Description
In this assignment, you will provide a brief overview of the article assigned to you this week, and
critique the analysis, results, and discussion section following the guidelines below.
You will submit your overview and critique in the form of a narrated PowerPoint presentation (6
minutes) that you will upload at the assignment link on Blackboard.
Please follow the outline below to organize your slides. Below are links to help you record a
slide show with narration. Recording with a video that is saved as mp4 is preferred.
• How to Record Audio in PowerPoint and Export as an MP4
• Record a slide show with narration and slide timings: PowerPoint for Microsoft 365
• PowerPoint: How to Add Audio to Powerpoint on Windows 10 and Mac: University of
Wisconsin
OUTLINE:
Slide 1: Brief overview of article: (~1 minute)
• State the research problem or study purpose.
• Briefly summarize the background and significance of the problem discussed in the article.
Slide 2: Study design (~1.5 minutes)
• What type of study design is this (name the design)? Was it appropriate and why?
• Was a conceptual or theoretical framework used? If yes, critique how it was used. If not,
critique the lack of its use in a study – if absent, should one have been used with this study
design?
• Are ethical concerns adequately addressed?
Slide 3: Methods (~1.5 minutes)
• Describe the sample, sampling design, recruitment, inclusion/exclusion criteria, and sample
size. Were they appropriate and why?
• Data analysis: what analysis strategies did the researchers use (describe and critique the
appropriateness of the analysis based on a qualitative or a quantitative design).
• Results: what were the main findings of this study? Were the results presented clearly and
were they understandable? Did the author answer their research questions/objectives?
Provide rational.
Slide 4: Implications for practice (~2 minutes)
• Critique the authors’ discussion of their results and their implications for practice in the
discussion and conclusion of the article.
• State whether you agree or disagree with their conclusion and why?
• Did they discuss the limitations of the research? Are there other limitations that they did not
address?
• Do you have additional suggestions to make in terms of this section? Did they leave out any
implications for practice? Support your statements (don’t just agree or disagree with the
authors; justify your critique).
• Conclusion: Overall summary of study critique and recommendations for future evidencebased research and practice.
Slide 5: Reference (no need for narration)
• Provide APA citation of your article.
Unformatted Attachment Preview
PREVENTION RESEARCH
A Randomized Trial of a Brief Behavioral Intervention for
PrEP Uptake Among Men Who Have Sex With Men at
Increased Risk for HIV Infection
Philip A. Chan, MD, MS,a,b Amy Nunn, ScD,b Jacob J. van den Berg, PhD,a,b,c Kevin Cormier, BS,a
Genoviva Sowemimo-Coker, MPH,a Siena C. Napoleon, MPH,a Trisha Arnold, PhD,d and
Ethan Moitra, PhDd
Background: The aim of this study was to evaluate the efficacy of
a novel, brief 2-session behavioral intervention to promote HIV preexposure prophylaxis (PrEP) uptake among men who have sex with
men (MSM) who are behaviorally at risk for HIV.
Setting: A pilot randomized controlled trial was conducted at a
sexually transmitted infection (STI) clinic to compare a brief
motivational interviewing intervention with passive referral only
for PrEP uptake.
Methods: MSM who scored as “high risk” on the HIV Incidence
Risk index for MSM was offered a brief (15–20 minutes) motivational interviewing–based intervention at the time of STI testing to
address barriers to PrEP uptake, including low risk perception,
stigma, side effects, and cost. The initial session was followed by a
brief, telephone booster session that lasted ,10 minutes. The primary outcome was attending a clinical PrEP appointment and accepting a prescription for PrEP.
Results: Participants were recruited from an urban STI clinic in the
United States. A total of 86 MSM who were behaviorally at risk for
HIV were enrolled in the study (N = 43 intervention; N = 43
treatment-as-usual, “TAU”). Participants randomized to the intervention were significantly more likely to attend a clinical appointment and accept a prescription for PrEP, compared with treatmentas-usual (52.3% versus 27.9%, respectively; odds ratio = 3.6; 95%
confidence interval: 1.5 to 8.9; P = 0.005).
