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Scales to Assess Knowledge, Motivation, and Self-Efficacy for HIV PrEP in Colombian MSM: PrEP-COL Study

Scales to Assess Knowledge, Motivation, and Self-Efficacy for HIV PrEP in Colombian MSM: PrEP-COL... Hindawi AIDS Research and Treatment Volume 2021, Article ID 4789971, 11 pages https://doi.org/10.1155/2021/4789971 Research Article Scales to Assess Knowledge, Motivation, and Self-Efficacy for HIV PrEP in Colombian MSM: PrEP-COL Study 1 2 3 He´ctor F. Mueses-Marı´n , Beatriz Alvarado-Llano, Julia´n Torres-Isasiga, 4 1 1 Pilar Camargo-Plazas, Maria C. Bolı´var-Rocha, Ximena Galindo-Orrego, and Jorge L. Mart´ınez-Cajas Corporacio´n de Lucha Contra el Sida, Carrera 56 2-120, Cali, Colombia Public Health Science, Queens University, Kingston, Ontario K7L 3N6, Canada Montefiore Medical Center, Moses Division, Albert Einstein College of Medicine, /e Oval Center at Montefiore, 3230 Bainbridge Avenue, Bronx, NY 10467, USA School of Nursing, Queen’s University, Kingston, Ontario K7L 3N6, Canada Division of Infectious Diseases, Department of Medicine, Queens University, Kingston, Ontario K7L 3N6, Canada Correspondence should be addressed to He´ctor F. Mueses-Mar´ın; centroinvestigaciones@cls.org.co Received 22 April 2021; Revised 19 July 2021; Accepted 6 August 2021; Published 8 September 2021 Academic Editor: Jose-Ramon Blanco Copyright © 2021 He´ctor F. Mueses-Mar´ın et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. We evaluated the construct validity Spanish version of knowledge, stigma, norms, and self-efficacy scales regarding PrEP in MSM. Methods. Sample of 287 MSM. Exploratory confirmatory factor analysis and item response theory were used to validate the constructs. Correlations and confidence interval-based estimation of relevance analyses were conducted to correlate the scales with willingness and intention to use PrEP. Results. Attitude, stigma, and descriptive and subjective norms scales showed good construct validity and were related to intention and willingness to use PrEP. However, the knowledge scale and self-efficacy scales require further refinement. Conclusions. *e study provides useful information for assessing information, motivation, and self-efficacy related to PrEP use. Our results could be used to test the scales and the theoretical model in other contexts to confirm their usefulness. identify appropriate targets for interventions is needed if 1. Introduction PrEP is to be adopted widely. As MSM continue to be disproportionately affected by HIV, One explanatory model for reducing HIV risk behav- a combination of preventive strategies, including pre- iours that has potential in MSM populations is the infor- exposure prophylaxis (PrEP), is urgently needed to curtail mation motivational behavioural (IMB) model [8]. *e IMB model posits that individuals will likely initiate and sustain a the rate of new HIV diagnoses worldwide. PrEP acceptance in MSM has been low despite years of availability and behaviour if they are well informed and motivated and demonstrated efficacy [1, 2]. In the United States only one of perceive themselves as having the skills to initiate and five PrEP-eligible MSM is taking PrEP [3, 4]. Latino MSM in maintain the behaviour. *e IMB model has been used to North America had lower PrEP knowledge, acceptance, and develop HIV prevention interventions proven to be effective uptake [5, 6]. In Latin American countries, where MSM in decreasing condomless sex [9] and increasing adherence account for 40% of the new cases of HIV each year, PrEP to antiretroviral therapy [10, 11]. Barriers related to PrEP awareness was reported around to 58%, and nearly 52% were uptake in MSM are also consistent with the IMB model, willing to use daily PrEP [6]. PrEP uptake is a complex including lack of knowledge, negative attitudes, lack of self- behaviour [1, 7], and the use of a theoretical model to efficacy, and low motivation due to stigma [12]. Hence, it is a 2 AIDS Research and Treatment relevant framework for the development of behavioural Colombia, and reported to be HIV-negative. *e majority of interventions for populations at risk of HIV infection and in participants reported a negative HIV test in the last 12 months. A total of 287 participants were eligible among 584 need of PrEP [12–14]. Identification of PrEP knowledge, motivation, and skills who clicked on the questionnaire. in MSM requires either new instruments or the adaptation and validation of existing ones in different populations. In a 2.3. Instruments. Items from the original English scales [14] recent publication, Walsh [14] used the IMB model to de- were translated by one of the team members who is bilingual velop new measures for these constructs and relate them to in Spanish and English and familiar with scale validation PrEP uptake. *e scales assessing knowledge, descriptive (BEA) and back-translated by another team member (JLM) norms, and subjective norms have high levels of reliability who is also bilingual in Spanish and English and an HIV with alphas of Cronbach greater than or equal to 0.90. *e expert. *en, the translated scales were reviewed using attitude, stigma, and self-efficacy scales had good alphas cognitive interview methodology with four MSM, which from 0.79 to 0.87. Confirmatory factor analyses supported resulted in some minor changes. *ese changes included the correlation of the scales and the item loading in each a wording, exclusion of two items of the knowledge scale (as priori latent construct, with most of the scales related to the they did not apply to the Colombian context), and changing intention to use PrEP, thus supporting the IMB model. Since the Likert scale from 5 to 3 answer categories for the scales of the scales have been recently developed and only used in attitudes, stigma, and descriptive norms. *is latter change MSM populations living in the United States and are not yet sought to decrease the degree of difficulty and time needed available in Spanish, in this paper, we present the assessment for completion. *e scales included ten items assessing of their internal coherence and construct validity in a sample knowledge on PrEP, five items assessing attitudes, five of MSM from Colombia. In this work, we explored if the assessing stigma, six assessing descriptive norms, six items of the scales represent one construct and a relationship assessing subjective norms, and eight items assessing self- exists between the scales and the intention to uptake PrEP. If efficacy: the PrEP scales are valid and the relations are supported, the results could be used to gain an understanding of PrEP Knowledge PrEP Scale. *is scale was initially com- uptake in other Spanish-speaking MSM populations and posed of 13 items but was reduced to 10 items after delineate interventions. excluding items related to PrEP coverage, the avail- ability of over-the-counter PrEP, and ways to have 2. Materials and Methods access to PrEP in the absence of health insurance. *ese items did not apply to the Colombian context, as PrEP 2.1. Design. *e data from this study came from an online was not covered nor was it available over the counter in open survey; thus anyone was able to access it by clicking on Colombia at the time of the survey. Each item was an online link. *e recruitment was between April and scored on a 3-point scale: 1 �true, 2 �false, and October 2020. *e link to the online survey was distributed 3 �don’t know. Scores on this scale were recoded as in different ways, including emails to gay and MSM leaders/ 1 �correct and 0 �incorrect/don’t know, with higher organizations who were asked to share it with their peers/ scores indicating a greater degree of knowledge. To members through social media, such as Facebook. A total of reduce the burden of the number of questions, par- 7 MSM or transgender-focused organizations posted the ticipants were randomly assigned (option available in study link. *e study was also advertised on Grindr for two Qualtrics) to 70% of the items of the knowledge scale, weeks geographically constricted to three Colombian cities: and imputation of nonassigned items was done using Cali, Bogota, and Medellin (total population ∼13 million). the R software (Supplementary Table 1). Individuals who were self-identified as MSM and self-re- PrEP Attitudes. PrEP attitudes consisted of a 5-item ported an HIV-negative status in the screening questions scale, which includes aspects such as perceptions of were prompted to complete the PrEP-related survey. *e effectiveness and safety. All original items were questionnaire was developed in Qualtrics, was anonymized, translated, and each item was scored on a 3-point scale and offered no incentives. Participation in the study was as 1 �disagree, 2 �neutral, and 3 �agree, with higher voluntary, and access to the questionnaire was granted to scores indicating more positive attitudes. those consenting online. *e full questionnaire was devel- PrEP Stigma. *is 5-item scale is related to concerns oped through an iterative process between team members regarding negative perceptions about PrEP use, for and PrEP experts and was reviewed by community members instance, the relationship between PrEP use and pro- of the MSM community in three