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

Identifying Effective Strategies for Improving Engagement in HIV Prevention and Care Among Transgender Persons in the United States: A Systematic Review

This systematic review synthesized published literature (2000 - 2023) to identify HIV interventions specifically designed for transgender persons in the United States (PROSPERO registration number: CRD42021256460). The review also summarized strategies for improving outcomes related to the four pillars of the Ending the HIV Epidemic (EHE) initiative in the United States: Diagnose, Treat, Prevent, and Respond. A comprehensive search was conducted using the Centers for Disease Control and Prevention's HIV Prevention Research Synthesis Project database, which included over 120,000 citations from routine systematic searches in CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts. Of 23 interventions that met inclusion criteria, 94% focused on transgender women of color and 22% focused on young transgender persons aged 15-29 years old. Most interventions focused on Treat or Prevent, few focused on Diagnosis, and none focused on Respond. Twenty interventions (87%) showed improvement in at least one EHE related outcome and a quarter of these effective interventions were tested with randomized controlled trials. Common strategies observed in effective interventions include the following: engaging the community in intervention development; pilot-testing with the focus population to ensure appropriateness and acceptability; addressing social determinants of health (e.g. stigma, discrimination, violence) through empowerment and gender-affirming approaches; increasing access to care, prevention, and services through co-location and one-stop shop models; and utilizing peer-led counseling, education, support, and navigation. Continuous effort is needed in addressing gaps, including more research for transgender men and rural settings and for how best to adopt and adapt best practices for subgroups of transgender population.

The relationship between anti-LGBTQ+ legislation and HIV prevention among sexual and gender minoritized youth

OBJECTIVE

The aim of this study was to estimate the longitudinal associations of state-level anti-LGBTQ+ policies and county-level politics with individual HIV prevention outcomes among sexual and gender minoritized (SGM) youth.

DESIGN

Keeping it LITE-1 prospectively enrolled 3330 SGM youth and young adults (ages 13-34) at increased risk of HIV throughout the United States from 2017 to 2022.

METHODS

Semiannual surveys collected self-reported HIV prevention measures [current preexposure prophylaxis (PrEP) use, weekly PrEP adherence, HIV/STI testing in the past 6 months]. Geolocation was linked with state-level LGBTQ+ policy data and county-level election data. Generalized linear models with GEE estimated the single and joint longitudinal associations for two exposures [state-level policy climate (more discriminatory vs. less discriminatory) and county-level political majority (Democratic/swing vs. Republican)] with each outcome.

RESULTS

Among participants living in a state with more discriminatory laws, those in a Democratic/swing county had a 6-percentage point increase in PrEP use (95% confidence interval: 0.02, 0.09) compared to those in a Republican county. Those living in a Republican county but a state with less discriminatory laws saw a similar increase (0.05; -0.02,0.11). Residing in both a Democratic/swing county and a state with less discriminatory laws, relative to a Republican county and a state with more discriminatory laws, was associated with a 10-percentage point increase in PrEP use (0.10; 0.06,0.14) and a 5-percentage point increase in HIV/STI testing (0.05; 0.00,0.09).

CONCLUSION

More progressive state and local policies were each associated with increased PrEP use, and together, doubled the magnitude of this association. PrEP is underutilized among SGM youth, and anti-LGBTQ+ policies may exacerbate this gap in coverage.

The Use of a Spanish-Translated PrEP Stigma Scale among the Latino Sample of the UNITE Cohort Study

Pre-Exposure Prophylaxis (PrEP) related stigma is linked to inadequate PrEP uptake, yet there are no validated scales to test this association among Spanish-speaking LSMM. The current study examined if the Spanish-translated PrEP Stigma Scale (PSS) was psychometrically appropriate for implementing in Spanish language dominant Latino/e/x Sexual Minority Men (SMM). Recruitment was conducted using geosocial networking applications, social media sites, and e-mail blasts (N=3,049). First, we utilized Item Response Theory (IRT) modeling to evaluate the reliability of the PSS items and the latent construct across both language groups (nEnglish = 2844 and nSpanish = 205). Subsequently, we applied the PSS scale in a theoretical application by examining its association with key steps in the PrEP uptake cascade (i.e., perceived PrEP candidacy, PrEP willingness, PrEP intentions, and having spoken to provider about PrEP) stratified by language. Results of the IRT analyses provided evidence that the translated version of the PSS was appropriate for use among this sample. Further, among English respondents, PrEP stigma was negatively associated with perceived PrEP candidacy (B=-0.30, p=<.001), PrEP willingness (B=-0.46, p=<.001), and PrEP intentions (B=-0.23, p=.003). PrEP stigma, among Spanish respondents, was not significantly associated with any of the PrEP cascade steps. This study demonstrated that the PSS scale performs adequately for both English and Spanish-speaking Latino SMM. However, researchers and health professionals alike should pay close attention to the nuanced effects in U.S. based English and Spanish language samples as PrEP stigma may impact the PrEP cascade for one language sample and not the other.