Conclusions: A brief behavioral intervention focused on the initial
steps in the PrEP care cascade demonstrated preliminary efficacy in
promoting uptake among MSM who are behaviorally at risk for HIV.
Received for publication November 17, 2020; accepted February 1, 2021.
From the Departments of aMedicine; and bBehavioral and Social Sciences,
Brown University, Providence, RI; cDepartment of Epidemiology, Harvard
University, Boston, MA; and dDepartment of Psychiatry and Human
Behavior, Brown University, Providence, RI.
Funded by the National Institute on Drug Abuse (R34DA042648).
The authors have no conflicts of interest to disclose.
Registered at clinicaltrials.gov: NCT03313765.
Correspondence to: Philip A. Chan, MD, MS, Department of Medicine,
Brown University, Providence, RI 02912 (e-mail: Philip_Chan@brown.
edu).
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Key Words: PrEP, intervention, MSM, HIV, motivational interviewing
(J Acquir Immune Defic Syndr 2021;87:937–943)
INTRODUCTION
HIV continues to be a significant cause of morbidity
and mortality in the United States (US) with a disproportionate number of infections among gay, bisexual, and other men
who have sex with men (MSM).1 Pre-exposure prophylaxis
(PrEP) has demonstrated efficacy in preventing HIV
infection2–5 and has the potential to significantly reduce
HIV incidence in populations at risk, such as MSM. The
Centers for Disease Control and Prevention estimated in 2015
that nearly 25% of sexually active MSM meet indications for
PrEP.6 Despite significant increases in PrEP awareness
among MSM since this time, PrEP use remains suboptimal,
particularly for African American/Black and Hispanic/Latinx
MSM.7 Given this, novel approaches to improve PrEP uptake
are needed.
Significant barriers to PrEP uptake include low perceived HIV risk, stigma, concern for side-effects, and
cost.8–11 Of these, low perceived HIV risk has emerged as a
significant challenge. Up to 37% of MSM presenting to a
sexually transmitted infection (STI) clinic who reported
condomless anal sex did not perceive themselves to be atrisk for HIV infection.12 This has been observed across
multiple other studies.13,14 Misperceptions about side effects
and lack of awareness of programs to defray cost
and minimize out-of-pocket expenses have also led to lower
PrEP uptake.15–17 Despite knowledge of these myriad
barriers, few interventions have successfully increased
PrEP uptake.
This goal of this study was to develop and evaluate the
feasibility, acceptability, and efficacy of a novel behavioral
intervention to promote PrEP uptake among MSM at
increased risk for HIV at an STI clinic who were not already
seeking PrEP. The intervention was designed to be brief and
applicable in a busy clinical setting. We hypothesized that the
intervention, relative to usual clinical care, would result in the
following: (1) increased willingness to schedule a PrEP
evaluation appointment, (2) increased likelihood to attend
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J Acquir Immune Defic Syndr Volume 87, Number 3, July 1, 2021
Chan et al
the appointment, and, (3) increased likelihood to accept a
PrEP prescription.
From January 2019 to March 2020, MSM who were not
currently taking PrEP and who were at an elevated risk for
HIV infection were recruited during routine clinical care at a
walk-in STI clinic. If they could not be approached during
their clinic visit, they were contacted as soon as possible and
within 1 week of their visit. Inclusion criteria were as follows:
(1) 18 years of age or older, (2) assigned male at birth and/or
currently identify as male, (3) scored at least 10 on the HIV
Incidence Risk Index for MSM (HIRI-MSM18), and (4) HIV
negative based on results of an antibody/antigen test.
Participants were excluded if they were currently taking
PrEP, had taken it in the past, or did not fluently speak
English. If participants had previously received a PrEP
prescription but never filled it, they were eligible to
participate. Participants who reported less than one condomless anal sex event in the past 3 months were also excluded.
