Intersecting Barriers to PrEP Awareness and Uptake in Black Men Who Have Sex with Men in Atlanta, GA: a Syndemic Perspective

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.

Examining the secondary impacts of the COVID-19 pandemic on syndemic production and PrEP use among gay, bisexual and other men who have sex with men (GBM) in Vancouver, Canada

BACKGROUND

The secondary impacts of the COVID-19 pandemic may disproportionately affect gay, bisexual, and other men who have sex with men (GBM), particularly related to HIV prevention and treatment outcomes. We applied syndemic theory to examine PrEP disruptions during the during the height of the COVID-19 pandemic in Vancouver, Canada.

METHODS

Sexually-active GBM, aged 16 + years, were enrolled through respondent-driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer-Assisted Self-Interview every six months and data were linked to the BC PrEP Program (program responsible for publicly funded PrEP in the province) to directly measure PrEP disruptions. The analysis period for this study was from March 2018-April 2021. We used univariable generalized linear mixed models to examine (1) six-month trends for syndemic conditions: the prevalence of moderate/severe depressive or anxiety symptoms, polysubstance use, harmful alcohol consumption, intimate partner violence, and (2) six-month trends for PrEP interruptions among HIV-negative/unknown GBM. We also applied 3-level mixed-effects logistic regression with RDS clustering to examine whether syndemic factors were associated with PrEP interruptions.

RESULTS

Our study included 766 participants, with 593 participants who had at least one follow-up visit. The proportion of respondents with abnormal depressive symptoms increased over the study period (OR = 1.35; 95%CI = 1.17, 1.56), but we found decreased prevalence for polysubstance use (OR = 0.89; 95%CI = 0.82, 0.97) and binge drinking (OR = 0.74; 95%CI = 0.67, 0.81). We also found an increase in PrEP interruptions (OR = 2.33; 95%CI = 1.85, 2.94). GBM with moderate/severe depressive symptoms had higher odds (aOR = 4.80; 95%CI = 1.43, 16.16) of PrEP interruptions, while GBM with experiences of IPV had lower odds (aOR = 0.38; 95%CI = 0.15, 0.95) of PrEP interruptions. GBM who met clinical eligibility for PrEP had lower odds of experiencing PrEP interruptions (aOR = 0.25; 95%CI = 0.11, 0.60).

CONCLUSION

There were increasing PrEP interruptions since March 2020. However, those most at risk for HIV were less likely to have interruptions. Additional mental health services and targeted follow-up for PrEP continuation may help to mitigate the impacts of the COVID-19 pandemic on GBM.

"Let's Be a Person to Person and Have a Genuine Conversation": Comparing Perspectives on PrEP and Sexual Health Communication Between Black Sexual Minority Men and Healthcare Providers

Patient-provider communication is a key factor affecting HIV pre-exposure prophylaxis (PrEP) awareness and access among Black sexual minority men (SMM). Optimizing patient-provider communication requires a deeper understanding of communication dynamics. In this study, we investigated the perspectives of both HIV-negative/status-unknown Black SMM and practicing community healthcare providers regarding patient-provider communication about PrEP and sexual health. We conducted eleven semi-structured qualitative focus groups (six with Black SMM; five with providers) in the Northeastern USA and thematically analyzed transcripts. A total of 36 Black SMM and 27 providers participated in the focus groups. Our analysis revealed points of alignment and divergence in the two groups' perspectives related to patient-provider communication. Points of alignment included: (1) the importance ascribed to maximizing patients' comfort and (2) belief in patients' right to non-discriminatory healthcare. Points of divergence included: (1) Black SMM's preference for sexual privacy versus providers' preference that patients share sexual information, (2) Black SMM's perception that providers have an ethical responsibility to initiate conversations about PrEP with patients versus providers' perception of such conversations as being optional, and (3) Black SMM's preference for personalized sexual health conversations versus providers' preference for standardized conversations. Findings underscore a need for providers to offer more patient-centered sexual healthcare to Black SMM, which should entail routinely presenting all prevention options available-including PrEP-and inviting open dialogue about sex, while also respecting patients' preferences for privacy about their sexuality. This approach could increase PrEP access and improve equity in the US healthcare system.

