Assessment of PrEP Awareness, PrEP Discussion with a Provider, and PrEP Use by Transmission Risk Group with an Emphasis on the Southern United States

Awareness and Uptake of Pre-Exposure Prophylaxis (PrEP) for HIV Prevention Among Men who have Sex with Men in Nepal

Pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention strategy that remarkably reduces HIV transmission risk. Although PrEP has been available in Nepal since 2019, very little is known about PrEP use among MSM in Nepal. This study aimed to examine PrEP awareness and its use among Nepali MSM and the factors influencing its adoption. A cross-sectional survey was conducted among MSM in Nepal between October and December 2022 (N = 250). Bivariate analysis and logistic regression were performed to determine factors associated with awareness and use of PrEP. In the study population, 59.6% of participants were aware of PrEP, however, only 30.4% of them had utilized it. The odds of PrEP awareness were higher among participants who had completed high school or above (aOR = 4.1; 95% CI = 1.8-9.6), those with health insurance coverage (aOR = 6.9; 95% CI = 2.1-22.3) and had tested for HIV (aOR = 21.2; 95% CI = 8.3-53.9). Similarly, participants who identified as gay (aOR = 3.4; 95% CI = 1.4-8.4), had visited a doctor within the past 6 months (aOR = 2.9; 95% CI = 1.2-6.5), had previously tested for HIV (aOR = 12.3; 95% CI = 3.4-44.7), and had been diagnosed with sexually transmitted infections (aOR = 7.0; 95% CI = 2.5-19.5) were more likely to have used PrEP. Our results highlight the critical importance of healthcare providers engaging in providing care for MSM, including facilitating as well as discussions about PrEP. In addition, there is a pressing need for innovative strategies (e.g., peer educators, social media, online facilitating technologies) to disseminate PrEP knowledge and reduce stigma surrounding PrEP.

Structural vulnerabilities and PrEP awareness among Boston heterosexuals and people who inject drugs at risk for HIV: findings from 2018 to 2019 cycles from the Boston, MA site of the NHBS

Little is known about biopsychosocial factors relating to pre-exposure prophylaxis (PrEP) awareness among people with either heterosexual or injection drug use HIV risk behaviors. Participants engaged in vaginal/anal sex with a person of the opposite sex (N = 515) or were people who injected drugs (PWID; N = 451) in the past 12 months from 2018-2019 in Boston, MA. We examined associations between PrEP awareness and: homelessness; perceived HIV-related stigma; country of birth; bacterial STDs, chlamydia, and/or gonorrhea in the past 12 months, lifetime hepatitis C virus (HCV) infection, sexual orientation, and poverty. More PWID (36.8%) were aware of PrEP than people with heterosexual HIV risk (28%; p = .001). Among people with heterosexual risk, homelessness (aOR = 1.99, p = .003), and among PWID: homelessness (aOR = 2.11, p = .032); bacterial STD (aOR = 2.96, p = .012); chlamydia (aOR = 6.14, p = .008); and HCV (aOR = 2.40, p < .001) were associated with increased likelihood of PrEP awareness. In the combined sample: homelessness (aOR = 2.25, p < .001); HCV (aOR = 2.18, p < .001); identifying as homosexual (aOR = 3.71, p = .036); and bisexual (aOR = 1.55, p = .016) were each associated with PrEP awareness. Although having an STD, HCV, identifying as homosexual or bisexual, and experiencing homelessness were associated with increased PrEP awareness, most participants were unaware of PrEP. Efforts to increase PrEP awareness could engage PWID and heterosexual HIV risk behavior.

