Persistent stigmatizing and negative perceptions of pre-exposure prophylaxis (PrEP) users: implications for PrEP adoption among Latino men who have sex with men

Culturally Targeted Video Intervention to Increase PrEP Use Intentions Among Latinx Sexual Minority Men: A Pilot Randomized Controlled Trial

Background: Latinx sexual minority men experience the greatest human immunodeficiency virus (HIV) burden in the United States. Pre-exposure prophylaxis (PrEP) is the most effective HIV prevention tool available, however, PrEP uptake remains low among this group. Methods: This two-arm pilot randomized controlled trial study aimed to assess the feasibility and preliminary efficacy of delivering an online culturally targeted video intervention that aims to increase PrEP uptake intentions among Latinx sexual minority men. The intervention group received a culturally targeted video that contained the same PrEP information as the control group and incorporated positive aspects of Latinx masculinity (i.e., caballerismo). Participants were recruited through Amazon's MTurk crowd-sourcing platform. A total of twenty-five participants met the study inclusion criteria (N = 25). Results: The control group had a higher mean PrEP intentions score (M: 3.3, 95% CI: 2.7-3.9) when compared with the intervention group. A moderate, negative, linear correlation was observed between machismo and PrEP intention scores (r = -.34). In contrast, a small, positive correlation was found between caballerismo and PrEP intentions (r = .19). Conclusions: While the culturally targeted video intervention did not increase PrEP use intentions, the study highlights the importance of understanding and addressing cultural factors such as Latin masculinity.

"PrEP a double-edged sword": Integrating implementation science methodology with Photovoice to guide culturally-tailored pre-exposure prophylaxis (PrEP) programs for Latino/a and non-Latino/a men who have sex with men in South Florida

BACKGROUND

DiversiPrEP is a culturally-tailored PrEP program for LMSM offered in South Florida. DiversiPrEP navigates LMSM through their PrEP journey, including education, deciding if PrEP is relevant for them, payment, and accessing/maintaining PrEP use. DiversiPrEP includes five ERIC strategies (Increase Demand, Promote Adaptability, Alter Client Fees, Intervene with Clients to Enhance Uptake and Adherence, and Tailor Strategies).

DESCRIPTION

Photovoice was used to conduct five two-part focus groups with LMSM (n = 12) and Non-LMSM (n = 12). In the first session, trainers provided guidance on selecting and contextualizing photos to generate CFIR themes. Then, participants captured photos that embodied their lived experiences accessing PrEP. In the second session, using SHOWeD, participants discussed photos, identifiedhow photos relate to culturally relevant issues. Triangulation approaches compared/contrasted themes between LMSM and Non-LMSM.

RESULTS

Five central themes emerged around barriers and facilitators to PrEP services: 1) the need for normalizing PrEP messages within the MSM community, 2) the need for normalizing PrEP messages outside the MSM community, 3) the need for expanding PrEP knowledge, 4) different motivations for using PrEP, and 5) the presence of structural barriers that limit PrEP access. This study compared similarities and differences of barriers and facilitators to PrEP use between Latino/a and non-Latino/a MSM. Similarities included the built environment (outer setting) as a barrier, the need for normalizing PrEP messaging within and outside of the MSM community, and the need to expand PrEP knowledge. Differences between Latino/a and non-Latino/a MSM were found in assessing the motivation and personal drivers (inner setting) for initiating PrEP associated with how participants viewed their responsibilities to self or others.

CONCLUSIONS

Photovoice with focus groups identified CFIR constructs that can guide the large-scale implementation of a client-centered PrEP service model with telehealth for both Latino/a and non-Latino/a MSM. Implementing client-centered accessible PrEP programs is an essential step to promoting sexual-health equity.

Adaptation and Reach of a Pre-Exposure Prophylaxis Social Marketing Campaign for Latino, Latina, and Latinx Populations: Development Study

BACKGROUND

Latino, Latina, and Latinx (Latino/a/x) individuals remain disproportionately impacted by HIV, particularly sexual minority men and transgender women. Pre-exposure prophylaxis (PrEP) is an effective means of biomedical HIV prevention, but awareness and uptake remain low among marginalized Latino/a/x populations. Social marketing campaigns have demonstrated promise in promoting PrEP in other populations but are poorly studied in Latino/a/x sexual minority men and transgender women.

OBJECTIVE

This study aims to (1) adapt and pilot a PrEP social marketing campaign tailored to Latino/a/x populations with a focus on sexual minority men and transgender women through community-based participatory research (CBPR) and (2) evaluate the reach and ad performance of the adapted PrEP social marketing campaign.

