Stigma, the Media, and Pre-exposure Prophylaxis for HIV Prevention: Observations for Enhancing Knowledge Translation and Resisting Stigma in the Canadian Context

A decade of PrEP: the evolution of HIV pre-exposure prophylaxis content and sentiments in South African print news media, 2012-2021

After nearly a decade of HIV pre-exposure prophylaxis (PrEP) rollout in sub-Saharan Africa, there has been limited study of PrEP messaging in news media. We selected twenty South African newspapers with the highest circulation volumes to retrieve articles published in 2012-2021 mentioning PrEP (N = 249). Using inductive content analysis, we developed a structured codebook to characterise PrEP-related content and sentiments, as well as their evolution over time, in the South African press. Many articles espoused favourable attitudes towards PrEP (52%), but a sizeable fraction espoused unfavourable attitudes (11%). Relative to PrEP-favourable articles, PrEP-unfavourable articles were significantly more likely to emphasise the drawbacks/consequences of PrEP use, including adherence/persistence requirements (52% vs. 24%, p = .007), cost (48% vs. 11%, p < .001), and risk compensation (52% vs. 5%, p < .001). Nevertheless, the presence of these drawbacks/consequences in print media largely declined over time. Key populations (e.g. adolescents, female sex workers) were frequently mentioned potential PrEP candidates. Despite message variations over time, prevention effectiveness and adherence/persistence requirements were the most widely cited PrEP benefits and drawbacks, respectively. Study findings demonstrate the dynamic nature of PrEP coverage in the South African press, likely in response to PrEP scale-up and real-world PrEP implementation during the study period.

The development of a conceptual framework on PrEP stigma among adolescent girls and young women in sub-Saharan Africa

INTRODUCTION

Stigma is a well-known barrier to HIV testing and treatment and is an emerging barrier to pre-exposure prophylaxis (PrEP) use. To guide future research, measurement and interventions, we developed a conceptual framework for PrEP stigma among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for PrEP.

METHODS

A literature review, expert consultations and focus group discussions (FGDs) were conducted to adapt the Health Stigma and Discrimination Framework, describing the stigmatization process nested within the socio-ecological framework. We reviewed all articles on PrEP stigma and on HIV, contraceptive or sexuality stigma among AGYW from 2009 to 2019. Expert consultations were conducted with 10 stigma or PrEP researchers and two Kenyan youth advisory boards to revise the framework. Finally, FGDs were conducted with AGYW PrEP users (4 FGDs; n = 20) and key influencers (14 FGDs; n = 72) in Kenya with the help of a Youth Research Team who aided in FGD conduct and results interpretation. Results from each phase were reviewed and the framework was updated to incorporate new and divergent findings. This was validated against an updated literature search from 2020 to 2023.

RESULTS

The conceptual framework identifies potential drivers, facilitators and manifestations of PrEP stigma, its outcomes and health impacts, and relevant intersecting stigmas. The main findings include: (1) PrEP stigma is driven by HIV, gender and sexuality stigmas, and low PrEP community awareness. (2) Stigma is facilitated by factors at multiple levels: policy (e.g. targeting of PrEP to high-risk populations), health systems (e.g. youth-friendly service availability), community (e.g. social capital) and individual (e.g. empowerment). (3) Similar to other stigmas, manifestations include labelling, violence and shame. (4) PrEP stigma results in decreased access to and acceptability of PrEP, limited social support and community resistance, which can impact mental health and decrease PrEP uptake and adherence. (5) Stigma may engender resilience by motivating AGYW to think of PrEP as an exercise in personal agency.

CONCLUSIONS

Our PrEP stigma conceptual framework highlights potential intervention targets at multiple levels in the stigmatization process. Its adoption would enable researchers to develop standardized measures and compare stigma across timepoints and populations as well as design and evaluate interventions.