Attitudes and Intentions toward Use of HIV Pre-Exposure Prophylaxis (PrEP) among Adults Receiving Treatment for Opioid Use

Background: Although pre-exposure prophylaxis (PrEP) prevents HIV, little is known about PrEP awareness and factors associated with intention to take PrEP among people with opioid use disorder (OUD). Methods: HIV-negative adults recruited from an outpatient treatment program in Cincinnati, Ohio completed self-administered surveys. Items derived from literature and health behavioral theory included demographics, sexual and drug use behaviors, HIV prevention practices, PrEP knowledge, and attitudes toward PrEP. Primary outcomes were 1) intention to ask a clinician about PrEP and 2) intention to accept PrEP if recommended by a clinician. Outcomes were dichotomized into higher vs. lower intention for analyses in logistic regression models. Results: Among 198 participants, 60.3% reported past injection drug use. Among 58 participants (29.3%) meeting criteria for PrEP, 24% were aware of PrEP, 15.5% had discussed it with a clinician, and 5% had taken it. Factors associated with intention to ask a clinician about PrEP included being somewhat confident about consistent condom use (p < 0.01), motivation to comply with normative beliefs (p < 0.01), and reporting that PrEP fits very well (p < 0.01) and is easy to fit (p < 0.01) into current prevention practices. Factors associated with intention to accept PrEP if recommended by a clinician included motivation to comply with normative beliefs (p < 0.01) and PrEP being easy to fit into current prevention practices (p < 0.01). Conclusion: Among participants meeting indications for PrEP, only 24% were aware of it and few had taken it. Interventions that normalize PrEP and target incorporating PrEP into current prevention practices may improve uptake among individuals with OUD.

Targeted social marketing of PrEP and the stigmatization of black sexual minority men

Disparities in HIV incidence and PrEP uptake suggest a need to prioritize Black sexual minority men (SMM) in PrEP social marketing initiatives. However, images linking Black SMM to HIV and PrEP may inadvertently reinforce stigma. We examined HIV-negative/status-unknown Black SMM's responses to targeted PrEP advertisements using mixed methods, including an experiment embedded in a longitudinal online survey (Time 1: n = 96; Time 2 [eight weeks]: n = 73) and four focus groups (n = 18). The full factorial experiment included between-groups and within-subjects comparisons. For between-groups comparisons, each participant was randomly assigned to view one of 12 advertisements, which varied by couple composition (Black SMM couple/Black heterosexual couple/multiple diverse couples/no couples) and campaign (PrEPare for the Possibilities/PlaySure/PrEP4Love). We examined couple composition, campaign, and interaction effects on: advertisement judgments (Time 1), PrEP stigma (Time 1), PrEP motivation (Times 1 and 2), and PrEP behavior (Time 2). For within-subjects comparisons, each participant viewed all 12 advertisements, and we examined couple composition, campaign, and interaction effects on advertisement judgments (Time 2). Focus group participants discussed advertising preferences and responded to the same set of advertisements. For between-groups and within-subjects comparisons, we found significant couple composition effects but no or limited campaign and interaction effects on advertisement judgments. Advertisements featuring Black SMM exclusively were judged as more stigmatizing than advertisements without couples. Advertisements with diverse (vs. no) couples were considered more eye-catching and motivating. There were minimal effects of couple composition and campaign on PrEP stigma, motivation, and behavior. Focus group participants corroborated concerns about the potential for PrEP advertisements to be stigmatizing, suggesting advertisements featuring Black SMM exclusively could be alienating and fuel conspiracy theories. Focus group participants generally favored diverse and less sexualized advertisements, particularly for public spaces. Findings collectively highlight the potential for targeted PrEP advertisements to stigmatize Black SMM and support diverse representation.

Variations in Pre-exposure Prophylaxis (PrEP) Awareness and Healthcare Provider Interactions in a Nationally Representative Sample of American Men Aged 15-49 Years: A Cross-Sectional Study