METHODS

We used the ADAPT-ITT (assessment, decision, adaptation, production, topical experts-integration, training, and testing) framework for adapting evidence-based interventions for new settings or populations. This paper presents how each phase of the ADAPT-ITT framework was applied via CBPR to create the PrEPárate ("Be PrEPared") campaign. Key community engagement strategies included shared ownership with community partners, focus groups to guide content, crowdsourcing to name the campaign, design by local Latino/a/x artists, and featuring local influencers as the faces of PrEPárate. We evaluated campaign reach and advertisement performance using social media platform metrics (paid and organic reach, impressions, unique clicks, and click-through rates [CTR]) and website use statistics from Google Analytics.

RESULTS

The PrEPárate campaign ran in Cook County, Illinois, from April to September 2022. The campaign reached over 118,750 people on social media (55,750 on Facebook and Instagram [Meta Platforms Inc] and 63,000 on TikTok [ByteDance Ltd]). The Meta ads performed over the industry benchmark with ads featuring local transgender women (2% CTR) and cisgender sexual minority men (1.4% CTR). Of the different Grindr (Grindr Inc) ad formats piloted, the interstitial Grindr ads were the highest performing (1183/55,479, 2.13% CTR). YouTube (Google) ads were low performing at 0.11% (153/138,337) CTR and were stopped prematurely, given limits on sexual education-related content. In the first year, there were 5006 visitors to the website.

CONCLUSIONS

Adaptation of an existing evidence-based intervention served as an effective method for developing a PrEP social marketing campaign for Latino/a/x audiences. CBPR and strong community partnerships were essential to tailor materials and provide avenues to systematically address barriers to PrEP access. Social marketing is a promising strategy to promote PrEP among underserved Latino/a/x populations.

Reconciling intimacy and safety: a qualitative systematic review of HIV pre-exposure prophylaxis implementation among gay and bisexual men

This review synthesises qualitative research on pre-exposure prophylaxis (PrEP) uptake by sexual minority men to provide an overarching conceptualisation of the implementation processes involved. Twenty-four studies-comprising 734 participants from USA, UK, France, Canada, and Taiwan-were synthesised using thematic synthesis. The synthesis elucidates the dual significance of PrEP uptake: (1) risk management: reinforcing relational circumstances, and rebalancing safety and risk; and (2) sexual empowerment: reclaiming health and sexuality and refocusing on sexual fulfillment and intimacy. Overall, the findings show how gay and bisexual men use PrEP to reconcile their antagonistic desires for intimacy and safety by recalibrating protection and reimagining intimacy. This review conceptualises the essence of users' experiences of PrEP implementation as reconciliation work-the labour and agency in making and remaking practices to manage discontinuities and incongruities-about the new HIV prevention modality. The concept of reconciliation work illustrates how using PrEP influences users' practices, which in turn, shape the meanings of PrEP use within the community. This work engenders contingent transformations and outcomes beyond HIV protection, encompassing the broader aspects of health and sexuality. Findings support the adoption of more holistic and empowering approaches to sexual health promotion and intervention.

The Pre-Exposure Prophylaxis Stigma Scale: Measurement Properties of an Adaptation in German and French

Objectives

This study aimed to adapt and validate the HIV PrEP Stigma Scale (HPSS) in French and German languages (HPSS-FR/DE) and assess its applicability across diverse linguistic and cultural contexts.

Methods

The original scale was adapted to French and German and administered through an online survey in multiple European nations. A four-factor structure was extracted from the data, including negative social consequences, social pressure, self-support, and external support. The scale's construct validity, reliability, and cross-linguistic consistency were evaluated.

Results

The adapted HPSS-FR/DE demonstrated robust psychometric properties, good construct validity, acceptable reliability, and consistent measurement across different languages. This adaptation enhances its utility in multicultural settings, offering a comprehensive tool to assess PrEP-related stigma.

Conclusion

This study provides a suitable tool to address PrEP stigma in multicultural environments to enhance PrEP uptake and adherence among men who have sex with men. Moreover, it lays the groundwork for further investigations into PrEP stigma across diverse populations and cultural settings, enabling the development of targeted public health interventions and policies to combat this issue effectively.

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.

Interpersonal and Community-Level Influences Across the PrEP Cascade Among Young Adult Latinx Men who Have Sex with Men Living in a US-Mexico Border Region: A Qualitative Study

Latinx men who have sex with men (MSM) are an at-risk population for new HIV diagnoses. Pre-exposure prophylaxis (PrEP) is a suite of biomedical approaches to prevent HIV infection. Latinx MSM are less likely to take PrEP compared to non-Latinx White MSM. This qualitative study identified interpersonal- and community-level barriers and facilitators of PrEP among young adult Latinx MSM. Using stratified purposeful sampling, 27 Latinx men, ages 19-29 years and living in a US-Mexico border region, completed self-report demographic surveys and participated in semi-structured in-depth interviews assessing barriers and facilitators to PrEP. Directed content analysis was used to identify both a priori and emerging themes. Most participants reported that other people, including peers, friends, partners, and health care providers were both supportive and discouraging of PrEP use. Participants' intersectional identities as members of both Latinx and LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer) communities both hindered and facilitated PrEP use.