After enrolling and completing a baseline assessment,
participants were randomized to motivational interviewing
(MI) or treatment-as-usual (TAU) with equal allocation
between conditions using a randomization scheduled generated by a nonstudy statistician. Follow-ups were conducted at
1-month, 3-month, and 6-month postbaseline to assess steps
completed in the initial PrEP care cascade. The 1-month
follow-up was also used to collect acceptability/satisfaction
data. Participants were compensated $50 for completing the
baseline and each additional assessment. No remuneration
was provided for intervention session attendance; participants
were paid only for completing study assessments. Follow-ups
occurred in person whenever possible. However, for participants’ convenience, follow-up assessments could be completed remotely by electronic data collection methods.
The 2-session, individual MI intervention was administered using a manualized, structured protocol that was
previously developed and revised in a small uncontrolled
pilot trial.19 The brief intervention was based on MI theory,
which was originally developed for use in alcohol treatment20
and was rooted in the perception that motivation to change
must be internally driven. The intervention was informed by
qualitative research with the target population.21 This qualitative research, conducted with other MSM at the clinic
before the start of this study, revealed that MSM requested
brief interventions and patient navigation at the STI clinic.
Our intervention addresses a diverse and wide range of
possible barriers to PrEP uptake. These were categorized as
follows: (1) clinical barriers (eg, concerns about PrEP side
effects), (2) individual barriers (eg, low self-perceived HIV
risk), (3) social barriers (eg, fear of disclosure), and (4)
structural barriers related to the health system (eg, challenges
associated with expenses related to copayments, deductibles,
and accessing patient navigation). Consequently, the intervention had built-in flexibility to allow interventionists to
discuss and address whichever barrier(s) the participant
reported.19 One minor revision was made to the manual in
October 2019 when tenofovir alafenamide with emtricitabine
(FTC) became available as a second PrEP medication. The
manual was revised to discuss tenofovir disoproxil fumarate
with FTC and tenofovir alafenamide/FTC.
The primary goals of the first intervention session were
to (1) develop rapport and a therapeutic relationship, (2)
provide psychoeducation about PrEP, (3) share normative
feedback on participants’ risk for HIV infection, (4) identify
and address barriers to PrEP uptake, and, (5) weigh the pros
and cons of PrEP uptake. We aimed to complete session 1 in
about 15 minutes. Extensive counseling about other HIV
prevention methods was not included in the intervention
because these were provided by the clinic’s usual care.
Session 2, scheduled for approximately 1 week later and
meant to be completed by telephone in less than 10 minutes,
was designed as a “booster” session, in which no additional
information was presented. Instead, the goals were to probe
for understanding and resonance of session 1 material and to
construct an action plan when appropriate.
The control condition was the clinic’s TAU procedures
for MSM expressing interest in PrEP. TAU did not include
any elements of MI. All participants received TAU services
that included referral to PrEP services. STI clinic counselors
were trained to discuss PrEP, to encourage its use among
individuals at an increased risk, and to facilitate PrEP uptake
by addressing structural barriers whenever possible (eg,
offering bus vouchers to overcome transportation issues, help
in navigating clinic, and industry-sponsored patient
assistance programs).
Interventionists were 4 state-certified STI clinic counselors who provided clinical services at the recruitment site.
One interventionist was a bachelor’s level provider and the
other individuals had master’s degrees. A 4-hour didactic
training workshop for the interventionists educated them on
the challenges of motivating MSM to take PrEP, MI
perspectives on health behavior change, and skills to help
patients make change plan decisions. The manual was
reviewed, and role plays of standard, challenging, and
emergency situations were conducted. Interventionists had
weekly telephone supervision during the trial. Supervision
was provided by one of the study’s principal investigators, a
doctoral-level clinical psychologist.
Study participants completed quantitative assessments
that included questions on demographics, medical treatment
access, recent sexual behaviors and sexual health, and
attitudes toward PrEP and possible barriers to PrEP uptake.
Hazardous drinking was examined with the short-form
Alcohol Use Disorders Identification Test-C (AUDIT-C22),
and substance use/misuse was examined with items from the
EXPLORE study, which studied risky behavior among
MSM.23 The EXPLORE substance items were used in lieu
of the HIRI-MSM to assess 12-month substance use.