Awareness of and discussions with a healthcare provider (HCP) around pre-exposure prophylaxis (PrEP), an effective HIV prevention method, are associated with PrEP uptake, yet few studies utilize representative samples or report on these outcomes using distinct behavioral risk subgroups. This cross-sectional study utilized responses given by men on the 2017-2019 National Survey of Family Growth, a nationally representative survey of Americans aged 15-49 years. Multiple logistic regression models were used to determine how respondents' sociodemographic characteristics and HIV risk behaviors were related to PrEP awareness and HCP discussions. PrEP awareness was low (29.40%) as was the proportion who reported ever discussing PrEP with an HCP (4.48%). Odds of being PrEP aware and discussing PrEP with an HCP varied significantly within sexual behavior subgroups based on sociodemographic and behavioral characteristics highlighting the differential risks within distinct behavioral subgroupings of men. Sexual behavior subgroupings should be considered when promoting PrEP awareness and discussions as HIV risk behaviors vary considerably and sexual identity alone may not sufficiently capture one's HIV risk.

Co-occurring Epidemic Conditions Among Southern U.S. Black Men Who Have Sex with Men in an Online eHealth Intervention

Black men who have sex with men (BMSM) face disproportionately higher risks for adverse sexual health outcomes compared to their non-Hispanic White counterparts. This disparity can be attributable to overlapping and intersecting risk factors at the individual and structural levels and can be understood through syndemic theory. Using longitudinal data from the HealthMPowerment trial (n = 363), six conditions related to stigma syndemics were indexed as a cumulative risk score: high alcohol use, polydrug use, depression and anxiety symptomology, and experiences of racism and sexual minority stigma. Using Poisson regression, we found a positive association between baseline risk scores and sexual risk behavior (b: 0.32, SE: 0.03, p < 0.001). Using a Generalized Estimating Equation, we also found a 0.23 decrease in the within-participant risk scores at 3-month follow-up (SE: 0.10, p < 0.020). Future work examining how care and prevention trials improve health outcomes in this population is needed.

An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers' PrEP-Related Clinical Judgments

Social biases may influence providers' judgments related to pre-exposure prophylaxis (PrEP) and patients' consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.

Reproductive intentions among HIV-negative gay and bisexual men initiating pre-exposure prophylaxis in the Sustainable Health Center Implementation pre-exposure prophylaxis pilot study, 2014-2016

INTRODUCTION

We assessed reproductive intentions and associated characteristics among men enrolled in the Sustainable Health Center Implementation pre-exposure prophylaxis (PrEP) Pilot (SHIPP) Study.

METHODS

We analyzed baseline data from 1275 men who self-identified as gay or bisexual and participated in the SHIPP study. SHIPP was a cohort study of PrEP implementation in five community health centers in Chicago, Jackson, Philadelphia, and Washington, D.C. conducted from 2014 to 2016. Participants completed audio computer-assisted self-interviews querying intentions to have a child in the future. We estimated the association between participants' reproductive intentions and their characteristics using Poisson regression models.

RESULTS

Approximately 47% of participants indicated their intentions to have a child. Black/non-Hispanic (aPR = 1.40; 95% CI: 1.10-1.78) and other/non-Hispanic participants (aPR = 1.40; 95% CI: 1.01-1.93) were more likely to report intentions to have a child than white/non-Hispanic participants. Participants were less likely to report intentions to have children as age increased (18-29 years, reference group; 30-39 years, aPR = 0.80, 95% CI: 0.64-0.99; 40-49 years, aPR = 0.49, 95% CI: 0.33-0.72; 50+ years, aPR = 0.07, 95% CI: 0.02-0.21).

CONCLUSIONS

Clinicians offering PrEP to black and other/non-Hispanic gay and bisexual men should assess their reproductive intentions as family-planning counseling may be an opportunity to introduce PrEP to HIV-negative gay and bisexual men.

Awareness of HIV Preexposure Prophylaxis Among People at Risk for HIV: Results From the 2017-2019 National Survey of Family Growth

BACKGROUND

Although daily preexposure prophylaxis (PrEP) is now widely accepted as a safe and effective method for reducing the risk of HIV in high-risk groups, uptake has been slow. The goal of this analysis was to identify factors associated with PrEP awareness among individuals at risk for HIV.

