Publications by authors named "Sarah K Calabrese"

56 Publications

Electronic Dissemination of a Web-Based Video Promotes PrEP Contemplation and Conversation Among US Women Engaged in Care at Planned Parenthood.

AIDS Behav 2021 Mar 11. Epub 2021 Mar 11.

Center for Interdisciplinary Research in AIDS, Yale University, New Haven, CT, USA.

We evaluated the acceptability and impact of a web-based PrEP educational video among women (n = 126) by comparing two Planned Parenthood centers: one assigned to a Web Video Condition and one to a Standard Condition. Most women reported the video helped them better understand what PrEP is (92%), how PrEP works (93%), and how to take PrEP (92%). One month post-intervention, more women in the Web Video Condition reported a high level of comfort discussing PrEP with a provider (82% vs. 48%) and commonly thinking about PrEP (36% vs. 4%). No women with linked medical records initiated PrEP during 1-year follow-up.
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http://dx.doi.org/10.1007/s10461-021-03210-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947376PMC
March 2021

Development and Evaluation of an Online Education-Entertainment Intervention to Increase Knowledge of HIV and Uptake of HIV Testing among Colombian Men Who Have Sex with Men (MSM).

Int J Environ Res Public Health 2021 Feb 12;18(4). Epub 2021 Feb 12.

Department of Psychological and Brain Sciences, The George Washington University, Washington, DC 20052, USA.

Using a community-based participatory approach, we developed a film to promote HIV testing among young men who have sex with men (MSM) in Bogotá. Using a 5-step process to develop the intervention, we conducted 11 focus groups with MSM (n = 141) to receive community feedback at each step. To evaluate the intervention we recruited 300 young MSM to complete a baseline survey in December 2017. Between February-June 2018, 63 participants watched the film and completed a post-viewing survey, which showed the intervention was acceptable for the target population. Between August-December 2018, 48 MSM who watched the film and 47 who did not (control group) completed a follow-up survey. To obtain preliminary evidence of the efficacy of the intervention, we assessed the main effect of time (baseline vs. follow-up) and the interaction between time and group (intervention vs. control) on HIV testing uptake and intentions, and knowledge of HIV transmission dynamics and HIV-related rights. Knowledge of HIV rights increased from baseline to follow-up in the intervention group only. HIV Knowledge increased for both groups. HIV testing intentions increased significantly more for non-gay-identified men in the intervention group, but the overall effect of the intervention was not significant. Testing uptake did not change.
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http://dx.doi.org/10.3390/ijerph18041811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7918496PMC
February 2021

Prioritising pleasure and correcting misinformation in the era of U=U.

Lancet HIV 2021 03;8(3):e175-e180

Department of Population Medicine, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA.

There is widespread unawareness and disbelief regarding the evidence-based conclusion that people who have a sustained undetectable HIV viral load cannot sexually transmit HIV-ie, undetectable=untransmittable (U=U). Long-standing, misguided fear about HIV transmission persists; consequently, so does the policing of sexual expression and the penalisation of pleasure faced by people with HIV. Many people with HIV with an undetectable viral load have unnecessarily abstained from condomless sex, avoided serodifferent partnering, and had anxiety about onward sexual transmission due to perceived HIV risk that is now known to be non-existent. Some health professionals have refrained from correcting this misinformation because of concerns that people with HIV will engage in more condomless sex or have more sexual partners upon learning of U=U. Withholding information about U=U is thus rooted in behavioural assumptions and is scientifically unfounded. Moreover, withholding such information violates medical ethics, perpetuates health inequities, and infringes on the sexual health and human rights of people with HIV. Health professionals and the broader public health community have an ethical responsibility to actively address misinformation about HIV transmission and disseminate the U=U message to all people.
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http://dx.doi.org/10.1016/S2352-3018(20)30341-6DOI Listing
March 2021

Birth Control Sabotage as a Correlate of Women's Sexual Health Risk: An Exploratory Study.

Womens Health Issues 2021 Mar-Apr;31(2):157-163. Epub 2020 Nov 18.

Department of Psychological and Brain Sciences, George Washington University, Washington, DC.

Introduction: To explore associations between birth control sabotage, a form of reproductive coercion, and women's sexual risk among women attending family planning health centers. Data were collected from a 2017 cross-sectional online survey of 675 women who attended Connecticut Planned Parenthood centers. Participants reported birth control sabotage; sexual risk (i.e., inconsistent condom use during vaginal and anal sex in the past 6 months, lifetime sexually transmitted infection diagnosis, lifetime exchange sex [trading sex for money, drugs, or other goods], and multiple sexual partners in the past 6 months); and sociodemographics. Bivariate and multivariable logistic regression models were used to examine associations between birth control sabotage and women's sexual risk.