Colombian cities. For this paper, we report selected parts of the questionnaire. *is miscuity. Each item was scored on a 3-point scale as 1 �disagree, 2 �neutral, and 3 �agree, with higher study was reviewed and approved by the Research Ethics Boards of both the Corporacion ´ de Lucha contra el Sida scores indicating a greater degree of stigma. (approval certificate no. 034 of May 16, 2018) and Queen’s Descriptive Norms PrEP. For this measure, participants University (DMED-2326-20). were asked to consider the perceptions and interests of friends and people in their community concerning PrEP. Six items were scored on a 3-point scale ranging 2.2. Participants. Participants were eligible for this analysis if they were self-identified as gay/bisexual men, resided in from 1 �disagree to 3 �agree, with higher scores AIDS Research and Treatment 3 conducted with the other half of the sample to assess the indicating more positive norms. *is was a change from the 5-point scale used by Walsh [14]. model fit of the exploratory analysis. *e model fit was assessed using traditional fit indices [15]. We performed an Subjective Norms PrEP. Participants were also asked to item response theory analysis to identify the degree of consider the perceptions of friends and their sexual difficulty of the items of the knowledge scale. *e associa- partners. *ree items were scored on a 3-point scale tions between variables were done using Spearman’s cor- ranging from 1 �disagree to 3 �agree, with higher relation analysis and confidence interval-based estimation of scores indicating a greater degree of positive norms relevance (CIBER) analysis [16]. All analyses were per- related to PrEP. formed using Stata/IC version 16 and R version 4.0.2. Self-Efficacy PrEP. *is 8-item scale assessed efficacy related to asking about PrEP, adherence to PrEP, and 3. Results payment of PrEP, among others. Each item was scored on a 4-point scale ranging from 1 �very difficult to *e baseline demographic characteristics of the 287 par- 4 �not difficult at all. Higher scores indicated more ticipants are shown in Table 1. self-efficacy. Willingness and Intention to Use PrEP. *is measure 3.1. Distribution of Items in the Scales. A total of 72% said was assessed with two questions: “If PrEP is effective in they had heard of PrEP and indicated they had a low- reducing the risk of HIV by 90%, and in the next 12 moderate level of knowledge about PrEP. Participants knew months PrEP was offered for free in Colombia, would the purpose of PrEP (78%), its efficacy (74%), and that it does you like to use PrEP to prevent HIV?” and “If in the not prevent other sexually transmitted infections (72%), but next 12 months, your doctor or other health profes- their knowledge on the importance of monitoring, adher- sional was available for a PrEP prescription, would you ence, and its relationship with HIV status was low. A high start taking the PrEP pills?” *e questions were rated percentage of positive attitudes toward PrEP was observed. on a 5-point scale ranging from 1 �definitely yes to Overall levels of PrEP stigma were low. *e descriptive 5 �definitely no. Willingness and intention to use PrEP norms items showed that participants think their commu- was dichotomized into two categories 1 � to definitely nities and friends would like to learn about PrEP. In terms of yes and probably yes and 0 � all other answer options: subjective norms, the level of support to use PrEP seemed neutral, probably not, definitely not. moderately high. Levels of self-efficacy varied across items, Before introducing respondents to PrEP scales, a sum- with more difficulty reported on items related to paying for mary of the meaning of PrEP was presented as follows. PrEP and visiting a doctor (data not shown). “Preexposure prophylaxis (PrEP) is an HIV infection prevention strategy where HIV-negative individuals take anti-HIV medications before coming into contact with HIV 3.2. Item Response Analysis and Factor Analysis. In the item to reduce their risk of becoming infected. Medications response analysis for the PrEP knowledge scale, only one prevent HIV from establishing an infection within the body. item failed to demonstrate an acceptable fit (“PrEP can be PrEP has been shown to reduce the risk of HIV infection taken by people who already have HIV,” p � 0.038). Four through sexual contact in gay and bisexual men, transgender items of the knowledge scale showed a high degree of dif- women, and heterosexual men and women, as well as in ficulty and did not show acceptable discrimination values people who inject drugs. It does not protect against other (Table 2). *e exclusion of the poor fit item and the difficult sexually transmitted infections (STIs) nor does it prevent four items represented an increase in the mean of knowledge pregnancy. It is not a cure for HIV. Using tenofovir/ from 52/100 points to 63/100 points (data not shown). emtricitabine–TDF/FTC as PrEP provides a 96% to 99% Exploratory factorial analysis (Table 3) revealed three reduction in the risk of infection in HIV-negative people factors for PrEP knowledge, a unique factor for PrEP atti- who take the pills every day as directed. If you miss a daily tudes, PrEP stigma, and PrEP subjective norms, and two dose, the level of protection against HIV may decrease. It factors for the PrEP descriptive norms and PrEP self-effi- only works if you take the medicine. People who use PrEP cacy. *e Cronbach’s alpha coefficients for the scales were correctly and consistently have higher levels of protection between 0.70 and 0.86. *e confirmatory factor analysis of against HIV.” the scales indicated that all items of the attitude scale had a good fit; for the other scales, the exclusion of one or two items increased the fit of the scales (Table 4). 2.4. Statistical Analyses. Descriptive statistics were used to summarize the social characteristics of the sample. *e next step in the analysis was to perform an exploratory factor 3.3. Intention to Use PrEP: CIBER Analysis by Items Scales for analysis with a random sample of 50% of participants. In PrEP. Two knowledge items were related to willingness and interpreting the factor pattern, a factor loading ≥0.40 was intention: “PrEP can be taken by people who already have considered good. For this analysis, a polychoric correlation HIV” and “You must take an HIV test every 3 months while matrix was used. Internal consistency and reliability were taking PrEP.” Additionally, two were related with intention: tested using Kuder-Richardson formulas and Cronbach’s “*e PrEP pill contains two medicines that are also used to coefficients. *en, confirmatory factor analysis was treat HIV” and “Daily PrEP use can lower the risk of getting 4 AIDS Research and Treatment Table 1: Baseline demographic characteristics of the study reporting less difficulty in paying were less likely to have participants. intention. *e R square was higher for the attitudes scale with 0.15 for willingness and 0.14 for intention to use PrEP 31.2; 8.9 Age, years (means; sd) (data not shown). n (%) Biological sex (men) 287 (100) Gender 3.3.1. Correlations. Positive and moderate correlations were Male 279 (97.2) found between the scales. *e PrEP knowledge scale was Nonconforming gender 3 (1.0) correlated to PrEP attitudes (r � 0.40) and subjective norms Other 3 (1.0) scales (r � 0.27) and negatively with PrEP stigma (r � −0.18). Prefer not to answer 2 (0.7) *e attitudes scale correlated to the stigma scale (r � −0.29), Sexual orientation descriptive norms (r � 0.20), subjective norms (r � 0.45), and Heterosexual 3 (1.0) Gay men 238 (82.9) self-efficacy (0.15<r< 0.25). *e stigma scale correlated with Bisexual 45 (15.7) descriptive norms (−0.17<r< −0.20), subjective norms Prefer not to answer 1 (0.3) (−0.47<r< −0.52), and self-efficacy (−0.18<r< −0.37). Civil status Descriptive norms correlated to subjective norms positively Married—common law 45 (15.7) (0.32<r< 0.37). Finally, subjective norms were correlated Single 236 (82.2) positively with the self-efficacy shorter scale (r � 0.18). Separated-widow 6 (2.1) Willingness and intention to use PrEP correlated positively Education level with PrEP knowledge (r � 0.23), attitudes (0.40<r< −0.42), Primary school 1 (0.3) descriptive norms (0.25<r< 0.31), and subjective norms Secondary school 26 (9.1) (0.24<r< 0.33) and inversely with stigma scales Technical-superior 260 (90.6) (−0.24<r< −0.32). No correlation was found between self- Socioeconomic stratum efficacy scale and willingness or self-efficacy and intention One-two (very low-low) 83 (28.9) (Figure 1). *ree-four (middle) 166 (57.8) Five-six (high) 39 (13.6) Occupation status (one or more options) 4. Discussion Work 184 (64.1) In our MSM study in Colombia, results indicated that the Housekeepers 9 (3.1) majority of the items and the scales developed by Walsh [14] Voluntary 11 (3.8) Student 59 (20.6) are reliable and show a good fit. Although a reduction of Unemployed 62 (21.6) items seems to favour a better fit in most of the scales, the Other 16 (5.6) majority of the relationships among constructs of the IBM Current monthly income model were supported by the data: better-informed par- No income 44 (15.3) ticipants have positive attitudes, more motivated (less stigma <1 59 (20.6) with