Refining Multilevel Barrier and Facilitator Measures for HIV Testing and PrEP Among Latino Sexual Minority Men

Abstract

Purpose

The purpose of this study is to refine and establish measures of multilevel barriers and facilitators to HIV testing and PrEP for Latino sexual minority men (LSMM).

Design

Cross-sectional measure validation.

Setting

Participants from Miami, FL.

Subjects

290 LSMM from the DÍMELO study.

Measures

Based on prior qualitative work, we developed two measures that evaluated multiple determinants (i.e., barriers and facilitators) to (1) HIV testing and (2) PrEP use.

Analysis

All measures included in this analysis assessed a set of theoretically distinct barriers and facilitators. We performed 11 exploratory factor analyses (EFA) to assess the dimensionality of theoretical groupings of items informed by prior qualitative work, including: knowledge, perceived need and benefit, mistrust and concerns, stigma and normalization, cultural competence, navigation support, provider demeanor, clinic and medical system issues, privacy concerns, cost, and language and immigration barriers. Based on EFA results, we conducted two confirmatory factor analyses (CFA), one for each measure.

Results

Within each measure, the 11 EFAs extracted 10 barrier factors and 7 facilitator factors. The CFAs for HIV testing and PrEP measures were consistent, such that all models retained the structures identified in the EFAs.

Conclusion

Findings support the use of these measures with LSMM. These measures can inform multilevel implementation strategies for health promotion professionals to scale up and disseminate HIV prevention services to LSMM.

Keywords

HIV prevention latino sexual minority men measurement

Purpose

Despite improvements in HIV prevention and treatment implementation, HIV continues to disproportionately affect marginalized groups. Specifically, sexual minority men (SMM; e.g., gay, bisexual, men who have sex with men) and Latinos are subgroups who face HIV-related health inequities. In 2019, 29% of new HIV diagnoses occurred among Latina/o/x¹ individuals² and 70% among SMM. These disparities intersect for Latino SMM (LSMM). Since 2015, HIV incidence among LSMM has steadily increased whereas incidence has decreased among non-Latino White SMM.² In South Florida, an epicenter of the U.S. HIV epidemic,³ LSMM made up approximately half of all new HIV diagnoses,⁴ making this a key population for health promotion professionals to focus their HIV prevention efforts.

Social and structural determinants of health and syndemic factors explain HIV disparities among sexual and ethnic minority groups. Syndemic theory suggests that co-occurring epidemics (e.g., depression, HIV) synergistically work together to exacerbate health challenges among affected groups. In the context of HIV, factors such as substance use, mental health, and trauma are syndemic conditions that are associated with increased behavioral vulnerability for HIV transmission among people who experience these conditions.⁵ Additionally, structural factors associated with socioeconomic marginalization such as poverty, suboptimal access to health insurance, housing instability, and a history of incarceration are barriers to engaging in HIV prevention services among racial, ethnic, and sexual minorities.^6-8 These social determinants and syndemic factors limit access to HIV prevention and treatment tools such as HIV testing and pre-exposure prophylaxis (PrEP).⁹ There is an urgent need for professionals in health promotion disciplines to support efforts to disseminate evidence-based HIV prevention tools to populations most impacted by HIV to achieve Ending the HIV Epidemic goals in the United States.¹⁰ Yet, with the number of potentially distinct social determinants and syndemic factors that could affect these dissemination efforts, it is important to provide tools to health promotion professionals to assess the most important determinants (i.e., barriers and facilitators), which in turn can inform prioritizing which determinants to act on within these dissemination efforts.

For LSMM, barriers and facilitators to utilizing preventative health services may be unique due to cultural factors. Latina/o/x individuals may be more inclined to provide emotional, psychological, and even physical support to their own family members than outside the family unit for assistance regarding health challenges due to factors such as familismo (obligation to family) and personalismo (warm, caring relationships with others).¹¹ On the one hand, these cultural values may be barriers such that LSMM may internalize values like familismo and, in turn, sacrifice their own health and well-being needs to maintain familial harmony.¹¹ In this case, cultural values could perpetuate internalized and interpersonal stigma toward HIV prevention services (e.g., PrEP, HIV testing) and potentially decrease LSMM’s likelihood to initiate services.¹² Alternatively, cultural values could serve as facilitators. For instance, familial or relational support for getting preventive services could uniquely influence LSMM’s decisions to uptake these preventive services.¹³

Although many factors, as discussed above, could impede or promote LSMM's use of HIV prevention services, there are no quantitative measures, to the authors’ knowledge, that can be used by health promotion professionals to comprehensively assess and directly compare and prioritize barriers and facilitators to HIV prevention. Therefore, a quantitative assessment of multilevel factors that can either be obstacles (i.e., barriers) or leverage points (i.e., facilitators) to HIV prevention can be a useful tool for health promotion professionals to determine which to prioritize mitigating or leveraging within health promotion efforts to engage LSMM in HIV testing and PrEP. Because quantitative measurement tools can be used both longitudinally and across different populations, they are often employed to collect data that is then used to guide future public health practice and policy development. Therefore, this gap in measures of multilevel barriers and facilitators of HIV prevention services is of major concern, because it limits health promotion professionals from systematically and comprehensively assessing, and in turn addressing, constructs that have potential to greatly influence HIV prevention service utilization among LSMM.

To begin to fill the gap in multilevel measures of HIV testing and PrEP use barriers and facilitators, our team conducted qualitative interviews with 28 LSMM with varying degrees of engagement in HIV prevention services and 10 stakeholders with experience delivering HIV prevention and behavioral health services to LSMM.¹⁴ Through this qualitative work, we identified multilevel barriers and facilitators to accessing HIV prevention services for LSMM. Drawing from our qualitative findings regarding these multilevel barriers and facilitators, as well as existing theory (e.g., syndemics, minority stress, and intersectionality theories)^13,14 we developed quantitative measures of multilevel barriers and facilitators of LSMM’s HIV testing and PrEP use. Given the dearth of measures that assess multilevel barriers and facilitators of HIV testing and PrEP that are also culturally grounded in LSMM’s lived experiences, the purpose of this study is to examine the psychometric properties of our measures of multilevel barriers and facilitators to HIV testing and PrEP for LSMM, thereby promoting their potential use among health promotion professionals and researchers.

