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AIDS Patient Care STDS. 2019 Feb;33(2):67-78. doi: 10.1089/apc.2018.0136. Epub 2019 Jan 17.

Decisional Balance and Contemplation Ladder to Support Interventions for HIV Pre-Exposure Prophylaxis Uptake and Persistence.

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1 Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, Wisconsin.
2 Department of Psychology, Center for HIV/AIDS Educational Studies & Training, Hunter College of the City University of New York (CUNY), New York, New York.
3 Health Psychology and Clinical Science Doctoral Program, The Graduate Center of the City University of New York (CUNY), New York, New York.
4 Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, The CUNY Institute for Implementation Science in Population Health, New York, New York.


Fewer than 60,000 males-inclusive of all sexual identities-were prescribed HIV pre-exposure prophylaxis (PrEP) by mid-2017 in the United States. Efforts to increase PrEP uptake among gay, bisexual, and other men who have sex with men (GBM), in particular, are ongoing in research and practice settings, but few tools exist to support interventions. We aimed to develop and validate tools to support motivational interviewing interventions for PrEP. In 2017, a national sample of HIV-negative GBM of relatively high socioeconomic status (n = 786) was asked about sexual behaviors that encompass Centers for Disease Control and Prevention guidelines for PrEP use, a 35-item decisional-balance scale (i.e., PrEP-DB) assessing benefits and consequences of PrEP use, and questions assessing location on the motivational PrEP cascade and derivative-the PrEP contemplation ladder. Principal axis factoring with oblique promax rotation was used for PrEP-DB construct identification and item reduction. The final 20-item PrEP-DB performed well; eigenvalues indicating a 4-factor solution provided an adequate fit to the data. Factors included the following: health benefits (α = 0.91), health consequences (α = 0.82), social benefits (α = 0.72), and social consequences (α = 0.86). Ladder scores increased across the cascade (ρ = 0.89, p < 0.001), and health benefits (β = 0.50, p < 0.001) and health consequences (β = -0.37, p < 0.001) were more strongly associated with ladder location than social benefits (β = 0.05, p > 0.05) and social consequences (β = -0.05, p > 0.05) in the fully adjusted regression model. The PrEP-DB demonstrated good reliability and predictive validity, and the ladder had strong construct validity with the motivational PrEP cascade. PrEP uptake and persistence interventions and additional empirical work could benefit from the utility of these measures.


HIV; men who have sex with men; motivational interviewing; pre-exposure prophylaxis


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