PrEP.

The majority of IDI participants from Lima were skeptical of using PrEP, though many did acknowledge that PrEP would be suitable for those most at risk, namely sex workers. The most adamant dismissal of PrEP was made out of concerns around the potential side effects (particularly weight gain) and the perception that it was not 100% effective. For some, they associated pill-taking with being sick and some thought daily use could be challenging; others said that pills would make members of their family curious (particularly bi-men) and would raise issues of confidentiality.

I'm not going to take a pill that a week later is going to give me a heart attack. (Lima, IDI 2)

It is notable that while the men participating in IDIs in Lima were more skeptical of PrEP than not, the men in the focus groups, particularly those who did not use condoms consistently seemed open to the idea. In one focus group most every participant thought PrEP sounded promising, particularly in combination with other prevention approaches. One man said:

It [the pill] gives you more confidence in yourself, you know. And to the person you are with, I mean, if I take my pill, I feel safer about having more sex with you, because I have more protection, plus the condom, plus circumcision, you feel safer about having sex with that person, it gives you more confidence. (Lima, FGD participant)

In Rio de Janeiro, almost all participants expressed interest in and willingness to take PrEP, both in the IDIs and the FGDs. Participants with more positive views on PrEP believed that it would alleviate underlying concerns about the risk of contracting HIV. Overwhelmingly, MSM in Rio considered PrEP to be an additional means of protection—a way to ensure they would not contract HIV. The idea of not using a condom while taking PrEP never spontaneously came up in discourse and when prompted, participants overwhelmingly perceived PrEP as an added value, not a replacement for condoms. This perception is consonant with the generally favorable culture of condoms. A participant who did not use condoms from Rio stated:

…in moments when I’m really turned on I let myself be convinced not to use a condom. This pill is another method [of prevention] that I can ingest—this would be an interesting option...” (Rio, IDI 12)

The typologies played a much larger role in New York and San Francisco, where MSM were split on the issue of PrEP. Generally, non-condom users demonstrated interest in PrEP as offering a form of “layered security.”

I would love to put my faith in a pill like that. That would be kinda cool. I'm, you know, I'm still, like, very sexually active right now. I'm not looking to settle down with someone in a monogamous relationship. So the idea of that [pill] happening would just, like, because so many times I just feel like when you're having sex there's just so much fear around it and, like, I would love to not have that fear… just the idea of that pill would just get rid of so much fear. (SF, FGD participant)

Disinterested men were largely ‘safety seekers’ and ‘intimacy/pleasure seekers’, generally comfortable with their current prevention strategies. In the US, those who had witnessed friends/ acquaintances endure side effects associated with early ARV regimens were often less amenable to the idea of taking PrEP. Some believed the drugs were somewhat toxic and hard on the body. Others raised issues related to the cost of the pill and the potential for risk compensation to occur. In San Francisco especially, many felt that PrEP was “great” for other people, but that they were not good candidates either because they were not pill-takers or because they already had solid HIV prevention practices in place. For these men, PrEP seemed best suited for the sexually “promiscuous or irresponsible” members of society (i.e., sex workers or barebackers).

HIV Home Testing.

Following condoms, the most commonly reported prevention strategy across all sites was HIV testing, which some MSM reporting use for sexual decision making (i.e. sharing results of recent testing with potential partners) and others reported using to alleviate the regret attached to any episode of anal sex without a condom. An HIV negative test result absolved participants from feelings of guilt or anxiety.

By and large men across the four cities had a favorable reaction to the HIV self-test kit. Across typologies, MSM reported that HIV self-testing would provide privacy, alleviate shame and/or embarrassment, and circumvent the inconvenience of traveling to a clinic, waiting in line (a substantial obstacle in Rio), and feeling judged once there. Enthusiasm and support for the HIV self-test kits was, however, tempered by questions about the cost of the test and the threat of a false positive result. Additionally, while conceptually men liked the idea of HIV home testing, some were not interested in personally using a self-test, preferring to be tested with a counselor in a clinic. For those men that “loved” the idea because of the convenience factor, they thought the easy availability and convenience would lead them to more frequent testing and many suggested that they would use self-tests with a partner.

Some differences in attitudes towards HIV self-testing emerged between sites and by typology. In Lima, MSM were interested with some stating they would test more frequently if they could test in the privacy of their own home and most also agreed they would test with trusted, long-term partners, though some were concerned about giving up clinic-based counseling, which most identified as comfortable and appreciated. As with PrEP, men in Rio were keen to add self-test kits to the repertoire of prevention options and consistently referred to the benefits of convenience and privacy. The more tempered responses to home testing in Rio (and elsewhere) were usually in reference to concerns that some men would not be ready to handle testing alone. Only 1 participant in Rio put himself in this category, while others were confident they were ready for self-testing. The general consensus was very positive:

I think that anything that could facilitate our lives—I think it is welcome and this thing [self-test] would facilitate a great deal… I have a super busy life, and I think that most other people have a lot going on as well. So if you can do a test at your house in minutes instead of having to go out in traffic, lose a day, I think it would be really good… I also understand that in general some people would not be prepared to get a positive test result alone. (Rio, IDI 09)

Men in the US sites supported the idea of home testing, but about half preferred to continue to test in their customary locations, particularly those who were comfortable with their current testing routine. Typology did not heavily influence opinions on testing in any category except for the mindful risk takers who were personally interested in using the home test.