more positive norms) participants have higher levels of Between 1 and 2 67 (23.3) self-efficacy, and those with more positive attitudes and less >2 117 (40.8) stigma had more intention to use PrEP. Future use must Health insurance/coverage (yes) 246 (86.0) consider the level of difficulty of the items of the knowledge Willingness to use PrEP (definitely yes) 187 (71.1) scale, and the self-efficacy scale needs to be refined and Intention to start PrEP (definitely yes) 167 (63.7) consider additional self-efficacy items. Willingness and intention to use PrEP was dichotomized into two cate- *e knowledge scale presented a high degree of difficulty gories: 1 � to definitely yes and probably yes and 0 � all other answer op- for participants, especially items describing the relationship tions: neutral, probably not, definitely not. between HIV and the need for extra monitoring. Interest- ingly, the items with a greater level of difficulty were cor- HIV from sex by more than 90%.” In the case of attitudes related with willingness and intention. *is particular and subjective norms, all items were related to intention and finding favours the need to provide accurate and relevant willingness in the direction expected: more positive attitudes knowledge of PrEP [17, 18]. Consistent with other studies, were related to greater willingness and intention. Con- knowledge of PrEP was related to intention to use PrEP [6], cerning stigma, strong negative associations were found for and knowledge was related to higher positive attitudes and all items, and from the descriptive norms scale, only one less stigma [19, 20]. *us, health education within MSM item was not related to both outcomes: “My friends would be communities on PrEP may need to emphasize the use of interested in learning more about PrEP.” Concerning sub- PrEP exclusively in HIV-negative individuals, the impor- jective norms, all items were related to willingness and tance of monitoring and follow-up, and the potential side intention, and for the items related to self-efficacy, two items effects associated with PrEP. were strongly related to willingness to use PrEP (being able Self-efficacy is a crucial element in developing strategies to take the medicine and being able to visit a doctor for for prevention in HIV [8], including PrEP uptake; however, monitoring) and one item was strongly related to intention we did not find a correlation of the scale with intention and (being able to take the medicine). Interestingly, participants willingness to use PrEP. Although Walsh’s validation study AIDS Research and Treatment 5 Table 2: Item response analysis—PrEP knowledge scale. Difficulty p Outfit Infit Outfit Item Chi sq df Infit t Discrim parameters value MSQ MSQ t PrEP is a daily pill you can take to reduce your risk of 0 168.769 200 0.947 0.840 0.899 −0.923 −1.056 0.35 becoming infected with HIV You should not use PrEP if you don’t know your 1.969 170.56 200 0.935 0.849 0.925 −1.503 −1.178 0.397 HIV status + If you do not take PrEP consistently, there may not be enough medicine in your bloodstream to block 0.965 207.431 200 0.344 1.032 0.984 0.348 −0.226 0.327 the HIV virus PrEP can be used to prevent STIs like gonorrhea, 0.329 191.344 200 0.658 0.952 0.952 −0.296 −0.560 0.327 chlamydia, syphilis, herpes, and HPV If you start taking PrEP, you will have to take it for 0.965 224.213 200 0.115 1.098 1.098 1.141 1.455 0.163 the rest of your life PrEP can be taken by people who already have 2.208 236.976 200 0.038 1.043 1.043 1.477 0.646 0.169 ∗∗ HIV You must take an HIV test every 3 months while 1.831 193.298 200 0.620 0.994 0.994 −0.364 −0.079 0.301 taking PrEP + *ere are many serious side effects of taking PrEP + 2.622 196.265 200 0.561 1.030 1.030 −0.108 0.398 0.206 *e PrEP pill contains two medicines that are also 2.135 167.826 200 0.953 0.867 0.867 −1.510 −2.063 0.446 used to treat HIV + Daily PrEP use can lower the risk of getting HIV 0.244 146.976 200 0.998 0.870 0.870 −1.936 −1.553 0.437 from sex by more than 90% ∗ ∗∗ *e difficulty parameter of this item had been fixed to 0. Items of the scale had a bad fit. +Items of the scale show a high degree of difficulty and did not show acceptable discrimination. and others have found self-efficacy as an important construct toward PrEP were the strongest predictor of willingness and for PrEP uptake, in other populations, self-efficacy has not intention to use PrEP. *e attitudes scale presented a good fit been associated with HIV risk behaviours [21]. In our and included attitudes toward adherence, effectiveness, and sample, only two items were related to intention and will- safety, which are important aspects related to PrEP uptake ingness to use PrEP: the degree of difficulty in taking the [14]. *e attitudes scale also showed a high correlation with medication and attending the monitoring appointment. *is knowledge and a moderate correlation with self-efficacy, finding conveyed the significance of adherence to treatment supporting the IMB model results again [8]. As a motivation construct in the IMB model, PrEP stigma and access to healthcare as facilitators of PrEP use [22, 23]. *is is not a surprising result, as access to treatments, care, is a clear barrier for PrEP uptake in our study as it has been and HIV prevention in Colombia is fragmented, limited, and observed in other settings [14, 29]. Yet, overall levels of stigma problematic due to the organization of its health system in our sample were not high, with participants more con- [24, 25]. One possible explanation for the lack of association cerned about family members’ attitudes toward taking PrEP of the self-efficacy scale and the outcomes is the choice of the than friends’ attitudes. *ese results could be explained by items of the scale. *e difficulty of assessing self-efficacy in MSM’s greater knowledge and exposure to information on the context of complex behaviours has been recognized [26]. HIV [30]. *is was expected to happen in a sample that had PrEP uptake skills include consulting a provider, discussing access to the internet and was relatively well informed [31]. PrEP, discussing sexual health, and adhering to condom use, *e descriptive and subjective norms had a good fit and medication, and monitoring and HIV testing. *e self-ef- worked well in our study population. PrEP descriptive and subjective norms were positively associated with willingness ficacy scale comprised items related to discussions with providers about sexual health or having access to HIV and intention to uptake PrEP and knowledge, attitudes, and testing, which participants may not relate directly to taking self-efficacy. *is result means that MSM would be more pills. motivated to use PrEP if friends and sexual partners had Interestingly, having difficulty paying for the medication positive attitudes and views about PrEP. *e results also was related to greater intention, a finding that contrasts with highlighted an important correlation between the stigma other studies that found the cost of PrEP was a detrimental scale and the scales related to norms, which agrees with barrier to PrEP uptake [18, 27]. A study in Brazil found that results in other contexts [32]. 75.8% of the participants reported they would use PrEP even *ese validated scales in Spanish language may prove if they had to pay for it [28]. *is result could be explained by useful in both the clinical and public health domains. In the participants’ positive attitudes toward PrEP and its effec- clinic, the assessment of potential PrEP users involves de- cision-making by the patient about taking or declining PrEP. tiveness in reducing HIV infection. In support of the IMB model, our data indicated that the Here, scientific evidence needs to be presented to the patient motivation construct had good construct validity and is to inform their decision. In this instance, the knowledge relevant for PrEP intention in the sample. *e attitudes scale items could be introduced at different stages of the 6 AIDS Research and Treatment Table 3: Factor loadings for item scale versions (pattern matrix). PrEP PrEP self- descriptive PrEP attitudes PrEP stigma PrEP subjective PrEP known factor efficacy norms factor factor norms factor solution, 9 items factor Scale items factor solution solution solution solution solution (F I) (F II) (F III) (F I) (F I) (F I) (F II) (F I) (F I) (F II) PrEP is a daily pill you can take to reduce your risk of becoming infected 0.60 with HIV You should not use PrEP if you don’t 0.60 know your HIV status If you do not take PrEP consistently, there may not be enough medicine in 0.66 your bloodstream to block the HIV virus PrEP can be used to prevent STIs like gonorrhea, chlamydia, syphilis, herpes, 0.66 and HPV If you start taking PrEP, you will have to 0.24 take it for the rest of your life PrEP can be taken by people who 0.37 already have HIV You must take an HIV test every 3 0.36 months while taking PrEP *ere are many serious side effects of 0.49 taking PrEP *e PrEP pill contains two medicines 0.41 that are also used to treat HIV PrEP is effective at preventing HIV 0.76 People who take PrEP are responsible 0.75 Taking PrEP is safe 0.85 It would be no trouble to take PrEP 0.63 every day *e government makes certain that 0.68 drugs like PrEP are safe Getting