Perspectives on unhealthy alcohol use among men who have sex with men prescribed HIV pre-exposure prophylaxis: A qualitative study

Unhealthy alcohol use is a common, often unaddressed behavior associated with increased risk for acquisition of HIV and may also be associated with decreased adherence to oral pre-exposure prophylaxis (PrEP) among gay, bisexual, and other men who have sex with men (MSM) living in the United States. To inform future alcohol-reduction interventions among individuals engaging in PrEP care, we sought to explore perspectives on alcohol use, PrEP adherence, and the acceptability of alcohol use treatment options for MSM prescribed oral formulations of PrEP in the Northeastern United States. Between February 2019 and July 2020, we conducted semi-structured interviews with 15 MSM without HIV who were prescribed PrEP and screened positive for unhealthy alcohol use with AUDIT-C ≥ 4 and were receiving care in Providence, Rhode Island or New Haven, Connecticut. Interviews were coded and analyzed using thematic analysis. Three themes emerged: 1) Consequences of fluctuations in drinking 2) Alcohol use negatively impacts health and relationships; and 3) Desire for a multimodal approach to treatment of unhealthy alcohol use. Our findings support the need to raise awareness of potential alcohol-related harms, address the spectrum of unhealthy alcohol use among MSM prescribed PrEP, and the acceptability and preferences for alcohol reduction interventions within PrEP programs.

Pre-exposure Prophylaxis Use and Discontinuation in a Federally Qualified Health Center in a Mexico-US Border City

BACKGROUND

Latino men who have sex with men (MSM) experience disproportionately high rates of HIV diagnoses in the United States. Pre-exposure prophylaxis (PrEP) use is critical to reduce this inequity, but PrEP awareness, access, and use are low among Latino MSM. This study aims to describe patterns of PrEP persistence and discontinuation among predominately Latino MSM accessing PrEP in a federally qualified health center (FQHC) in El Paso, Texas.

METHODS

This retrospective cohort comprised individuals who were eligible for PrEP at a FQHC in El Paso, Texas, between January 30, 2019, and August 15, 2021. We defined hierarchical categories of PrEP use and discontinuation, which was defined as more than 120 days between PrEP visits. We used Kaplan-Meier survival plots to estimate median time to first PrEP discontinuation.

RESULTS

There were 292 patients evaluated for PrEP; 91% were Latino. The majority of PrEP patients (70%, 205/292) experienced any PrEP discontinuation, and the median time to first PrEP discontinuation was 202 days (95% CI: 179-266). The proportion of patients who remained on PrEP at 3 months after initiation was 82% (95% CI: 76%, 87%) and at 6 months after initiation was 55% (95% CI: 46%, 62%).

CONCLUSION

While 3-month PrEP retention was high in this predominately Latino MSM patient population, PrEP discontinuation was common. Interventions that enhance longer-term persistence and support for restarting PrEP are needed to reduce the persistent ethnoracial disparities in HIV incidence.

Using a Structural-Ecological Model to Facilitate Adoption of Preexposure Prophylaxis Among Latinx Sexual Minority Men: A Systematic Literature Review

Research has consistently shown that individual, interpersonal, community and structural factors influence the degree to which individuals' access and utilize health care services, and these factors may play a role in explaining racial and ethnic differences in health care outcomes. Differences in HIV prevalence and treatment between Latinx adults and white adults in the U.S. must be considered in the context of these factors. However, much of the existing research connecting these factors and HIV/AIDS outcomes in Latinxs remains disparate, limited in scope, and has yet not been applied to the use of biomedical HIV preventions. The following systematic literature review examined research related to PrEP in Latinx sexual minority men (SMM) to build a structural-ecological framework of the existing research, while identifying gaps in the literature and areas for future research. We searched two electronic databases using a systematic review protocol, screened 71 unique records, and identified 23 articles analyzing data from Latinx SMM and intended and/or actual PrEP-use in the United States. Based on the present review, disparities in PrEP uptake by Latinx SMM could be explained, in part, by examining how all levels of the structural-ecological framework uniquely contributes to how Latinx SMM engage with HIV prevention measures and come to understand PrEP. It is clear from the existing literature base that some of the most prominent barriers deterring Latinx SMM from seeking PrEP services are the lack of information surrounding PrEP and HIV/gay stigmas. However, higher order structural-level risks can facilitate or reduce access to PrEP. We propose a structural-ecological model to help visualize multi-level domains of unique stressors that limit the implementation of PrEP among Latinxs. At this stage, the available literature provides little guidance beyond suggesting that culturally adapted interventions can be effective in this population. The model developed here provides that needed specificity regarding targeted interventions that will fit the needs of this population.

