Exposing the gaps: HIV prevention perspectives, use, and preferences among priority populations in Seattle, Washington

Abstract

While the rate of new HIV diagnoses has decreased over the past decade in Seattle and King County, Washington, HIV incidence remains high among gay, bisexual, and other men who have sex with men (GBMSM), transgender persons, and people who inject drugs (PWID). Biomedical HIV prevention, including daily oral and long-acting injectable pre-exposure prophylaxis (PrEP), has the potential to address these disparities but several individual, interpersonal, and structural barriers can impede uptake and optimal use. To better contextualize HIV incidence in the era of PrEP, it is imperative to understand the population-specific barriers and facilitators to use, the utilization of other behavioral risk reduction methods in the absence of PrEP, and the preferences for different prevention products and delivery models of PrEP-eligible populations.In the following dissertation, we explore HIV prevention perspectives, use, and preferences among high-incidence populations in Seattle, Washington. In Chapter II, we conducted a convergent parallel mixed-methods study among women who inject drugs (WWID) accessing community-based services in North Seattle to explore PrEP uptake, interest, and facilitators and barriers to use. In Chapter III, we described the individual- and partnership-level correlates of the non-use of HIV prevention strategies among GBMSM not on PrEP and seeking HIV testing. In Chapter IV, we conducted a discrete choice experiment among GBMSM, transgender persons, and non-binary individuals to estimate preference for different PrEP products and delivery models. We found that (Chapter II) among WWID, interest in PrEP was high but use was low and met with significant misconceptions about PrEP and complex, intersecting barriers to uptake and persistence. (Chapter III) Among GBMSM who were not using PrEP, non-use of HIV prevention strategies was significantly higher among participants who used methamphetamine or had never previously tested for HIV. At the partnership level, not knowing a partner’s age, meeting a partner in a sex venue, reporting a one-time sexual relationship, and perceptions of non-commitment were associated with non-use of HIV prevention strategies. (Chapter IV) Finally, among a similar sample with mixed PrEP experience, we found that product efficacy drove decision-making, and participants preferred highly efficacious long-acting products delivered in non-clinical spaces with a hybrid approach to follow-up PrEP monitoring. Taken together, our findings reinforce that there is no single solution to HIV prevention that currently meets the needs of all who may benefit. A combination of community-specific HIV prevention messaging and low-barrier, preference-centered PrEP programs could engage a greater proportion of the population and ultimately decrease HIV incidence.