Barriers and facilitators to uptake and persistence on prep among key populations in Southern Province, Zambia: a thematic analysis

BACKGROUND

Especially in high HIV prevalence contexts, such as Zambia, effective biomedical prevention tools are needed for priority populations (PPs), including key populations (KPs), who are at higher risk. HIV pre-exposure prophylaxis (PrEP) has been scaled up nationally in Zambia, but little is known about barriers to PrEP use among specific PPs to date.

METHODS

To understand barriers and facilitators to PrEP use in Zambia, we conducted a qualitative case study of PrEP services to PPs including sero-discordant couples (SDCs), female sex workers (FSWs), and men who have sex with men (MSM) in Livingstone. The study conducted in 2021 included in-depth interviews (n = 43) guided by the socio-ecological model, and focus group discussions (n = 4) with clinic and community-based providers and PrEP-eligible clients including users and non-users across PP groups. We used thematic analysis to analyze data using codes derived both deductively and inductively.

RESULTS

We found multilevel barriers and facilitators to PrEP use. Cross-cutting barriers shared across PP groups included amplifying effects of PrEP being mistaken for antiretroviral drugs used to treat HIV, including anticipated stigma, and concerns about side-effects based on both misinformation and experience. In addition, stigmatized identities, particularly that of MSM, served as a barrier to PrEP use. The fear of being mislabeled as having HIV was of greatest concern for FSWs. Facilitators to PrEP use primarily included the importance of confidential, KP-sensitive services, and the role of informed, supportive family, friends, and peers. Participants across all PP groups urged expanded education efforts to increase awareness of PrEP within the general population toward mitigating concerns of being mislabeled as living with HIV.

CONCLUSION

To our knowledge, this is the first qualitative study of the PrEP cascade among multiple PPs in Zambia. This study provides important explanation for the low rates of PrEP continuation found in earlier demonstration trials among KPs in Zambia. The study also offers recommendations for programming efforts going forward such as inclusive PrEP awareness campaigns, expanded KP sensitivity training, and related efforts to thwart PrEP stigma while expanding access.

Randomized Clinical Trial of Stigma Counseling and HIV Testing Access Interventions to Increase HIV Testing Among Black Sexual Minority Men and Transwomen

Advances in HIV prevention tools have outpaced our ability to ensure equitable access to these tools. Novel approaches to reducing known barriers to accessing HIV prevention, such as stigma and logistical-related factors, are urgently needed. To evaluate the efficacy of a randomized controlled trial with four intervention arms to address barriers to HIV/STI testing uptake (primary outcome) and PrEP use, depression, and HIV test results (secondary outcomes). We tested a 2 × 2 research design: main effect 1-stigma-focused vs. health information evaluation-focused counseling, main effect 2-offering HIV/STI testing appointments in person vs. at home with a counselor via video chat, and the interaction of the main effects. Participants (N = 474) residing in the southeastern USA were screened and enrolled in a longitudinal trial. Intervention efficacy was established using generalized linear modeling with binomial or Poisson distributions. Intervention efficacy demonstrated an increase in HIV/STI testing uptake when testing was made available at home with a counselor via video chat vs. in person (83% vs. 75% uptake, p < .05), and participants were also more likely to test positive for HIV over the course of the study in the at-home condition (14.5% vs. 9.4%, p < .05). Stigma-focused counseling resulted in lower depression scores and greater uptake of PrEP among participants < 30 years of age when compared with health information counseling (15.4% vs. 9.6%, p < .05). In order to prevent further disparities between HIV prevention advances and access to HIV prevention tools, we must prioritize improvements in linking people to care. Novel interventions, such as those proposed here, offer a practical, evidence-based path to addressing long-standing barriers to HIV prevention strategies. Trial registration: NCT03107910.

When Stigma, Disclosure, and Access to Care Collide: An Ethical Reflection of mpox Vaccination Outreach

Experiences of stigma in health care encounters among LGBTQ+ populations (lesbian, gay, bisexual, transgender, and queer and questioning) have long been a barrier to care. Marginalization and historically grounded fears of stigmatization have contributed to a reluctance to disclose sexual behavior and/or gender identity to health care providers. We reflect on how student nurses grappled with the ethics of patient disclosure while providing mobile outreach in Chicago for mpox (formerly monkeypox) from fall 2022 to spring 2023. Student nurses addressed how requiring disclosure of sexual behavior or sexual orientation may serve as a barrier to accessing preventive care, such as mpox vaccination. Accounts of stigma and criminalization experienced by LGBTQ+ people provide insight on challenges historically associated with disclosure in health care.