Health Care Worker Perspectives of HIV Pre-exposure Prophylaxis Service Delivery in Central Uganda

Background

Scale-up of HIV pre-exposure prophylaxis (PrEP) services in Uganda is ongoing. However, health care workers (HCWs) may not be aware of PrEP nor what offering this service entails. We explored the impact of standardized HCW training on the knowledge and perspectives of PrEP service delivery in Uganda.

Methods

We recruited HCWs from facilities that offered HIV-related services in Central Uganda. Using the Uganda Ministry of Health curriculum, we trained HCWs on PrEP services. We collected data about PrEP knowledge, preparedness, and willingness to deliver PrEP to multiple key populations before the training, immediately after the training, and >6 months later (exit). We additionally conducted 15 qualitative interviews after the exit survey. Quantitative data were analyzed by Fisher exact test, while qualitative interview data were analyzed inductively.

Results

We recruited 80 HCWs from 35 facilities in urban (N = 24, 30%), peri-urban (N = 30, 37%), and rural (N = 26, 33%) areas. Most HCWs were nurse counselors (N = 52, 65%) or medical/clinical officers (N = 15, 18%). Surveys indicated that awareness of PrEP increased after the training and remained high. Knowledge of PrEP (i.e., as an effective, short-term antiretroviral medication to use before HIV exposure for people at high risk) generally increased with training, but significant gaps remained, and knowledge decreased with time. Most HCWs recommended PrEP for female sex workers and HIV serodifferent couples, as well as other key populations. We observed increases in the number of HCW who felt their facility was prepared to cater for HIV prevention and provide PrEP, but this view was not universal. HCWs believed in PrEP effectiveness and embraced it as an additional HIV prevention method. Concerns included patient adherence and behavioral risk compensation. HCWs noted challenges in PrEP delivery in terms of inadequate clinic preparedness, infrastructure, staff capacity, and poor attitudes toward key populations by untrained health workers. They felt further training was needed to ensure a smooth scale-up of services without stigmatization.

Conclusions

Standardized training improved knowledge, willingness, and preparedness to offer PrEP services among most HCWs in Central Uganda. Ongoing training will be needed to optimize PrEP delivery services and expand delivery to levels needed for population-level impact.

The impact of stigma on HIV testing decisions for gay, bisexual, queer and other men who have sex with men: a qualitative study

Background

Stigmatization may prompt gay, bisexual, queer and other men who have sex with men (GBQMSM) to avoid or delay HIV testing. There has been little attention to GBQMSMs’ perspectives about how stigma may influence their decisions about whether, where, and how often to get tested for HIV.

Methods

We conducted nine focus groups with 64 adult GBQMSM in Metropolitan Detroit, including HIV-negative men and people living with HIV (PLWH). Data were thematically analyzed deductively and inductively in three rounds.

Results

Three themes emerged regarding whether to get tested: (1) Perceived promiscuity, risk perceptions and HIV testing; (2) Fearing sexual rejection; and (3) Fearing friend and family member distancing and rejection. Themes concerning where to get tested included: (4) Conflating HIV testing and diagnosis; and (5) Seeking privacy and safety at specialized services. As for how often to get tested, themes included: (6) Reducing contact with healthcare providers due to intersectional stigma; (7) Responsibility and regular testing; and (8) HIV stigma and testing as routine care. Black participants articulated themes (3), (4), and (6) with greater frequency than other participants. Framing HIV testing as a personal responsibility may have created a “new stigma,” with unintended consequences not observed with “routine healthcare” messaging.

Conclusions

GBQMSMs’ perspectives indicate the potential for new foci for HIV testing promotion interventions based on stigma-related issues that they deem important. There is a need for interventions to challenge the “promiscuity” stereotype, and to reduce the sexual stigmatization of GBQMSM living with HIV/AIDS—especially online. Provider stigma requires both intervention and continued availability of specialized services. Future stigma-reduction interventions for Black GBQMSM could focus on building family support/acceptance, awareness of multiple testing options, and integrating LGBTQ-related issues into initiatives for racial justice in health care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12761-5.