a PrEP prescription from a 0.77 doctor would be embarrassing People who take PrEP are 0.73 promiscuous I would be concerned if my family 0.86 found out I was taking it I would be concerned if my friends 0.91 found out I was taking it I would be concerned if my sexual 0.86 partner(s) found out I was taking it People in my community would be interested in learning more about 0.85 PrEP People in my community would be willing to talk with their doctors about 0.95 using PrEP People in my community would 0.92 consider taking PrEP My friends would be interested in 1.00 learning more about PrEP My friends would be willing to talk with 0.94 their doctors about using PrEP My friends would consider taking PrEP 0.86 My friends would be supportive of me 0.70 using PrEP AIDS Research and Treatment 7 Table 3: Continued. PrEP PrEP self- descriptive PrEP attitudes PrEP stigma PrEP subjective PrEP known factor efficacy norms factor factor norms factor solution, 9 items factor Scale items factor solution solution solution solution solution (F I) (F II) (F III) (F I) (F I) (F I) (F II) (F I) (F I) (F II) My friends would think it was smart if I 0.84 used PrEP My friends would think it was 0.90 responsible if I used PrEP My sexual partner(s) would be 0.87 supportive of me using PrEP My sexual partner(s) would think it was 0.85 smart if I used PrEP My sexual partner(s) would think it was 0.85 responsible if I used PrEP How difficult would it be for you to seek out more information about PrEP to 0.67 decide if it is right for you? How difficult would it be for you to talk with your sexual partner(s) about the 0.64 decision to take PrEP? How difficult would it be for you to visit 0.82 a doctor who can provide PrEP? How difficult would it be for you to talk openly and honestly with a doctor 0.78 about your sexual behaviours? How difficult would it be for you to get 0.56 tested for HIV? How difficult would it be for you to find 0.58 a way to pay for PrEP? How difficult would it be for you to take 0.93 medicine like PrEP every day? How difficult would it be for you to visit a doctor every three months for routine 0.87 screenings? Proportion variance 0.33 0.54 0.69 0.63 0.23 0.70 0.39 0.18 Scale items had a bad fit and were excluded. Knowledge PrEP scale: each item was scored on a 3-point scale: 1 � true, 2 � false, and 3 � don’t know. Scores on this scale were recoded as 1 � correct and 0 � incorrect/don’t know, with higher scores indicating a greater degree of knowledge. Each item was scored on a 3- point scale as 1 � disagree, 2 � neutral, and 3 � agree, to scales of attitudes, stigma, descriptive norms, and subjective norms, with higher scores indicating more positive attitudes, a greater degree of stigma, and more positive norms. And for the self-efficacy scale, each item was scored on a 4-point scale ranging from 1 � very difficult to 4 � not difficult at all. Higher scores indicated more self-efficacy. Table 4: *e confirmatory factor analysis of the scales (CFA). Items CFA fit, confirmatory sample (n � 240) Model-PrEP scale BTS Cronbach’s alpha Initial Final KMO CFI TLI SRMR RMSEA Prob> chi2-excluding item (p value) coefficients LR test of model vs. saturated: PrEP attitudes 5 5 0.749 <0.001 1.00 1.01 0.03 0.00 chi2 (5) � 4.71, 0.70 prob> chi2 � 0.4517 LR test of model vs. saturated: PrEP stigma 5 5 0.7814 <0.001 0.90 0.79 0.06 0.18 chi2 (5) � 26.18, 0.81 prob> chi2 � 0.0001 PrEP stigma LR test of model vs. saturated: (excluding two 5 3 0.68 <0.001 1.00 1.00 0.00 0.00 0.81 chi2 (0) � 0.00, prob> chi2 � items) LR test of model vs. saturated: All: 0.8386 PrEP descriptive 6 6 0.76 <0.001 0.94 0.90 0.05 0.15 chi2 (8) � 31.79, subitems: 0.8094; norms prob> chi2 � 0.0001 0.8597 8 AIDS Research and Treatment Table 4: Continued. Items CFA fit, confirmatory sample (n � 240) Model-PrEP scale BTS Cronbach’s alpha Initial Final KMO CFI TLI SRMR RMSEA Prob> chi2-excluding item (p value) coefficients PrEP descriptive R test of model vs. saturated: All: 0.8259 norms (excluding 6 5 0.79 <0.001 1.00 1.02 0.01 0.00 chi2 (4) � 1.56, subitems: 0.8094; one item) prob> chi2 � 0.8158 0.8597 LR test of model vs. saturated: PrEP subjective 6 6 0.78 <0.001 0.900 0.834 0.059 0.180 chi2 (9) � 47.19, 0.864 norms prob> chi2 � 0.0000 PrEP subjective LR test of model vs. saturated: norms (excluding 6 4 0.69 <0.001 0.997 0.990 0.020 0.049 chi2 (2) � 2.63, 0.810 two items) prob> chi2 � 0.2681 LR test of model vs. saturated: All: 0.7423; PrEP self-efficacy 8 8 0.65 <0.001 0.793 0.694 0.102 0.153 chi2 (19) � 78.46, subitems: 0.7290; prob> chi2 � 0.0000 0.7601. PrEP self-efficacy LR test of model vs. saturated: All: 0.6283 (excluding two 8 6 0.57 <0.001 0.948 0.903 0.069 0.078 chi2 (8) � 14.53, subitems: 0.5379; items) prob> chi2 � 0.0689 0.7601 PrEP self-efficacy LR test of model vs. saturated: All: 0.5628; (excluding three 8 5 0.61 <0.001 1.000 1.091 0.033 0.000 chi2 (4) � 2.03, subitems: 0.5379; items) prob> chi2 � 0.7298 Two factors were obtained. A good fit is indicated by CFI and TLI values greater than 0.95 and RMSEA values less than 0.05 and acceptable fit by CFI and TLI # 2 values over 0.90 and RMSEA values less than 0.06. Chi cannot be estimated because the model fits three items. Means and associations of PrEP scales with Willingness (R2 = [.18; .41]) & Intention (R2 = [.15; .38]) PrEP Know-9 items (score from 0 to 9) Lo Hi PrEP Attitudes (score from 5 to 15) Lo Hi PrEP stigma (score from 5 to 15) Lo Hi PrEP stigma-3 items (score from 3 to 9) Lo Hi PrEP Descriptive norms (score from 6 to 18) Lo Hi PrEP Descriptive norms-5 items (score from 5 to 15) Lo Hi Hi PrEP subjective norms (score from 6 to 18) Lo PrEP subjective norms-4 items (score from 4 to 12) Lo Hi PrEP self-efficacy (score from 8 to 32) Lo Hi PrEP self-efficacy-6 items (score from 6 to 24) Lo Hi PrEP self-efficacy-5 items (score from 5 to 20) Lo Hi 0 5 10 15 20 25 30 –1.0 –0.5 0.0 0.5 1.0 Scores and 99.99% Cls 95% Cls of associations Figure 1: *e output of the confidence interval-based estimation of relevance (CIBER) analysis regarding determinants of willingness (purple color) and intention (yellow color) to use PrEP among MSM. Diamonds in the left-hand panel indicate the means and corre- sponding 99% confidence interval of each scale’s scores (scales of PrEP attitudes, stigma, descriptive norms and subjective norms, and PrEP self-efficacy). Green diamonds represent MSM who have a willingness and intention to use PrEP, and purple diamonds represent those who did not. Diamonds in the right-hand panel represent the 95% confidence intervals of the associations (Cohen’s d) between each determinant and willingness and intention to use PrEP. Willingness and intention to use PrEP” was dichotomized into two categories: 1 � to definitely yes and probably yes and 0 � all other answer options: neutral, probably not, definitely not. AIDS Research and Treatment 9 interaction patient-healthcare provider to ensure key items Data Availability of PrEP knowledge are delivered to and assimilated by PrEP *e data tables used to support the findings of this study are users. Similarly, the attitude scale can help determine if the available upon request to the corresponding author. education delivered in the clinic has impacted PrEP can- didates’ attitudes toward PrEP. In addition, some items of Conflicts of Interest the stigma scale can help recognize situations where healthcare providers need to intervene to reinforce positive *e authors declare no conflicts of interest concerning the messaging regarding PrEP use. In the public health domain, research, authorship, and/or publication of this article. agencies can use these scales to monitor the trends of PrEP knowledge, attitudes, stigma, norms, and self-efficacy over Acknowledgments time in populations of interest following PrEP imple- mentation and detect areas where improvement or adjust- *e authors thank the participants and organizations of ments are needed or whether PrEP campaigns are reaching LGBTI for assisting in the recruitment of survey partici- goals. pants. *e authors thank Dr. Ernesto Mart´ınez-Buitrago for providing constructive feedback on an earlier draft of this paper. *is work was supported by grants from the Ministry 4.1. Limitations and Strengths. Our validation sample was of Science-Colombia (code: 334780762872). composed of MSM living in 25 cities in Colombia recruited through different media and using an online survey. *is Supplementary Materials sample may not reflect the sociodemographic or sexual practices of all MSM in Colombia. *e sample of partici- Supplementary Table 1: knowledge PrEP scale—imputation pants was highly educated and with favourable socioeco- of nonassigned items. (Supplementary Materials) nomic statuses. *ey were also recruited via social media, which may have excluded those that do not use these re- References sources or have access to them. Despite this, our results were consistent with the IMB model, and the scales show good [1] M. Annequin, V. Villes, R. M. Delabre et al., “Are PrEP reliability and construct validity. We observed high atti- services in France reaching all those exposed to HIV who want tudes, low stigma levels, and high self-efficacy. Although our to take PrEP? 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Scales to Assess Knowledge, Motivation, and Self-Efficacy for HIV PrEP in Colombian MSM: PrEP-COL Study