That’d be great. If it was affordable, I’d use it. There’s the convenience factor. It’s immediate. Privacy clearly would be an advantage there. (NY, IDI 06)

Couples Counseling as a Prevention Strategy.

Men in South America were more amendable to the idea of couples-based interventions, most specifically counseling focused on improving communication with sexual partners. Most participants recognized couples counseling as beneficial, a way to build trust and encourage discussion about prevention, particularly as men in the South American sites reported that discussing HIV serostatus with sex partners prior to having sex was not at all normative. In fact, the very idea of asking for this conversation was anathema to most of the men interviewed, particularly in Lima.

The basic question is, ‘do you take care of yourself”? It is not, ‘have you taken any tests, or are you negative or positive’. (Lima, IDI 06)

Here no one asks [about serostatus]. What we have to do is use the tools that we have to keep ourselves safe. (Rio, IDI 02)

The reluctance to discuss serostatus was partially an issue of privacy and respect and also a way to avoid implicating oneself as a risk to potential partners by raising the question of status. Having a counselor to help negotiate or ease the conversation was appealing to most MSM in Lima with main partners; similarly, in Rio, all but one MSM with a main partner were very open to the idea of couples counseling.

At the U.S. sites, where disclosure is more common, less than half of the participants said they would seek couples counseling, and unlike the case with PrEP or home testing, this did not differ by prevention typology. About half of the participants in New York endorsed the idea of a sexual health counselor for couples, however, most participants felt they generally did not need sexual health counseling of any kind, and recommended counseling as a strategy for others in their communities (e.g., young gay men, couples early on in a relationship, gay men without access to social support).

People love to talk to people. Especially if they’re going to somebody who has more knowledge than them about a certain situation that they want to know. They can ask all the questions they want and the counselor can answer everything…and they can be open and honest. A lot of people just want to talk and get shit off their chest, you know? (NY, IDI 10)

In San Francisco, some men liked the idea of consulting a counselor to find ways to approach sensitive questions with partners. Other men in San Francisco expressed no interest in the concept of a sexual health counselor with a partner (or alone). Some stated that counseling is too stigmatizing, particularly within economically disadvantaged and ethnic minority communities, ineffective, or simply irrelevant.

There's a stigma with counseling, even educational counseling. There's a stigma to it. What are you doing wrong that you need it? (SF, IDI 10)

Using Technology to Facilitate HIV Prevention.

Because discussions of technology were somewhat limited in the IDIs, there were insufficient data to explore perceptions of technology-based strategies by prevention typology; however, some important themes emerged in the data. Across the sites, all participants had experiences using the Web, but only a few described currently using it for the purposes of locating information about HIV and other sexual health related issues. In the U.S., participants described CDC-like websites as informative, but not user friendly. They would prefer a site with the same quality and trustworthiness of these sites, but in layman’s language.

In South America, some MSM mentioned using the internet to self-diagnose a sexually transmitted infection (STI) (e.g. if they had a wart or sore), but most used it solely for social networking and entertainment, mentioning high rates of utilization of sites like Orkut and Facebook, including use of these sites to identify sex partners. South American MSM generally liked the idea of using social networking sites for educational opportunities or the idea of creating a dedicated site for sexual health promotion that was interactive, easy to use, with accessible language, and MSM friendly.

In the US, topics that were spontaneously offered as recommendations by the focus group participants included access to counseling or sexual health experts on the web, ideally in real-time, and the use of vignettes (video clips) of real stories coming from people living with HIV to promote strategies around disclosure. Reception to the idea of “virtual” counseling was also well received in South American FGDs, however, participants were clear they would not want these virtual services to replace face-to-face counseling. Men in Peru stipulated that any virtual providers would need to be skilled in using basic and straightforward language to ensure client understanding, which they thought would be more challenging in a virtual setting.

Providers’ Perceptions of PrEP.

Across sites, the providers were conflicted about the potential for diverting resources used for treating HIV to cover the costs of PrEP. That said, U.S. providers were interested in PrEP, seeking further information, and conducting research on PrEP. Enthusiasm was dampened by what they perceived as a lack of demand and the potential barrier of prohibitive costs.

People are HIV positive and cannot get meds for free. It [PrEP] feels very unethical to me. It’s an issue for me. (SF, NGO-based provider)

We have a protocol at our center. We offer it. It’s one more thing to offer. It’s not been very successful. Patients are uninsured and therefore have no access to medications. Realistically cost is a barrier… (NYC, MD)

In Brazil and Peru, only providers from the research sites (where HIV prevention and treatment clinical trials have been conducted) were informed about PrEP. In both South American sites providers were unsure whether PrEP would be authorized or even considered as a national strategy, given the prohibitive costs and lack of support from the Ministries of Health (as of 2012, which has since changed in Brazil). Peruvian providers were hypothetically and cautiously optimistic about the potential of PrEP, though they also had reservations about the populations’ ability and interest in adhering to a regimen when not ill. Brazilian providers were also worried about poor adherence as well as risk compensation, but interested in thinking about how PrEP could be used to enhance prevention in combination with counseling and cautiously distributed in through the public health system.