Methods

Sample

The study included 290 LSMM who participated in the DÍMELO study, a cohort study evaluating LSMM’s engagement in evidence-based HIV prevention and behavioral health services. Eligible participants were LSMM between the ages of 18-60, lived in the greater Miami, FL area, and reported being HIV-negative or unknown HIV status. Complete participant demographics are reported in the main outcome paper for the parent study.¹³ The [MASKED FOR REVIEW] Institutional Review Board approved this study with a waiver of signed consent (No. 20181006). Participants reviewed consent information within REDCap, where the study was administered, and clicked a box indicating consent to participate.

Measures

Participants completed a demographic questionnaire, indicating their age (years), nativity, and years lived in the U.S. (see Table 1).

Table 1.

Sample Demographic Characteristics for Overall Sample (N = 290).

Variable	Frequency (%) or Mean (SD)
Age	31.9 (8.32)
Sexual orientation
Gay	243 (83.8%)
Bisexual	26 (9.0%)
Other sexual minority	21 (7.2%)
Nativity
Continental United States	140 (48.3%)
Outside of Continental United States	149 (51.4%)
Decline to answer	1 (.3%)
Race & Ethnicity
White Latino	230 (79.3%)
Black Latino	14 (4.8%)
Asian Latino	2 (.7%)
Indigenous Latino	11 (3.8%)
Other Race and Latino	4 (1.4%)
Multiracial Latino	26 (9.0%)
Missing Race (Decline) & Latino	3 (1.0%)
Education Level
9^th to 11^th grade	4 (1.4%)
GED (High school equivalent)	3 (1.0%)
High School Diploma	22 (7.6%)
Some college/university	69 (23.8%)
College/University degree	192 (66.2%)

Multilevel Barriers and Facilitators to HIV Testing and PrEP

Informed directly by our prior qualitative work with LSMM in South Florida,¹⁴ we developed measures of 1) multilevel barriers and facilitators to PrEP use and 2) multilevel barriers and facilitators to HIV testing among LSMM. Each measure evaluated a set of theoretically derived barriers and facilitators to PrEP use and HIV testing, that were selected based on our prior qualitative work and related theory (i.e., syndemic, minority stress, intersectionality theories). We intentionally created measures that were comprehensive; and therefore, contained numerous items to ensure that the theoretical domains identified from our qualitative work were assessed. The multilevel barriers and facilitators to PrEP use measure contained 49 barrier items and 29 facilitator items. The multilevel barriers and facilitators to HIV testing measure contained 46 barrier items and 28 facilitator items. Sample barrier items included, “Concerns about side effects or negative effects of PrEP” and “Not knowing that HIV testing services exist.” Facilitator items included, “PrEP being available for free or low cost” and “Someone helping me figure out where to go for HIV testing.” Participants rated all barriers from 1 (didn’t get in the way of using the service at all) to 5 (completely got in the way of using the service). All facilitators were rated from 1 (didn’t or wouldn’t help me get the service at all) to 5 (completely did or would help me get the service). Of note, we developed these measures with the idea that the measures would not produce an “overall” multilevel barriers and facilitators scale; rather, as with our qualitative work, we anticipated that the measures would be scored within their theoretical domains (e.g., producing a score for degree of cost-related barriers, immigration-related barriers, etc.). Measures were first written in English, then translated to Spanish using an established three-step translation process (forward translation, back translation, and comparison of original to back translated version).¹⁵

Analysis

Below is an outline of the steps in our analytic plan. Our goal within the manuscript is to describe the analytic plan in an accessible way for all readers. For readers interested in additional technical details, please see the Technical Appendix (Supplementary File 1).

Step 1: Determine Theoretical Groupings

The multilevel barriers and facilitators to PrEP use and HIV testing measures were developed based on our prior qualitative work.¹⁴ As noted above, we did not develop these measures with the expectation that they would yield one overall score; rather, we expected that the measures, would yield scores within the theoretical domains identified in our qualitative work. As such, we used the findings from our prior qualitative study to group the items within each of our measures (in other words, the theoretical item groupings directly map onto our prior qualitative findings). The resulting theoretical groupings of items for both measures included: (1) knowledge, (2) perceived need and benefit, (3) mistrust and concerns, (4) stigma and normalization, (5) cultural competence, (6) navigation support, (7) provider demeanor, (8) clinic and medical system issues, (9) privacy concerns, (10) cost, and (11) language and immigration barriers. Therefore, we expected to derive scores within each of these theoretical groupings, not at the overall measure level.

Step 2: Conduct Exploratory Factor Analyses

Exploratory factor analysis (EFA) is useful when minimal research has been conducted regarding the structure of a construct or measure, as was the case in this study. Because we had 11 theoretical groups of items per measure, we conducted 11 exploratory factor analyses (EFAs) for the multilevel barriers and facilitators to PrEP measure and the multilevel barriers and facilitators to HIV testing measure (i.e., one EFA was performed for each theoretical domain – for example, one EFA was run for the “knowledge” domain on the multilevel barriers and facilitators to PrEP measure, one EFA was run for the “perceived need and benefit domain of the multilevel barriers and facilitators to PrEP measure, and so on). It would not be possible to run one large EFA for each of the measures because some of the theoretically derived groupings would not be associated with each other. If the EFA was unidimensional, meaning that all items in the domain “hung together,” the theoretical grouping became a scale. If the EFA was multidimensional, meaning that the items were grouped into two subgroups that “hung together,” the theoretical grouping became two scales.

Step 3: Conduct Confirmatory Factor Analyses

Confirmatory factor analysis (CFA) can be subsequently used to evaluate if the structure(s) that emerged from the EFA are consistent in an independent sample. We conducted the CFAs based on the results of the EFAs.