Results: One in six women (16.4%; n = 111) reported experiencing birth control sabotage. Women who reported birth control sabotage had a greater odds of ever having an sexually transmitted infection (adjusted odds ratio, 2.18; 95% confidence interval, 1.31-3.60; p = .003), ever engaging in exchange sex (adjusted odds ratio, 2.77; 95% confidence interval, 1.17-6.53; p = .020), and having multiple sexual partners in the past 6 months (adjusted odds ratio, 1.96; 95% confidence interval, 1.21-3.18; p = .006).

Conclusions: Our findings demonstrate increased engagement in sexual risk taking among women who reported birth control sabotage compared with women did not.
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http://dx.doi.org/10.1016/j.whi.2020.10.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005431PMC
November 2020

Understanding, Contextualizing, and Addressing PrEP Stigma to Enhance PrEP Implementation.

Curr HIV/AIDS Rep 2020 12 23;17(6):579-588. Epub 2020 Sep 23.

Department of Psychological and Brain Sciences, The George Washington University, 2125 G Street NW, Washington, DC, 20052, USA.

Purpose Of Review: HIV pre-exposure prophylaxis (PrEP) is a safe and effective preventive intervention that could play a central role in ending the HIV epidemic. However, low uptake in general, and among certain social groups in particular, underscores the need to identify and address barriers to PrEP use. PrEP stigma has emerged as a key factor interfering with PrEP interest, uptake, and continuation. The purpose of this article is to describe and contextualize PrEP stigma and to offer recommendations on how to address it in future PrEP implementation initiatives.

Recent Findings: PrEP users are commonly stereotyped as sexually irresponsible, promiscuous, and immoral. These stereotypes and associated prejudice manifest at multiple levels and discourage PrEP interest and uptake, disrupt PrEP adherence, and motivate PrEP discontinuation. Intersecting forms of stigma may influence the nature, magnitude, and impact of PrEP stigma across social groups and otherwise hinder PrEP use. Current PrEP implementation strategies that narrowly focus on risk and target stigmatized groups with disproportionately high HIV incidence have yielded limited success and are counterproductive to the extent that they perpetuate stigma. Implementation strategies involving more inclusive messaging and further integration of PrEP within healthcare may help to reduce PrEP stigma and mitigate its impact, ultimately increasing PrEP use. PrEP stigma is a barrier to PrEP interest, uptake, and continuation that manifests at multiple levels. Understanding and addressing PrEP stigma requires consideration of its origins and intersections. Targeted, risk-focused implementation strategies perpetuate stigma and undermine use.
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http://dx.doi.org/10.1007/s11904-020-00533-yDOI Listing
December 2020

Health Profession Students' Awareness, Knowledge, and Confidence Regarding Preexposure Prophylaxis: Results of a National, Multidisciplinary Survey.

Sex Transm Dis 2021 Jan;48(1):25-31

DeWitt C. Baldwin Institute for Interprofessional Education, Rosalind Franklin University of Medicine and Science, North Chicago, IL.

Background: Preexposure prophylaxis (PrEP) is a highly effective, pharmacologic method of HIV prevention. Despite its safety and efficacy, PrEP prescription remains low in those patients who are at highest risk for HIV infection. One possible reason for this may be the lack of inclusion of PrEP and HIV prevention discussions within the curricula of health professions education.

Methods: An online survey was administered to a cross-sectional sample of future prescribers (osteopathic/allopathic medical and physician assistant students), future nurses, and future pharmacists (n = 2085) in the United States between January and July 2019 to assess and compare awareness of PrEP, PrEP education, PrEP knowledge, and confidence in 2 areas related to PrEP.

Results: We show that, overall, awareness of PrEP is high among future health care providers (81.6%), with the future pharmacists reporting the greatest awareness (92.2%; P < 0.001) and more commonly reporting PrEP education (71.0%). Students had mixed knowledge of PrEP, with future pharmacists reporting the highest knowledge of PrEP. Approximately 30% of students in all disciplines reported having low confidence counseling a patient about PrEP and low confidence educating a colleague about PrEP. Knowledge of PrEP was a significant predictor of confidence counseling a patient about PrEP (P < 0.001) and educating a colleague about PrEP (P < 0.001).

Conclusions: This study identifies opportunities to improve and incorporate evidence-based strategies for educating future health care providers about PrEP for HIV prevention within health professions curricula.
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http://dx.doi.org/10.1097/OLQ.0000000000001263DOI Listing
January 2021

Health Profession Students' Awareness, Knowledge, and Confidence Regarding Preexposure Prophylaxis: Results of a National, Multidisciplinary Survey.

Sex Transm Dis 2021 Jan;48(1):25-31

DeWitt C. Baldwin Institute for Interprofessional Education, Rosalind Franklin University of Medicine and Science, North Chicago, IL.

Background: Preexposure prophylaxis (PrEP) is a highly effective, pharmacologic method of HIV prevention. Despite its safety and efficacy, PrEP prescription remains low in those patients who are at highest risk for HIV infection. One possible reason for this may be the lack of inclusion of PrEP and HIV prevention discussions within the curricula of health professions education.

