Measuring PrEP Preferences within Military MSM Using Conjoint Analysis

PURPOSE
Proposed is a cross-sectional study to determine the acceptability and preferences of Pre-Exposure Prophylaxis (PrEP) as a means to prevent HIV infection among active duty military men who sex with men (MSM). In civilian studies, PrEP is a once-daily pill that has been demonstrated to reduce the risk of HIV acquisition by over 90% when taken consistently. Despite this result, data are sparse to evaluate the use of PrEP within an active duty military population. Yet, HIV remains a serious threat affecting military preparedness for armed forces across the country and around the world. Between the years 2012 to 2017, 1,991 U.S. military members tested positive for HIV, and the incidence has remained stable across those years. The demographics of at-risk
military members tend to mirror those of their civilian counterparts; namely, younger military men (median age 26), African-Americans and MSM were at highest risk among U.S. Army soldiers between 2012-2014. While civilian and military populations may share similar trends and demographics in HIV infection, the military may have unique factors that are associated with HIV infection not typically reflected within a civilian population. For example, socioeconomic status and a lack of resources have been linked to HIV infection risk among civilian African-Americans, and concerns over a lack of health insurance and affordability were perceived as barriers to PrEP in younger, civilian MSM. However, a military member’s guaranteed access to a steady
income, health insurance, and medical care offsets these concerns. This suggests that HIV infection within the U.S. Armed Forces may be driven by factors other than socioeconomic status and lack of resources. As of 2017, no Department of Defense-level policy or guidance is in place on the use of PrEP for military members, and we know of no evidence that examines the acceptability or preferences of PrEP within this population. However, the impressive efficacy of PrEP makes it an ideal intervention for military members at risk for HIV acquisition.

AIMS
1. Characterize and compare the acceptability and preferences of currently available and hypothetical models of PrEP among an active duty, MSM military population. In addition to doing frequency distributions for the full sample, I will cross-tabulate acceptability and preferences by the following characteristics: 1a. modifying factors (socio-demographics, depressive symptoms), 1b. subjective/objective knowledge of information factors (PrEP Knowledge, HIV Knowledge), 1c. factors affecting motivation (anticipated stigma, prevention altruism,
personal risk/safe sex practices, social/peer approval)1d. behavioral skills factors (health seeking behaviors, self-efficacy for using PrEP).
2. Identify the relationships between the aforementioned factors predictive for the acceptability and preferences of currently available and hypothetical models of PrEP delivery as a means to prevent HIV infection among active duty military MSM.

METHODS
This study will be guided by the Information-Motivation-Behavioral Skills Model of PrEP Uptake; a framework proposing that at-risk groups are likely to overcome and initiate PrEP if they are well-informed about the intervention, are motivated to act upon this information, and possess the necessary behavioral skills to seek out and initiate PrEP. First, an online survey will be developed utilizing validated instruments and items supported from the literature, and will be used to collect data on the variables of interest described in the primary aims. Next, a convenience sample of participants will be recruited from the social media group, Outserve-SLDN; an an online social media group with a membership of over 7,000 LGBT military members. Socio-demographics and factors on information/knowledge, motivation and behavioral skills will be collected by the online survey, and data on PrEP preferences and acceptability will be collected utilizing Choice-Based Conjoint Analysis. Once collected, SAS will then be used for the data analysis, and bivariate and multivariate analysis will be performed to explore associations between the variables of interest and PrEP acceptability and preferences.

RELEVANCE TO MILITARY NURSING SCIENCE
Providing comprehensive, preventative care to all active duty military personnel regardless of sexual orientation is crucial to force readiness. Military members are placed in assignments in numerous places around the world; including locations where the prevalence of HIV is high. Since the repeal of Don’t Ask, Don’t Tell, there is a ripe opportunity to investigate the unique health problems faced by MSM military members, and to use this information to tailor PrEP interventions specific to this vulnerable population.