Communicative appeals and messaging frames in visual media for HIV pre-exposure prophylaxis promotion to cisgender and transgender women

Women in the USA represent 15% of new HIV diagnoses but only 5% of pre-exposure prophylaxis (PrEP) users. We sought to characterise communicative appeals and messaging frames used in US visual media to cultivate PrEP demand among cisgender and transgender women using content analysis methodology. We catalogued and coded media items (images and videos) from US PrEP marketing campaigns featuring women. Production and content characteristics were abstracted, and communicative appeals from media items were qualitatively coded in duplicate. We then descriptively summarised production and content characteristics and identified discrete subgroups of media items, clustering around specific messaging frames, through qualitative thematic analysis. Racial/ethnic minorities and sexual/gender minority women were heavily featured, and numerous media items leveraged cognitive and social communicative appeals to promote PrEP. We identified three unique messaging frames emerging from coded media items, portraying PrEP as: (1) necessary prevention (protection frame), (2) a desirable yet accessible commodity (aspiration frame), and (3) a conduit to sexual autonomy (empowerment frame). To effectively communicate PrEP information and promote PrEP to women, PrEP marketing should leverage alternative appeals (subjective norms, self-efficacy), address anticipated barriers to uptake (stigma, cost, medication interactions), and deconstruct misconceptions of PrEP use(rs).

Sex Conservatism, Internalized Homonegativity, PrEP Stigma, and Intention to Use PrEP: A Study of Chinese-Speaking Gay and Bisexual Male Youth in Hong Kong

Pre-exposure prophylaxis (PrEP) stigma has been found to be a major barrier to PrEP acceptability and uptake. Research has found that different ethnic/cultural groups display varying levels of PrEP stigma. This article studies sex conservatism and internalized homonegativity as two sexuality- and culture-related aspects that influence PrEP stigma and intention to use PrEP. An online survey of 279 young gay and bisexual men in Hong Kong found that internalized homonegativity was positively associated with PrEP stigma. Respondents who were more conservative about sex showed lower intention to use PrEP, whereas those who had higher income and more positive attitudes about PrEP were more likely to express intention to use PrEP. This study provides novel empirical evidence for understanding PrEP stigma and uptake from a sexuality and cultural perspective. The influence of sexuality- and culture-related factors on PrEP stigma and uptake warrants greater attention, especially in the Asia-Pacific region.

Trends in HIV Stigma Experienced by People Living With HIV in the Netherlands: A Comparison of Cross-Sectional Surveys Over Time

We investigated whether HIV stigma has changed in recent years. We compared data on stigma settings and manifestations from 2007 (n = 667) and, specifically for health care, 2009 (n = 262), to data acquired in 2019/2020 (n = 258). Results showed reductions in stigma from friends, family, acquaintances, at work, in the financial services sector, and in media, but stigmatizing messages in media remained highly prevalent. Stigma in the LGBTQI+ community, with sexual partners, and while partying also remained prevalent and, disconcertingly, relatively unchanged. Stigma in health care increased. HIV stigma was positively related to psychological distress, and negatively related to social support and medication adherence. Further, most participants were familiar with U=U and PrEP, but 13.3% questioned the accuracy of U=U. Stigma reduction efforts should focus on reducing stigma in media, in the LGBTQI+ community and while dating, and in health care, with U=U as a key message.

The Impact of Misinformation and Health Literacy on HIV Prevention and Service Usage

There are an increasing number of online resources people can use to gain access to information, including for health-related issues, such as for HIV prevention. Trend data show that the way individuals obtain news and information has changed from years past. Health literacy, therefore, is an important skill to ensure adequate understanding of the data available about HIV in the media and online. Unfortunately, the proliferation of misinformation is ubiquitous and may have deleterious effects on individual health behavior, and consequently, the public’s health. This commentary focuses on sources of online misinformation as it relates to HIV and how misinformation impacts seeking health services.