Providers’ Perceptions on HIV Home Testing.

Home testing drew the most inconsistent and emotionally-charged responses from providers across sites, where a continuum of opinions emerged, ranging from strong reservations to cautious support and interest. Those who were enthusiastic voiced strong support to expand access to testing and saw home test kits as an opportunity to let MSM make their own testing choices—whether they use home tests as their primary testing source or as an “in-between” clinic visit strategy. Those who were most reserved voiced concern about the preparedness of their clients for receiving an HIV positive result alone and handling the news if positive.

I am completely against it [HIV testing at home]…I have worked with HIV for more than 10 years, and each person reacts in a different way. People you think are going to completely fall apart end up receiving the news calmly and concerned about what they can do in the future. Others who you think are going to be completely fine end up falling apart in front of you, cry, think that their life is over…I think that without any form of counseling, it simply should not be done… (Rio, Infectious disease specialist)

There were also major qualms about how MSM would be linked into follow-up testing and care after receiving a positive HIV self-test result, and about interpreting and acting on a negative test result in light of the window period if not properly counseled. Other logistical concerns surfaced around structural barriers, such as laws stating a requirement for pre-test counseling as part of national HIV testing services (Lima) and whether restrictions for sale or distribution of home test kits would exist for populations under the age of 18. Some of those providers who did not like the idea generally, however, were open to the idea of providing home tests following an assessment of “readiness” or for repeat testers or clients in sero-discordant relationships.

Provider’s Perceptions of Couples Counseling.

Providers interviewed were generally supportive of couples HIV testing and counseling across sites, recognizing a need in the community while also noting logistical stumbling blocks and a need to systematize the practice and a roadmap for implementation. The major concern was volume and human resources. If a counselor needed to meet with each member of the couple first and then together, introducing this into already overstretched clinics would strain resources. Providers were also puzzled about how one would determine who qualified as a couple, when this prevention approach would be most optimal, and whether counseling would only be HIV focused or include broader mental health and communication issues. In Brazil, the inclusion of couples counseling was perceived as politically important for recognizing gay and trans couples. In New York, providers were more apt to support this strategy for younger men in need of more support but also recognized that this service might not be attractive for young men. Interestingly, a large number of providers reported already providing this service informally—but none had a “partners’ program” per se, with guidelines or specific training. This is well illustrated in a quote from a medical provider in New York:

I do that [couples counseling] all the time, because every time somebody is in a new relationship, I know that getting rid of condoms is a goal and people are in a real rush to get there and so I very much talk about what I see as the components about making that decision. … We don’t make heterosexual couples use condoms in long term relationships, there’s no reason to make gay men in monogamous couples do that, but how do you negotiate that question? … Basically, I ask people are you willing, can you make an agreement that if this person comes to you I played around and we have to use condoms for 6 months. Do you agree not to go running screaming for the door, because without that level of commitment, then you’re not ready to give up condoms. People’s eyes open up. They never thought about it that way. I think it makes a big difference. … It would be great to have some professional advice on what I’m doing. (NY, medical provider)

Technology.

All providers interviewed used technology in some ways to reach patients or clients either through websites or Facebook, YouTube or Twitter. The CBOs/NGOs maximized the use of social media to reach MSM. Providers agreed that in today’s world, it is necessary to use online tools for prevention and disseminating information, yet were hesitant about the extent to which these technologies could be forums for discussion in the absence of an educated moderator. For example, for those with experience with chat rooms, they noted that when they tried to insert prevention messages into sex chats, they were largely unsuccessful as they perceived people as not wanting to talk about prevention in these spaces.

The idea of “virtual” counseling or a web-based tool (having clients respond to interactive questions that generate a personalized risk score) got mixed reviews among U.S. providers. It appealed to some, but others were concerned about the veracity of the data provided and thus of the ensuing score. There was no consensus about the best format to complete risk questions or to present risk score results to clients (i.e. use alone or with a counselor).

I like the idea of people thinking about risk. The basic concept—I like it. But I’m concerned people will put in inaccurate information, not intentionally, underestimate risk and end up with an inaccurate summary because of that. The score is only as good as the information going in. (SF, Sexual health clinic rep)

Great strategy, but not alone, needs to be done with more. Good to have the support for a larger prevention strategy but not as a stand-alone thing. (NY, CBO provider)

However, providers were more encouraging in Peru and Brazil that such a tool could both be helpful to MSM using it alone and definitely as a tool to facilitate prevention conversation and support (but not replace) counseling.

Good idea to have a patient score that could be like a speedometer, little risk is green, yellow, red. It would be a great tool. (Lima, Counselor)