Factors Associated with PrEP Stigma Among Gay, Bisexual, and Other Men Who Have Sex with Men (gbMSM): A Systematic Review

Gay, bisexual, and other men who have sex with men (gbMSM) are disproportionately affected by HIV. While pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition, uptake of PrEP among gbMSM is low, which may in part be due to stigma associated with PrEP use. This systematic review aimed to explore experiences of PrEP stigma and to identify factors associated with this. Four databases were searched for papers including terms relating to (i) gbMSM, (ii) PrEP, and (iii) stigma, with narrative synthesis used to analyze results. After screening, 70 studies were included in the final analysis. Experiences of PrEP stigma were found to be characterized by a number of stereotypes and came from a range of sources. Five categories of factors were associated with stigma: (i) healthcare-related factors, (ii) cultural and contextual factors, (iii) sociodemographic factors, (iv) peer-discussion, and (v) psychosocial factors. These findings suggest that stigma can be a common experience for gbMSM. However, some are more at risk than others. Interventions aimed at reducing PrEP stigma may be useful in increasing uptake.

Sexual Identity Development and Social Ecological Facilitators and Barriers of PrEP Uptake and Adherence Among Latinx Men Who Have Sex with Men

Latinx gay, bisexual, and other men who have sex with men (LMSM) report lower pre-exposure prophylaxis (PrEP) use than their white, non-Latinx counterparts. We hypothesize that this disparity is partially attributable to social ecological factors that can be addressed via prevention interventions. In this retrospective study, we first examined data from 253 LMSM to determine whether theorized associations existed between acquisition of a PrEP prescription (uptake) in relation to several social ecological factors based on a conceptual framework of determinants of access to and uptake of PrEP for LMSM. We also explored relations between frequency of PrEP use (adherence) and social ecological factors with a subsample of 33 LMSM who had initiated PrEP 12 months prior to assessment. In this study, individual-level factors from this framework included age and socioeconomic status. Perceived access to medical care represented both individual- and community-level determinants of PrEP uptake and adherence. Interpersonal-level factors were social support and relationship status. Structural/cultural-level factors were sexual identity development status, the masculinity norm of heterosexual self-presentation, traditional Latinx masculine gender role beliefs of machismo and caballerismo, racial identity, and immigration status. Results indicated that older men and those who endorsed the synthesis/integration status of sexual identity development were more likely to acquire a PrEP prescription during their lifetime in comparison to peers. PrEP adherence was linked with being older, reporting higher socioeconomic status, reporting more appraisal social support, self-identifying as white-Latinx, being U.S.-born, and endorsing less sexual identity uncertainty and more heterosexual self-presentation. Results specify modifiable factors that may inform tailored, community-based prevention efforts to increase PrEP use and decrease existing HIV/AIDS disparities among LMSM.

Mediating role of food insecurity in the relationship between perceived MSM related stigma and depressive symptoms among men who have sex with men in Nepal

BACKGROUND

Previous studies have indicated the association between stigma and depressive symptoms among frequently stigmatized groups, such as men who have sex with men (MSM). While this association has been suggested in the literature, there is a dearth of evidence that examines whether food insecurity statistically mediates the relationship between stigma and depressive symptoms.

METHODS

This cross-sectional study conducted between October and December 2022 among a sample of 250 MSM in Kathmandu, Nepal, recruited through respondent-driven sampling. An unadjusted model including the exposure (stigma), mediator (food insecurity), and outcome variables (depressive symptoms) and an adjusted model that controlled for sociodemographic, behavioral, and health-related confounders were used. Bootstrapping was utilized to estimate the coefficients of these effects and the corresponding 95% confidence intervals. Via bootstrap approach, we find out the mediating role of food insecurity in the association between stigma and depressive symptoms.

RESULTS

Depressive symptoms, stigma, and food insecurity were 19.6%, 24.4%, and 29.2%, respectively, among MSM. Food insecurity was associated with higher age (b = 0.094; 95% CI = 0.039, 0.150) and monthly income (b = -1.806; 95% CI = -2.622, -0.985). Depressive symptoms were associated with condom-less sex in past six months (b = -1.638; 95% CI = -3.041, -0.092). Stigma was associated with higher age (b = 0.196; 95% CI = 0.084, 0.323) and PrEP uptake (b = 2.905; 95% CI = 0.659. 5.248). Food insecurity statistically mediated 20.6% of the indirect effect of stigma in depressive symptoms.

CONCLUSION

Our findings show that food insecurity affects the relationship between stigma and depressive symptoms in this population. Reducing food insecurity and addressing the stigma surrounding sexual orientation should be a priority when addressing mental health concerns among MSM in Nepal and other resource-limited countries with similar socio-cultural settings.

Barriers to Oral PrEP: A Qualitative Study of Female Sex Workers, PrEP Prescribers, Policymakers, and Community Advocates in Morocco

In 2017, Morocco became the first Arab country to incorporate pre-exposure prophylaxis (PrEP) in its HIV-prevention program. Yet no research has been published on PrEP from Morocco. Although female sex workers are one of the target populations of PrEP in Morocco, their enrollment in PrEP is lower than men who have sex with men. In this study, we conducted 38 semi-structured interviews with female sex workers, physicians who prescribe PrEP, policymakers, and community advocates to identify problems associated with access to and use of PrEP. We also investigated preferences for daily oral, vaginal ring, and long-acting injectable PrEP. A reflexive thematic analysis revealed seven themes: PrEP stigma; stigmatization and criminalization of sex work; one size doesn't fit all; knowledge and misconceptions about PrEP; economic burden; inconvenience of PrEP pills; and preferred PrEP modalities. This paper discusses the implications of the findings for increasing access and use of PrEP in Morocco.

