Access to healthcare, HIV/STI testing, and preferred pre-exposure prophylaxis providers among men who have sex with men and men who engage in street-based sex work in the US.
BACKGROUND
Pre-exposure prophylaxis (PrEP) is a promising strategy for HIV prevention among men who have sex with men (MSM) and men who engage in sex work. But access will require routine HIV testing and contacts with healthcare providers. This study investigated men's healthcare and HIV testing experiences to inform PrEP implementation.


METHODS
We conducted 8 focus groups (n = 38) in 2012 and 56 in-depth qualitative interviews in 2013-14 with male sex workers (MSWs) (n = 31) and other MSM (n = 25) in Providence, RI. MSWs primarily met clients in street-based sex work venues. Facilitators asked participants about access to healthcare and HIV/STI testing, healthcare needs, and preferred PrEP providers.


RESULTS
MSWs primarily accessed care in emergency rooms (ERs), substance use clinics, correctional institutions, and walk-in clinics. Rates of HIV testing were high, but MSWs reported low access to other STI testing, low insurance coverage, and unmet healthcare needs including primary care, substance use treatment, and mental health services. MSM not engaging in sex work were more likely to report access to primary and specialist care. Rates of HIV testing among these MSM were slightly lower, but they reported more STI testing, more insurance coverage, and fewer unmet needs. Preferred PrEP providers for both groups included primary care physicians, infectious disease specialists, and psychiatrists. MSWs were also willing to access PrEP in substance use treatment and ER settings.


CONCLUSIONS
PrEP outreach efforts for MSWs and other MSM should engage diverse providers in many settings, including mental health and substance use treatment, ERs, needle exchanges, correctional institutions, and HIV testing centers. Access to PrEP will require financial assistance, but can build on existing healthcare contacts for both populations.
Yale Center for Interdisciplinary Research on AIDS/Yale Law School, Yale University, New Haven, Connecticut, United States of America.
Kristen
K
Underhill
Centers for Behavioral & Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, United States of America.
Kathleen M
KM
Morrow
Centers for Behavioral & Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, United States of America.
Christopher M
CM
Colleran
Project Weber, Providence, Rhode Island, United States of America.
Richard
R
Holcomb
School of Public Health, Brown University, Providence, Rhode Island, United States of America.
Don
D
Operario
Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America.
Sarah K
SK
Calabrese
School of Public Health, Brown University, Providence, Rhode Island, United States of America.
Omar
O
Galárraga
The Fenway Institute, Fenway Health, Boston, Massachusetts, United States of America.
Kenneth H
KH
Mayer
D000328:Adult; D000554:Ambulatory Care Facilities; D003695:Delivery of Health Care; D015658:HIV Infections / Q000175:diagnosis / Q000517:prevention & control*; D017048:Health Care Costs; D006297:Health Services Accessibility; D018451:Homosexuality, Male; D006801:Humans; D019458:Insurance Coverage; D008297:Male; D008571:Men; D008605:Mental Health Services; D010342:Patient Acceptance of Health Care; D065129:Pre-Exposure Prophylaxis; D012237:Rhode Island; D011477:Sex Work; D060386:Sex Workers; D012749:Sexually Transmitted Diseases / Q000175:diagnosis / Q000517:prevention & control*; D016320:Substance Abuse Treatment Centers; D014481:United States