Participant mental health symptoms were characterized by
the Patient Health Questionnaire-9 (PHQ-924) and the Generalized Anxiety Disorder-7 (GAD-725). A PrEP stage of
change measure was used to characterize perceived willingness to take PrEP and perceived need.26
In a qualitative exit interview at the 1-month follow-up,
we asked participants about positive and negative aspects of
MI and solicited ideas for improvements. To examine MI
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METHODS
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J Acquir Immune Defic Syndr Volume 87, Number 3, July 1, 2021
satisfaction, the 8-item Client Satisfaction QuestionnaireRevised (CSQ-R27) was administered. The CSQ-R has been
extensively studied and has shown excellent internal consistency, reliability, and convergent validity and has been shown
to operate similarly across different racial and ethnic groups.
As performed in prior research, including work at our
site,12 we assessed the following primary outcomes of
interest: (1) scheduling an appointment with a clinic prescriber to discuss PrEP, (2) attending the prescriber appointment, and (3) accepting a PrEP prescription. These data were
objectively gathered through a review of participants’ electronic medical records. Thus, we obtained these data for all
participants except those who were withdrawn from the study.
We relied on participant self-report if individuals received
PrEP from an external prescriber. This occurred in one case.
The MI intervention was designed to increase participants’
perception of HIV risk and increase their openness to PrEP.
These factors were assessed at baseline by self-report with the
Perceived HIV Risk Scale28 and items developed to assess
individuals’ willingness and perceived need to take PrEP,
based on the work by Parsons et al.26
All statistical analyses were conducted in SPSS.
Descriptive statistics were used to summarize feasibility and
acceptability outcomes related to the following: MI fidelity,
MI session length, MI session attendance, recruitment rates,
data collection retention rates, responses to exit interviews
with participants, and satisfaction ratings at treatment completion. Descriptive statistics were calculated to characterize
the sample. We used t-tests and x2 tests for between group
comparisons
on
continuous
and
categorical
variables, respectively.
Preliminary effects of MI on PrEP uptake outcomes,
compared with TAU, were assessed using logistic regression
analyses. No covariates were used in these models because
we did not specify any covariates a priori. Baseline comparisons revealed that MI and TAU participants were equivalent
on most characteristics. Because of the pilot nature of this
work, statistical power was not prioritized. All procedures
were approved by the Miriam Hospital Institutional
Review Board.
Brief Behavioral Intervention for PrEP Uptake
During the study period, a total of 828 MSM were
screened, and 287 were approached during STI care. Of those
approached, 147 (51.2%) agreed to participate. At the time of
recruitment, 60 individuals expressed willingness to participate in the study, but they were not ultimately enrolled or
consented because they did not complete the baseline
assessment. Of the remaining 87 MSM, one individual was
withdrawn after randomization to the MI condition when it
became clear that he had previously taken PrEP. Thus, the
final sample consisted of 86 MSM. The majority of these
participants (n = 52; 60.5%) completed the endpoint of 6month self-report follow-up data collection procedures. In
addition, because our primary outcomes related to PrEP
uptake were measured objectively through chart review, we
obtained data on all participants who did not withdraw from
the study (n = 82; 94.3%). Four participants withdrew from
the study after baseline (4.7% of sample; 2 MI, 2 TAU).
These individuals mostly discontinued because of time
constraints, although 1 person withdrew because of privacy
concerns. See Figure 1 for study flow.
One participant was assigned female at birth but
identified as male; otherwise, all other participants were
assigned male at birth. The sample mostly identified their
gender as male (n = 84; 97.7%), with 2 participants
identifying as genderqueer (2.3%). Most participants
described their sexual orientation as same-gender loving or
gay (n = 68; 79.1%), with bisexual being the second most
common orientation (n = 14; 16.3%). Participants were
younger adults (M = 32.0 years old; SD = 13.0 years old).
All participants surpassed the HIRI-MSM risk cut-off of 10
(M = 20.0; SD = 6.1). The sample was primarily non-Latinx
White (n = 56; 66.7%) although a sizeable group identified as
being ethnically Latinx (n = 22; 26.8%). The overall sample
was highly educated, with 60 participants having at least a
college degree.