Digital Interventions to Enhance PrEP Uptake and Adherence Through Stigma Reduction

PURPOSE OF REVIEW

Although pre-exposure prophylaxis (PrEP) is effective for reducing risk of HIV transmission, stigma persists as a barrier to HIV prevention. Digital technologies present opportunities to access hard-to-reach populations and increase the efficiency of established interventions. This review examines current digital interventions addressing stigma to improve PrEP-related outcomes.

RECENT FINDINGS

Digital technologies are increasingly used for HIV prevention and include a wide range of formats. Recent interventions focused on stigma and PrEP tend to engage mobile phone-related technology and focus on younger populations with particular attention to men who have sex with men and transgender women. Digital interventions that address stigma are promising for improving PrEP-related outcomes. No single technology currently demonstrates consistent superiority. Limited access to PrEP and heightened stigma in under-resourced countries present challenges for interventions supporting diverse communities. Further research should examine how digital interventions can reduce stigma beyond the individual level to enhance PrEP use and explore opportunities to improve and integrate approaches to stigma measurement.

Effects of mode of transportation on PrEP persistence among urban men who have sex with men

Little is known about the effect of travel-related factors, such as mode of transportation, on retention in PrEP care, or PrEP persistence. We used data from the 2020 American Men's Internet Survey and conducted multilevel logistic regression to estimate the association between mode of transportation used for healthcare access and PrEP persistence among urban gay, bisexual, and other men who have sex with men (MSM) in the U.S. MSM using public transportation were less likely to report PrEP persistence (aOR: 0.51; 95% CI: 0.28-0.95) than MSM using private transportation. There were no significant associations between PrEP persistence and using active transportation (aOR: 0.67; 95% CI: 0.35-1.29) or multimodal transportation (aOR: 0.85; 95% CI: 0.51-1.43) compared to using private transportation. Transportation-related interventions and policies are needed to address structural barriers to accessing PrEP services and to improve PrEP persistence in urban areas.

Target users' acceptance of a pharmacist-led prescribing service for pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV)

Background

Pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) is a highly effective way to reduce virus transmission. There have been increasing calls to improve access to PrEP in Canada. One way to improve access is by having more prescribers available. The objective of this study was to determine target users' acceptance of a PrEP-prescribing service by pharmacists in Nova Scotia.

Methods

A triangulation, mixed-methods study was conducted consisting of an online survey and qualitative interviews underpinned by the Theoretical Framework of Acceptability (TFA) constructs (affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy). Participants were those eligible for PrEP in Nova Scotia (men who have sex with men or transgender women, persons who inject drugs and HIV-negative individuals in serodiscordant relationships). Descriptive statistics and ordinal logistic regression were used to analyze survey data. Interview data were deductively coded according to each TFA construct and then inductively coded to determine themes within each construct.

Results

A total of 148 responses were captured by the survey, and 15 participants were interviewed. Participants supported pharmacists' prescribing PrEP across all TFA constructs from both survey and interview data. Identified concerns related to pharmacists' abilities to order and view lab results, pharmacists' knowledge and skills for sexual health and the potential for experiencing stigma within pharmacy settings.

Conclusion

A pharmacist-led PrEP-prescribing service is acceptable to eligible populations in Nova Scotia. The feasibility of PrEP prescribing by pharmacists should be pursued as an intervention to increase access to PrEP.

Women's perspectives on barriers to potential PrEP uptake for HIV prevention: HIV risk assessment, relationship dynamics and stigma

HIV remains a significant health issue for women, and multiple overlapping factors shape women's HIV-related risk. Pre-exposure prophylaxis (PrEP) offers critical advantages over other existing options, yet it remains significantly underused among women in the USA where limited work has explored women's opinions on barriers to potential PrEP use. Using open-ended text responses from a sample of women seeking care at a US urban family planning health centre, this study aimed to understand perceptions of factors affecting potential PrEP use. Three themes concerning key factors impacting potential PrEP use emerged: HIV risk assessment, relationship dynamics, and anticipated stigma. Women's assessment of HIV risk suggests that identifying women in clinical settings as having low self-perceived risk may overlook the complexity of how women determine HIV-related risk and prevention needs. Women frequently referenced relationship dynamics when considering PrEP and discussed anticipated partner reactions about use contributing to non-use. Fear or worry of stigma were expressed as motivations to not use PrEP. Study results highlight the importance of public health and health care professionals normalising PrEP as a strategy in women's HIV prevention and sexual health decision-making. Woman-centred PrEP education, screening and communication strategies reflective of their unique HIV-related risk context are needed.