The Influence of Family Bonding, Support, Engagement in Healthcare, on PrEP Stigma among Young Black and Latino Men Who Have Sex with Men: A Path Analysis

This study employs the ecodevelopmental theory to examine the influence of mother and father bonding, family engagement in healthcare, and family support on PrEP stigma among BLMSM. We used a cross-sectional sample from wave five of the Healthy Young Men (HYM) study, with a survey sample of 399 participants aged 16−24 years. We conducted two-path analyses to test multiple hypotheses: (1) mother/father bonding is associated with an increase in family engagement in healthcare; (2) family engagement in healthcare is associated with family social support; and (3) family social support is associated with PrEP stigma. Family social support was negatively correlated with PrEP stigma (r = −0.15; p < 0.001). The findings show that families either led by a Black/Latino father or mother have a significant impact on the sexual health-seeking behavior of BLMSM and their perception of HIV and PrEP.

Exploring Awareness, Perceptions, and Willingness to Use HIV Pre-Exposure Prophylaxis: A Qualitative Study of Ghanaian Immigrants in the United States

HIV/AIDS disproportionately burdens African immigrants in the United States. Oral pre-exposure prophylaxis (PrEP) is an effective prevention tool for people at high HIV risk, yet uptake is low among racial and ethnic minorities-particularly immigrants. This study explores the awareness, perception, and willingness to use PrEP among Ghanaian immigrants in the United States. WhatsApp, a social media platform, was used to recruit and conduct semi-structured oral interviews with 40 Ghanaian immigrants in March 2020. Interview questions explored awareness of PrEP (whether the participants knew or had knowledge of PrEP before the study), perceptions of PrEP and PrEP users, and willingness to use PrEP. Interviews were audiorecorded, and transcribed. We used NVivo-12 Plus to analyze transcripts for emergent themes. Our sample consisted of Ghanaian adult immigrants (N = 40, 57% male, 71% college educated, age = 32.8 ± 5.7 years, 68% had lived in the United States between 1 and 10 years) residing in 12 US cities. Four major themes emerged: (1) low awareness of PrEP; (2) positive perception of PrEP for HIV prevention; (3) divergent views on PrEP users; and (4) mixed views on willingness to use PrEP. This study presents formative qualitative work, which suggests that Ghanaian immigrants, despite having low awareness of PrEP, may be willing to use PrEP. A key study implication was that stigma reduction interventions might facilitate PrEP scale-up in this population.

Can HIV epidemics among MSM be eliminated through participation in preexposure prophylaxis rollouts?

OBJECTIVE

To study the conditions under which preexposure prophylaxis (PrEP) coverage can eliminate HIV among MSM in the Paris region.

DESIGN

Mathematical modeling.

METHODS

We propose an innovative approach, combining a transmission model with a game-theoretic model, for decision-making about PrEP use. Individuals at high risk of HIV infection decide to use PrEP, depending on their perceived risk of infection and the relative cost of using PrEP versus antiretroviral treatment (ART), which includes monetary and/or nonmonetary aspects, such as price and access model of PrEP, consequences of being infected and lifelong ART.

RESULTS

If individuals assessed correctly their infection risk, and the cost of using PrEP were sufficiently low, then the PrEP rollout could lead to elimination. Specifically, assuming 86% PrEP effectiveness, as observed in two clinical trials, a minimum PrEP coverage of 55% [95% confidence interval (CI) 43-64%] among high-risk MSM would achieve elimination in the Paris region. A complete condom drop by MSM using PrEP slightly increases the minimum PrEP coverage required for elimination, by ∼1%, whereas underestimation of their own HIV infection risk would require PrEP programs reduce the cost of using PrEP by a factor ∼2 to achieve elimination.

CONCLUSION

Elimination conditions are not yet met in the Paris region, where at most 47% of high-risk MSM were using PrEP as of mid-2019. Further lowering the cost of PrEP and promoting a fair perception of HIV risk are required and should be maintained in the long-run, to maintain elimination status.

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.

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.

Sociodemographic Characteristics of HIV Pre-Exposure Prophylaxis Use and Reasons for Nonuse Among Gay, Bisexual, and Other Men Who Have Sex with Men from Three US Cities