Independent sample t-tests and x2 analyses were used to
compare baseline participant characteristics between MI and
TAU. The TAU group had statistically, significantly higher
depressive symptoms: t (1) = 2.01, P = 0.048, compared with
individuals in MI. However, closer inspection revealed that
these differences were minor, as the MI group’s mean PHQ-9
score was 3.4 (SD = 2.9), whereas the TAU group’s mean
score was 5.3 (SD = 5.4). Both represent minimal to no
depression. Although TAU participants also demonstrated
statistically significantly higher perceived need to take PrEP
[t(1) = 2.40, P = 0.019], these differences were not clinically
meaningful either. Otherwise, results revealed no baseline
differences on demographic or clinical variables between
intervention groups. See Table 1 for demographic summary,
comparing the 2 intervention groups.
All sessions were audiotaped, and 20% of sessions were
randomly selected for fidelity evaluation using an internally
developed measure. Review of these audio files was evenly
split between the first and second sessions. All 4 study
interventionists had sessions coded for fidelity by a nonstudy
rater. According to this rater, interventionists’ adherence to
the intervention manual was 99.3% in session 1 and 97.2% in
session 2. Both MI sessions lasted about as long as planned.
On average, session 1 was 21.1 minute (SD = 5.2 minutes),
and session 2 was 6.3 minutes (SD = 2.1 minute). Interventionists had the option to provide “check-in calls” with MI
participants in cases in which a scheduling issue or payment
concern arose for those ultimately interested in taking PrEP.
This check-in did not include any additional information or
intervention. Only one participant received a check-in call
during the course of the study.
All participants randomized to MI (n = 43) attended
session 1. Session 2 attendance was very good: n = 37
(84.1%). Otherwise, 2 MI participants withdrew from the
study during the course of follow-up (4.7%). Totals on the
CSQ-R, which has a maximum score of 32, were highly
positive for MI participants: mean = 30.0, SD = 2.7. On the
study-designed exit interview measure, in which item ratings
ranged from 0 to 6, with higher scores indicating increased
agreement, feedback was generally positive; participants
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RESULTS
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Chan et al
J Acquir Immune Defic Syndr Volume 87, Number 3, July 1, 2021
FIGURE 1. Study flow chart.
found the sessions helpful (mean = 5.6, SD = 0.7), sessions
helped participants better understand PrEP (mean = 5.6, SD =
0.9), and they appreciated having the initial session at the
sexually transmitted disease clinic (mean = 5.5, SD = 0.9).
Open-ended feedback was also supportive of the intervention.
No adverse events occurred during this trial.
Logistic regression analyses showed significant efficacy
for the intervention group versus TAU on all primary PrEP
outcomes. In comparison with those randomized to TAU,
participants in the intervention group were significantly more
likely to (1) schedule an appointment to further discuss PrEP
with a prescriber [odd ratios (OR) = 6.0; 95% confidence
interval (CI): 2.3 to 15.6; P , 0.001], (2) attend the prescriber
appointment (OR = 3.6; 95% CI: 1.5 to 8.9; P = 0.005), and
(3) receive and accept a prescription for PrEP (OR = 3.6; 95%
CI: 1.5 to 8.9; P = 0.005). See Figure 2 for graphical
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J Acquir Immune Defic Syndr Volume 87, Number 3, July 1, 2021
summary of conditions at each step of the initial PrEP
uptake cascade.
Brief Behavioral Intervention for PrEP Uptake
TABLE 1. Demographic, Health, and Sexual Behavior
Characteristics at Baseline (n = 86)
DISCUSSION
This is among the first studies to demonstrate efficacy
of a behavioral intervention to promote PrEP uptake for MSM
who are behaviorally at a significant risk for HIV acquisition.
The intervention was designed to be brief and easy to
implement in a busy STI clinic setting. MSM who underwent
the intervention had a 6-fold increase in scheduling a PrEP
clinical appointment and 3-fold increase in attending the
appointment and accepting a prescription. The intervention
was highly acceptable among all participants. In general,
retention rates were high for MI and the study assessments
considering that this was a substance-using, younger, nonPrEP seeking sample (Fig. 1). For the purposes of this
analysis, alcohol and other drugs were combined when
describing this sample given their high usage of a variety of
substances. Results from the HIRI-MSM, used as a measure
of increased risk for HIV transmission, revealed that substances such as amyl nitrates were used by a large proportion
of our sample (n = 45; 52.3%).