METHODS

This investigation analyzed data from the Centers for Disease Control and Prevention nationally representative survey, National Survey of Family Growth, for the years 2017 to 2019. Logistic regression was used to explore the relationship between PrEP awareness and demographics, HIV risk factors, and provider HIV risk screening.

RESULTS

Only 37% of survey respondents with an increased risk of HIV were aware of PrEP. Several segments of the at-risk population had lower odds of being aware of PrEP, including heterosexual women, heterosexual men, individuals younger than 20 years, and individuals with lower levels of education. Those who participate in sex in exchange for money or drugs had significantly lower odds of being aware of PrEP. In comparison, PrEP awareness was significantly higher among nonheterosexual men and both men and women whose partners were HIV positive. Lastly, those who had been screened by a provider for HIV risk had significantly higher odds of being aware of PrEP.

CONCLUSIONS

This research supports the need for policies and programs to increase awareness of PrEP, especially among certain segments of the population at increased risk for HIV.

Providers PrEP: Identifying Primary Health care Providers' Biases as Barriers to Provision of Equitable PrEP Services

BACKGROUND

Despite their disparately high HIV incidence and voiced willingness to use pre-exposure prophylaxis (PrEP), Black cisgender women's knowledge and uptake of PrEP are low, especially relative to White cisgender women and men who have sex with men. Mounting evidence demonstrates that health care provider recommendations are a critical factor in women's awareness, willingness, and ability to uptake PrEP. Health care providers may make clinical judgments about who is (not) a good candidate for PrEP based on unconscious and conscious stereotypes and prejudice.

SETTING

We conducted an online experiment among N = 160 health care providers with prescribing privileges in the 48 HIV hotspot counties.

METHOD

Providers received 1 of 4 vignettes about a PrEP eligible woman. Vignettes varied by patient race and substance use status. Then, providers reported their willingness to discuss PrEP with the patient and willingness to prescribe PrEP to her.

RESULTS

We tested 2 models predicting providers (1) willingness to discuss and (2) willingness to prescribe PrEP, contingent on their racial attitudes. Providers who scored high on a modern racism measure were less willing to discuss and prescribe PrEP to the Black patient. These effects were mediated by provider perceptions of patients' abilities to adhere to PrEP, but not their expectations of risk compensatory behaviors.

CONCLUSIONS

Our findings highlight the importance of applying an intersectional lens in documenting the processes that exacerbate inequities in PrEP use. This study provides evidence to support the development of interventions that address the mechanisms that work to thwart optimal care.

Prevalence of U = U Awareness and Its Association with Anticipated HIV Stigma Among Low-Income Heterosexually Active Black and Latino Adults in New York City, 2019

The fact that people with HIV (PWH) who have an undetectable viral load cannot sexually transmit HIV has been disseminated under the messaging "Undetectable = Untransmittable" (U = U). U = U messaging intends to destigmatize HIV by demonstrating that PWH can have healthy sexual lives. Among a sample of low-income heterosexually active Black and Latino adults, we aimed to (1) measure the prevalence of U = U awareness and (2) determine its association with anticipated HIV stigma. Low-income heterosexually active adults were recruited through respondent-driven sampling in New York City. Among Black and Latino participants who self-reported not having HIV, multiple linear regression was used to determine the association between U = U awareness with the following types of anticipated HIV stigma, as determined by principal component analyses: (1) general; (2) dating related; and (3) sex related. Of 485 participants, 35% were aware of U = U. Those who were aware reported less dating-related [adjusted B: -0.20; 95% confidence interval (CI): -0.37 to -0.03] and sex-related (adjusted B: -0.15; 95% CI: -0.29 to -0.002) anticipated HIV stigma. Although the prevalence of U = U awareness was much lower than reported in other populations (e.g., gender and sexual minorities and PWH), prevalence was moderate in our sample, given that awareness efforts have generally not focused on heterosexually active adults. Our findings provide preliminary evidence that U = U awareness may have an impact on anticipated HIV stigma related to dating and sex. Additional methods to disseminate U = U messaging and dismantle HIV stigma in this population should be explored.