HIV pre-exposure prophylaxis (PrEP) is a preventive medication that could reduce new infections among men who have sex with men (MSM). There are limited data on differing reasons for PrEP nonuse by condomless anal sex (CAS). We examined demographic and behavioral variables associated with PrEP use and reasons for PrEP nonuse by CAS. Data are from the M-cubed Study, collected in a 2018 baseline assessment of MSM (n = 798) in Atlanta, Detroit, and New York City. Participants reported current PrEP use (31%), previous use (8%), and never use (61%). MSM reporting CAS [adjusted odds ratio (aOR) = 2.60, confidence interval (95% CI) = 1.73-3.91], age 18-29 (aOR = 2.11, 95% CI = 1.26-3.52), 30-39 (aOR = 2.12, 95% CI = 1.25-3.59), with a college degree (aOR = 1.96, 95% CI = 1.20-3.21), or postgraduate education (aOR = 2.58, 95% CI = 1.51-4.40) had greater odds of current (vs. never) use; uninsured (aOR = 0.30, 95% CI = 0.16-0.57) men had lower odds of current (vs. never) use. For never use, more MSM who reported CAS (vs. did not) endorsed the following reasons (p's < 0.05): Insurance wouldn't cover PrEP (20% vs. 12%), Didn't know where to get it (33% vs. 24%) and fewer reported Didn't need PrEP (23% vs. 39%) and Started a committed relationship (7% vs. 25%). For discontinuation, more MSM who reported CAS (vs. did not) endorsed Worry about the safety of PrEP (19% vs. 3%). Efforts are needed to enhance PrEP as an option among older, less educated, and uninsured MSM. These findings may inform how providers can facilitate PrEP use by messaging on access and safety for MSM who reported CAS.

Predictors of Awareness, Accessibility and Acceptability of Pre-exposure Prophylaxis (PrEP) Among English- and Spanish-Speaking Latino Men Who have Sex with Men in Los Angeles, California

Uptake of pre-exposure prophylaxis (PrEP) among Latino men who have sex with men (LMSM) remains low. We examined awareness, accessibility, acceptability and use of PrEP among LMSM. LMSM were recruited using social/sexual networking apps. Multiple Logistic regressions identified significant predictors of PrEP awareness, accessibility and acceptability. Among 276 participants, only 6% reported current PrEP use. Among non-PrEP users, 85% reported PrEP awareness, 71% indicated high likelihood of future PrEP use, but only 35% reported knowledge about accessing PrEP. In multiple logistic regressions, a lower likelihood of PrEP awareness was associated with lower level education, whereas a higher likelihood was associated with reporting 6-10 or over 10 sexual partners. A lower likelihood of PrEP accessibility was associated with lower level education and undocumented status. A lower likelihood of PrEP acceptability was associated with an income of $15,001-30,000, whereas a higher likelihood was associated with lower level education and reporting 6-10 or over 10 sexual partners. PrEP promotion targeting Latino MSM should be expanded for those with lower levels of education and those who are undocumented.

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

INTRODUCTION

A growing number of Liaison Committee on Medical Education-accredited allopathic medical schools offer formal bilingual (English and Spanish) medical education, and numerous other schools offer medical Spanish through elective workshops as part of their curricula. One significant health disparity in the Hispanic community is the incidence of HIV among Spanish-speaking men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) has emerged as an effective strategy to reduce the risk of HIV transmission.

METHODS

We developed an education module to train clinicians to discuss PrEP with Spanish-speaking MSM. Our module is adapted from an English module on PrEP education. It includes a Spanish-language PowerPoint slide deck with information about PrEP as well as a Spanish-language videotaped scripted clinical encounter.

RESULTS

The module was implemented on three occasions with 18 participants, and learners reported increased comfort in discussing and confidence in prescribing PrEP with Spanish-speaking patients.

DISCUSSION

This workshop can be incorporated within medical Spanish curriculums offered at health professional schools and community-based organizations dedicated to reducing the HIV burden in the Spanish-speaking Hispanic community.

The acceptability and feasibility of a pilot study examining the impact of a mobile technology-based intervention informed by behavioral economics to improve HIV knowledge and testing frequency among Latinx sexual minority men and transgender women

Background

We developed a novel intervention that uses behavioral economics incentives and mobile-health text messages to increase HIV knowledge and testing frequency among Latinx sexual minority men and Latinx transgender women. Here we provide a theoretically-grounded assessment regarding the intervention’s acceptability and feasibility.

Methods

We conducted 30-min exit interviews with a stratified sample of participants (n = 26 Latinx sexual minority men, 15 Latinx transgender women), supplemented with insights from study staff (n = 6). All interviews were recorded, transcribed, and translated for a content analysis using Dedoose. Cohen’s Kappa was 89.4% across coded excerpts. We evaluated acceptability based on how participants cognitively and emotionally reacted to the intervention and whether they considered it to be appropriate. We measured feasibility based on resource, scientific and process assessments (e.g., functionality of text messaging service, feedback on study recruitment procedures and surveys).