Methods: An online survey was administered to a cross-sectional sample of future prescribers (osteopathic/allopathic medical and physician assistant students), future nurses, and future pharmacists (n = 2085) in the United States between January and July 2019 to assess and compare awareness of PrEP, PrEP education, PrEP knowledge, and confidence in 2 areas related to PrEP.

Results: We show that, overall, awareness of PrEP is high among future health care providers (81.6%), with the future pharmacists reporting the greatest awareness (92.2%; P < 0.001) and more commonly reporting PrEP education (71.0%). Students had mixed knowledge of PrEP, with future pharmacists reporting the highest knowledge of PrEP. Approximately 30% of students in all disciplines reported having low confidence counseling a patient about PrEP and low confidence educating a colleague about PrEP. Knowledge of PrEP was a significant predictor of confidence counseling a patient about PrEP (P < 0.001) and educating a colleague about PrEP (P < 0.001).

Conclusions: This study identifies opportunities to improve and incorporate evidence-based strategies for educating future health care providers about PrEP for HIV prevention within health professions curricula.
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http://dx.doi.org/10.1097/OLQ.0000000000001263DOI Listing
January 2021

Stigma impedes HIV prevention by stifling patient-provider communication about U = U.

J Int AIDS Soc 2020 07;23(7):e25559

Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1002/jia2.25559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369401PMC
July 2020

Racial and ethnic differences in women's HIV risk and attitudes towards pre-exposure prophylaxis (PrEP) in the context of the substance use, violence, and depression syndemic.

AIDS Care 2021 02 14;33(2):219-228. Epub 2020 May 14.

Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA.

Women with syndemic conditions, i.e., two or more co-occurring epidemics, are at elevated risk for HIV acquisition and are therefore prime candidates for pre-exposure prophylaxis (PrEP). However, PrEP uptake remains low among women, especially among Black and Hispanic women. This study examined associations of syndemic conditions with PrEP attitudes and HIV risk among women, and the moderating effect of race and ethnicity. In 2017, 271 non-Hispanic Black, non-Hispanic White, and Hispanic, PrEP-eligible women engaged in care at Planned Parenthood in the northeastern region of the U.S. completed an online survey. Participants reported syndemic conditions (i.e., intimate partner violence, depression, substance use), PrEP attitudes (e.g., PrEP interest), HIV sexual risk (e.g., multiple male sexual partners), and sociodemographics. Structural equation modeling was used to examine the effects of syndemic conditions on PrEP attitudes and HIV risk, and the moderating effect of race and ethnicity. Women with more syndemic conditions had a higher odds of reporting multiple male sexual partners. Syndemic conditions were positively associated with PrEP attitudes for Hispanic women than non-Hispanic Black and White women. Women with syndemic conditions, particularly Hispanic women, may be receptive to interventions promoting PrEP.
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http://dx.doi.org/10.1080/09540121.2020.1762067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666028PMC
February 2021

Contraception as a Potential Gateway to Pre-Exposure Prophylaxis: US Women's Pre-Exposure Prophylaxis Modality Preferences Align with Their Birth Control Practices.

AIDS Patient Care STDS 2020 03;34(3):132-146

Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut.

Addressing women's low uptake of HIV pre-exposure prophylaxis (PrEP) requires improved understanding of their product preferences. Such preferences should be contextualized according to other aspects of their reproductive health, including their contraception practices. We investigated women's preferences across 10 PrEP modalities currently available or under study and examined associations between PrEP modality preferences and contraception practices. Heterosexually active women recently engaged in care at Connecticut Planned Parenthood centers ( = 563) completed an online survey. Participants were presented with images and descriptions of 10 PrEP modalities and asked to indicate their preference and specify their reasoning in an open-response format. Participants also reported prior and current use of 16 contraception modalities along with relationship, sexual health, and sociodemographic characteristics. The sample included women ages 18-45 (45.3% 25 or younger) who were predominantly non-Hispanic black (35.7%) or white (33.7%). All PrEP modalities presented were preferred by at least some women, with daily pills (24.9%), injections (24.3%), and invisible implants (14.9%) preferred most commonly. Across all modalities, associated reasoning often centered around ease of use and comfort. Coincidence with contraception modality was the third-most common reason underlying women's preferences. Women currently using the analogous contraception modality versus never having used it had higher odds of preferring PrEP daily pills [adjusted odds ratio (AOR) = 2.03], injections (AOR = 8.45), invisible implants (AOR = 11.63), and vaginal rings (AOR = 8.66). Diversification of available PrEP modalities and prioritization of those coinciding with popular contraception practices-especially daily pills, injections, and implants-could optimize PrEP acceptability, encourage PrEP uptake, and ultimately reduce HIV incidence among women.
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http://dx.doi.org/10.1089/apc.2019.0242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7087409PMC
March 2020

Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers.

Prev Med Rep 2020 Mar 21;17:101012. Epub 2019 Oct 21.

Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, United States.

Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP's preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs' PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers ("all trained") (42%) or having an onsite PrEP specialist ("on-site specialist") (43%). Only 15% preferred referring patients out of the practice to a specialist ("refer out"). Compared to those who preferred to "refer out," participants who preferred the "all trained" model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the "refer out" or on-site specialist" models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.
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http://dx.doi.org/10.1016/j.pmedr.2019.101012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926349PMC
March 2020

Content analysis of psychological research with lesbian, gay, bisexual, and transgender people of color in the United States: 1969-2018.

Am Psychol 2019 11;74(8):898-911

Department of Psychology, George Washington University.

This article updates previous content analyses that identified a relative paucity of U.S.-based psychological research on lesbian, gay, bisexual, and transgender (LGBT) people of color by extending the period covered to 2018. In addition to documenting how many such studies occurred and when, it considers the research questions asked, funding sources, impact, and journal outlets. This richer description of this research area allowed us to describe historically not only when LGBT people of color in the United States were studied but why they were studied, which journals published this work, and which published studies were most influential. We found that the literature starts in 1988 for LGB people of color and in 2009 for transgender people of color and that a significant shift occurred in 2009, with the majority of the articles being published in the last 10 years. Findings suggest that U.S. federal funding and support for LGBT research as well as divisions of the American Psychological Association focused on minoritized identities and their journals played a role in the recent increase. Half of the studies investigated psychological symptoms, and more than a third of studied experiences and psychological processes related to holding multiple minority statuses, many of which focused on potentially deleterious aspects of these identities. These findings indicate that this literature has a significant focus on pathology. Underrepresented groups included cisgender and transgender women; transgender men; older individuals; Asian Americans, Native Hawaiians, and Pacific Islanders; American Indians and Alaska Natives; and multiracial individuals. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/amp0000562DOI Listing
November 2019

Implementation guidance needed for PrEP risk-prediction tools.

Lancet HIV 2019 10;6(10):e649

George Washington University, 2125 G Street NW, Washington, DC 20052, USA. Electronic address:

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http://dx.doi.org/10.1016/S2352-3018(19)30298-XDOI Listing
October 2019

A Person-Centered Approach to HIV-Related Protective and Risk Factors for Young Black Men Who Have Sex with Men: Implications for Pre-exposure Prophylaxis and HIV Treatment as Prevention.

AIDS Behav 2019 Oct;23(10):2803-2815

University of California, UCSF Mailcode 0886, 550 16th St., 3rd Floor, San Francisco, CA, 94158, USA.

Although young Black men who have sex with men (YBMSM) are disproportionately affected by HIV, they may be more heterogeneous as a group than is typically appreciated. Thus, the present study used a person-centered data-analytic approach to determine profiles of HIV-related risk among YBMSM and whether these profiles could be distinguished by age, HIV status, and socioeconomic risk (i.e., socioeconomic distress). YBMSM (N = 1808) aged 18 to 29 years completed a survey of sociodemographic characteristics, HIV status, and HIV-related behavioral and attitudinal factors (i.e., safer-sex self-efficacy, negative condom attitudes, being in difficult sexual situations, being in difficult sexual relationships, HIV treatment optimism, perceived HIV stigma). Latent profile analysis was used to identify HIV risk profiles and whether age, HIV status, and socioeconomic distress were associated with these profiles. Four profiles emerged: low-, medium-, and high-risk profiles, respectively, and a mixed profile characterized by a tendency to be in difficult sexual situations and relationships while also reporting high safer-sex self-efficacy and low negative attitudes toward condom use. Difficult sexual situations emerged as the key defining indicator of whether a profile reflected higher or lower risk. Younger age, being HIV-positive, and socioeconomic distress were associated with having a higher-risk profile. Given that unique risk profiles emerged that were differentially predicted by sociodemographic characteristics and HIV status, these findings have implications for tailoring interventions to the needs of different subgroups of YBMSM. Also, disempowering or risky sexual situations and relationships among YBMSM must be addressed.
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http://dx.doi.org/10.1007/s10461-019-02630-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299803PMC
October 2019

Current US Guidelines for Prescribing HIV Pre-exposure Prophylaxis (PrEP) Disqualify Many Women Who Are at Risk and Motivated to Use PrEP.

J Acquir Immune Defic Syndr 2019 08;81(4):395-405

Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT.

Background: US Centers for Disease Control and Prevention clinical guidelines for HIV pre-exposure prophylaxis (PrEP) are widely used to assess patients' PrEP eligibility. The guidelines include 2 versions of criteria-guidance summary criteria and recommended indications criteria-that diverge in a potentially critical way for heterosexually active women: Both require women's knowledge of their own risk behavior, but the recommended indications also require women's knowledge of their partners' HIV risk or recognition of a potentially asymptomatic sexually transmitted infection. This study examined women's PrEP eligibility according to these 2 different versions of criteria across risk and motivation categories.

Setting/methods: HIV-negative women (n = 679) recently engaged in care at Connecticut Planned Parenthood centers were surveyed online in 2017. The survey assessed PrEP eligibility by both versions of Centers for Disease Control and Prevention criteria, HIV risk indicators, PrEP motivation indicators, and sociodemographic characteristics.