Results

Exploratory Factor Analyses

Multilevel Barriers and Facilitators to PrEP Measure

As shown in Table 2, from the PrEP EFAs we found that there were a total of 17 factors: 10 PrEP barrier factors (i.e., scales within the overall measure that assess a unique barrier to PrEP) and 7 PrEP facilitator factors (i.e., scales within the overall measure that assess a unique facilitator to PrEP). Some of the theoretical domains (e.g., mistrust and concerns, navigation support, clinic and medical systems issues, privacy concerns, and language and immigration barriers) were unidimensional, meaning that the items within the domain “hung together” and formed individual scales. In these cases, the original grouping only contained questions pertaining to either barriers or facilitators, and not both and thus created their own scale. The remaining theoretical domains (e.g., knowledge, perceived need and benefit, stigma and normalization, cultural competence, provider demeanor, and cost) were multidimensional, meaning that the items within the domain formed two subgroups of items that “hung together,” and therefore formed two scales. For instance, the knowledge domain had two groups of items that hung together, and therefore formed two scales: Lack of PrEP Knowledge (a barrier scale) and PrEP Knowledge (a facilitator scale). Decisions on the extracted factors were made based on fit indices that are described in the Technical Appendix (Supplementary File 1).

Table 2.

PrEP EFA.

Theoretically Derived Domain^a	Factor	Extracted Factor Name	Item^b	Factor Loading	Communalities	Eigenvalues	Variance (%)	Accumulated Variance (%)
PrEP Knowledge	1	Lack of PrEP knowledge	Not knowing that PrEP existed	.986	.975	1.52	30.40	30.40
			Not knowing how or where to get PrEP	.919	.849
			Not knowing enough about PrEP to feel comfortable using it	.726	.547
	2	PrEP Knowledge	Completely understanding how PrEP works	.695	.468	1.752	35.05	65.45
			Knowing how to work through challenges in getting access to PrEP	.662	.436
PrEP Need and Benefit	1	Perceived Benefits of PrEP	Feeling that I would benefit from being on PrEP	.961	.934	2.897	32.19	32.19
			Feeling like PrEP would provide peace of mind or make me feel better	.847	.716
			Trusting that PrEP is effective	.804	.641
			Knowing whether or not I might benefit from PrEP	.745	.557
	2	Lack of Perceived Need or Urgency for PrEP	Feeling that PrEP should only be used as a last resort	.769	.585	1.757	19.52	51.71
			Preferring to change my sexual behavior than to use PrEP	.721	.525
			Having too many other stressors to deal with	.553	.302
			Feeling like it's better to leave things up to fate	.487	.246
			Feeling like I didn't need PrEP	.379	.148
Mistrust and Concerns Related to PrEP	1	PrEP Mistrust and Concerns	Concerns that PrEP is not really safe, and is still being tested/evaluated	.930	.865	1.841	46.02	46.02
			Concerns about side effects or negative effects of PrEP	.749	.561
			Concerns that using PrEP could make things worse	.554	.307
			Preferring natural or holistic solutions	.328	.107
			Avoiding medications or medical settings in general	.097c	.407
			Not wanting to have to take a pill every day	-.094c	.832
Stigma and Normalization related to PrEP	1	PrEP Stigma	Being concerned about someone seeing me or finding out that I'm using PrEP	.864	.755	5.693	31.63	31.63
			People would think I'm sick or something is wrong with me if I use PrEP	.851	.717
			My family would think worse of me if I used PrEP	.789	.652
			Being concerned that people will find out that I have sex with men if I use PrEP	.759	.929
			Being embarrassed about needing PrEP	.748	.58
			My friends would think worse of me if I used PrEP	.735	.577
			Not wanting to talk to a doctor or healthcare provider about my sex life	.694	.487
			My healthcare provider would think worse of me if I used PrEP	.69	.635
			Not knowing people who use PrEP	.684	.461
			Being uncomfortable requesting PrEP or asking for a referral for PrEP	.671	.492
			Feeling that men who need PrEP are weak or feminine	.597	.354
			Organizations that provide PrEP are too medical or focused on “risk"	.332	.135
	2	PrEP is Normalized	Seeing/hearing about other Latino men using PrEP	1.003	.921	4.237	21.14	57.76
			PrEP providers/staff being from the same background as me (Latino, men, gay/bisexual, etc.)	.794	.632
			Seeing/hearing about my friends using PrEP	.627	.78
			A friend suggesting that I use PrEP	.038	.884
			A healthcare provider suggesting that I use PrEP	.015	.692
			Someone in my family suggesting that I use PrEP	-.082	.575
Cultural Competence Related to PrEP Services	1	Lack of Culturally Competent PrEP Providers and Outreach	Providers, staff, or organizations that provide PrEP not being LGBTQ affirming	.881	.767	1.645	27.42	27.42
			Difficulty finding a PrEP provider who is a good fit and understands me	.792	.612
			Providers, staff, or organizations not being knowledgeable about Latino/Hispanic people	.755	.583
			Outreach/advertising for PrEP not being geared toward me/my community	.483	.252
	2	Culturally Competent PrEP Providers and Outreach
	2	Culturally Competent PrEP Providers and Outreach	The providers, staff, or organization cater to the Latino community	.999	.999	2.086	34.76	62.18
			The providers, staff, or organization cater to the LGBTQ community	.718	.517
PrEP Navigation	1	PrEP Navigation Support	Someone helping me figure out where to get PrEP	.953	.908	4.154	69.23	69.23
			Someone helping me figure out what to do if I have problems getting PrEP	.897	.805
			Someone I trust recommending a specific provider/organization to get PrEP	.86	.739
			Someone helping me build up the motivation to get PrEP	.821	.675
			Someone helping me decide if I should use PrEP	.735	.54
			Someone holding me accountable and following up to make sure I get PrEP	.698	.487
PrEP Provider Qualities	1	Negative PrEP Provider Demeanor	PrEP providers not being professional enough	.994	.999	1.666	33.32	33.32
			PrEP providers not being caring enough	.771	.585
			Having a bad past experience with PrEP	.079c	.007
	2	Positive PrEP Provider Demeanor	PrEP providers/staff being highly professional and business-like	.850	.718	1.365	27.31	60.62
	2	Positive PrEP Provider Demeanor	PrEP providers/staff taking a personal and caring approach	.846	.721	1.365	27.31	60.62
Clinic and Medical System Issues Related to PrEP Services	1	Clinic and Medical System Issues for PrEP	Organizations having limited appointments or hours	.811	.658	2.308	46.162	46.16
			The process for getting PrEP taking too long	.750	.563
			The medical system being confusing or hard to navigate	.661	.437
			Getting bad “customer service” while trying to get PrEP	.617	.380
			PrEP not being available in my community	.519	.270
			PrEP services being convenient and not time consuming	-.184c	.163
PrEP Related Privacy Concerns	1	PrEP Privacy Concerns	Organizations asking for too much personal information to get PrEP	.862	.743	1.626	54.213	54.21
			Concern about there being a “record” of my use of PrEP (medical record, insurance, etc.)	.695	.484
			Wanting to keep my private life private	.632	.399
			Not having to give a lot of personal information to get PrEP	.254c	.064
PrEP Cost Related Issues	1	PrEP Cost and Insurance Issues	Not being able to afford PrEP	.970	.926	4.448	48.96	48.96
			Not having insurance or having insurance that doesn't cover enough of the cost of PrEP	.891	.790
			Billing for PrEP being a big hassle	.791	.651
	2	PrEP Affordability	PrEP being available for free or low cost	.845	.715	1.235	24.70	73.66
			Having insurance that covers PrEP	.774	.600
PrEP related Language/Immigration Issues	1	PrEP Language/Immigration Concerns	Problems finding PrEP services in Spanish	.402	.162	1.918	47.96	47.96
			Problems finding PrEP services in the same kind of Spanish that I speak (e.g. same country/dialect)	.413	.171
			Uncertainty about what services I am eligible for if I don’t have U.S. citizenship	.999	.999
			Worry that getting PrEP could cause problems in terms of my immigration process	.766	.588

