Freedom as Prevention: Mechanisms of Autonomy Support for Promoting HIV Pre-Exposure Prophylaxis Use and Condom Use among Black MSM in 3 US Cities-HPTN 073

LaRon E Nelson^{1

2

3}, Donte T Boyd^{4

5}, Geetha Beauchamp⁶, Lynda Emel⁶, Leo Wilton^{7

8}, Darren Whitfield⁹, S Raquel Ramos^{10

4}, Wale Ajiboye¹¹, Mandy J Hill¹², Donaldson F Conserve¹³, Portia Thomas^{4

14}, Lisa Hightow-Weidman¹⁵, Steve Shoptaw¹⁶, Manya Magnus¹⁷, Kenneth H Mayer¹⁸, Estelle Piwowar-Manning¹⁹, Sheldon D Fields²⁰, Darrell P Wheeler²¹; HPTN 073 Study Team

Affiliations

¹ School of Nursing, Yale University, 400 West Campus Drive, New Haven, CT, USA. laron.nelson@yale.edu.
² Center for Interdisciplinary Research On AIDS, School of Public Health, Yale University, New Haven, CT, USA. laron.nelson@yale.edu.
³ MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. laron.nelson@yale.edu.
⁴ Center for Interdisciplinary Research On AIDS, School of Public Health, Yale University, New Haven, CT, USA.
⁵ College of Social Work, The Ohio State University, Columbus, OH, USA.
⁶ Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
⁷ Department of Human Development, College of Community and Public Affairs, State University of New York at Binghamton, Binghamton, NY, USA.
⁸ Department of Humanities, University of Johannesburg, Johannesburg, South Africa.
⁹ School of Social Work, University of Maryland Baltimore, Baltimore, MD, USA.
¹⁰ School of Nursing, Yale University, 400 West Campus Drive, New Haven, CT, USA.
¹¹ MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
¹² Department of Emergency Medicine, McGovern Medical School, University of Texas Health, Houston, TX, USA.
¹³ Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington Universty, Washington, DC, USA.
¹⁴ Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY, USA.
¹⁵ Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
¹⁶ Division of Family Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
¹⁷ Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
¹⁸ The Fenway Institute, Fenway Health, Boston, MA, USA.
¹⁹ Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
²⁰ Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, PA, USA.
²¹ Iona College, New Rochelle, NY, USA.

PMID: 35939181
PMCID: PMC9727017
DOI: 10.1007/s11524-022-00666-y

Freedom as Prevention: Mechanisms of Autonomy Support for Promoting HIV Pre-Exposure Prophylaxis Use and Condom Use among Black MSM in 3 US Cities-HPTN 073

LaRon E Nelson et al. J Urban Health. 2022 Dec.

. 2022 Dec;99(6):1157-1169.

doi: 10.1007/s11524-022-00666-y. Epub 2022 Aug 8.

Authors

Affiliations

¹ School of Nursing, Yale University, 400 West Campus Drive, New Haven, CT, USA. laron.nelson@yale.edu.
² Center for Interdisciplinary Research On AIDS, School of Public Health, Yale University, New Haven, CT, USA. laron.nelson@yale.edu.
³ MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. laron.nelson@yale.edu.
⁴ Center for Interdisciplinary Research On AIDS, School of Public Health, Yale University, New Haven, CT, USA.
⁵ College of Social Work, The Ohio State University, Columbus, OH, USA.
⁶ Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
⁷ Department of Human Development, College of Community and Public Affairs, State University of New York at Binghamton, Binghamton, NY, USA.
⁸ Department of Humanities, University of Johannesburg, Johannesburg, South Africa.
⁹ School of Social Work, University of Maryland Baltimore, Baltimore, MD, USA.
¹⁰ School of Nursing, Yale University, 400 West Campus Drive, New Haven, CT, USA.
¹¹ MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
¹² Department of Emergency Medicine, McGovern Medical School, University of Texas Health, Houston, TX, USA.
¹³ Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington Universty, Washington, DC, USA.
¹⁴ Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY, USA.
¹⁵ Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
¹⁶ Division of Family Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
¹⁷ Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
¹⁸ The Fenway Institute, Fenway Health, Boston, MA, USA.
¹⁹ Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
²⁰ Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, PA, USA.
²¹ Iona College, New Rochelle, NY, USA.

PMID: 35939181
PMCID: PMC9727017
DOI: 10.1007/s11524-022-00666-y

Abstract

Healthcare providers who use controlling or coercive strategies may compel short-term enactment of HIV and sexually transmitted infection prevention behaviors but may inadvertently undermine their client's motivation to maintain those behaviors in the absence of external pressure. Autonomous motivation refers to the self-emanating and self-determined drive for engaging in health behaviors. It is associated with long-term maintenance of health behaviors. We used structural equation modeling to investigate whether autonomy support was associated with increased odds of therapeutic serum levels of pre-exposure prophylaxis, through a pathway that satisfies basic psychological needs for autonomous self-regulation and competence regarding pre-exposure prophylaxis use. We also investigated whether autonomy support was associated with decreased odds of condomless anal intercourse via the same psychological needs-satisfaction pathway of autonomous self-regulation and competence regarding condom use. We tested these two theorized pathways using secondary data from a longitudinal sample of Black men who have sex with men from across three cities in the US (N = 226). Data from the sample fit the theorized models regarding the pathways by which autonomy support leads to the presence of therapeutic PrEP levels in serum (χ² = 0.56; RMSEA = 0.04; CFI = .99, TLI = 0.98) and how it also leads to decreased odds of condomless anal intercourse (χ² = 0.58; RMSEA = 0.03; CFI = 0.99; TLI = 0.98). These findings provide scientific evidence for the utility of self-determination theory as a model to guide intervention approaches to optimize the implementation and impact of PrEP for Black men who have sex with men.

Keywords: Autonomy support; Black MSM; Disparities; HIV; HIV Prevention Trials Network; HIV prevention; HPTN; Multi-level intervention; Multicomponent intervention; Path analysis; PrEP; Self-determination theory; Sexually transmitted infection; Structural equation modeling Condom use.

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Figures

**Fig. 1**
Theoretical model of hypothesized effect pathway of autonomy support on health behavior

**Fig. 2**
Structural equation model: effect of autonomy support and basic psychological needs satisfaction for PrEP on therapeutic PrEP levels (N = 226). Note: BNS PrEP Use—basic psychological needs satisfaction for PrEP use. PrEP use autonomous self-regulation was measured at every study visit, including the baseline visit. Autonomy support and perceived competence for PrEP use were measured at every study visit starting at week 4. Standardized betas are reported.

**Fig. 3**
Structural equation model: effect of autonomy support and basic psychological needs satisfaction for condom use on CAI (N = 226). Note: BNS Condom Use—basic psychological needs satisfaction needs for condom use. CAI—condomless anal intercourse. Condom use autonomous self-regulation was measured at every study visit, including the baseline visit. Autonomy support and perceived competence for condom use were measured at every study visit starting with week 4. CAI was measured at week 52. Standardized betas are reported.

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Freedom as Prevention: Mechanisms of Autonomy Support for Promoting HIV Pre-Exposure Prophylaxis Use and Condom Use among Black MSM in 3 US Cities-HPTN 073

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Freedom as Prevention: Mechanisms of Autonomy Support for Promoting HIV Pre-Exposure Prophylaxis Use and Condom Use among Black MSM in 3 US Cities-HPTN 073

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