Men who have sex with men (MSM) bear a disproportionate burden of the HIV epidemic in the United States (US), and the number of new HIV diagnoses among MSM is increasing every year. Despite HIV incidence remaining relatively stable overall, HIV incidence is increasing among MSM, and among Black/African American (hereafter AA) young MSM (YMSM) in particular. Black/AA MSM represent less than 1% of the population but account for 25% of new HIV diagnoses. Compared to MSM of other races, AA MSM are 3 times more likely to be HIV infected. Among YMSM, the disparities are greatest; AA MSM aged 20-29 have an HIV prevalence of 34%, whereas White MSM in the same age range have an HIV prevalence of 5.5%. Additionally, the American South accounts for 46% of new HIV diagnoses in the US and 45% of new AIDS diagnoses. Mississippi is ranked 7th in the country in HIV case rates, with an overall rate of 20.7 per 100,000 persons; however, some census tracts have rates of 2-5%, which is comparable to some sub-Saharan African countries. There are alarming racial disparities related to HIV/AIDS; in Mississippi, AAs comprise 37% of the population but accounted for 76% of HIV infection reported in 2013. Between 2011 and 2013, the number of infections among MSM in Mississippi increased 43%, with an even sharper increase among AA YMSM, who have among the highest rates of infection in the nation.

Given the disproportionate burden of HIV, worse HIV outcomes, and current social climate, innovative and novel HIV prevention interventions are urgently needed for AA YMSM in the South, and in Mississippi in particular. HIV pre-exposure prophylaxis (PrEP) is a newer HIV prevention strategy that consists of a daily oral antiretroviral pill taken on an ongoing basis by HIV-uninfected but at-risk individuals. Its efficacy has been well established in randomized controlled trials and open-label studies for MSM and other groups. Although acceptability studies have demonstrated high interest in PrEP in the US, uptake remains limited. To date, studies of PrEP initiation have largely been limited to settings in which PrEP is provided free of charge. Barriers to PrEP initiation and retention in PrEP care in real world settings are likely more complex, since payment for PrEP can be a substantial financial burden. Although most health insurance programs are covering the cost of PrEP, and the industry-sponsored PrEP Medication Assistance Program exists to assist people who do not have insurance, these programs require patient and clinician awareness, sufficient staffing and appropriate infrastructure.

A body of evidence is only beginning to emerge related to PrEP adherence and little is known about retention in PrEP care, most of which is in the context of either RCTs or open-label studies in which PrEP is provided free of charge. The efficacy of PrEP is closely tied to adherence, and evidence suggests that efficacy decreases exponentially with fewer doses of PrEP per week; maximum efficacy is achieved when 6-7 doses are taken per week, but PrEP provides high protection with at least 4 doses per week. In an open label study of PrEP uptake and adherence in MSM, 71% of participants receiving PrEP had drug detected after initiation of PrEP. AA YMSM in Jackson, MS face many challenges to optimal adherence and retention in care, including inconsistent routines, socioeconomic challenges, and logistical difficulty in returning for follow-up visits. MSM may not want to disclose use of PrEP to family or friends, due to the potential for unintended disclosure of sexual orientation, which may result in reduced social support for PrEP adherence or returning for care. Understanding barriers and facilitators to adherence and retention in care for AA YMSM, and subsequently the development of interventions to improve them, will be necessary to ensure maximum PrEP effectiveness.

The ADAPT_ITT approach will be used to develop and pilot test a RAMP intervention that aims to promote PrEP adherence and retention in care in Jackson, MS and focuses on recruiting AA YMSM in a city with some of the highest HIV infection rates in the country. This study will include formative research to understand the cultural and social contexts that influence AA YMSM's PrEP use patterns and the acceptability of our proposed intervention. Results from these qualitative interviews will inform the study intervention which will be tested and refined in a dynamic open pilot evaluation.

Qualitative interviews (Phase 1) will "assess" individual, interpersonal and structural contexts of sexual risk behavior, anticipated adoption and use of new prevention technologies, barriers and facilitators to PrEP initiation and adherence, and optimal content and format for a PrEP initiation and adherence intervention. Using results of the qualitative interviews and input from key opinion leaders, the investigators will "decide" on intervention components and structure of the intervention package. The investigators will then "adapt" the Life-Steps intervention to be responsive to the unique context and complex needs of AA YMSM in Jackson, and "produce" a draft of the intervention manual. Our study team is made up of "topical experts" who will all have a central role in developing the intervention manual. Moreover, the open pilot evaluation (Phase 2) will be used to obtain further input on the draft intervention manual and protocol. After "integrating" the feedback obtained from the open pilot evaluation and exit interviews into the intervention manual and protocol, study staff will be "trained" in all final study procedures, and a provisional theory-based intervention to overcome barriers to PrEP adherence and retention, and reduce sexual risk behavior, among AA YMSM will be "tested" in a pilot Randomized Control Trial (RCT) (Phase 3). This intervention will have broad generalizability for AA YMSM across the South and the country as PrEP programs expand nationwide.