HIV Pre-exposure Prophylaxis Education for Clinicians Caring for Spanish-Speaking Men Who Have Sex With Men (MSM)

Introduction A growing number of Liaison Committee on Medical Education–accredited allopathic medical schools offer formal bilingual (English and Spanish) medical education, and numerous other schools offer medical Spanish through elective workshops as part of their curricula. One significant health disparity in the Hispanic community is the incidence of HIV among Spanish-speaking men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) has emerged as an effective strategy to reduce the risk of HIV transmission. Methods We developed an education module to train clinicians to discuss PrEP with Spanish-speaking MSM. Our module is adapted from an English module on PrEP education. It includes a Spanish-language PowerPoint slide deck with information about PrEP as well as a Spanish-language videotaped scripted clinical encounter. Results The module was implemented on three occasions with 18 participants, and learners reported increased comfort in discussing and confidence in prescribing PrEP with Spanish-speaking patients. Discussion This workshop can be incorporated within medical Spanish curriculums offered at health professional schools and community-based organizations dedicated to reducing the HIV burden in the Spanish-speaking Hispanic community.


Introduction
An estimated 1.7 million new HIV infections occur each year worldwide. 1 In 2018, 37,968 individuals were newly diagnosed with HIV in the United States; men who have sex with men (MSM) objective. Providers' lack of comfort with prescribing PrEP has emerged as a factor that consequently affects access to its use. 14 Educating clinicians on the appropriate testing prior to initiation of the medication, as well as monitoring parameters including laboratory data, adherence, and discontinuation parameters, is an essential objective of this module. Another barrier to PrEP access may be clinicians' limited Spanish proficiency and the challenges of caring for a growing Spanish-speaking population that now surpasses 50 million people in the United States. [15][16][17] Additional barriers include the stigmatization of high-risk populations, limited access to PrEP-informed providers, and mistrust of the medical community among Hispanic MSM. 18 In light of these, the main objectives of this module are to build provider awareness of atrisk populations who could benefit from PrEP, enhance provider comfort in prescribing PrEP, and develop cultural humility to improve PrEP uptake.
The CDC, through the Act Against AIDS initiative, provides culturally informed and language appropriate prevention campaigns using mass media to deliver HIV prevention messages. Current programs in the CDC compendium include interventions and strategies to reduce sexual risk in HIVnegative individuals, including the use of PrEP and postexposure prophylaxis. Currently, there are limited strategies and interventions specifically tailored for Hispanic MSM. 18,19 Furthermore, there exists a need for the development and implementation of educational programs for clinicians to promote PrEP use and adherence. 20 With a paucity of research in PrEP access, existing barriers contributing to disparities in HIV outcomes, and existing need for culturally informed interventions, an educational instruction to better prepare trainees in caring for Spanish-speaking Hispanic MSM populations is needed. Uniquely, this module provides standardized medical Spanish curricular content related to HIV and PrEP education.
There are five MedEdPORTAL publications that address medical Spanish education. [21][22][23][24][25] The published medical Spanish modules focus on the proper use of medical interpreters in clinical encounters, 21 the use of Spanish-language vignettes to teach medical Spanish, 25 and the use of role-play scenarios to teach medical Spanish. 23 Given the scarcity of data addressing the specific challenges that providers face when attending to the needs of special at-risk populations, such as Spanish-speaking Hispanic MSM, whether it is providers' level of comfort with Spanish language, with prescribing PrEP, or with establishing a dialogue about sexual practices in the setting of HIV risk, we consider the inclusion of this topic of utmost importance. Therefore, to support the development of the current module, we have adapted components of an English-language module on PrEP education. 26 Our innovations for this module include the creation of new content and instructional materials. New content includes HIV incidence and prevalence in the United States and Latin America and PrEP access among Hispanic MSM living in the United States and Latin America. Knowledge of the unique health disparities among Hispanic MSM and their access to PrEP will inform the learners' capacity to prescribe PrEP and tailor HIV prevention strategies. Our instructional materials to promote medical Spanish innovate by providing content via audio-recorded PowerPoint (PPT) slides, in both Spanish and English, and a Spanish-language videotaped scripted clinical encounter with Spanish-and English-language transcripts. Additionally, our content and instructional materials address medical Spanish core competencies and corresponding performance objectives designated by health professionals with expertise in medical Spanish. 16 A team of Spanish-proficient faculty, fellows, and medical students with knowledge of PrEP and of caring for members of the LGBTQ community developed, implemented, and/or evaluated the workshop. Each team member was a firstgeneration Hispanic American or native of Latin America. An associate professor of internal medicine with clinical PrEP prescribing experience and research expertise, an assistant professor of internal medicine with teaching and research experience, and an internal medicine instructor with clinical PrEP prescribing experience served as workshop facilitators. Additionally, three authors identified as gay.
The six-step Kern model 27 was applied as a framework for the design, implementation, and evaluation of this educational innovation as indicated below: 1. Problem identification and general needs assessment: These were performed via literature review and input from medical students, residents, fellows, and medical school faculty. Lack of awareness, comfort, and familiarity prescribing PrEP; lack of culturally informed practices and need for medical Spanish; and lack of standardized educational instructional material were identified as issues. 2. Targeted needs assessment: To better assess PrEP education needs across a subset of medical schools, we conducted a needs assessment to evaluate PrEP-related education.  16 We organized the instruction of our goals and objectives in Spanish-and English-language PPT presentations (Appendices A and B). 4. Educational strategies: The material was presented via an in-person presentation at three sites: Rutgers New Jersey Medical School (n = 6); Universidad Central del Caribe School of Medicine, Bayamon, Puerto Rico (n = 6); and Weill Cornell Medicine, New York City, New York (n = 6). The 18 participants included nine medical students, five academic faculty, one resident, one nurse, one staff member of a community-based organization, and one researcher. Each session was offered as a presentation at an academic medicine professional development conference sponsored by Building the Next Generation of Academic Physicians. At these conferences, participants received information on best practices in preparing for an academic medicine career, including the development of medical education portfolios. Additionally, the three sites allowed access to participants who included native Spanish speakers and native English speakers. Presenters utilized a discussion guide to teach the appropriate content (Appendix E). A video demonstrating Spanish-language communication skills utilized during PrEP counseling was shown during the presentation (Appendix F). 5. Implementation: The 1-hour presentation was administered in the summer of 2019 and was offered to medical students, residents, fellows, and faculty. 6. Evaluation and feedback: Each participant was given the opportunity to complete a pre-and postpresentation form to evaluate the workshop design and content (Appendices I and J