Exploring preferences and decision-making about long-acting injectable HIV pre-exposure prophylaxis (PrEP) among young sexual minority men 17-24 years old

Intramuscular cabotegravir for long-acting injectable HIV pre-exposure prophylaxis (i.e., LAI-PrEP) was approved by the U.S. FDA in 2021. We sought to explore LAI-PrEP decision-making among a nationwide sample of young sexual minority men (YSMM) 17-24 years old. In 2020, HIV-negative/unknown YSMM (n = 41) who met CDC criteria for PrEP were recruited online to participate in synchronous online focus groups eliciting preferences and opinions about LAI-PrEP, as well as the impact of a potential self-administered option. Data were analyzed using inductive and deductive thematic analysis with constant comparison. Preferences and decision-making about LAI-PrEP varied widely among YSMM, with participants frequently comparing LAI-PrEP to oral PrEP regimens. We identified five key themes related to LAI-PrEP decision-making including concerns about adherence to PrEP dosing and clinic appointments, awareness and knowledge of PrEP safety and efficacy data, comfort with needles, minimizing PrEP stigma, and considerations of self-administration. YSMM acknowledged more PrEP options as beneficial to supporting uptake and persistence.

Development and Validation of the Youth Pre-Exposure Prophylaxis (PrEP) Stigma Scale

To date, there are no established scales to assess PrEP stigma among youth. We validated the Youth PrEP Stigma Scale within the Adolescent Trials Network P3 study (2019-2021). Data from sexual and gender minority youth (16-24 years) who were prescribed PrEP across nine domestic sites were evaluated (N = 235). Descriptive statistics, exploratory factor analysis, and correlation coefficients are reported. Results yielded a three-factor solution (PrEP Disapproval by Others, Enacted PrEP Stigma, and PrEP User Stereotypes) with strong factor loadings and Cronbach's alphas ranging from 0.83 to 0.90, suggesting excellent internal consistency. Correlations between this Scale, anticipated HIV stigma, perceived HIV risk, and disclosure of sexual identity were significant, indicating potential for robust application. Given the persistence of HIV infections among youth, stigma as a barrier to prevention, and expansion of PrEP modalities, the Youth PrEP Stigma Scale could enhance intervention and mechanistic research among youth at elevated risk for HIV acquisition.

Development of a Mobile App to Increase the Uptake of HIV Pre-exposure Prophylaxis Among Latino Sexual Minority Men: Qualitative Needs Assessment

BACKGROUND

HIV disproportionally impacts Latino sexual minority men (SMM). Uptake of pre-exposure prophylaxis (PrEP), an effective biomedical intervention to prevent HIV, is low in this group compared with White SMM. Mobile health technology represents an innovative strategy to increase PrEP uptake among Latino SMM.

OBJECTIVE

We aimed to describe the qualitative process leading to the development of SaludFindr, a comprehensive HIV prevention mobile app aiming to increase PrEP uptake, HIV testing, and condom use by Latino SMM.

METHODS

We conducted 13 in-depth interviews with Latino SMM living in the Atlanta area to explore their main barriers and facilitators to PrEP uptake and to analyze their opinions of potential SaludFindr app functionalities. To explore potential app functions, we used HealthMindr, an existing HIV prevention app, as a template and added new proposed features intended to address the specific community needs.

RESULTS

We identified general PrEP uptake barriers that, although common among non-Latino groups, had added complexities such as the influence of religion and family on stigma. Low perceived PrEP eligibility, intersectional stigma, lack of insurance, cost concerns, and misconceptions about PrEP side effects were described as general barriers. We also identified Latino-specific barriers that predominantly hinder access to existing services, including a scarcity of PrEP clinics that are prepared to provide culturally concordant services, limited availability of Spanish language information related to PrEP access, distrust of peers as credible sources of information, perceived ineligibility for low-cost services owing to undocumented status, fear of immigration authorities, and competing work obligations that prevent PrEP clinic attendance. Health care providers represented a trusted source of information, and 3 provider characteristics were identified as PrEP facilitators: familiarity with prescribing PrEP; being Latino; and being part of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) group or ally. The proposed app was very well accepted, with a particularly high interest in features that facilitate PrEP access, including a tailored list of clinics that meet the community needs and a private platform to seek PrEP information. Spanish language availability and free or low-cost PrEP care represented the 2 main clinic criteria that would facilitate PrEP uptake. Latino representation in clinic staff and providers; clinic perception as a safe space for undocumented patients; and LGBTQIA+ representation was listed as additional criteria. Only 8 of 47 clinics listed on the Centers for Diseases Control and Prevention PrEP locator website for the Atlanta area fulfilled at least 2 main criteria.

CONCLUSIONS

This study provides further evidence of the substantial PrEP uptake barriers that Latino SMM face; exposes the urgent need to increase the number of accessible PrEP-providing clinics for Latino SMM; and proposes an innovative, community-driven, and mobile technology-based tool as a future intervention to overcome some of these barriers.

Discontinuation of government subsidized HIV pre-exposure prophylaxis in Australia: a whole-of-population analysis of dispensing records

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) has been government subsidized in Australia since April 2018 and while uptake is high among men who have sex with men, rates of discontinuation are also high. The aims of this study were to examine the impact of discontinuation on overall PrEP usage, the proportion of PrEP users who discontinue and the predictors of discontinuation.