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Hindawi AIDS Research and Treatment Volume 2021, Article ID 4789971, 11 pages https://doi.org/10.1155/2021/4789971 Research Article Scales to Assess Knowledge, Motivation, and Self-Efficacy for HIV PrEP in Colombian MSM: PrEP-COL Study 1 2 3 He´ctor F. Mueses-Marı´n , Beatriz Alvarado-Llano, Julia´n Torres-Isasiga, 4 1 1 Pilar Camargo-Plazas, Maria C. Bolı´var-Rocha, Ximena Galindo-Orrego, and Jorge L. Mart´ınez-Cajas Corporacio´n de Lucha Contra el Sida, Carrera 56 2-120, Cali, Colombia Public Health Science, Queens University, Kingston, Ontario K7L 3N6, Canada Montefiore Medical Center, Moses Division, Albert Einstein College of Medicine, /e Oval Center at Montefiore, 3230 Bainbridge Avenue, Bronx, NY 10467, USA School of Nursing, Queen’s University, Kingston, Ontario K7L 3N6, Canada Division of Infectious Diseases, Department of Medicine, Queens University, Kingston, Ontario K7L 3N6, Canada Correspondence should be addressed to He´ctor F. Mueses-Mar´ın; centroinvestigaciones@cls.org.co Received 22 April 2021; Revised 19 July 2021; Accepted 6 August 2021; Published 8 September 2021 Academic Editor: Jose-Ramon Blanco Copyright © 2021 He´ctor F. Mueses-Mar´ın et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. We evaluated the construct validity Spanish version of knowledge, stigma, norms, and self-efficacy scales regarding PrEP in MSM. Methods. Sample of 287 MSM. Exploratory confirmatory factor analysis and item response theory were used to validate the constructs. Correlations and confidence interval-based estimation of relevance analyses were conducted to correlate the scales with willingness and intention to use PrEP. Results. Attitude, stigma, and descriptive and subjective norms scales showed good construct validity and were related to intention and willingness to use PrEP. However, the knowledge scale and self-efficacy scales require further refinement. Conclusions. *e study provides useful information for assessing information, motivation, and self-efficacy related to PrEP use. Our results could be used to test the scales and the theoretical model in other contexts to confirm their usefulness. identify appropriate targets for interventions is needed if 1. Introduction PrEP is to be adopted widely. As MSM continue to be disproportionately affected by HIV, One explanatory model for reducing HIV risk behav- a combination of preventive strategies, including pre- iours that has potential in MSM populations is the infor- exposure prophylaxis (PrEP), is urgently needed to curtail mation motivational behavioural (IMB) model [8]. *e IMB model posits that individuals will likely initiate and sustain a the rate of new HIV diagnoses worldwide. PrEP acceptance in MSM has been low despite years of availability and behaviour if they are well informed and motivated and demonstrated efficacy [1, 2]. In the United States only one of perceive themselves as having the skills to initiate and five PrEP-eligible MSM is taking PrEP [3, 4]. Latino MSM in maintain the behaviour. *e IMB model has been used to North America had lower PrEP knowledge, acceptance, and develop HIV prevention interventions proven to be effective uptake [5, 6]. In Latin American countries, where MSM in decreasing condomless sex [9] and increasing adherence account for 40% of the new cases of HIV each year, PrEP to antiretroviral therapy [10, 11]. Barriers related to PrEP awareness was reported around to 58%, and nearly 52% were uptake in MSM are also consistent with the IMB model, willing to use daily PrEP [6]. PrEP uptake is a complex including lack of knowledge, negative attitudes, lack of self- behaviour [1, 7], and the use of a theoretical model to efficacy, and low motivation due to stigma [12]. Hence, it is a 2 AIDS Research and Treatment relevant framework for the development of behavioural Colombia, and reported to be HIV-negative. *e majority of interventions for populations at risk of HIV infection and in participants reported a negative HIV test in the last 12 months. A total of 287 participants were eligible among 584 need of PrEP [12–14]. Identification of PrEP knowledge, motivation, and skills who clicked on the questionnaire. in MSM requires either new instruments or the adaptation and validation of existing ones in different populations. In a 2.3. Instruments. Items from the original English scales [14] recent publication, Walsh [14] used the IMB model to de- were translated by one of the team members who is bilingual velop new measures for these constructs and relate them to in Spanish and English and familiar with scale validation PrEP uptake. *e scales assessing knowledge, descriptive (BEA) and back-translated by another team member (JLM) norms, and subjective norms have high levels of reliability who is also bilingual in Spanish and English and an HIV with alphas of Cronbach greater than or equal to 0.90. *e expert. *en, the translated scales were reviewed using attitude, stigma, and self-efficacy scales had good alphas cognitive interview methodology with four MSM, which from 0.79 to 0.87. Confirmatory factor analyses supported resulted in some minor changes. *ese changes included the correlation of the scales and the item loading in each a wording, exclusion of two items of the knowledge scale (as priori latent construct, with most of the scales related to the they did not apply to the Colombian context), and changing intention to use PrEP, thus supporting the IMB model. Since the Likert scale from 5 to 3 answer categories for the scales of the scales have been recently developed and only used in attitudes, stigma, and descriptive norms. *is latter change MSM populations living in the United States and are not yet sought to decrease the degree of difficulty and time needed available in Spanish, in this paper, we present the assessment for completion. *e scales included ten items assessing of their internal coherence and construct validity in a sample knowledge on PrEP, five items assessing attitudes, five of MSM from Colombia. In this work, we explored if the assessing stigma, six assessing descriptive norms, six items of the scales represent one construct and a relationship assessing subjective norms, and eight items assessing self- exists between the scales and the intention to uptake PrEP. If efficacy: the PrEP scales are valid and the relations are supported, the results could be used to gain an understanding of PrEP Knowledge PrEP Scale. *is scale was initially com- uptake in other Spanish-speaking MSM populations and posed of 13 items but was reduced to 10 items after delineate interventions. excluding items related to PrEP coverage, the avail- ability of over-the-counter PrEP, and ways to have 2. Materials and Methods access to PrEP in the absence of health insurance. *ese items did not apply to the Colombian context, as PrEP 2.1. Design. *e data from this study came from an online was not covered nor was it available over the counter in open survey; thus anyone was able to access it by clicking on Colombia at the time of the survey. Each item was an online link. *e recruitment was between April and scored on a 3-point scale: 1 �true, 2 �false, and October 2020. *e link to the online survey was distributed 3 �don’t know. Scores on this scale were recoded as in different ways, including emails to gay and MSM leaders/ 1 �correct and 0 �incorrect/don’t know, with higher organizations who were asked to share it with their peers/ scores indicating a greater degree of knowledge. To members through social media, such as Facebook. A total of reduce the burden of the number of questions, par- 7 MSM or transgender-focused organizations posted the ticipants were randomly assigned (option available in study link. *e study was also advertised on Grindr for two Qualtrics) to 70% of the items of the knowledge scale, weeks geographically constricted to three Colombian cities: and imputation of nonassigned items was done using Cali, Bogota, and Medellin (total population ∼13 million). the R software (Supplementary Table 1). Individuals who were self-identified as MSM and self-re- PrEP Attitudes. PrEP attitudes consisted of a 5-item ported an HIV-negative status in the screening questions scale, which includes aspects such as perceptions of were prompted to complete the PrEP-related survey. *e effectiveness and safety. All original items were questionnaire was developed in Qualtrics, was anonymized, translated, and each item was scored on a 3-point scale and offered no incentives. Participation in the study was as 1 �disagree, 2 �neutral, and 3 �agree, with higher voluntary, and access to the questionnaire was granted to scores indicating more positive attitudes. those consenting online. *e full questionnaire was devel- PrEP Stigma. *is 5-item scale is related to concerns oped through an iterative process between team members regarding negative perceptions about PrEP use, for and PrEP experts and was reviewed by community members instance, the relationship between PrEP use and pro- of the MSM community in three Colombian cities. For this paper, we report selected parts of the questionnaire. *is miscuity. Each item was scored on a 