Methods
Workshop Content by Appendix r Appendix A-Spanish PPT slide deck presentation: The content of the Spanish-language workshop was provided in the PPT presentation, which outlined the core content for learners, including key terms, the epidemiology of HIV in the United States and Latin America, a brief history of HIV prevention, best-practice guidelines for PrEP prescribing, and barriers to uptake of PrEP in Hispanic MSM.
r Appendix B-English PPT slide deck presentation: The content of the English-language PPT presentation was a direct translation of Appendix A. The presentation outlined the core content for learners, including key terms, the epidemiology of HIV in the United States and Latin America, a brief history of HIV prevention, best-practice guidelines for PrEP prescribing, and barriers to uptake of PrEP in Hispanic MSM.
r Appendix C-Spanish audio-guided PPT slide deck presentation: The flow and content of the workshop were featured in this video presentation. The Spanishlanguage presentation outlined the core content for learners, including key terms, the epidemiology of HIV in Latin America, a brief history of HIV prevention, bestpractice guidelines for PrEP prescribing, and barriers to uptake of PrEP in Hispanic MSM.
r Appendix D-English audio-guided PPT slide deck presentation: The flow and content of the workshop were featured in this video presentation. The English-language presentation was a direct translation of Appendix C, and it outlined the core content for learners, including key terms, the epidemiology of HIV in Latin America, a brief history of HIV prevention, best-practice guidelines for PrEP prescribing, and barriers to uptake of PrEP in Hispanic MSM.
r Appendix E-discussion guide: This discussion guide was used to facilitate an in-person presentation of the provided PPT slides. The following medical Spanish core competencies were addressed in the workshop 16 : 1. Medical Spanish knowledge regarding organ systems and medical interviewing, including a complete medical interview script. 2. Medical Spanish knowledge regarding common disease entities, including comprehension of information provide in Spanish by the patient and synthesis of information gathered into a working assessment/plan. 3. Patient-centered explanation of medical diagnoses/assessment, including ability to explain medical diagnoses in colloquially understandable language. 4. Patient-centered explanation of treatment/evaluation plan, including testing (blood, imaging, urine, etc.), medication management/instructions, therapeutic interventions and procedural discussions, and referrals/follow-up care.
The following medical Spanish performance objectives were addressed in the workshop 16 : 1. Obtaining an accurate, age-appropriate, focused medical history.
2. Successfully conducting the medical interview by asking appropriate questions that demonstrate evaluation of pertinent positives/negatives that sufficiently address differential diagnostic considerations for a given chief complaint. 3. Assessing patient comprehension of the information provided and addressing gaps in the patient's knowledge. 4. Orally communicating the treatment plan to the patient, adjusted for cultural, emotional, and literacy needs. 5. Assessing patient comprehension of the information provided and addressing gaps in the patient's knowledge.