^aTheoretically derived domains are based on our prior qualitative work.¹⁴

^bParticipants rated all barriers from 1 (didn’t get in the way of using the service at all) to 5 (completely got in the way of using the service). All facilitators were rated from 1 (didn’t or wouldn’t help me get the service at all) to 5 (completely did or would help me get the service).

^cItems removed from model. Information for preceding items is after model was respecified.

Multilevel Barriers and Facilitators to HIV Testing Measure

Similar to the PrEP EFAs, for the HIV EFAs, we found that there were a total of 17 factors: 10 HIV testing barrier factors (i.e., scales within the overall measure that assess a unique barrier to HIV testing) and 7 HIV testing facilitator factors (i.e., scales within the overall measure that assess a unique facilitator to HIV testing; Table 3). Some of the HIV testing theoretical domains (e.g., mistrust and concerns, navigation support, clinic and medical systems issues, privacy concerns, and language and immigration barriers) were unidimensional (i.e., only contained questions pertaining to either barriers or facilitators) and formed individual scales. The remaining theoretical domains (e.g., knowledge, perceived need and benefit, stigma and normalization, cultural competence, provider demeanor, and cost) were multidimensional. For instance, the perceived need and benefit domain had two groups of items that hung together, and therefore formed two scales: Lack of Perceived Benefits of HIV Testing (a barrier scale) and Perceived Benefits of HIV Testing (a facilitator scale). Decisions on the extracted factors were made based on fit indices that are described in the Technical Appendix (Supplementary File 1).

Table 3.

HIV Testing EFA.

Theoretically Derived Domain^a	Factor	Factor Name	Item^b	Factor Loading	Communalities	Eigenvalues	Variance (%)	Accumulated Variance (%)
HIV Testing Knowledge	1	Lack of HIV Testing knowledge	Not knowing how or where to get an HIV test	.893	.798	2.278	23.95	23.95
			Not knowing that HIV testing services exist	.797	.633
			Not knowing enough about HIV testing to feel comfortable about getting a test	.702	.499
	2	HIV Testing Knowledge	Knowing how to work through challenges in getting access to HIV testing	.980	.959	1.210	38.39	62.34
			Knowing how HIV testing works	.476	.230
HIV Testing Need and Benefit	1	Perceived Benefits of HIV Testing	Feeling that I would benefit from getting an HIV test	.99	.947	2.091	29.86	29.86
			Knowing when I need to be tested for HIV	.752	.631
			Feeling like getting tested would provide peace of mind or make me feel better	.697	.48
	2	Lack of Perceived Need or Urgency for HIV Testing	Feeling that testing is only for very high risk situations	.773	.598	1.728	21.35	51.22
			Feeling like I didn't need to be tested	.632	.397
			Having too many other stressors to deal with	.556	.324
			Feeling like it's better to leave things up to fate	.464	.208
Mistrust and Concerns Related to HIV Testing	1	HIV Testing Mistrust and Concerns	Concerns about HIV testing having a negative impact on me	.999	.999	1.632	40.81	40.81
			Concerns that being tested for HIV could make things worse	.536	.288
			Avoiding medications or medical settings in general	.500	.250
			Preferring natural or holistic solutions	.31	.096
Stigma and Normalization related to HIV Testing	1	HIV Testing Stigma	My friends would think worse of me if they knew I was getting tested for HIV	.858	.695	5.619	31.22	31.22
			My family would think worse of me if they knew I was getting tested for HIV	.803	.613
			Being concerned about someone seeing me or finding out that I tested for HIV	.779	.719
			People would think I'm sick or something is wrong with me if I got HIV testing	.723	.591
			My healthcare provider would think worse of me if I asked to be tested for HIV	.661	.427
			Being embarrassed about needing an HIV test	.609	.808
			Not knowing people who get HIV testing on a regular basis	.552	.344
			Being concerned that people will find out that I have sex with men if I got HIV testing	.548	.392
			Being uncomfortable asking for an HIV test or a referral for HIV testing	.545	.728
			Feeling that men who need HIV testing are weak or feminine	.503	.282
			Not wanting to talk to a doctor or healthcare provider about my sex life	.491	.796
			Organizations that provide HIV testing are too medical or focused on “risk”	.207^c	.054
	2	HIV Testing is Normalized	Seeing/hearing about my friends getting tested	.911	.823	3.76	20.88	52.10
			Seeing/hearing about other Latino men getting tested	.853	.740
			A friend suggesting that I get tested	.733	.593
			HIV testing providers/staff being from the same background as me (Latino, men, gay/bisexual, etc.)	.705	.488
			Someone in my family suggesting that I get tested	.631	.483
			A healthcare provider suggesting that I get tested	.528	.363
Cultural Competence Related to HIV Testing Services	1	Lack of Culturally Competent HIV Testing Providers and Outreach	Providers, staff, or organizations that provide HIV testing not being LGBTQ affirming	.877	.776	1.453	24.22	24.22
			Providers, staff, or organizations that provide HIV testing not being knowledgeable about Latino/Hispanic people	.784	.62
			Difficulty finding a HIV testing provider who is a good fit and understands me	.676	.458
			Outreach/advertising for HIV testing not being geared toward me/my community	.517	.268
	2	Culturally Competent HIV Testing Providers and Outreach	The providers, staff, or organization cater to the LGBTQ community	.999	.999	2.107	35.11	54.58
			The providers, staff, or organization cater to the Latino community	.662	.439
HIV Testing Navigation	1	HIV Testing Navigation Support	Someone helping me build up the motivation to get tested	.860	.739	4.394	62.77	62.77
			Someone helping me figure out what to do if I have problems getting an HIV test	.844	.713
			Someone helping me figure out where to go for HIV testing	.820	.673
			Someone explaining how HIV testing works	.802	.644
			Someone holding me accountable and following up to make sure I get tested	.762	.581
			Someone helping me decide if I should get tested	.761	.579
			Someone I trust recommending a specific provider/organization to get HIV testing	.683	.466
HIV Testing Provider Qualities	1	Negative HIV Testing Provider Demeanor	The people who provide HIV testing not being professional enough	.967	.940	1.356	27.11	27.11
			The people who provide HIV testing not being caring enough	.880	.795
			Organizations that provide HIV testing are too medical or focused on risk	.362^c	.148
	2	Positive HIV Testing Provider Demeanor	HIV testing providers/staff being highly professional and business-like	1.009	.999	1.846	36.91	64.02
			HIV testing providers/staff taking a personal and caring approach	.560	.319
Clinic and Medical System Issues Related to HIV Testing Services	1	Clinic and Medical System Issues for HIV Testing	Organizations having limited appointments or hours for HIV testing	.746	.556	1.805	34.80	34.80
			Getting bad “customer service” while trying to get or getting HIV testing	.647	.418
			The process for getting an HIV test taking too long	.559	.312
			HIV testing not being available in my community	.553	.305
			The medical system being confusing or hard to navigate	.462	.213
			HIV testing being convenient and not time consuming	.077^c	.025
HIV Testing Related Privacy Concerns	1	HIV Testing Privacy Concerns	Organizations asking for too much personal information to get an HIV test	.904	.818	1.638	52.40	52.40
			Concern about there being a “record” of me being tested for HIV (medical record, insurance, etc.)	.691	.478
			Wanting to keep my private life private	.585	.342
			Not having to give a lot of personal information to get tested	-.027^c	.447
HIV Testing Cost Related Issues	1	HIV Testing Cost and Insurance Issues	Not being able to afford HIV testing	.941	.881	2.212	44.23	44.23
			Billing for HIV testing being a big hassle	.837	.713
			Not having insurance or having insurance that doesn't cover enough of the cost of HIV testing	.787	.622
	2	HIV Testing Affordability	Having insurance that covers testing	.878	.772	.981	19.61	63.85
			HIV testing being available for free or low cost	.451	.205
HIV Testing related Language/Immigration Issues	1	Language/Immigration Concerns	Problems finding HIV testing services in Spanish	.916	.839	2.467	61.69	61.69
			Problems finding HIV testing services in the same kind of Spanish that I speak (e.g., same country/dialect)	.802	.643
			Worry that getting tested for HIV could cause problems in terms of my immigration process	.749	.562
			Uncertainty about what services I am eligible for if I don't have U.S. citizenship	.651	.423