These findings suggest that a brief MI-based intervention, which flexibly addresses common barriers to PrEP
uptake, could be successful in promoting uptake among
MSM who are at an increased risk for HIV infection. In this
study, the research team used the HIRI-MSM to screen for
HIV risk, a highly sensitive but only moderately specific tool
by which to evaluate HIV risk. A scale-up of the MI
intervention could be applied to anyone who may be at risk,
and not just based on the HIRI-MSM. In addition, although
individuals with a previous history of PrEP use were not
included in this study, the MI intervention can likely be
applied to those with a previous history of PrEP use.
A notable advantage of MI, relative to other behaviorally based therapies, is that it can be efficacious over a very
short duration, with as few as 2 to 4 intervention sessions
leading to positive outcomes.29 This is ideal in a busy clinical
setting where contact with patients can be very brief. Thus,
this intervention has the potential to be applicable and easily
implemented in both clinical and community settings which
engage MSM at increased risk for HIV. Moreover, as noted in
a recent review,30 there are few existing, theoretically driven
PrEP uptake interventions. Indeed, to date, few interventions
have demonstrated any efficacy for PrEP uptake.31
This intervention also addressed structural determinants
of PrEP. Structural determinants of health “shape the
distribution and availability of health-relevant resources,
including systems of power and privilege in society.32”
Structural determinants related to the health system such as
deductibles and copayments and assistance with accessing
patient assistance programs were included as key components
of this PrEP intervention; these details have been explored
elsewhere.32 Our results demonstrate that, taken together, this
suite of intervention strategies was associated with a significant increase in PrEP uptake.
Limitations of our study include the generalizability of
the sample. Our sample was somewhat small and mostly
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Age, mean (SD)
Race
White, n (%)
African American/Black, n (%)
Asian, n (%)
Others/, n (%)
Latinx ethnicity, n (%)
People born male, n (%)
Male gender identity, n (%)
College graduate, n (%)
Currently student, n (%)
Employed part-time or full-time,
n (%)
Single, n (%)
Income (,$35000/yr), n (%)
Currently insured, n (%)
Total sex partners (3 mo),
mean (SD)
STD positive (12 mo), n (%)
Gonorrhea
Syphilis
Chlamydia
Sex worker (12 mo), n (%)
HIV acquisition risk (HIRI),
mean (SD)
Perceived HIV risk (PRHS),
mean (SD)
PrEP stages of change, mean (SD)
Willingness to take PrEP
Perceived need to take PrEP
Primary PrEP uptake barrier,
n (%)
Side effects
Cost
Does not want daily medication
Believes PrEP not needed
Stigma
Hazardous drinking (AUDIT-C),
mean (SD)
Substance use/misuse (12 mo),
n (%)
Depressive symptoms (PHQ-9)
mean (SD)
Anxiety symptoms (GAD-7),
mean (SD)
Descriptive Statistics
Group
Comparisons
MI
(n = 43)
t or x2 (P)
32.3
(12.8)
TAU
(n = 43)
31.8 (13.3) 20.18 (0.861)
28 (63.6)
4 (9.1)
3 (6.8)
7 (15.9)
11 (26.2)
43 (97.7)
43 (97.7)
31 (73.8)
11 (25)
34 (79.1)
2.75 (0.766)
28 (70)
5 (12.5)
2 (5)
4 (10)
11 (27.5)
0.02 (0.894)
42 (100)
0.97 (0.326)
41 (97.6) ,0.01 (0.973)
29 (72.5)
5.23 (0.265)
9 (21.4)
0.15 (0.695)
30 (71.4)
4.67 (0.458)
39 (88.6)
21 (51.2)
25 (59.5)
5.1 (3.7)
35 (87.5)
21 (53.8)
26 (66.7)
5.5 (5.2)
6 (13.6)
5 (11.4)
6 (13.6)
1 (2.3)
19.9 (5.6)
8 (19)
6 (14.3)
3 (7.1)
3 (7.1)
20.0 (6.6)
1.15 (0.284)
0.09 (0.931)
17.4 (2.8)
17.2 (2.6)
20.42 (0.679)
1.4 (0.5)
1.5 (0.6)
1.5 (0.6)
1.8 (0.7)
0.93 (0.355)
2.40 (0.019)
6.04 (0.302)
20 (48.8)
18 (43.9)
3 (7.3)
0
0
3.6 (1.7)
16 (41)
14 (35.9)
4 (10.3)
3 (7.7)
1 (2.6)
3.8 (2.1)
0.52 (0.602)
36 (81.8)
36 (85.7)
0.24 (0.625)
3.4 (2.9)
5.3 (5.4)
2.01 (0.048)
3.5 (3.5)
5.1 (4.7)
1.83 (0.071)
1.70 (0.428)
3.05 (0.931)
0.44 (0.506)
0.49 (0.623)
0.48 (0.788)
STD, sexually transmitted disease; PRHS, Perceived Risk of HIV Scale.