METHODS

We used linked de-identified dispensing records of all government subsidized PrEP in Australia between April 2018 and September 2021: a whole-of-population data set. Defining discontinuation as 180 days or more without PrEP after the final dispensed supply, we calculated the number of people who discontinued at each 6-month interval during the study period, the proportion who had discontinued 2 years after the first supply and, using Cox regression, predictors of discontinuation.

RESULTS

Of 49,164 people dispensed PrEP (98.5% male, median age 34 years), 40.3% (19,815) had discontinued by September 2021. Within 2 years of their first supply, 11,150 (37.7%) of 29,549 PrEP users had discontinued, including 10.0% after a single dispensed supply. Large variations were observed, particularly according to prescriber characteristics: discontinuation was higher among people prescribed PrEP by low caseload (≤10 patients) prescribers (61.2%) than by high caseload (>100 patients) prescribers (31.1%, p<0.001), and by prescribers practising in areas with low estimated prevalence (<1.0%) of gay men (64.1%) than high (>5%) prevalence (36.7%, p<0.001). Women and younger people were more likely to discontinue, while patients receiving a higher level of government subsidy were less likely. The independent predictors of discontinuation with the greatest effect size were female sex (adjusted hazards ratio [aHR] 2.99, p<0.001), low estimated gay prevalence of prescriber location (aHR 1.98, p<0.001) and low prescriber PrEP caseload (aHR 1.79, p<0.001).

CONCLUSIONS

There are high rates of PrEP discontinuation in Australia and some populations are at increased risk of discontinuation. Strategies are needed to support persistence on PrEP and the re-starting of PrEP during periods of risk.

Identifying Strategies for Improving Pre-exposure Prophylaxis Adherence: Perspectives from a Sample of Highly Adherent Young Men Who have Sex with Men

Most research on pre-exposure prophylaxis (PrEP) adherence and persistence uses a deficit-based approach to identify negative influences on PrEP adherence; however, an alternative set of approaches (such as resilience, asset-based, and positive variation) may identify equally important positive influences on PrEP adherence. Thus, the current study presents qualitative perspectives of PrEP adherence strategies from a sample of adherent YMSM. PrEP-using YMSM living in the Chicago area from a larger cohort study were recruited into a 90-day diary study that measured sexual health behaviors including PrEP use. A subset (n = 28) were then recruited for in-depth interviews between April and September 2020 covering topics of PrEP use and adherence. Thematic analysis was used to interpret patterns within the data. The analytic sample (n = 19) consistently reported high levels of adherence. Adherence strategies were organized into three broader categories: psychological (e.g. mindfulness, pill auditing), technical/instrumental (e.g. automated reminders, pill organizers), and social strategies (e.g. checking in with friends, or getting suggestions from friends). The majority of participants described using multiple strategies and changing strategies to respond to barriers to adherence. Other themes that were related to adherence included having a daily medication history and a generally positive outlook toward the PrEP regimen. Those who had medication histories were able to draw from experience to develop strategies for PrEP adherence. Findings suggest the need for pre-emptive counseling for PrEP-initiators on the use of multiple strategies, how to prepare for PrEP adherence, to adapt to challenges, and to adopt a range of potential strategies for adherence.

Black Sexual Minority Men's Stigma-Based Experiences Surrounding Pre-exposure Prophylaxis in the Southern United States

Purpose: Intersecting experiences of stigma related to pre-exposure prophylaxis (PrEP) influence PrEP uptake among Black sexual minority men (BSMM) living in the southern United States; however, it is unclear what stigmatized identities and behaviors are impacted when accessing human immunodeficiency virus prevention options. To inform identity-specific PrEP interventions, this study examined stigma in BSMM's lives relating to intersecting experiences of PrEP stigma. Methods: We conducted 32 virtual, semistructured qualitative interviews with BSMM residing in the southeastern United States between February and April 2019. Results: We identified three themes (anticipated stigma, experiences of prejudice and stereotyping, and negative attitudes) and one subtheme within negative attitudes (othering social/sexual groups). Across all themes, PrEP stigma was often manifested through stigma against BSMM's sexual orientation or sexual behavior. BSMM in othering social/sexual groups displayed instances of cognitive dissonance by regularly expressing negative attitudes about and explicitly distancing themselves from social/sexual groups based on sexual orientation and sexual behavior. BSMM's race and gender were rarely mentioned as being stigmatized. Conclusions: Interventions focused on PrEP use could benefit from expanding their definition of PrEP stigma to include a stronger emphasis on intersecting identities and work to reduce cognitive dissonance in BSMM in the form of internalized homophobia.

PrEP-related stigma and PrEP use among gay, bisexual and other men who have sex with men in Ontario and British Columbia, Canada

Background

We aimed to explore the association between PrEP-related stereotypes and perceived disapproval (hereafter PrEP-related stigma), and PrEP use.