^aTheoretically derived domains are based on our prior qualitative work.¹⁴

^cItems removed from model. Information for preceding items is after model was respecified.

Confirmatory Factor Analyses

The CFA for both measures were consistent with the results of the EFAs, meaning that they retained the structure identified in the EFAs. This means that the CFAs included ten barrier factors (and therefore, scales) for each measure: (1) lack of knowledge, (2) lack of perceived need or urgency, (3) mistrust and concerns, (4) stigma, (5) lack of culturally competent providers and outreach, (6) negative provider demeanor, (7) clinic and medical system issues, (8) privacy concerns, (9) cost and insurance issues, and (10) language and immigration barriers and seven facilitator factors (and therefore, scales) for each measure: (1) knowledge, (2) perceived benefits, (3) the service being normalized, (4) culturally competent providers and outreach, (5) navigation support, (6) positive provider demeanor, and (7) affordability. The final items and factor loadings for PrEP and HIV testing can be found in Tables 4 and 5, respectively. Decisions on the extracted factors were made based on fit indices that are described in the Technical Appendix (Supplementary File 1).

Table 4.

Items and Factor Loadings for PrEP Barriers and Facilitators.

Factor	Factor Name	Factor Loading	Item
Barriers
1	Lack of PrEP knowledge	.870	Not knowing enough about PrEP to feel comfortable using it
		.806	Not knowing how or where to get PrEP
		.668	Not knowing that PrEP existed
2	Lack of Perceived Need or Urgency for PrEP	.720	Having too many other stressors to deal with
		.708	Feeling that PrEP should only be used as a last resort
		.691	Feeling like it's better to leave things up to fate
		.599	Preferring to change my sexual behavior than to use PrEP
		.428	Feeling like I didn't need PrEP
3	PrEP Mistrust and Concerns	.864	Preferring natural or holistic solutions
		.771	Concerns that using PrEP could make things worse
		.669	Concerns that PrEP is not really safe, and is still being tested/evaluated
		.652	Concerns about side effects or negative effects of PrEP
4	PrEP Stigma	.833	People would think I'm sick or something is wrong with me if I use PrEP
		.819	Not wanting to talk to a doctor or healthcare provider about my sex life
		.810	Being concerned that people will find out that I have sex with men if I use PrEP
		.806	My healthcare provider would think worse of me if I used PrEP
		.786	Being embarrassed about needing PrEP
		.780	Organizations that provide PrEP are too medical or focused on “risk"
		.757	Being concerned about someone seeing me or finding out that I'm using PrEP
		.742	Being uncomfortable requesting PrEP or asking for a referral for PrEP
		.731	My friends would think worse of me if I used PrEP
		.725	Not knowing people who use PrEP
		.706	My family would think worse of me if I used PrEP
		.649	Feeling that men who need PrEP are weak or feminine
5	Lack of Culturally Competent PrEP Providers and Outreach	.911	Providers, staff, or organizations not being knowledgeable about Latino/Hispanic people
		.808	Providers, staff, or organizations that provide PrEP not being LGBTQ affirming
		.678	Difficulty finding a PrEP provider who is a good fit and understands me
		.619	Outreach/advertising for PrEP not being geared toward me/my community
6	Negative PrEP Provider Demeanor	.930	PrEP providers not being caring enough
		.903	PrEP providers not being professional enough
7	Clinic and Medical System Issues for PrEP	.797	The medical system being confusing or hard to navigate
		.784	Getting bad “customer service” while trying to get PrEP
		.736	The process for getting PrEP taking too long
		.680	Organizations having limited appointments or hours
		.641	PrEP not being available in my community
8	PrEP Privacy Concerns	.809	Wanting to keep my private life private
		.806	Organizations asking for too much personal information to get PrEP
		.716	Concern about there being a “record” of my use of PrEP (medical record, insurance, etc.)
9	PrEP Cost and Insurance Issues	.867	Billing for PrEP being a big hassle
		.808	Not being able to afford PrEP
		.736	Not having insurance or having insurance that doesn't cover enough of the cost of PrEP
10	Language/Immigration Concerns	.826	Problems finding PrEP services in the same Spanish that I speak (e.g., same country/dialect)
		.794	Problems finding PrEP services in Spanish
		.757	Worry that getting PrEP could cause problems in term of my immigration process
		.714	Uncertainty about what services I am eligible for if I don't have U.S. citizenship
Facilitators
11	PrEP Knowledge	.827	Knowing how to work through challenges in getting access to PrEP
		.795	Completely understanding how PrEP works
12	Perceived Benefits of PrEP	.977	Feeling that I would benefit from being on PrEP
		.935	Trusting that PrEP is effective
		.879	Knowing whether or not I might benefit from PrEP
		.869	Feeling like PrEP would provide peace of mind or make me feel better
13	PrEP is Normalized	.819	Seeing/hearing about my friends using PrEP
		.745	Seeing/hearing about other Latino men using PrEP
		.728	PrEP providers/staff being from the same background as me (Latino, men, gay/bisexual, etc.)
		.712	A friend suggesting that I use PrEP
		.642	A healthcare provider suggesting that I use PrEP
		.509	Someone in my family suggesting that I use PrEP
14	Culturally Competent PrEP Providers and Outreach	.939	The providers, staff, or organization cater to the LGBTQ community
		.817	The providers, staff, or organization cater to the Latino community
15	PrEP Navigation Support	.926	Someone helping me figure out where to get PrEP
		.866	Someone helping me figure out what to do if I have problems getting PrEP
		.863	Someone helping me build up the motivation to get PrEP