Learners and Facilitators
This workshop was designed for clinicians and physicians-intraining and as such could be presented to medical students, residents, and/or faculty. Participants could be native Spanish speakers who had completed high school or non-native Spanish speakers who had passed a high-school advanced placement Spanish-language exam or college-equivalent course. The ideal facilitators were clinicians with an MD, DO, PA, or NP degree and with Spanish proficiency, experience in HIV prevention, and LGBTQ health care. The entire presentation could be completed within a 1-hour block.
In preparation for the workshop, facilitators reviewed the video presentation and evaluation forms. Reviewing the material took approximately 3 hours. Should future facilitators choose, they can give an oral presentation using the PPT slides provided. The content in the PPT slides is an exact replica of the audio-recorded PPT presentation.

Materials
Additional materials needed to administer this workshop included pens, audiovisual equipment to show the PPT or video presentation, and printed copies of the evaluation forms. r Option 3: Trainees are emailed the audio-guided PPT video presentation (Appendix C or D) and evaluation forms (Appendices I and J). We recommend that the instructor follows up with trainees via an in-person small-group discussion to discuss their comfort and knowledge as they pertain to PrEP prescribing.

Results
This workshop was implemented at three sites: Universidad Central del Caribe School of Medicine (n = 6), Weill Cornell Medicine (n = 6), and Rutgers New Jersey Medical School (n = 6).

Rutgers New Jersey Medical School
Participants included six medical students who self-identified as native Spanish-speaking. Participants were asked to rate their level of agreement (1 = strongly disagree, 5 = strongly agree) with seven statements. The Mann-Whitney U test was used to assess a statistical difference in pre-and posttest responses. The results of these assessments are described in Table 1.

Universidad Central del Caribe School of Medicine and Weill Cornell Medicine
Participants included five academic faculty, three medical students, one resident, one nurse, one staff member of a community-based organization, and one researcher. Participants were asked to rate their level of confidence regarding the learning objectives. The Mann-Whitney U test did not show a statistical difference in pre-and posttest responses per learning objective. Additionally, participants were asked to rate quality of the lecture and scripted clinical encounter. The results of these assessments are described in Table 2.
In qualitative feedback, learners reported that the workshop was "well-organized" and "provided new information." Participants recommended "correcting grammatical issues" and "providing alternatives for prevention." The video was valued for "showing application of the material used in the PowerPoint" and was "a good tutorial" and "an excellent example on how to discuss PrEP with patients."

Discussion
This workshop to educate future clinicians on best practices in prescribing PrEP to Spanish-speaking Hispanic MSM is a successful educational innovation.
The module aligns with the National Hispanic Health Foundation and University of Illinois College of Medicine multidisciplinary Abbreviations: MSM, men who have sex with men; NS, not significant; PrEP, pre-exposure prophylaxis. a Rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). expert panel consensus recommendations for integrating medical Spanish educational initiatives and training efforts as a strategy to improve Hispanic health and assess medical student learner skills through standardized patient encounters. 16 The workshop addresses four core competencies and corresponding performance objectives recommended by the medical Spanish panel of experts. In alignment with multidisciplinary expert panel consensus recommendation 4, "provide a consensus core curriculum as a recommended structure for medical Spanish courses in U.S. medical schools," 16 our workshop seeks to build on appropriate usage of terminology (through the use of culturally accepted term use) and culturally appropriate health explanations, such as the exploration of barriers to PrEP uptake. Additionally, our videotaped scripted clinical encounter can be used as a standardized patient encounter instructional strategy, which aligns with consensus recommendation 5, "assessment of medical Spanish learner skills through standardized patient (SP) encounters that incorporate interactive communication and interpersonal skills." 16 We learned some lessons in the development of this  28 Specific resources for other at-risk populations include webpages catering to cisgender women, 29 intravenous drug users, 30 and transwomen. 31 Limitations Evaluation of this project was limited to three academic medical centers. The effectiveness of this education may also vary with audience. For example, senior health professionals who are uncomfortable with discussing sexual orientation or LGBTQ health may be more uncomfortable prescribing PrEP and may need additional training. This innovation also does not address skills acquisition. The workshop did not assess participants' ability to apply the material when engaging with Spanish-speaking patients, for example, via an observed standardized clinical examination. However, future presentations could potentially do so if role-plays with learner feedback are included. Additionally, PrEP prescribing recommendations may vary as new medications become available. We recommend that educators and participants review the CDC's PrEP website 32 for up-to-date clinical recommendations. Finally, the impact of this workshop is limited in that we have assessed its immediate influence on participants' comfort and confidence prescribing PrEP. Sustained comfort and confidence may require repeated training and reinforcement via observed clinical encounters and continuing medical education activities.

Conclusion
As U.S. medical schools develop, implement, and evaluate medical Spanish modules for their medical students, this module can serve as a seminal workshop for delivering medical Spanish training related to PrEP, HIV prevention, or sexual history taking. The module was developed by native Spanish speakers and reviewed by faculty who have been involved in implementing bilingual medical education for the past 10 years. Spanish is the second most common language spoken in the U.S., and the Hispanic population is expected to be one in four residents by 2050. Thus, medical Spanish modules on topics of a disparate burden to Hispanics are critical to providing equitable care for patients in the United States.