3-point scale as 1 �disagree, 2 �neutral, and 3 �agree, with higher study was reviewed and approved by the Research Ethics Boards of both the Corporacion ´ de Lucha contra el Sida scores indicating a greater degree of stigma. (approval certificate no. 034 of May 16, 2018) and Queen’s Descriptive Norms PrEP. For this measure, participants University (DMED-2326-20). were asked to consider the perceptions and interests of friends and people in their community concerning PrEP. Six items were scored on a 3-point scale ranging 2.2. Participants. Participants were eligible for this analysis if they were self-identified as gay/bisexual men, resided in from 1 �disagree to 3 �agree, with higher scores AIDS Research and Treatment 3 conducted with the other half of the sample to assess the indicating more positive norms. *is was a change from the 5-point scale used by Walsh [14]. model fit of the exploratory analysis. *e model fit was assessed using traditional fit indices [15]. We performed an Subjective Norms PrEP. Participants were also asked to item response theory analysis to identify the degree of consider the perceptions of friends and their sexual difficulty of the items of the knowledge scale. *e associa- partners. *ree items were scored on a 3-point scale tions between variables were done using Spearman’s cor- ranging from 1 �disagree to 3 �agree, with higher relation analysis and confidence interval-based estimation of scores indicating a greater degree of positive norms relevance (CIBER) analysis [16]. All analyses were per- related to PrEP. formed using Stata/IC version 16 and R version 4.0.2. Self-Efficacy PrEP. *is 8-item scale assessed efficacy related to asking about PrEP, adherence to PrEP, and 3. Results payment of PrEP, among others. Each item was scored on a 4-point scale ranging from 1 �very difficult to *e baseline demographic characteristics of the 287 par- 4 �not difficult at all. Higher scores indicated more ticipants are shown in Table 1. self-efficacy. Willingness and Intention to Use PrEP. *is measure 3.1. Distribution of Items in the Scales. A total of 72% said was assessed with two questions: “If PrEP is effective in they had heard of PrEP and indicated they had a low- reducing the risk of HIV by 90%, and in the next 12 moderate level of knowledge about PrEP. Participants knew months PrEP was offered for free in Colombia, would the purpose of PrEP (78%), its efficacy (74%), and that it does you like to use PrEP to prevent HIV?” and “If in the not prevent other sexually transmitted infections (72%), but next 12 months, your doctor or other health profes- their knowledge on the importance of monitoring, adher- sional was available for a PrEP prescription, would you ence, and its relationship with HIV status was low. A high start taking the PrEP pills?” *e questions were rated percentage of positive attitudes toward PrEP was observed. on a 5-point scale ranging from 1 �definitely yes to Overall levels of PrEP stigma were low. *e descriptive 5 �definitely no. Willingness and intention to use PrEP norms items showed that participants think their commu- was dichotomized into two categories 1 � to definitely nities and friends would like to learn about PrEP. In terms of yes and probably yes and 0 � all other answer options: subjective norms, the level of support to use PrEP seemed neutral, probably not, definitely not. moderately high. Levels of self-efficacy varied across items, Before introducing respondents to PrEP scales, a sum- with more difficulty reported on items related to paying for mary of the meaning of PrEP was presented as follows. PrEP and visiting a doctor (data not shown). “Preexposure prophylaxis (PrEP) is an HIV infection prevention strategy where HIV-negative individuals take anti-HIV medications before coming into contact with HIV 3.2. Item Response Analysis and Factor Analysis. In the item to reduce their risk of becoming infected. Medications response analysis for the PrEP knowledge scale, only one prevent HIV from establishing an infection within the body. item failed to demonstrate an acceptable fit (“PrEP can be PrEP has been shown to reduce the risk of HIV infection taken by people who already have HIV,” p � 0.038). Four through sexual contact in gay and bisexual men, transgender items of the knowledge scale showed a high degree of dif- women, and heterosexual men and women, as well as in ficulty and did not show acceptable discrimination values people who inject drugs. It does not protect against other (Table 2). *e exclusion of the poor fit item and the difficult sexually transmitted infections (STIs) nor does it prevent four items represented an increase in the mean of knowledge pregnancy. It is not a cure for HIV. Using tenofovir/ from 52/100 points to 63/100 points (data not shown). emtricitabine–TDF/FTC as PrEP provides a 96% to 99% Exploratory factorial analysis (Table 3) revealed three reduction in the risk of infection in HIV-negative people factors for PrEP knowledge, a unique factor for PrEP atti- who take the pills every day as directed. If you miss a daily tudes, PrEP stigma, and PrEP subjective norms, and two dose, the level of protection against HIV may decrease. It factors for the PrEP descriptive norms and PrEP self-effi- only works if you take the medicine. People who use PrEP cacy. *e Cronbach’s alpha coefficients for the scales were correctly and consistently have higher levels of protection between 0.70 and 0.86. *e confirmatory factor analysis of against HIV.” the scales indicated that all items of the attitude scale had a good fit; for the other scales, the exclusion of one or two items increased the fit of the scales (Table 4). 2.4. Statistical Analyses. Descriptive statistics were used to summarize the social characteristics of the sample. *e next step in the analysis was to perform an exploratory factor 3.3. Intention to Use PrEP: CIBER Analysis by Items Scales for analysis with a random sample of 50% of participants. In PrEP. Two knowledge items were related to willingness and interpreting the factor pattern, a factor loading ≥0.40 was intention: “PrEP can be taken by people who already have considered good. For this analysis, a polychoric correlation HIV” and “You must take an HIV test every 3 months while matrix was used. Internal consistency and reliability were taking PrEP.” Additionally, two were related with intention: tested using Kuder-Richardson formulas and Cronbach’s “*e PrEP pill contains two medicines that are also used to coefficients. *en, confirmatory factor analysis was treat HIV” and “Daily PrEP use can lower the risk of getting 4 AIDS Research and Treatment Table 1: Baseline demographic characteristics of the study reporting less difficulty in paying were less likely to have participants. intention. *e R square was higher for the attitudes scale with 0.15 for willingness and 0.14 for intention to use PrEP 31.2; 8.9 Age, years (means; sd) (data not shown). n (%) Biological sex (men) 287 (100) Gender 3.3.1. Correlations. Positive and moderate correlations were Male 279 (97.2) found between the scales. *e PrEP knowledge scale was Nonconforming gender 3 (1.0) correlated to PrEP attitudes (r � 0.40) and subjective norms Other 3 (1.0) scales (r � 0.27) and negatively with PrEP stigma (r � −0.18). Prefer not to answer 2 (0.7) *e attitudes scale correlated to the stigma scale (r � −0.29), Sexual orientation descriptive norms (r � 0.20), subjective norms (r � 0.45), and Heterosexual 3 (1.0) Gay men 238 (82.9) self-efficacy (0.15<r< 0.25). *e stigma scale correlated with Bisexual 45 (15.7) descriptive norms (−0.17<r< −0.20), subjective norms Prefer not to answer 1 (0.3) (−0.47<r< −0.52), and self-efficacy (−0.18<r< −0.37). Civil status Descriptive norms correlated to subjective norms positively Married—common law 45 (15.7) (0.32<r< 0.37). Finally, subjective norms were correlated Single 236 (82.2) positively with the self-efficacy shorter scale (r � 0.18). Separated-widow 6 (2.1) Willingness and intention to use PrEP correlated positively Education level with PrEP knowledge (r � 0.23), attitudes (0.40<r< −0.42), Primary school 1 (0.3) descriptive norms (0.25<r< 0.31), and subjective norms Secondary school 26 (9.1) (0.24<r< 0.33) and inversely with stigma scales Technical-superior 260 (90.6) (−0.24<r< −0.32). No correlation was found between self- Socioeconomic stratum efficacy scale and willingness or self-efficacy and intention One-two (very low-low) 83 (28.9) (Figure 1). *ree-four (middle) 166 (57.8) Five-six (high) 39 (13.6) Occupation status (one or more options) 4. Discussion Work 184 (64.1) In our MSM study in Colombia, results indicated that the Housekeepers 9 (3.1) majority of the items and the scales developed by Walsh [14] Voluntary 11 (3.8) Student 59 (20.6) are reliable and show a good fit. Although a reduction of Unemployed 62 (21.6) items seems to favour a better fit in most of the scales, the Other 16 (5.6) majority of the relationships among constructs of the IBM Current monthly income model were supported by the data: better-informed par- No income 44 (15.3) ticipants have positive attitudes, more motivated (less stigma <1 59 (20.6) with more positive norms) participants have higher levels of Between 1 and 2 67 (23.3) self-efficacy, and those with more