		.783	Someone helping me decide if I should use PrEP
		.768	Someone holding me accountable and following up to make sure I get PrEP
		.735	Someone I trust recommending a specific provider/organization to get PrEP
16	Positive PrEP Provider Demeanor	.908	PrEP providers/staff taking a personal and caring approach
		.849	PrEP providers/staff being highly professional and business-like
17	PrEP Affordability	.757	PrEP being available for free or low cost
		.712	Having insurance that covers PrEP

Table 5.

Items and Factor Loadings for HIV Testing Barriers and Facilitators.

Factor	Factor Name	Factor Loading	Item
Barriers
1	Lack of HIV Testing Knowledge	.887	Not knowing how or where to get an HIV test
		.746	Not knowing that HIV testing services exist
		.745	Not knowing enough about HIV testing to feel comfortable about getting a test
2	Lack of Perceived Need or Urgency for HIV Testing	.685	Feeling like it's better to leave things up to fate
		.636	Having too many other stressors to deal with
		.450	Feeling like I didn't need to be tested
3	HIV Testing Mistrust and Concerns	.749	Concerns about HIV testing having a negative impact on me
		.729	Concerns that being tested for HIV could make things worse
		.604	Avoiding medications or medical settings in general
		.440	Preferring natural or holistic solutions
4	HIV Testing Stigma	.881	Being concerned about someone seeing me or finding out that I tested for HIV
		.842	Being uncomfortable asking for an HIV test or a referral for HIV testing
		.811	Being embarrassed about needing an HIV test
		.810	People would think I'm sick or something is wrong with me if I got HIV testing
		.790	My family would think worse of me if they knew I was getting tested for HIV
		.766	Not wanting to talk to a doctor or healthcare provider about my sex life
		.746	My friends would think worse of me if they knew I was getting tested for HIV
		.697	Not knowing people who get HIV testing on a regular basis
		.648	Being concerned that people will find out that I have sex with men if I got HIV testing
		.577	My healthcare provider would think worse of me if I asked to be tested for HIV
		.409	Feeling that men who need HIV testing are weak or feminine
5	Lack Of Culturally Competent HIV Testing Providers and Outreach	.817	Difficulty finding a HIV testing provider who is a good fit and understands me
		.685	Providers, staff, or organizations that provide HIV testing not being knowledgeable about Latino/Hispanic people
		.579	Outreach/advertising for HIV testing not being geared toward me/my community
		.536	Providers, staff, or organizations that provide HIV testing not being LGBTQ affirming
6	Negative HIV Testing Provider Demeanor	.961	The people who provide HIV testing not being caring enough
		.698	The people who provide HIV testing not being professional enough
7	Clinic and Medical System Issues for HIV Testing	.638	Organizations having limited appointments or hours for HIV testing
		.585	The medical system being confusing or hard to navigate
		.550	Getting bad “customer service” while trying to get or getting HIV testing
		.543	HIV testing not being available in my community
		.482	The process for getting an HIV test taking too long
8	HIV Testing Privacy Concerns	.790	Concern about there being a “record” of me being tested for HIV (medical record, insurance, etc.)
		.789	Wanting to keep my private life private
		.610	Organizations asking for too much personal information to get an HIV test
9	HIV Testing Cost and Insurance Issues	.941	Not being able to afford HIV testing
		.838	Not having insurance or having insurance that doesn't cover enough of the cost of HIV testing
		.631	Billing for HIV testing being a big hassle
10	Language/Immigration Concerns	.995	Problems finding HIV testing services in Spanish
		.672	Problems finding HIV testing services in the same kind of Spanish that I speak (e.g., same country/dialect)
		.291	Uncertainty about what services I am eligible for if I don't have U.S. citizenship
Facilitators
11	HIV Testing Knowledge	.696	Knowing how HIV testing works
		.633	Knowing how to work through challenges in getting access to HIV testing
12	Perceived Benefits of HIV Testing	.798	Knowing when I need to be tested for HIV
		.660	Feeling like getting tested would provide peace of mind or make me feel better
		.651	Feeling that I would benefit from getting an HIV test
13	HIV Testing is Normalized	.835	Seeing/hearing about my friends getting tested
		.803	Seeing/hearing about other Latino men getting tested
		.644	A friend suggesting that I get tested
		.637	HIV testing providers/staff being from the same background as me (Latino, men, gay/bisexual, etc.)
		.574	Someone in my family suggesting that I get tested
		.573	A healthcare provider suggesting that I get tested
14	Culturally Competent HIV Testing Providers and Outreach	.792	The providers, staff, or organization cater to the Latino community
		.735	The providers, staff, or organization cater to the LGBTQ community
15	HIV Testing Navigation Support	.831	Someone helping me figure out where to go for HIV testing
		.807	Someone helping me build up the motivation to get tested
		.797	Someone helping me figure out what to do if I have problems getting an HIV test
		.794	Someone explaining how HIV testing works
		.78	Someone helping me decide if I should get tested
		.759	Someone I trust recommending a specific provider/organization to get HIV testing
		.679	Someone holding me accountable and following up to make sure I get tested
16	Positive HIV Testing Provider Demeanor	.681	HIV testing providers/staff taking a personal and caring approach
		.596	HIV testing providers/staff being highly professional and business-like
17	HIV Testing Affordability	.750	Having insurance that covers testing
		.539	HIV testing being available for free or low cost