Correlates of PrEP Uptake Among Young Sexual Minority Men and Transgender Women in New York City: The Need to Reframe "Risk" Messaging and Normalize Preventative Health

Pre-exposure prophylaxis (PrEP) is an effective form of HIV prevention, but young sexual minority men face myriad barriers to PrEP uptake. Participants (n = 202) completed a survey on healthcare experiences and beliefs about HIV and PrEP. While 98% of the sample knew about PrEP, only 23.2% reported currently taking PrEP. Participants were more likely to be taking PrEP if they received PrEP information from a healthcare provider and endorsed STI-related risk compensation. Conversely, PrEP uptake was less likely among those with concerns about medication use and adherence. While there were no racial/ethnic differences in PrEP uptake, there were differences in correlates of PrEP use for White participants and participants of color. To facilitate PrEP uptake, clinicians should provide PrEP education and screen all patients for PrEP candidacy. Additionally, public health messaging must reframe HIV "risk", highlight benefits of STI testing, and emphasize the importance of preventive healthcare for SMM.

Biomedicalization, Stigma, and "Re-Gaying" HIV/AIDS in the Israeli Media

HIV and AIDS are not merely biomedical conditions-they are socially constructed phenomena. Media coverage plays a prominent role in the public's understanding of HIV/AIDS. "Biomediatization" denotes the coproduction of HIV/AIDS by biomedicine and mass media. Nevertheless, despite the importance of the media in the social construction of HIV/AIDS, research on HIV/AIDS coverage in the Israeli media is negligible. This study examined the social construction of HIV/AIDS in Israel. The sample includes all items (88 texts and videos) published in three of the top news websites in a 1-year period that mentioned HIV or AIDS. Thematic analysis was employed. Three themes were identified. "The biomedicalization of HIV/AIDS" depicted HIV/AIDS as a one-faceted, biological phenomenon that concerns the body of the individual and is a public health issue. The second theme, "HIV/AIDS and stigma," consisted of subthemes: "acknowledging stigma" and "constructing stigma." In the former, the stigma ascribed to HIV/AIDS was acknowledged and discussed. The latter revealed various mechanisms employed by the media to construct and perpetuate HIV/AIDS stigma. The third theme we identified, "re-gaying HIV/AIDS," concerned the various venues through which HIV/AIDS is associated with gay men. The findings show that HIV/AIDS was depicted as a biomedical condition that concerns the individual. The implications of our study include a need to change the rhetoric of HIV/AIDS in the Israeli media such that it will address the complex issues of power and inequality that HIV/AIDS entails.

Socio-demographic, clinical and service use determinants associated with HIV related stigma among people living with HIV/AIDS: a systematic review and meta-analysis

Background

Defining HIV-related stigma (HRS) can be problematic due to structural inequalities, cultural differences, discrimination by health care providers and the limitations of tools measuring stigma for people living with HIV (PLWH). This meta-analysis aimed to determine self-reported HRS and its association with socio-demographic and clinical determinants.

Methods

PubMed, Scopus, Web of Science, PsycInfo, SciELO and Cochrane electronic databases were searched and after reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes criteria. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR) and 95% confidence intervals.

Results

Thirty-one studies containing 10,475 participants met the eligibility criteria. Among the potential risk factors: age > 30 years (OR = 0.93, 95%CI = 0.86, 1), living with a spouse (OR = 0.07, 95%CI = 0.02, 0.17), CD4 count < 200 (OR = 0.5, 95% CI = 0.31, 0.68), medication adherence (OR = 0.96, 95%CI = 0.94, 0.99), poor access to care (OR = 0.79, 95%CI = 0.65, 0.93), time since diagnosis, and accessibility to care (OR = 0.37, 95%CI = 0.11, 0.86) were all significantly associated with self-reported HIV stigma among PWLH.

Conclusion

Stigma is correlated with numerous negative consequences in marginalised populations including PLWH. Considering the negative association that stigma has on HIV prevention and treatment targeted evidence-based stigma reduction interventions are recommended. Interventions that are focused on a particular group, such as healthcare professionals are warranted. Rigorously designed studies with specific and validated outcome measures associated with targeted interventions may help to improve the reduction of HRS for PLWH.

