao, S., Eldahan, A.I. et al. “Let’s Be a Person to Person and Have a Genuine Conversation”: Comparing Perspectives on PrEP and Sexual Health Communication Between Black Sexual Minority Men and Healthcare Providers. Arch Sex Behav 51, 2583–2601 (2022). https://doi.org/10.1007/s10508-021-02213-3
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DOI: https://doi.org/10.1007/s10508-021-02213-3