Results: Participants were mostly non-Hispanic white (33.9%) or black (35.8%) and had low income (<$30,000/year; 58.3%). Overall, 82.3% were eligible for PrEP by guidance summary criteria vs. 1.5% by recommended indications criteria. Women disqualified by recommended indications criteria included those reporting condomless sex with HIV-positive or serostatus-unknown male partners (n = 27, 11.1% eligible); 1 or more recent sexually transmitted infection(s) (n = 53, 3.8% eligible); multiple sex partners (n = 168, 3.0% eligible); intended PrEP use (n = 211, 2.8% eligible); and high self-perceived risk (n = 5, 0.0% eligible).

Conclusion: Current guidelines disqualify many women who could benefit from PrEP and may lead to discrepant assessments of eligibility. Guideline reform is needed to improve clarity and increase women's PrEP access and consequent HIV protection.
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http://dx.doi.org/10.1097/QAI.0000000000002042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594908PMC
August 2019

Intimate Partner Violence Influences Women's Engagement in the Early Stages of the HIV Pre-exposure Prophylaxis (PrEP) Care Continuum: Using Doubly Robust Estimation.

AIDS Behav 2020 Feb;24(2):560-567

Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA.

Intimate partner violence (IPV) is associated with pre-exposure prophylaxis (PrEP) acceptability among US women, but whether IPV influences other steps along the PrEP care continuum remains unclear. This study estimated the causal effects of IPV on the early stages of the PrEP care continuum using doubly robust (DR) estimation (statistical method allowing causal inference in non-randomized studies). Data were collected (2017-2018) from a cohort study of 124 US women without and 94 women with IPV experiences in the past 6 months (N = 218). Of the 218 women, 12.4% were worried about getting HIV, 22.9% knew of PrEP, 32.1% intended to use PrEP, and 40.4% preferred an "invisible" PrEP modality. IPV predicts HIV-related worry (DR estimate = 0.139, SE = 0.049, p = 0.004). IPV causes women to be more concerned about contracting HIV. Women experiencing IPV are worried about HIV, but this population may need trauma-informed approaches to help facilitate their PrEP interest and intentions.
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http://dx.doi.org/10.1007/s10461-019-02469-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6763353PMC
February 2020

Providers should discuss U=U with all patients living with HIV.

Lancet HIV 2019 04 13;6(4):e211-e213. Epub 2019 Feb 13.

Harvard Medical School and The Fenway Institute, Boston, MA, USA.

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http://dx.doi.org/10.1016/S2352-3018(19)30030-XDOI Listing
April 2019

Risk Compensation and Clinical Decision Making - The Case of HIV Preexposure Prophylaxis.

N Engl J Med 2019 Feb;380(6):510-512

From the Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute (J.L.M., D.S.K.), and the Division of Infectious Diseases, Beth Israel Deaconess Medical Center (D.S.K.) - all in Boston; the Department of Dermatology, Kaiser Permanente San Francisco Medical Center, San Francisco (K.A.K.); and the Department of Psychology, George Washington University, Washington, DC (S.K.C.).

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http://dx.doi.org/10.1056/NEJMp1810743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6396306PMC
February 2019

Considering Stigma in the Provision of HIV Pre-Exposure Prophylaxis: Reflections from Current Prescribers.

AIDS Patient Care STDS 2019 02;33(2):79-88

14 Department of Psychology, Yale University, New Haven, Connecticut.

Efforts to identify and address social inequities in HIV pre-exposure prophylaxis (PrEP) access are urgently needed. We investigated early-adopting PrEP prescribers' beliefs about how stigma contributes to PrEP access disparities in health care and explored potential intervention strategies within the context of PrEP service delivery. US-based PrEP prescribers were recruited through professional networks and participant referrals. Qualitative interviews were conducted, transcribed, and thematically analyzed. Participants (n = 18) were primarily male (72%); white (39%) or Asian (33%); and heterosexual (56%). Most practiced in the Northeastern (67%) or Southern (22%) United States; were physicians (94%); and specialized in HIV/infectious disease (89%). Participants described multiple forms of structural and interpersonal stigma impeding PrEP access. The requirement that PrEP be prescribed was a perceived deterrent for populations with medical mistrust and/or low health literacy. Practice norms such as discussing PrEP only in response to patient requests were seen as favoring more privileged groups. When probed about personally held biases, age-related stereotypes were the most readily acknowledged, including assumptions about older adults being sexually inactive and uncomfortable discussing sex. Participants criticized providers who chose not to prescribe PrEP within their clinical practice, particularly those whose decision reflected personal values related to condomless sex or discomfort communicating about sex with their patients. Suggested solutions included standardizing PrEP service delivery across patients and increasing cultural competence training. These early insights from a select sample of early-adopting providers illuminate mechanisms through which stigma could compromise PrEP access for key populations and corresponding points of intervention within the health care system.
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http://dx.doi.org/10.1089/apc.2018.0166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386080PMC
February 2019

US Guideline Criteria for Human Immunodeficiency Virus Preexposure Prophylaxis: Clinical Considerations and Caveats.