Methods

We used data from a cross-sectional online survey among adult gay, bisexual, other men who have sex with men in Ontario and British Columbia, Canada. Participants were recruited 2019–2020 in-person from sexual health clinics and outreach programs, and online through dating mobile applications and websites. We used logistic regression models to explore the relationship between PrEP-related stigma and: 1-being a ‘never’ versus ‘current’ PrEP user, and 2-being a ‘former’ versus ‘current’ user.

Results

The median age of the sample was 32 (Q1-Q3 = 27–40), most were white born in Canada (48%), 45% had never used PrEP, 16% were former PrEP users and 39% were current PrEP users. Of 1527 individuals who started the survey, 1190 participants answered questions about PrEP-related stigma: 254 (21.3%) were classified as having low level of PrEP-related stigma, 776 (65.2%) intermediate, and 160 (13.5%) high. No significant association was found when never PrEP users and current PrEP users were compared: adjusted OR = 1.44 (95%-CI: 0.8–2.5). High PrEP-related stigma was positively associated with being a former PrEP user compared to being a current PrEP user: adjusted OR = 2.5 (95%-CI: 1.3–4.9).

Conclusion

PrEP-related stigma is associated with not using PrEP, particularly with PrEP discontinuation. Our findings indicate that stigma persists as a barrier to PrEP use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-022-00473-0.

Assumptions about patients seeking PrEP: Exploring the effects of patient and sexual partner race and gender identity and the moderating role of implicit racism

Introduction

Daily pre-exposure prophylaxis (PrEP) for HIV-prevention is an essential component of national plans to end the HIV epidemic. Despite its well-documented safety and effectiveness, PrEP prescription has not met the public health need. Significant disparities between White and Black people exist with respect to PrEP prescription, as do disparities between men and women. One factor contributing to these disparities is clinicians’ assumptions about patients seeking PrEP.

Methods

The present study sought to investigate medical students’ assumptions about patients seeking PrEP (anticipated increased condomless sex, extra-relational sex, and adherence to PrEP), and assumed HIV risk when presenting with their sexual partner. We systematically varied the race (Black or White) and gender (man or woman) of a fictional patient and their sexual partner. All were in serodifferent relationships including men who have sex with men (MSM), women (MSW), and women who have sex with men (WSM). Participants also completed an implicit association test measuring implicit racism against Black people. We evaluated the moderation effects of patient and partner race on assumptions as well as the moderated moderation effects of implicit racism.

Results

A total of 1,472 students participated. For MSM patients, having a Black partner was associated with higher assumed patient non-adherence to PrEP compared to a White partner, however a White partner was associated with higher assumed HIV risk. For MSW patients, a White male patient was viewed as being more likely to engage in more extra-relational sex compared to a Black male patient. For WSM patients, White women were assumed to be more likely to have condomless and extra-relational sex, be nonadherent to PrEP, and were at higher HIV risk. Overall, implicit racism was not related to negative assumptions about Black patients as compared to White patients based on patient/partner race.

Discussion

Medical education about PrEP for HIV prevention must ensure future health professionals understand the full range of patients who are at risk for HIV, as well as how implicit racial biases may affect assumptions about patients in serodifferent couples seeking PrEP for HIV prevention. As gatekeepers for PrEP prescription, clinicians’ assumptions about patients seeking PrEP represent a barrier to access. Consistent with prior research, we identified minimal effects of race and implicit racism in an experimental setting.

Race and Sexual Identity Differences in PrEP Continuum Outcomes Among Latino Men in a Large Chicago Area Healthcare Network

U.S. HIV incidence is threefold higher among Latino individuals than non-Latino Whites. Pre-exposure prophylaxis (PrEP) uptake remains low among Latino men. Most HIV studies view Latino communities as a monolithic group, ignoring racial and sexual diversity. This analysis examines PrEP-related outcomes including eligibility, first prescription, and second prescription across race and sexual identity in a sample of Latino cisgender men (n = 8271) who sought services from a healthcare network in Chicago in 2012-2019. Logistic regression was used to calculate adjusted odds ratios. Latino-only participants had lower odds of PrEP eligibility and first prescription compared to White-Latino participants. No other significant differences by race were detected. While bisexual participants had equivalent odds of PrEP eligibility, they had lower odds of first PrEP prescription compared to gay participants. Heterosexual participants also had lower odds of PrEP eligibility and initiation. Future research should address unique factors shaping PrEP-related outcomes among diverse Latino populations.

Correlates of Homonegativity Towards Men Who Have Sex With Men Among Black Individuals in the United States

This study aims to identify the factors that are associated with homonegativity toward men who have sex with men (MSM) within Black communities since the expansion of LGBTQ rights. A survey was completed in 2016 by a nationally representative sample of 868 Black respondents, 18-50 years old, via e-mail. Demographics, perception of same-gender sexual behaviors, religiosity, experienced racism, and contact with the carceral system (CS) were assessed. 61.6% of respondents endorsed at least one homonegative belief. Being male, residing in the South, attending religious services, receiving homonegative faith messaging, and having contact with the CS were significantly associated with homonegativity toward MSM while experiencing racism, older age, and residing in a non-metropolitan area were not. Education efforts on LGBTQ identities in Black communities should engage faith communities, extend to metropolitan and non-metropolitan areas of the South, and include younger and older adults. Programs that decrease the arrest of Black individuals may also help reduce homonegativity toward MSM.