White cisgender MSM recruited from one site. Future studies
should explore efficacy of the intervention in other populations with larger sample sizes. Participants were compensated
during this trial, but compensation was equal for both
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Chan et al
J Acquir Immune Defic Syndr Volume 87, Number 3, July 1, 2021
FIGURE 2. Number of participants at
initial PrEP uptake cascade steps by
condition.
conditions, and those participants receiving MI were not paid
for attendance at MI sessions. Although it is possible that the
prospect of participant payment may have biased the sample,
the sample chosen was unique and important given that
patients were not initially PrEP-seeking. The research team
felt that it was crucial to offer participants modest remuneration for their time and effort. In the future, with possible
scale-up of MI for PrEP services, it may be worthwhile to
consider whether paying participants to engage in MI could
be a useful strategy for enhancing rates of PrEP initiation.
Future research could further evaluate efficacy of the MI
intervention while controlling for other predictors of PrEP
use, such as condomless sex, number of partners, etc. The
HIRI-MSM was used as a primary inclusion and screening
tool. As noted in recent studies,33,34 the HIRI-MSM’s
sensitivity in identifying individuals who are likely to acquire
HIV is 63%–85%, with lower sensitivity among people of
color. Although the HIRI-MSM is not a perfect screening
tool, it identifies a sizable proportion of patients who might
benefit from PrEP. We further note that only 10 participants
were excluded because of a low HIRI-MSM score. The HIRIMSM, coupled with our other intervention components, can
be readily implemented in clinical settings because of
its brevity.
Moreover, the control condition was the clinic’s usual
care practices for patients who might benefit from PrEP. As
such, intervention participants might have had increased
contact and discussions with staff about PrEP. The next step
would be to compare the intervention protocol to an attentionmatched control condition. Although we monitored receipt of
the PrEP prescription, we did not determine if participants
actually filled the prescription. Expanding follow-up to assess
this important next step, and potentially examining longitudinal adherence, as well, would be important in future
research of this intervention. Individuals with a history of
taking PrEP were excluded from this study. This was
intentional because of our focus on MSM not already seeking
or receptive to PrEP. However, future studies could test this
approach with PrEP-experienced MSM. Finally, a sizeable
proportion of eligible patients either declined to participate or
agreed, but never completed enrollment procedures. This
highlights the importance of flexibly delivering an intervention, such as the one developed here, as the target population
is not necessarily treatment seeking and might encounter
other barriers to seeking or obtaining care. One solution might
be to offer remote contact if time or travel is a barrier.
In conclusion, this is one of the first studies to
demonstrate efficacy of an intervention to promote PrEP
uptake among MSM at high risk for HIV acquisition. This
intervention, suitable for real-world settings, coupled brief
counseling, patient navigation, and risk assessments to
enhance PrEP uptake. The next step will be to assess the
intervention’s effectiveness in larger and more diverse
samples and its impact on downstream endpoints in the PrEP
care continuum.
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