Clin Infect Dis 2019 08;69(5):884-889

Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University.

Clinical guidelines for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) developed by the US Centers for Disease Control and Prevention have been instrumental in the implementation of PrEP in medical practices throughout the country. However, the eligibility criteria contained within may inadvertently limit PrEP access for some patients. We describe the following key considerations and caveats related to these criteria: promotion of a selective vs universal approach to sexual health education involving PrEP; misalignment between criteria stated in the table and text boxes; problematic categorization and confounding of sexual orientation, gender identity, and risk behavior; underemphasis of network/community-level drivers of HIV transmission; oversimplification of serodiscordant risk; and lack of clarity surrounding the relevance of condoms to PrEP eligibility. We offer concrete recommendations to address the identified issues and strengthen future iterations of the guidelines, applying these recommendations in an alternative table of "criteria."
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http://dx.doi.org/10.1093/cid/ciz046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320075PMC
August 2019

Social Networks and Its Impact on Women's Awareness, Interest, and Uptake of HIV Pre-exposure Prophylaxis (PrEP): Implications for Women Experiencing Intimate Partner Violence.

J Acquir Immune Defic Syndr 2019 04;80(4):386-393

Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT.

Background: In the United States, women represent less than 5% of all pre-exposure prophylaxis (PrEP) users. Social networks may promote and/or inhibit women's PrEP awareness, which could influence PrEP intentions. Furthermore, women experiencing intimate partner violence (IPV) may have smaller, less supportive networks, which could deter or have no impact on PrEP care engagement. This study examined associations between network characteristics and women's PrEP awareness, interest, uptake, and perceived candidacy and analyzed IPV as an effect modifier.

Setting/methods: From 2017 to 2018, data were collected from a prospective cohort study of 218 PrEP-eligible women with (n = 94) and without (n = 124) IPV experiences in Connecticut. Women completed surveys on demographics, IPV, social networks, and PrEP care continuum outcomes.

Results: Adjusted analyses showed that PrEP awareness related to having more PrEP-aware alters. PrEP intentions related to having more alters with favorable opinions of women's potential PrEP use and a smaller network size. Viewing oneself as an appropriate PrEP candidate related to having more PrEP-aware alters and more alters with favorable opinions of women's potential PrEP use. IPV modified associations between network characteristics and PrEP care. Having members who were aware of and/or used PrEP was positively associated with PrEP care engagement for women without IPV experiences but had either no effect or the opposite effect for women experiencing IPV.

Conclusion: Improving PrEP attitudes might improve its utilization among women. Social network interventions might be one way to increase PrEP uptake among many US women but may not be as effective for women experiencing IPV.
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http://dx.doi.org/10.1097/QAI.0000000000001935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408934PMC
April 2019

Differences in Medical Mistrust Between Black and White Women: Implications for Patient-Provider Communication About PrEP.

AIDS Behav 2019 Jul;23(7):1737-1748

Department of Psychology, George Washington University, 2125 G Street NW, Washington, DC, 20052, USA.

Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention method. PrEP uptake has been persistently low among US women, particularly Black women, who account for 61% of new HIV diagnoses among women. Further understanding of barriers to Black women accessing PrEP is needed. This 2017 cross-sectional survey study explored race-based differences in PrEP interest and intention among women and the indirect association between race and comfort discussing PrEP with a healthcare provider through medical mistrust. The sample consisted of 501 adult women (241 Black; 260 White) who were HIV-negative, PrEP-inexperienced, and heterosexually active. Black women reported greater PrEP interest and intention than White women. However, Black women expressed higher levels of medical mistrust, which, in turn, was associated with lower comfort discussing PrEP with a provider. Medical mistrust may operate as a unique barrier to PrEP access among Black women who are interested in and could benefit from PrEP.
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http://dx.doi.org/10.1007/s10461-018-2283-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690288PMC
July 2019

Interpreting Gaps Along the Preexposure Prophylaxis Cascade and Addressing Vulnerabilities to Stigma.

Am J Public Health 2018 10;108(10):1284-1286

Sarah K. Calabrese is with the Department of Psychology, George Washington University, Washington, DC.

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http://dx.doi.org/10.2105/AJPH.2018.304656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137772PMC
October 2018

Prevention paradox: Medical students are less inclined to prescribe HIV pre-exposure prophylaxis for patients in highest need.

J Int AIDS Soc 2018 06;21(6):e25147

Social and Behavioral Sciences Department, Yale School of Public Health, Yale University, New Haven, CT, USA.

