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Freedom as Prevention: Mechanisms of Autonomy Support for Promoting HIV Pre-Exposure Prophylaxis Use and Condom Use among Black MSM in 3 US Cities—HPTN 073

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Abstract

Healthcare providers who use controlling or coercive strategies may compel short-term enactment of HIV and sexually transmitted infection prevention behaviors but may inadvertently undermine their client’s motivation to maintain those behaviors in the absence of external pressure. Autonomous motivation refers to the self-emanating and self-determined drive for engaging in health behaviors. It is associated with long-term maintenance of health behaviors. We used structural equation modeling to investigate whether autonomy support was associated with increased odds of therapeutic serum levels of pre-exposure prophylaxis, through a pathway that satisfies basic psychological needs for autonomous self-regulation and competence regarding pre-exposure prophylaxis use. We also investigated whether autonomy support was associated with decreased odds of condomless anal intercourse via the same psychological needs-satisfaction pathway of autonomous self-regulation and competence regarding condom use. We tested these two theorized pathways using secondary data from a longitudinal sample of Black men who have sex with men from across three cities in the US (N = 226). Data from the sample fit the theorized models regarding the pathways by which autonomy support leads to the presence of therapeutic PrEP levels in serum (χ2 = 0.56; RMSEA = 0.04; CFI = .99, TLI = 0.98) and how it also leads to decreased odds of condomless anal intercourse (χ2 = 0.58; RMSEA = 0.03; CFI = 0.99; TLI = 0.98). These findings provide scientific evidence for the utility of self-determination theory as a model to guide intervention approaches to optimize the implementation and impact of PrEP for Black men who have sex with men.

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Acknowledgements

Overall support for the HIV Prevention Trials Network (HPTN) is provided by the National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH) under Award Numbers UM1AI068619 (HPTN Leadership and Operations Center), UM1AI068617 (HPTN Statistical and Data Management Center), and UM1AI068613 (HPTN Laboratory Center). Additional support was provided by the National Institute on Drug Abuse and the National Institute of Mental Health, of the National Institutes of Health, US Department of Health and Human Services. This was also made possible by core services and support provided by the Yale University Center for Interdisciplinary Research on AIDS (P30 MH062294) and the Yale Research Education Institute for Diverse Scholars (R25 MH087271).

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Authors and Affiliations

  1. School of Nursing, Yale University, 400 West Campus Drive, New Haven, CT, USA

    LaRon E. Nelson & S. Raquel Ramos

  2. Center for Interdisciplinary Research On AIDS, School of Public Health, Yale University, New Haven, CT, USA

    LaRon E. Nelson, Donte T. Boyd, S. Raquel Ramos & Portia Thomas

  3. MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada

    LaRon E. Nelson & Wale Ajiboye

  4. College of Social Work, The Ohio State University, Columbus, OH, USA

    Donte T. Boyd

  5. Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Geetha Beauchamp & Lynda Emel

  6. Department of Human Development, College of Community and Public Affairs, State University of New York at Binghamton, Binghamton, NY, USA

    Leo Wilton

  7. Department of Humanities, University of Johannesburg, Johannesburg, South Africa

    Leo Wilton

  8. School of Social Work, University of Maryland Baltimore, Baltimore, MD, USA

    Darren Whitfield

  9. Department of Emergency Medicine, McGovern Medical School, University of Texas Health, Houston, TX, USA

    Mandy J. Hill

  10. Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA

    Manya Magnus

  11. Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY, USA

    Portia Thomas

  12. Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA

    Lisa Hightow-Weidman

  13. Division of Family Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA

    Steve Shoptaw

  14. The Fenway Institute, Fenway Health, Boston, MA, USA

    Kenneth H. Mayer

  15. Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA

    Estelle Piwowar-Manning

  16. Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, PA, USA

    Sheldon D. Fields

  17. Iona College, New Rochelle, NY, USA

    Darrell P. Wheeler

  18. Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington Universty, Washington, DC, USA

    Donaldson F. Conserve

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  1. LaRon E. Nelson
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Nelson, L.E., Boyd, D.T., Beauchamp, G. et al. Freedom as Prevention: Mechanisms of Autonomy Support for Promoting HIV Pre-Exposure Prophylaxis Use and Condom Use among Black MSM in 3 US Cities—HPTN 073. J Urban Health 99, 1157–1169 (2022). https://doi.org/10.1007/s11524-022-00666-y

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