Potential Role of Conversational Agents in Encouraging PrEP Uptake

Approximately 1.2 million people are living with HIV, with many of them unaware of their infection. Pre-exposure prophylaxis (PrEP) is available to minimize transmission among those at high risk for infection, including men who have sex with men, people who inject drugs, and female sex workers. Despite its availability, there is low usage of PrEP. To address this problem, various digital tools have been examined in HIV research. Among those, conversational agents are still underused and their capacity warrants examination to reach at-risk populations. In this paper, we discuss the potential of conversational agents in increasing uptake of PrEP by addressing barriers experienced among those at high risk for infection.

What will it take to meet UNAIDS targets for preexposure prophylaxis users?

PURPOSE OF REVIEW

Preexposure prophylaxis (PrEP) is a critical strategy to curb new HIV infections globally. National and global targets have been set for people starting PrEP. However, global PrEP initiations fell short of UNAIDS 2020 targets, and reflection is needed on how we set and meet targets for PrEP use.

RECENT FINDINGS

Recent literature documents challenges to meeting ambitious goals for PrEP coverage in multiple phases of PrEP: PrEP initiations are limited by gaps in the identification of those who might benefit from PrEP. Conversely, getting PrEP to those who need it most is threatened by inaccurate risk perception and HIV and PrEP stigma. Once people are on PrEP, a substantial number discontinue PrEP in the first year (the 'PrEP Cliff'), a finding that is robust across groups of PrEP users (e.g., women, men who have sex with men, transwomen) and across global prevention settings. Further, PrEP inequities - by which we refer to utilization of PrEP in a specific group that is not commensurate with their epidemic risk - threaten the overall population benefit of PrEP because those at highest risk of acquiring HIV are not adequately protected.

SUMMARY

To realize global goals for PrEP utilization and impact, we must address multiple points of PrEP delivery programs that address not just PrEP starts, but also retention in PrEP and measurement and accountability to PrEP equity. We call for new approaches to better identify PrEP candidates, suggest additional research to address the known and consistent reasons for PrEP discontinuations, and advocate for metrics to measure and be accountable to PrEP equity.

Expanding the Pie-Differentiated PrEP Delivery Models to Improve PrEP Uptake in the San Francisco Bay Area

BACKGROUND

Pre-exposure prophylaxis (PrEP) uptake among trans people to date has been low. Recommendations implemented in San Francisco to offer PrEP with feminizing hormones have not led to improvement of PrEP uptake in trans communities. New delivery models may be needed. The aim of this study was to examine whether a PrEP-only clinic was more likely to serve trans people at highest risk of HIV than trans-affirming primary care clinics.

METHODS

Participants were recruited between 2017 and 2019 as part of a PrEP demonstration project in the San Francisco Bay Area. Survey data including sociodemographics, HIV-related risk behavior, barriers to PrEP, and self-reported PrEP adherence were collected at baseline, 3 months, and 6 months for all participants. Bivariable Poisson regression models were used to examine differences between participants in the primary care clinics and PrEP-only clinic delivered to participants.

RESULTS

Baseline survey data were collected from 153 participants. Those with a higher number of sexual partners were significantly more likely to use the PrEP-only clinic rather than the primary care clinics. Participants with higher perceived HIV risk and those who engaged in sex work were also more likely to use the PrEP-only clinic compared with the primary care clinic. Medical mistrust was higher at baseline among participants of the PrEP-only clinic. PrEP adherence was not significantly different by delivery model. Few participants identified PrEP barriers, such as interactions with feminizing hormones, to be determinants of PrEP uptake.

CONCLUSIONS

A PrEP-only delivery model could improve PrEP uptake and may better meet the needs of trans people who could most benefit from PrEP.

PrEP Willingness and Adherence Self-Efficacy Among Men Who have Sex with Men with Recent Condomless Anal Sex in Urban China

This study investigates PrEP willingness, adherence self-efficacy and potential impact of PrEP among HIV-negative, Chinese men who have sex with men (MSM; n = 622) with recent condomless anal sex. Facilitative factors of PrEP willingness included migrant status, sexual risk, and prior PrEP use, whereas barriers included concerns over being treated as an HIV/AIDS patient, recent HIV testing, identity concealment, and HIV prevention service usage. Adherence self-efficacy was associated with PrEP knowledge and confidence in PrEP efficacy of HIV prevention. A total of 39.3% anticipated increase in sex partners, 25.6% anticipated decrease in condom use, and 38.0% anticipated increased HIV testing following PrEP uptake. Results suggest a two-step approach to (1) promote PrEP acceptance among Chinese MSM and (2) enhance adherence and risk monitoring among PrEP-willing MSM. Efforts to reduce stigma, incorporate PrEP in the HIV prevention continuum, and increase PrEP knowledge will be crucial to optimize PrEP implementation.