Introduction: Despite healthcare providers' growing awareness of pre-exposure prophylaxis (PrEP), prescription rates remain low. PrEP is an efficacious HIV prevention strategy recommended for use with condoms but still protective in their absence. Concern about the impact of PrEP on condom use and other risk behaviour is, nonetheless, among the barriers to prescription commonly reported. To understand the implications of this concern for PrEP access, we examined how medical students' willingness to prescribe PrEP varied by patients' condom use and partnering practices. We also assessed the perceived acceptability of various reasons for condom discontinuation with PrEP.

Methods: An online survey was distributed to 854 medical students in the Northeastern US in 2015. Participants (n = 111) were surveyed about their willingness to prescribe PrEP for each of six male patients who systematically differed in their reported condom use (sustained use, sustained nonuse, or discontinuation with PrEP) and partnering practices (single male partner with untreated HIV or multiple male partners of unknown HIV status). Participants also reported perceived acceptability of four reasons for condom discontinuation: pleasure, sexual functioning, intimacy, and conception.

Results: Willingness to prescribe PrEP was inconsistent with patient risk: When the patient used condoms and planned to sustain condom use, most participants were willing to prescribe PrEP - 93% if the patient had a single partner and 86% if the patient had multiple partners. Fewer were willing to prescribe if the patient did not use condoms and planned to sustain nonuse (53% and 45%, respectively) or used condoms but planned to discontinue use (27% and 28%). Significantly fewer participants were willing to prescribe for a patient with multiple partners versus a single partner when the patient reported sustained condom use or sustained condom nonuse. The number of participants who were willing to prescribe was similarly low for a patient with multiple partners versus a single partner when the patient reported that he planned to discontinue condom use. More participants accepted a patient discontinuing condoms for conception (69%) than for intimacy (23%), pleasure (14%), or sexual functioning (13%).

Conclusion: Medical students' clinical judgments were misaligned with patient risk and suggest misconceptions or personal values may undermine provision of optimal HIV prevention services.
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http://dx.doi.org/10.1002/jia2.25147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016621PMC
June 2018

HIV Pre-Exposure Prophylaxis Stigma as a Multidimensional Barrier to Uptake Among Women Who Attend Planned Parenthood.

J Acquir Immune Defic Syndr 2018 09;79(1):46-53

Social and Behavioral Sciences Department, Yale School of Public Health, Yale University, New Haven, CT.

Background: Pre-exposure prophylaxis (PrEP) uptake has lagged among US women. PrEP stigma is a recognized barrier to uptake among men who have sex with men but remains largely unexplored among women. This study examined the pervasiveness of PrEP stigma among US women and its implications for uptake.

Setting/methods: In a 2017 online survey of Planned Parenthood patients drawn from the 3 cities with the highest numbers of new HIV infections in Connecticut, 597 heterosexually active, HIV-negative, PrEP-inexperienced women reported background characteristics, 2 dimensions of anticipated PrEP stigma (PrEP-user stereotypes and PrEP disapproval by others), and 3 indicators of potential PrEP uptake (interest in learning more about PrEP, intention to use PrEP, and comfort discussing PrEP with a provider).

Results: Participants commonly perceived PrEP-user stereotypes, with many believing that others would regard them as promiscuous (37%), HIV-positive (32%), bad (14%), or gay (11%) if they used PrEP. Thirty percent would feel ashamed to disclose PrEP use. Many participants expected disapproval by family (36%), sex partners (34%), and friends (25%). In adjusted analyses, perception of PrEP-user stereotypes was uniquely associated with less comfort discussing PrEP with a provider. Expected PrEP disapproval by others was uniquely associated with less PrEP interest, less intention to use PrEP, and less comfort discussing PrEP with a provider. Exploratory moderation analyses suggested that intention to use PrEP was greatest when participants anticipated low levels of both PrEP-user stereotypes and PrEP disapproval by others.

Conclusions: Findings highlight the need for positive messaging targeting potential PrEP users and their social networks to increase PrEP acceptance and uptake.
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http://dx.doi.org/10.1097/QAI.0000000000001762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092222PMC
September 2018

Temporal Fluctuations in Behavior, Perceived HIV Risk, and Willingness to Use Pre-Exposure Prophylaxis (PrEP).

Arch Sex Behav 2018 10 11;47(7):2109-2121. Epub 2018 Jan 11.

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

Individual perceptions of HIV risk influence willingness to use pre-exposure prophylaxis (PrEP) for HIV prevention. Among men who have sex with men (MSM) and male sex workers (MSWs), temporal or episodic changes in risk behavior may influence perceived risk and PrEP acceptability over time. We investigated fluctuations in perceived HIV risk and PrEP acceptability, comparing MSWs against MSM who do not engage in sex work. We conducted 8 focus groups (n = 38) and 56 individual interviews among MSM and MSWs in Providence, RI. Perceived HIV risk shaped willingness to use PrEP among both MSWs and MSM who did not engage in sex work, and risk perceptions changed over time depending on behavior. For MSWs, perceived risk cycled according to patterns of substance use and sex work activity. These cycles yielded an "access-interest paradox": an inverse relationship between willingness to use and ability to access PrEP. MSM who did not engage in sex work also reported temporal shifts in risk behavior, perceived risk, and willingness to use PrEP, but changes were unrelated to access. MSM attributed fluctuations to seasonal changes, vacations, partnerships, behavioral "phases," and episodic alcohol or drug use. Efforts to implement PrEP among MSM and street-based MSWs should address temporal changes in willingness to use PrEP, which are linked to perceived risk. Among MSWs, confronting the access-interest paradox may require intensive outreach during high-risk times and efforts to address low perceived risk during times of reduced sex work.
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http://dx.doi.org/10.1007/s10508-017-1100-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041197PMC
October 2018

Calabrese et al. Respond.