positive attitudes and less >2 117 (40.8) stigma had more intention to use PrEP. Future use must Health insurance/coverage (yes) 246 (86.0) consider the level of difficulty of the items of the knowledge Willingness to use PrEP (definitely yes) 187 (71.1) scale, and the self-efficacy scale needs to be refined and Intention to start PrEP (definitely yes) 167 (63.7) consider additional self-efficacy items. Willingness and intention to use PrEP was dichotomized into two cate- *e knowledge scale presented a high degree of difficulty gories: 1 � to definitely yes and probably yes and 0 � all other answer op- for participants, especially items describing the relationship tions: neutral, probably not, definitely not. between HIV and the need for extra monitoring. Interest- ingly, the items with a greater level of difficulty were cor- HIV from sex by more than 90%.” In the case of attitudes related with willingness and intention. *is particular and subjective norms, all items were related to intention and finding favours the need to provide accurate and relevant willingness in the direction expected: more positive attitudes knowledge of PrEP [17, 18]. Consistent with other studies, were related to greater willingness and intention. Con- knowledge of PrEP was related to intention to use PrEP [6], cerning stigma, strong negative associations were found for and knowledge was related to higher positive attitudes and all items, and from the descriptive norms scale, only one less stigma [19, 20]. *us, health education within MSM item was not related to both outcomes: “My friends would be communities on PrEP may need to emphasize the use of interested in learning more about PrEP.” Concerning sub- PrEP exclusively in HIV-negative individuals, the impor- jective norms, all items were related to willingness and tance of monitoring and follow-up, and the potential side intention, and for the items related to self-efficacy, two items effects associated with PrEP. were strongly related to willingness to use PrEP (being able Self-efficacy is a crucial element in developing strategies to take the medicine and being able to visit a doctor for for prevention in HIV [8], including PrEP uptake; however, monitoring) and one item was strongly related to intention we did not find a correlation of the scale with intention and (being able to take the medicine). Interestingly, participants willingness to use PrEP. Although Walsh’s validation study AIDS Research and Treatment 5 Table 2: Item response analysis—PrEP knowledge scale. Difficulty p Outfit Infit Outfit Item Chi sq df Infit t Discrim parameters value MSQ MSQ t PrEP is a daily pill you can take to reduce your risk of 0 168.769 200 0.947 0.840 0.899 −0.923 −1.056 0.35 becoming infected with HIV You should not use PrEP if you don’t know your 1.969 170.56 200 0.935 0.849 0.925 −1.503 −1.178 0.397 HIV status + If you do not take PrEP consistently, there may not be enough medicine in your bloodstream to block 0.965 207.431 200 0.344 1.032 0.984 0.348 −0.226 0.327 the HIV virus PrEP can be used to prevent STIs like gonorrhea, 0.329 191.344 200 0.658 0.952 0.952 −0.296 −0.560 0.327 chlamydia, syphilis, herpes, and HPV If you start taking PrEP, you will have to take it for 0.965 224.213 200 0.115 1.098 1.098 1.141 1.455 0.163 the rest of your life PrEP can be taken by people who already have 2.208 236.976 200 0.038 1.043 1.043 1.477 0.646 0.169 ∗∗ HIV You must take an HIV test every 3 months while 1.831 193.298 200 0.620 0.994 0.994 −0.364 −0.079 0.301 taking PrEP + *ere are many serious side effects of taking PrEP + 2.622 196.265 200 0.561 1.030 1.030 −0.108 0.398 0.206 *e PrEP pill contains two medicines that are also 2.135 167.826 200 0.953 0.867 0.867 −1.510 −2.063 0.446 used to treat HIV + Daily PrEP use can lower the risk of getting HIV 0.244 146.976 200 0.998 0.870 0.870 −1.936 −1.553 0.437 from sex by more than 90% ∗ ∗∗ *e difficulty parameter of this item had been fixed to 0. Items of the scale had a bad fit. +Items of the scale show a high degree of difficulty and did not show acceptable discrimination. and others have found self-efficacy as an important construct toward PrEP were the strongest predictor of willingness and for PrEP uptake, in other populations, self-efficacy has not intention to use PrEP. *e attitudes scale presented a good fit been associated with HIV risk behaviours [21]. In our and included attitudes toward adherence, effectiveness, and sample, only two items were related to intention and will- safety, which are important aspects related to PrEP uptake ingness to use PrEP: the degree of difficulty in taking the [14]. *e attitudes scale also showed a high correlation with medication and attending the monitoring appointment. *is knowledge and a moderate correlation with self-efficacy, finding conveyed the significance of adherence to treatment supporting the IMB model results again [8]. As a motivation construct in the IMB model, PrEP stigma and access to healthcare as facilitators of PrEP use [22, 23]. *is is not a surprising result, as access to treatments, care, is a clear barrier for PrEP uptake in our study as it has been and HIV prevention in Colombia is fragmented, limited, and observed in other settings [14, 29]. Yet, overall levels of stigma problematic due to the organization of its health system in our sample were not high, with participants more con- [24, 25]. One possible explanation for the lack of association cerned about family members’ attitudes toward taking PrEP of the self-efficacy scale and the outcomes is the choice of the than friends’ attitudes. *ese results could be explained by items of the scale. *e difficulty of assessing self-efficacy in MSM’s greater knowledge and exposure to information on the context of complex behaviours has been recognized [26]. HIV [30]. *is was expected to happen in a sample that had PrEP uptake skills include consulting a provider, discussing access to the internet and was relatively well informed [31]. PrEP, discussing sexual health, and adhering to condom use, *e descriptive and subjective norms had a good fit and medication, and monitoring and HIV testing. *e self-ef- worked well in our study population. PrEP descriptive and subjective norms were positively associated with willingness ficacy scale comprised items related to discussions with providers about sexual health or having access to HIV and intention to uptake PrEP and knowledge, attitudes, and testing, which participants may not relate directly to taking self-efficacy. *is result means that MSM would be more pills. motivated to use PrEP if friends and sexual partners had Interestingly, having difficulty paying for the medication positive attitudes and views about PrEP. *e results also was related to greater intention, a finding that contrasts with highlighted an important correlation between the stigma other studies that found the cost of PrEP was a detrimental scale and the scales related to norms, which agrees with barrier to PrEP uptake [18, 27]. A study in Brazil found that results in other contexts [32]. 75.8% of the participants reported they would use PrEP even *ese validated scales in Spanish language may prove if they had to pay for it [28]. *is result could be explained by useful in both the clinical and public health domains. In the participants’ positive attitudes toward PrEP and its effec- clinic, the assessment of potential PrEP users involves de- cision-making by the patient about taking or declining PrEP. tiveness in reducing HIV infection. In support of the IMB model, our data indicated that the Here, scientific evidence needs to be presented to the patient motivation construct had good construct validity and is to inform their decision. In this instance, the knowledge relevant for PrEP intention in the sample. *e attitudes scale items could be introduced at different stages of the 6 AIDS Research and Treatment Table 3: Factor loadings for item scale versions (pattern matrix). PrEP PrEP self- descriptive PrEP attitudes PrEP stigma PrEP subjective PrEP known factor efficacy norms factor factor norms factor solution, 9 items factor Scale items factor solution solution solution solution solution (F I) (F II) (F III) (F I) (F I) (F I) (F II) (F I) (F I) (F II) PrEP is a daily pill you can take to reduce your risk of becoming infected 0.60 with HIV You should not use PrEP if you don’t 0.60 know your HIV status If you do not take PrEP consistently, there may not be enough medicine in 0.66 your bloodstream to block the HIV virus PrEP can be used to prevent STIs like gonorrhea, chlamydia, syphilis, herpes, 0.66 and HPV If you start taking PrEP, you will have to 0.24 take it for the rest of your life PrEP can be taken by people who 0.37 already have HIV You must take an HIV test every 3 0.36 months while taking PrEP *ere are many serious side effects of 0.49 taking PrEP *e PrEP pill contains two medicines 0.41 that are also used to treat HIV PrEP is effective at preventing HIV 0.76 People who take PrEP are responsible 0.75 Taking PrEP is safe 0.85 It would be no trouble to take PrEP 0.63 every day *e government makes certain that 0.68 drugs like PrEP are safe Getting a PrEP prescription from a 0.77 doctor would be embarrassing People who take PrEP are 0.73 promiscuous I would be