Discussion

The results of this study contribute to the existing literature by establishing the psychometric properties of the multilevel barriers and facilitators to PrEP and HIV testing measures, developed based on qualitative work with LSMM. This is critical to advancing health promotion practice and research because this type of measure comprehensively evaluates both facilitators and barriers to critical prevention services, allowing practitioners and researchers to prioritize among many different potential determinants. We found consistency in the factors (i.e., scales) for each of the measures such that barriers and facilitators for both PrEP and HIV testing were similar. These findings provide evidence for measures of multilevel, culturally grounded determinants of PrEP and HIV testing that may be used among LSMM. The final and complete Multilevel Barriers and Facilitators to PrEP Measure and Multilevel Barriers and Facilitators to HIV Testing Measure can be found in Supplementary File 2.

The measures evaluated in the current study are multilevel, meaning that they assess discrete barriers and facilitators at the individual, interpersonal, and cultural/structural level that could positively or negatively affect LSMM’s PrEP use and HIV testing behaviors. These multilevel measures do not yield overall scores; rather, they serve to provide health promotion professionals and researchers with a quantitative assessment of different types of obstacles (i.e., barriers) and leverage points (i.e., facilitators) to engaging LSMM in HIV prevention across multiple levels of influence. This approach is consistent with the National Institute on Minority Health and Health Disparities Research Framework, which encourages research to document and address multilevel determinants in order to reduce health disparities.¹⁶ Tools such as the Multilevel Barriers and Facilitators to PrEP and HIV Testing measures can help health promotion professionals to decide which factors, within multiple levels (i.e., system/cultural-, interpersonal-, and individual-level), to target. Health promotion professionals are often required to make difficult choices about where to focus their efforts; these measures can help in ensuring that the most important and influential determinants are targeted through health promotion efforts.

A barrier for LSMM was related to PrEP and HIV testing stigma. Items within the stigma scale (in both the PrEP and HIV testing measures) were related to LSMM’s concerns that they would be perceived as weak or feminine, that something was wrong with them, or that others may find out that they have sex with men if they were to pursue these services. Even if LSMM are seeking HIV prevention services, internalized and interpersonal stigma may impede them from accessing HIV prevention care.^17,18 Provider cultural competence was also a key determinant for both measures and may relate to the stigma that LSMM encounter; it may be difficult for LSMM to find a PrEP/HIV testing provider who is a good fit for them because they may not be LGBTQ affirming and/or may not be knowledgeable about LSMM.¹⁹ By administering the measure, stigma at the interpersonal-level and cultural competence at the structural-level may arise as factors deterring LSMM from obtaining PrEP services. As a response, a health promotion tactic may be to develop stigma reduction campaigns and/or cultural training.

Other pervasive system-level barriers for LSMM were related to clinic and medical system issues. LSMM may have even more trouble accessing HIV testing/PrEP when organizations have limited appointments or hours, when the process takes too long, and when the medical system is difficult to navigate. Notably, for both PrEP and HIV testing, items which indicated that services may not be available in the LSMM communities were included in both models, highlighting the lack of systems in place to provide HIV prevention services to LSMM. Collectively, our findings suggest the importance of thinking beyond individual-level influences on engagement (e.g., knowledge, perceived need) when developing health promotion interventions.

Importantly, these measures also identified language and immigration-related barriers to PrEP and HIV testing among LSMM as a unified set of items. In our prior qualitative work, LSMM in South Florida noted that strategies to equitably scale up HIV prevention services should be available in multiple languages, most importantly, Spanish and English.¹⁹ Additionally, LSMM’s immigration status should be considered with regard to engagement in HIV prevention services; research has shown that a fear of deportation had an indirect effect on reduced HIV testing among Latina/o/x individuals.²⁰ in practice, it may be useful in some settings for health promotion professionals to determine whether higher scores on this factor are driven more by language, immigration, or both when using the findings to inform their work.

Existing literature on PrEP and HIV testing determinants often focuses on factors that impede engagement. Contributing to the literature, our measures also include culturally grounded PrEP and HIV testing facilitators. Among the facilitator scales identified in our analyses was “perceived need and/or benefit”, a facilitating factor found within both the PrEP and HIV testing measures. Items in this scale reflected the degree to which LSMM perceived that they would benefit from using PrEP or getting an HIV test or if they felt that receiving PrEP or getting an HIV test would provide them with peace of mind. This is consistent with prior literature showing that men who have sex with men (MSM) of color identified belief in the benefit of knowing one’s HIV status as a factor that can increase general HIV testing uptake.²¹

Many PrEP and HIV testing outreach campaigns target perceived risk (i.e., a loss prevention message) rather than perceived benefits (i.e., a health promotion message)²² which may be a missed opportunity in engaging LSMM in HIV prevention efforts. To the degree that perceived benefits is rated as an influential facilitator for LSMM in a given setting, this suggests the need to develop programs and campaigns that leverage this health promotion mentality rather than a risk prevention perspective. For instance, campaigns that underscore the positive benefits of being on PrEP and getting HIV testing, rather than messaging the negative outcomes of not getting PrEP or HIV testing may have a greater likelihood in engaging LSMM in HIV prevention services.