Am J Public Health 2018 01;108(1):e1-e2

Sarah K. Calabrese is with the Department of Psychology, George Washington University, Washington, DC. Kristen Underhill is with Columbia Law School and the Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY. Kenneth H. Mayer is with The Fenway Institute, Boston, MA, and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.

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http://dx.doi.org/10.2105/AJPH.2017.304172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719699PMC
January 2018

A Closer Look at Racism and Heterosexism in Medical Students' Clinical Decision-Making Related to HIV Pre-Exposure Prophylaxis (PrEP): Implications for PrEP Education.

AIDS Behav 2018 04;22(4):1122-1138

Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA.

Social biases among healthcare providers could limit PrEP access. In this survey study of 115 US medical students, we examined associations between biases (racism and heterosexism) and PrEP clinical decision-making and explored prior PrEP education as a potential buffer. After viewing a vignette about a PrEP-seeking MSM patient, participants reported anticipated patient behavior (condomless sex, extra-relational sex, and adherence), intention to prescribe PrEP to the patient, biases, and background characteristics. Minimal evidence for racism affecting clinical decision-making emerged. In unadjusted analyses, heterosexism indirectly affected prescribing intention via all anticipated behaviors, tested as parallel mediators. Participants expressing greater heterosexism more strongly anticipated increased risk behavior and adherence problems, which were associated with lower prescribing intention. The indirect effect via condomless sex remained significant adjusting for background characteristics. Prior PrEP education did not buffer any indirect effects. Heterosexism may compromise PrEP provision to MSM and should be addressed in PrEP-related medical education.
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http://dx.doi.org/10.1007/s10461-017-1979-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878986PMC
April 2018

Integrating HIV Preexposure Prophylaxis (PrEP) Into Routine Preventive Health Care to Avoid Exacerbating Disparities.

Am J Public Health 2017 12 19;107(12):1883-1889. Epub 2017 Oct 19.

Sarah K. Calabrese is with the Department of Psychology, George Washington University, Washington, DC. Douglas S. Krakower and Kenneth H. Mayer are with the Fenway Institute, Boston, MA, and the Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.

More than 3 decades since its emergence in the United States, HIV continues to spread and disproportionately affect socially marginalized groups. Preexposure prophylaxis (PrEP), a highly effective prevention strategy federally approved since 2012, could fundamentally alter the course of the epidemic. However, PrEP's potential has not been fully realized, in part because health care providers have been slow to adopt PrEP in clinical practice and have been selective in their discussion of PrEP with patients. This nonstandardized approach has constrained PrEP access. PrEP access has not only been inadequate but also inequitable, with several groups in high need showing lower rates of uptake than do their socially privileged counterparts. Recognizing these early warning signs that current approaches to PrEP implementation could exacerbate existing HIV disparities, we call on health professionals to integrate PrEP into routine preventive health care for adult patients-particularly in primary care, reproductive health, and behavioral health settings. Drawing on the empirical literature, we present 4 arguments for why doing so would improve access and access equity, and we conclude that the benefits clearly outweigh the challenges.
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http://dx.doi.org/10.2105/AJPH.2017.304061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678380PMC
December 2017

HIV Preexposure Prophylaxis and Condomless Sex: Disentangling Personal Values From Public Health Priorities.

Am J Public Health 2017 10 17;107(10):1572-1576. Epub 2017 Aug 17.

Sarah K. Calabrese is with the Department of Psychology, George Washington University, Washington, DC. Kristen Underhill is with Columbia Law School, Columbia University, New York, NY. Kenneth H. Mayer is with The Fenway Institute, Boston, MA, and the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston.

Daily HIV preexposure prophylaxis (PrEP) is an effective form of HIV protection that remains unknown and inaccessible for many people in the United States despite receiving federal approval over five years ago. PrEP is supported by the public health community, but forgoing condoms while taking PrEP has proven controversial; this controversy may be contributing to the lag in PrEP uptake. We argue that limiting PrEP access based on anticipated or actual sexual behavior contradicts the goals of public health research and practice and is not scientifically justified. As evidence for the effectiveness of novel forms of biomedical HIV protection emerges, public health professionals need to accept new definitions of "protected sex" and ensure that their personal values do not override empirical evidence when determining public health priorities.
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http://dx.doi.org/10.2105/AJPH.2017.303966DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607676PMC
October 2017