Integrated Next Step Counseling (iNSC) for Sexual Health and PrEP Use Among Young Men Who Have Sex with Men: Implementation and Observations from ATN110/113

Abstract

Pre-exposure prophylaxis (PrEP) for the prevention of HIV infection among young men who have sex with men is a critical part of the HIV prevention landscape in the US. Given the unique challenges and resources of young MSM negotiating safer sex practices, including PrEP, counseling and supportive discussions to optimize both PrEP use and sexual health protection more generally may facilitate reaching HIV prevention goals. Within the context of a large, open-label PrEP study (ATN110/113), support for sexual health promotion and PrEP use was provided through use of integrated Next Step Counseling (iNSC) as part of study visits. We detail iNSC and, using session documentation collected throughout this study, we characterize iNSC implementation and the content generated from these discussions. We detail features of iNSC, training of counselors and the implementation of iNSC in a multi-site PrEP study with young MSM in the US. Case report forms completed by iNSC counselors at study visits at weeks 4, 8, 12, 24, 36, and 48 were evaluated. Implementation of each intervention step for each discussion is summarized at and across timepoints, as well as features of specific steps (e.g., kinds of facilitators and barriers). Implementation differences by group (e.g., race/ethnicity, age) were examined. iNSC case report forms from 1000 sessions involving 178 unique participants ages 15–22 from sessions conducted between 2013 and 2015 were reviewed. High fidelity to iNSC steps in terms of inclusion in sessions was reported; 98–100% of sessions included critical steps for sexual health protection discussions and 96–98% for PrEP use discussions. The vast majority of sessions appeared to flow in line with iNSC’s emphasis on exploration and open discussion prior to considering specific needs and related strategies. Nearly three-quarters of sessions noted ‘commitment to staying negative’ as a motivator towards sexual health protection (more commonly reported by those identifying as White), while ‘assuming partner is negative’ was the most common challenge (less common for the older cohort), and ‘having access’ to a sexual health protection tool or strategy (besides PrEP) was the most common “need” (more common for those identifying as White or Latino). Carrying dose(s) to have them on-hand when needed was the most common PrEP adherence facilitator, drug and alcohol use was the most common challenge noted, and access to a dose when needed was the most common “need” (more common for participants self-identified as White). iNSC was implemented consistently throughout ATN110/113, and patient-centered discussions about sexual health protection and PrEP-use appeared feasible to incorporate into clinical care visits.

Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Men Who Have Sex with Men (MSM): A Scoping Review on PrEP Service Delivery and Programming

“…Mixed evidence exists with regard to PrEP and risk compensation, with the concept that PrEP use increases condomless sexual practices and STIs, which in turn undermines the positive aspects of PrEP and impacts on PrEP rollout among MSM [38,[134][135][136][137][138][139][140][141][142]. However, the review underscores the importance of PrEP to MSM service users and how it should be considered as a commitment to protect oneself and others [54,92,108]. Furthermore, PrEP provision in a service creates the opportunity for MSM to access sexual health care, testing, treatment, counselling regarding condom use and STI testing and psychological support that would not be accessed otherwise [12,60].…”

“…Tellalian et al [63] and Stekler et al [107] identified that service level support was needed in order to improve correct use of PrEP, adherence and retention. Other barriers to PrEP adherence at service user level included medication concerns, for example the pill being too big or tasting unpleasant, [108] missing clinics, [109] forgetting to take medication [54,75,103,110] and cost [111,112]. Disruption in routine was also reported [54,93,103,108] but Vaccher et al [103] stated that this could be reduced by carrying spare medication for emergencies.…”

“…Other barriers to PrEP adherence at service user level included medication concerns, for example the pill being too big or tasting unpleasant, [108] missing clinics, [109] forgetting to take medication [54,75,103,110] and cost [111,112]. Disruption in routine was also reported [54,93,103,108] but Vaccher et al [103] stated that this could be reduced by carrying spare medication for emergencies. Certain service user groups were identified as being at risk of low PrEP adherence, including those from ethnic minorities, [73,91,111] young MSM, [91] smokers, [111] and those with problematic alcohol or substance use, [91] all of which are exacerbated by systemic disadvantages within society or from an individual's predisposition to risky behaviour.…”

“…For example, Calabrese et al [68] stated that there was a gap for 'the development of curricula and evaluation standards for PrEP-related medical education', whilst Newman et al [120] highlighted the importance of online experiences in bringing together the gay and bisexual male (GBM) PrEP community. The third element is the identification of potential PrEP users [52,61,73,96,108,127]. This could be through existing relationships between the individuals and healthcare providers or counsellors but also through established referral systems.…”

“…Additionally, young MSM require further investigation as they are less likely to be seeking HIV/STI testing, diagnosis or treatment for HIV [145]. While Amico et al [108], Desrosiers et al [66] and Refugio et al [130] discuss interventions and techniques to help increase the uptake of PrEP among youths, namely through technology and apps, considerably more research needs to be done. At service level, the majority of service providers described positive attitudes towards PrEP prescribing with only two studies reporting that providers did not feel comfortable with the current procedures [61,76].…”