concerned if my family 0.86 found out I was taking it I would be concerned if my friends 0.91 found out I was taking it I would be concerned if my sexual 0.86 partner(s) found out I was taking it People in my community would be interested in learning more about 0.85 PrEP People in my community would be willing to talk with their doctors about 0.95 using PrEP People in my community would 0.92 consider taking PrEP My friends would be interested in 1.00 learning more about PrEP My friends would be willing to talk with 0.94 their doctors about using PrEP My friends would consider taking PrEP 0.86 My friends would be supportive of me 0.70 using PrEP AIDS Research and Treatment 7 Table 3: Continued. PrEP PrEP self- descriptive PrEP attitudes PrEP stigma PrEP subjective PrEP known factor efficacy norms factor factor norms factor solution, 9 items factor Scale items factor solution solution solution solution solution (F I) (F II) (F III) (F I) (F I) (F I) (F II) (F I) (F I) (F II) My friends would think it was smart if I 0.84 used PrEP My friends would think it was 0.90 responsible if I used PrEP My sexual partner(s) would be 0.87 supportive of me using PrEP My sexual partner(s) would think it was 0.85 smart if I used PrEP My sexual partner(s) would think it was 0.85 responsible if I used PrEP How difficult would it be for you to seek out more information about PrEP to 0.67 decide if it is right for you? How difficult would it be for you to talk with your sexual partner(s) about the 0.64 decision to take PrEP? How difficult would it be for you to visit 0.82 a doctor who can provide PrEP? How difficult would it be for you to talk openly and honestly with a doctor 0.78 about your sexual behaviours? How difficult would it be for you to get 0.56 tested for HIV? How difficult would it be for you to find 0.58 a way to pay for PrEP? How difficult would it be for you to take 0.93 medicine like PrEP every day? How difficult would it be for you to visit a doctor every three months for routine 0.87 screenings? Proportion variance 0.33 0.54 0.69 0.63 0.23 0.70 0.39 0.18 Scale items had a bad fit and were excluded. Knowledge PrEP scale: each item was scored on a 3-point scale: 1 � true, 2 � false, and 3 � don’t know. Scores on this scale were recoded as 1 � correct and 0 � incorrect/don’t know, with higher scores indicating a greater degree of knowledge. Each item was scored on a 3- point scale as 1 � disagree, 2 � neutral, and 3 � agree, to scales of attitudes, stigma, descriptive norms, and subjective norms, with higher scores indicating more positive attitudes, a greater degree of stigma, and more positive norms. And for the self-efficacy scale, each item was scored on a 4-point scale ranging from 1 � very difficult to 4 � not difficult at all. Higher scores indicated more self-efficacy. Table 4: *e confirmatory factor analysis of the scales (CFA). Items CFA fit, confirmatory sample (n � 240) Model-PrEP scale BTS Cronbach’s alpha Initial Final KMO CFI TLI SRMR RMSEA Prob> chi2-excluding item (p value) coefficients LR test of model vs. saturated: PrEP attitudes 5 5 0.749 <0.001 1.00 1.01 0.03 0.00 chi2 (5) � 4.71, 0.70 prob> chi2 � 0.4517 LR test of model vs. saturated: PrEP stigma 5 5 0.7814 <0.001 0.90 0.79 0.06 0.18 chi2 (5) � 26.18, 0.81 prob> chi2 � 0.0001 PrEP stigma LR test of model vs. saturated: (excluding two 5 3 0.68 <0.001 1.00 1.00 0.00 0.00 0.81 chi2 (0) � 0.00, prob> chi2 � items) LR test of model vs. saturated: All: 0.8386 PrEP descriptive 6 6 0.76 <0.001 0.94 0.90 0.05 0.15 chi2 (8) � 31.79, subitems: 0.8094; norms prob> chi2 � 0.0001 0.8597 8 AIDS Research and Treatment Table 4: Continued. Items CFA fit, confirmatory sample (n � 240) Model-PrEP scale BTS Cronbach’s alpha Initial Final KMO CFI TLI SRMR RMSEA Prob> chi2-excluding item (p value) coefficients PrEP descriptive R test of model vs. saturated: All: 0.8259 norms (excluding 6 5 0.79 <0.001 1.00 1.02 0.01 0.00 chi2 (4) � 1.56, subitems: 0.8094; one item) prob> chi2 � 0.8158 0.8597 LR test of model vs. saturated: PrEP subjective 6 6 0.78 <0.001 0.900 0.834 0.059 0.180 chi2 (9) � 47.19, 0.864 norms prob> chi2 � 0.0000 PrEP subjective LR test of model vs. saturated: norms (excluding 6 4 0.69 <0.001 0.997 0.990 0.020 0.049 chi2 (2) � 2.63, 0.810 two items) prob> chi2 � 0.2681 LR test of model vs. saturated: All: 0.7423; PrEP self-efficacy 8 8 0.65 <0.001 0.793 0.694 0.102 0.153 chi2 (19) � 78.46, subitems: 0.7290; prob> chi2 � 0.0000 0.7601. PrEP self-efficacy LR test of model vs. saturated: All: 0.6283 (excluding two 8 6 0.57 <0.001 0.948 0.903 0.069 0.078 chi2 (8) � 14.53, subitems: 0.5379; items) prob> chi2 � 0.0689 0.7601 PrEP self-efficacy LR test of model vs. saturated: All: 0.5628; (excluding three 8 5 0.61 <0.001 1.000 1.091 0.033 0.000 chi2 (4) � 2.03, subitems: 0.5379; items) prob> chi2 � 0.7298 Two factors were obtained. A good fit is indicated by CFI and TLI values greater than 0.95 and RMSEA values less than 0.05 and acceptable fit by CFI and TLI # 2 values over 0.90 and RMSEA values less than 0.06. Chi cannot be estimated because the model fits three items. Means and associations of PrEP scales with Willingness (R2 = [.18; .41]) & Intention (R2 = [.15; .38]) PrEP Know-9 items (score from 0 to 9) Lo Hi PrEP Attitudes (score from 5 to 15) Lo Hi PrEP stigma (score from 5 to 15) Lo Hi PrEP stigma-3 items (score from 3 to 9) Lo Hi PrEP Descriptive norms (score from 6 to 18) Lo Hi PrEP Descriptive norms-5 items (score from 5 to 15) Lo Hi Hi PrEP subjective norms (score from 6 to 18) Lo PrEP subjective norms-4 items (score from 4 to 12) Lo Hi PrEP self-efficacy (score from 8 to 32) Lo Hi PrEP self-efficacy-6 items (score from 6 to 24) Lo Hi PrEP self-efficacy-5 items (score from 5 to 20) Lo Hi 0 5 10 15 20 25 30 –1.0 –0.5 0.0 0.5 1.0 Scores and 99.99% Cls 95% Cls of associations Figure 1: *e output of the confidence interval-based estimation of relevance (CIBER) analysis regarding determinants of willingness (purple color) and intention (yellow color) to use PrEP among MSM. Diamonds in the left-hand panel indicate the means and corre- sponding 99% confidence interval of each scale’s scores (scales of PrEP attitudes, stigma, descriptive norms and subjective norms, and PrEP self-efficacy). Green diamonds represent MSM who have a willingness and intention to use PrEP, and purple diamonds represent those who did not. Diamonds in the right-hand panel represent the 95% confidence intervals of the associations (Cohen’s d) between each determinant and willingness and intention to use PrEP. Willingness and intention to use PrEP” was dichotomized into two categories: 1 � to definitely yes and probably yes and 0 � all other answer options: neutral, probably not, definitely not. AIDS Research and Treatment 9 interaction patient-healthcare provider to ensure key items Data Availability of PrEP knowledge are delivered to and assimilated by PrEP *e data tables used to support the findings of this study are users. Similarly, the attitude scale can help determine if the available upon request to the corresponding author. education delivered in the clinic has impacted PrEP can- didates’ attitudes toward PrEP. In addition, some items of Conflicts of Interest the stigma scale can help recognize situations where healthcare providers need to intervene to reinforce positive *e authors declare no conflicts of interest concerning the messaging regarding PrEP use. In the public health domain, research, authorship, and/or publication of this article. agencies can use these scales to monitor the trends of PrEP knowledge, attitudes, stigma, norms, and self-efficacy over Acknowledgments time in populations of interest following PrEP imple- mentation and detect areas where improvement or adjust- *e authors thank the participants and organizations of ments are needed or whether PrEP campaigns are reaching LGBTI for assisting in the recruitment of survey partici- goals. pants. *e authors thank Dr. Ernesto Mart´ınez-Buitrago for providing constructive feedback on an earlier draft of this paper. *is work was supported by grants from the Ministry 4.1. Limitations and Strengths. Our validation sample was of Science-Colombia (code: 334780762872). composed of MSM living in 25 cities in Colombia recruited through different media and using an online survey. *is Supplementary Materials sample may not reflect the sociodemographic or sexual practices of all MSM in Colombia. *e sample of partici- Supplementary Table 1: knowledge PrEP scale—imputation pants was highly educated and with favourable socioeco- of nonassigned items. (Supplementary Materials) nomic statuses. *ey were also recruited via social media, which may have excluded those that do not use these re- References sources or have access to them. Despite this, our results were consistent with the IMB model, and the scales show good [1] M. Annequin, V. Villes, R. M. Delabre et al., “Are PrEP reliability and construct validity. We observed high atti- services in France reaching all those exposed to HIV who want tudes, low stigma levels, and high self-efficacy. Although our to take PrEP? 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AIDS Research and Treatment – Hindawi Publishing Corporation

Published: Sep 8, 2021

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