Results

Regarding acceptability, most participants clearly understood the intervention as a program to receive information about HIV prevention methods through text messages. Participants who did not complete the intervention shared they did not fully understand what it entailed at their initial enrollment, and thought it was a one-time engagement and not an ongoing program. Though some participants with a higher level of education felt the information was simplistic, most appreciated moving beyond a narrow focus on HIV to include general information on sexually transmitted infections; drug use and impaired sexual decision-making; and differential risks associated with sexual positions and practices. Latinx transgender women in particular appreciated receiving information about Pre-Exposure Prophylaxis. While participants didn’t fully understand the exact chances of winning a prize in the quiz component, most enjoyed the quizzes and chance of winning a prize. Participants appreciated that the intervention required a minimal time investment. Participants shared that the intervention was generally culturally appropriate. Regarding feasibility, most participants reported the text message platform worked well though inactive participants consistently said technical difficulties led to their disengagement. Staff shared that clients had varying reactions to being approached while being tested for HIV, with some unwilling to enroll and others being very open and curious about the program. Both staff and participants relayed concerns regarding the length of the recruitment process and study surveys.

Conclusions

Our theoretically-grounded assessment shows the intervention is both acceptable and feasible.

Trial registration

The trial was registered on May 5, 2017 with the ClinicalTrials.gov registry [NCT03144336].

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10335-5.

Experiences of Pre-Exposure Prophylaxis (PrEP)-Related Stigma among Black MSM PrEP Users in Los Angeles

Black men who have sex with men (BMSM) are disproportionately affected by HIV infection in the USA. Pre-exposure prophylaxis (PrEP) is a proven efficacious biomedical prevention strategy with the potential to alter significantly the course of the epidemic in this population. However, the social stigma attached to PrEP and those who use it may act as a barrier to the uptake and continuation of PrEP among high-risk BMSM. In-depth, semi-structured qualitative interviews were conducted with 26 BMSM PrEP users to explore their experiences of stigma related to their PrEP use. BMSM reported multiple experiences or manifestations of PrEP-related stigma, which included (1) perception that PrEP users engage in elevated sexual risk behaviors; (2) conflicts in relationships attributed to PrEP; (3) experiences of discomfort or judgment from medical providers; (4) assumption that PrEP users are HIV-positive; and (5) gay stigma in families limiting PrEP disclosure. The experiences of stigma typically occur within the context of PrEP disclosure and have significant personal and social consequences for PrEP users. Efforts to address PrEP and other social-stigmas within the Black community may help facilitate PrEP uptake and continuation with BMSM.

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.

Experienced barriers to adherence to pre-exposure prophylaxis for HIV prevention among MSM: a systematic review and meta-ethnography of qualitative studies

Men who have sex with men (MSM) in the United States are at disproportionate risk for HIV. Once-daily pre-exposure prophylaxis (PrEP) for HIV prevention is a highly effective method of preventing HIV infection; however, optimal adherence is necessary to maintain effectiveness. Many studies have profiled perceived barriers to adherence among at-risk MSM; however, nearly a decade after FDA approval, there has been little work examining experienced barriers to adherence among MSM who have previously used the medication. To assess the current state of this literature and its implications for behavioral interventions, we conducted a meta-ethnography (i.e., A systematic review and synthesis of qualitative studies) of experiences with PrEP use among cis-gender MSM in the United States. We found that structural-level interventions, such as telehealth and pharmacist-prescribed approaches to PrEP distribution, may circumvent barriers to uptake and adherence for some MSM, but may not be enough for already underserved communities, such as MSM of color. Furthermore, interpersonal-level factors, such as enacted PrEP stigma by providers and peers, highlight the necessary consideration of social identity in the branding of PrEP for HIV prevention. Tailored interventions should consider experienced barriers to PrEP adherence across socioecological levels to be most effective.

CE: HIV Update: An Epidemic Transformed

: The field of HIV treatment and prevention has evolved rapidly over the past four decades. New therapies that are more potent and streamlined have transformed HIV into a chronic disease, while the use of such preventive strategies as preexposure prophylaxis and postexposure prophylaxis provide effective options for reducing the risk of HIV infection. These medical breakthroughs have enabled more people living with HIV (PLWH) to reach older adulthood. But they also mean that nurses are seeing more PLWH who have developed long-term complications of living with HIV or of exposure to antiretroviral therapy, as well as concurrent chronic conditions associated with advanced age. Nurses play a critical role in caring for PLWH and those at risk for HIV infection. This article discusses HIV epidemiology, describes the current state of HIV treatment and prevention, and highlights common comorbidities often seen in PLWH who are over age 50.

Feasibility and Acceptability of an Electronic Health HIV Prevention Toolkit Intervention With Concordant HIV-Negative, Same-Sex Male Couples on Sexual Agreement Outcomes: Pilot Randomized Controlled Trial

BACKGROUND

There is a need to develop innovative and accessible dyadic interventions that provide male couples with the behavioral skills to manage the risk of HIV transmission within their relationship.