Additionally, the navigation support factor, again found in both the HIV testing and PrEP measures, highlights the importance of evaluating whether LSMM have someone who can provide suggestions and/or support throughout the process of engaging in HIV testing and/or PrEP services. In fact, in our prior quantitative work with LSMM in South Florida, we found that this PrEP Navigation Support scale was positively associated with LSMM’s engagement in PrEP services.¹³ Patient navigation is a frequently used and implemented health promotion program to enhance PrEP uptake, and our findings suggest the relevance and need for this type of programming particularly for LSMM.

This study is not without limitations. First, the data used in this secondary analysis are cross-sectional; it is possible that the factors identified may vary as a function of time and might be confounded by additional factors such as immigration status. Future studies should examine these factors longitudinally and consider additional influences that are specific to LSMM which may impact uptake of these services. Although we have found in our prior work that some of the scales in the multilevel barriers and facilitators to PrEP measure are associated with PrEP engagement among LSMM¹³ (e.g., PrEP mistrust and concerns was negatively associated with PrEP engagement and PrEP Navigation Support was positively associated with PrEP engagement, suggesting predictive validity), future studies should examine how the multilevel barrier and facilitator HIV testing and PrEP measures predict HIV and PrEP related outcomes. Second, due to the narrow geographical area of the sample, results can only be generalized to LSMM living in South Florida. These measures should be validated in other geographic areas and explore whether these measures are consistent among LSMM living in other HIV epicenters and within Latina/o/x’s more broadly. Relatedly, our sample of LSMM may not be generalizable to national samples of LSMM because approximately two-thirds of participants obtained college and/or other degrees; this suggests the need to validate the measures with a more nationally representative group of LSMM. Third, issues with bias (e.g., desirability, recall, selection) should also be considered due to the self-report nature of the survey data collection. Fourth, given the size of the half-sample utilized for the EFAs (n = 152), the HIV knowledge EFA was under-identified and was conducted on the full study sample, however, the results were consistent with the results of the PrEP knowledge EFA and the CFA confirmed the extracted structures. Similarly, although the ratio of items to subject size was large, models still had good fit to the data. Future studies with larger samples of LSMM should replicate this finding. Finally, given that the items were theoretically grouped together, but in groupings that would not necessarily be associated with each other, it would not be possible to run one large EFA analysis for the entire measure.

However, there are notable strengths. Foremost, this study contributed to the establishment of much-needed multilevel measures that are culturally grounded (through our prior qualitative work) in LSMM’s lived experiences. Although further research is needed to validate the measures more broadly, our study contributes an essential starting point. This study allowed us to examine the psychometric properties of measures of multilevel barriers and facilitators to HIV testing and PrEP for use among LSMM. The fact that the results were similar across both HIV testing and PrEP also speaks to the consistency of the results and measures. This ensures that when developing multilevel health promotion programs and outreach campaigns to increase uptake of HIV prevention services among LSMM, health promotion professionals can tailor their efforts to the most relevant barriers and facilitators, which is key in resource limited contexts. These measures provide insights into a breadth of domains that capture several different barriers and facilitators of HIV testing and PrEP use among LSMM and can subsequently inform health promotion professionals’ efforts to increase uptake of such services.

SO WHAT?

What is already known on this topic?

HIV prevention tools such as HIV testing and PrEP are insufficiently disseminated to Latino sexual minority men (LSMM). Yet, few measures exist to evaluate these multilevel barriers and facilitators and inform health promotion practice efforts.

What does this article add?

Evidence supporting the psychometric properties of the multilevel barriers and facilitators to PrEP and HIV testing measures, suggesting the utility of these measures in health promotion practice and research settings.

What are the implications for health promotion practice or research?

The Multilevel Barriers and Facilitators to HIV testing and PrEP measures can be used among health promotion professionals to provide a quantitative assessment of system/cultural-, interpersonal-, and individual-level factors that can be obstacles (i.e., barriers) or leverage points (i.e., facilitators) to engaging LSMM in HIV prevention. This can subsequently inform health promotion program development, ensuring that the key facilitators and barriers are targeted.

Supplemental Material

Supplemental Material - Refining Multilevel Barrier and Facilitator Measures for HIV Testing and PrEP Among Latino Sexual Minority Men

Supplemental Material for Refining Multilevel Barrier and Facilitator Measures for HIV Testing and PrEP Among Latino Sexual Minority Men by Alyssa Lozano, Elliott R. Weinstein, Alejandra Fernandez, Sierra Bainter, Pranusha Atuluru, Abigail Hurtado, Vanessa Morales, Guillermo Prado, Steve A. Safren, and Audrey Harkness in American Journal of Health Promotion.

Supplemental Material

Supplemental Material - Refining Multilevel Barrier and Facilitator Measures for HIV Testing and PrEP Among Latino Sexual Minority Men

Footnotes

Author Contributions

All authors met the four ICMJE requirements for authorship. All authors made substantial contributions to the conception or design of the work, the acquisition, analysis, or interpretation of data for the work, drafted the work or revised it critically for important intellectual content, approved the final version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Safren receives royalties for books published by Guilford Press, Oxford University Press, and Springer/Humana Press. No other potential conflict of interest was reported by the authors.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Research reported in this publication was supported by the Center for AIDS Research (CFAR) at the University of Miami under Award Number P30AI073961 (Pawha), the National Institute on Minority Health and Health Disparities under Award Number U54MD002266 (Behar-Zusman) and K23MD015690 (Harkness), and the National Institute of Mental Health under Award Number P30MH116867 (Safren). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Ethics Statement

ORCID iD

Alyssa Lozano

Supplemental Material

Supplemental material for this article is available online.

Note

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