Risk Behaviors Associated with Patterns of Sexualized Stimulant and Alcohol Use among Men Who Have Sex with Men: a Latent Class Analysis

Substance use during sexual encounters (sexualized substance use) is an important driver of HIV and sexually transmitted infection (STI) disparities that are experienced by men who have sex with men (MSM). This analysis aimed to identify patterns of sexualized substance use and their associations with HIV risk behaviors. We utilized visit-level data from a longitudinal cohort of predominantly Black/Latinx MSM, half with HIV and half with substance use in Los Angeles, California. Every 6 months from 8/2014 to 3/2020, participants underwent STI testing and completed surveys on demographics, sexualized substance use (stimulant and/or alcohol intoxication during oral sex, receptive anal intercourse [RAI] and/or insertive anal intercourse [IAI]), transactional sex, biomedical HIV prevention (pre-/post-exposure prophylaxis use or undetectable viral load), and depressive symptoms. Latent class analysis was used to identify patterns of sexualized substance use. Multinomial logit models evaluated risk behaviors associated with latent classes. Among 2386 study visits from 540 participants, 5 classes were identified: no substance use, sexualized stimulant use, sexualized alcohol use, sexualized stimulant and alcohol use, and stimulant/alcohol use during oral sex and RAI. Compared to the no sexualized substance use class, sexualized stimulant use was associated with transactional sex, current diagnosis of STIs, not using HIV biomedical prevention, and depressive symptoms. Sexualized alcohol use had fewer associations with HIV risk behaviors. Patterns of sexual activities, and the substances that are used during those activities, confer different risk behavior profiles for HIV/STI transmission and demonstrate the potential utility of interventions that combine substance use treatment with HIV prevention.

Relationships among Substance Use, Sociodemographics, Pre-Exposure Prophylaxis (PrEP) Awareness and Related Attitudes among Young Adult Men Who Have Sex with Men

Men who have sex with men (MSM) account for two-thirds of new HIV diagnoses. Pre-exposure prophylaxis (PrEP), a highly efficacious HIV preventive medication, is underutilized. Identifying correlates of PrEP awareness and attitudes may help increase PrEP use. Thus, we evaluated (1) PrEP awareness; (2) differences in awareness related to substance use and sociodemographics; (3) initial PrEP information sources; and (4) possible associations between information sources and PrEP-related attitudes.

Young adult (ages 18-30) HIV-negative MSM from Southern U.S. undertook a web survey including questions about substance use, sexual behaviors, perceived HIV risk, and PrEP. Participants were recruited using in-person and online approaches between January 2018-January 2020.

Of 506 participants, 89% were aware of PrEP. Participants with high alcohol consumption and greater perceived HIV risk had higher odds of PrEP unawareness with a trend for minority race/ethnicity. PrEP-aware participants reported high overall perceived safety, confidence in PrEP's efficacy, and low perceived difficulties with adherence though those with higher perceived HIV risk and individuals who used tobacco had less favorable attitudes. Most participants first heard about PrEP from the internet. There were no statistically significant differences in PrEP-related attitudes across initial information sources.

Associations between substance use and racial/ethnic minority status and lack of PrEP awareness suggest priority subgroups for educational campaigns. Future campaigns may tailor outreach materials to the respective audience (e.g., Spanish materials for Hispanic people) and disseminate where individuals who use substances may be more likely to see them (e.g., liquor and convenience stores).

Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2022.2040030 .

A Scoping Review Investigating Relationships between Depression, Anxiety, and the PrEP Care Continuum in the United States

Men who have sex with men and transgender women in the United States are at increased risk for HIV and may benefit from pre-exposure prophylaxis (PrEP), a once-a-day pill to prevent HIV. Due to stigma and discrimination, sexual and gender minority (SGM) populations are also at risk for depression and anxiety. This scoping review sought to identify literature addressing relationships between the PrEP care continuum, depression, and anxiety among SGM individuals and others at high risk for HIV. We conducted a systematic review of four databases (i.e., PubMed, PsycInfo, Web of Science, Google Scholar) and identified 692 unique articles that were screened for inclusion criteria, with 51 articles meeting the final inclusion criteria. Data were extracted for key study criteria (e.g., geographic location, participant demographics, study design, main findings). Results suggest that while depression and anxiety are not associated with PrEP awareness or willingness to use, they can be barriers to seeking care and to PrEP adherence. However, empirical studies show that taking PrEP is associated with reductions in anxiety. Findings suggest the need to implement mental health screenings in PrEP clinical care. In addition, addressing systemic and structural issues that contribute to mental health disorders, as well as PrEP-related barriers, is critical.

Pre-exposure Prophylaxis in LGBT Communities

Gay, bisexual and other men who have sex with men (MSM) and transgender individuals face the highest burden of human immunodeficiency virus (HIV) infection. HIV pre-exposure prophylaxis (PrEP) is an effective evidence-based biomedical intervention to reduce acquisition of HIV infection but uptake has been suboptimal in lesbian, gay, bisexual, and transgender (LGBT) populations. Primary care providers play an integral role in addressing HIV disparities by educating patients and facilitating access to PrEP. After PrEP initiation, primary care providers should assess for and manage adverse effects, provide appropriate laboratory monitoring, support adherence, and assist patients with access to low-cost or free PrEP options if needed.