The social meanings of PrEP use - A mixed-method study of PrEP use disclosure in Antwerp and Amsterdam

Pre-Exposure Prophylaxis (PrEP) is a novel HIV prevention tool. PrEP stigma is a frequently reported barrier, while social disclosure of PrEP use may be an important facilitator. We explored how PrEP users managed PrEP use disclosure using a symbolic interactionist approach. We interviewed 32 participants from two PrEP demonstration projects (Be-PrEP-ared, Antwerp; AMPrEP, Amsterdam). We validated qualitative findings through Be-PrEP-ared questionnaire data. A minority of participants had received negative reactions on PrEP. The way PrEP use was disclosed was highly dependent on the social situation. In a sexual context among MSM, PrEP use was associated with condomless sex. Friends endorsed PrEP use as a healthy choice, but also related it to carelessness and promiscuity. It was seldom disclosed to colleagues and family, which is mostly related to social norms dictating when it is acceptable to talk about sex. The study findings reveal that PrEP stigma experiences were not frequent in this population, and that PrEP users actively manage disclosure of their PrEP user status. Frequent disclosure and increased use may have helped PrEP becoming normalised in these MSM communities. To increase uptake, peer communication, community activism and framing PrEP as health promotion rather than a risk-reduction intervention may be crucial.

A Scoping Review of HIV Pre-exposure Prophylaxis Stigma and Implications for Stigma-Reduction Interventions for Men and Transwomen Who Have Sex with Men

HIV remains a public health concern in the United States. Although pre-exposure prophylaxis (PrEP) can be expected to reduce HIV incidence, its uptake, adherence, and persistence remain limited, particularly among highest priority groups such as men who have sex with men and transwomen (MSMTW). Using a socioecological framework, we conducted a scoping review to examine PrEP-related stigma to inform future research, policy, and programmatic planning. Using the PRISMA extension for scoping reviews, we conducted database searches from August 2018 to April 2020 for articles addressing PrEP stigma. Studies were independently screened and coded by three authors, resulting in thematic categorization of several types of PrEP stigma on four socioecological levels. Of 557 references, a final sample of 23 studies was coded, 61% qualitative, and 87% focusing exclusively on MSMTW. Most instances of PrEP-related stigma occurred on the interpersonal level and included associations of PrEP with risk promotion, HIV-related stigma, and promiscuity. Other frequent themes across socioecological levels included provider distrust and discrimination, government and pharmaceutical industry distrust, internalized homonegativity, PrEP efficacy distrust, and anticipated homonegativity. Notably, PrEP was also framed positively as having physical and psychological benefits, and assuming responsibility for protecting one's community via PrEP awareness-raising. PrEP-related stigma persists, demanding interventions to modify its impact. Leveraging PrEP-positive discourses to challenge PrEP stigma is an emerging avenue, alongside efforts to increase provider willingness to promote PrEP routinely by reducing provider bias, aligning with the national strategy to End the HIV Epidemic.

Configuring the PrEP user: framing pre-exposure prophylaxis in UK newsprint 2012-2016

Pre-exposure prophylaxis (PrEP) has been hailed as a revolutionary intervention for HIV prevention. PrEP's controversial status in the UK has generated significant media coverage. It is important to understand what role the media plays in framing PrEP policy issues. We undertook a qualitative analysis of UK newsprint articles between 2012 and 2016 to examine how PrEP was framed as a public health intervention up until a controversial policy decision not to provide PrEP in England. We identified how scientific evidence was deployed to shape two narratives: ir/responsible citizens focused on imagined PrEP users and their capacity to use PrEP effectively; and the public health imperative, which described the need for PrEP. Our analysis demonstrates the particular ways in which scientific evidence contributed to the certainty of PrEP as an effective intervention within UK newsprint. Scientific evidence also played a key role in framing PrEP as an intervention specifically for cis-gendered gay and bisexual men, playing into wider debates about who is a deserving patient and the appropriate use of public resources. Practitioners in the UK and elsewhere should be aware of these constructions of the PrEP user to ensure equitable access to PrEP beyond gay and bisexual men.

Understanding, Contextualizing, and Addressing PrEP Stigma to Enhance PrEP Implementation

PURPOSE OF REVIEW

HIV pre-exposure prophylaxis (PrEP) is a safe and effective preventive intervention that could play a central role in ending the HIV epidemic. However, low uptake in general, and among certain social groups in particular, underscores the need to identify and address barriers to PrEP use. PrEP stigma has emerged as a key factor interfering with PrEP interest, uptake, and continuation. The purpose of this article is to describe and contextualize PrEP stigma and to offer recommendations on how to address it in future PrEP implementation initiatives.

RECENT FINDINGS

PrEP users are commonly stereotyped as sexually irresponsible, promiscuous, and immoral. These stereotypes and associated prejudice manifest at multiple levels and discourage PrEP interest and uptake, disrupt PrEP adherence, and motivate PrEP discontinuation. Intersecting forms of stigma may influence the nature, magnitude, and impact of PrEP stigma across social groups and otherwise hinder PrEP use. Current PrEP implementation strategies that narrowly focus on risk and target stigmatized groups with disproportionately high HIV incidence have yielded limited success and are counterproductive to the extent that they perpetuate stigma. Implementation strategies involving more inclusive messaging and further integration of PrEP within healthcare may help to reduce PrEP stigma and mitigate its impact, ultimately increasing PrEP use. PrEP stigma is a barrier to PrEP interest, uptake, and continuation that manifests at multiple levels. Understanding and addressing PrEP stigma requires consideration of its origins and intersections. Targeted, risk-focused implementation strategies perpetuate stigma and undermine use.

Results from a difference-in-differences evaluation of health facility HIV and key population stigma-reduction interventions in Ghana

INTRODUCTION

Stigma undermines all aspects of a comprehensive HIV response, as reflected in recent global initiatives for stigma-reduction. Yet a commensurate response to systematically tackle stigma within country responses has not yet occurred, which may be due to the lack of sufficient evidence documenting evaluated stigma-reduction interventions. With stigma present in all life spheres, health facilities offer a logical starting point for developing and expanding stigma reduction interventions. This study evaluates the impact of a "total facility" stigma-reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff in Ghana.

METHODS

We evaluated the impact of a total facility stigma-reduction intervention by comparing five intervention to five comparable non-intervention health facilities in Ghana. Interventions began in September 2017. Data collection was in June 2017 and April 2018. The primary outcomes were composite indicators for three stigma drivers, self-reported stigmatizing avoidance behaviour, and observed discrimination. The principal intervention variable was whether the respondent worked at an intervention or comparison facility. We estimated intervention effects as differences-in-differences in each outcome, further adjusted using inverse probability of treatment weighting (IPTW).

RESULTS

We observed favourable intervention effects for all outcome domains except for stigmatizing attitudes. Preferring not to provide services to people living with HIV (PLHIV) or a key population member improved 11.1% more in intervention than comparison facility respondents (95% CI 3.2 to 19.0). Other significant improvements included knowledge of policies to protect against discrimination (difference-in-differences = 20.4%; 95% CI 12.7 to 28.0); belief that discrimination would be punished (11.2%; 95% CI 0.2 to 22.3); and knowledge of and belief in the adequacy of infection control policies (17.6%; 95% CI 8.3 to 26.9). Reported observation of stigma and discrimination incidents fell by 7.4 percentage points more among intervention than comparison facility respondents, though only marginally significant in the IPTW-adjusted model (p = 0.06). Respondents at intervention facilities were 19.0% (95% CI 12.2 to 25.8) more likely to report that staff behaviour towards PLHIV had improved over the last year than those at comparison facilities.

CONCLUSIONS

These results provide a foundation for scaling up health facility stigma-reduction within national HIV responses, though they should be accompanied by rigorous implementation science to ensure ongoing learning and adaptation for maximum effectiveness and long-term impact.