OBJECTIVE

We conducted a pilot randomized controlled trial (RCT) to assess the feasibility and acceptability of the electronic health (eHealth) HIV prevention toolkit intervention to encourage seroconcordant negative male couples in the United States to establish and adhere to a sexual agreement (SA).

METHODS

Eligible, consented couples were randomly assigned to the intervention or education control and followed up for 6 months, with assessments occurring every 3 months after baseline. Acceptability items were assessed at both follow-up assessments. Descriptive and comparative statistics summarized cohort characteristics, relationship dynamics, and SA outcomes for the entire cohort and by trial arm. To examine the association between couples' relationship dynamics and their establishment of an SA over time and by trial arm, multilevel logistic regression analyses were performed with a random intercept to account for correlations of repeated measurements of relationship dynamics at months 3 and 6; the odds ratio (OR) of establishment of an SA and the corresponding 95% confidence interval were then reported.

RESULTS

Overall, 7959 individuals initiated screening. Reasons for individual ineligibility varied. An electronic algorithm was used to assess couple-level eligibility, which identified 1080 ineligible and 266 eligible dyads. Eligible couples (n=149) were enrolled in the pilot RCT: 68 received the intervention and 81 received the education control. Retention was 71.5% (213/298 partnered men) over the 6 months. Participants reported high acceptability of the intervention along with some areas for improvement. A significantly higher proportion of couples who received the intervention established an SA at 6 months compared with those who received the education control (32/43, 74% vs 27/50, 54%; P=.05). The OR of establishing an SA for couples in the intervention versus those in the control condition was greater than 2 when controlling for a number of different relationship dynamics. In addition, the odds of establishing an SA increased by 88% to 322% for each unit increase in a variety of averaged relationship dynamic scores; the opposite result was found for dynamics of stigma. Differences between trial arms for SA type and adherence were nonsignificant at each assessment. However, changes in these 2 SA aspects were noted over time. The average number of items couples included in their SA was 18, and about one-fourth to one-third of couples included HIV prevention items.

CONCLUSIONS

The findings demonstrate strong evidence for the acceptability and feasibility of the eHealth toolkit as a brief, stand-alone, couples-based HIV prevention intervention. These findings support the need to update the toolkit and evaluate it in a larger clinical trial powered for efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02494817; http://clinicaltrials.gov/ct2/show/NCT02494817.

Young black MSM's exposures to and discussions about PrEP while navigating geosocial networking apps

Young Black gay, bisexual and other men who have sex with men (YBMSM) carry a disproportionate HIV burden perpetuated by exposure to sexual networks with higher untreated HIV prevalence and incidence. In Baltimore, these sexual networks include high utilization of geosocial networking apps (GSN-apps). Our prior work suggests these apps can be important access points for targeted interventions like PrEP. To inform online PrEP outreach we explored YBMSM GSN-app users' exposure to and discussions about PrEP while navigating apps. We actively recruited YBMSM (n=17) age 18-24 from the GSN-app most frequently reported by newly diagnosed HIV-infected MSM in Baltimore. Participants were recruited through direct messaging within the GSN-app while logged-on in high HIV transmission areas. Participants completed 60-90 minute semi-structured interviews, which were analyzed using a 3-stage analytic coding strategy. While some participants had not heard of PrEP, the majority described mentions or conversations about PrEP on GSN-apps. Three themes emerged: (1) Mistrust of PrEP, (2) Association with sexual promiscuity, and (3) Concerns about lack of protection from other STIs. Proper messaging, accurate information, and education are needed to account for the negative perceptions that surround PrEP; otherwise, continued underuse among YBMSM will expand rather than reduce HIV disparities.

Motivational Interviewing to Reduce Drug Use and HIV Incidence Among Young Men Who Have Sex With Men in Relationships and Are High Priority for Pre-Exposure Prophylaxis (Project PARTNER): Randomized Controlled Trial Protocol

Background

Men who have sex with men (MSM) currently account for more than two-thirds of new HIV diagnoses in the United States and, among young MSM (YMSM) aged 20 to 29 years, as many as 79% to 84% of new infections occur between primary partners. Contributing to HIV risk, YMSM use drugs at comparatively high rates. To date, no interventions have been developed that specifically address the unique needs of partnered YMSM or incorporate a focus on relationship factors in addressing personal motivation for change.

Objective

The study’s primary aim is to evaluate the efficacy of the PARTNER intervention and evaluate potential moderators or mediators of intervention effects. The study’s secondary aims were to gather ideographic data to inform a future effectiveness implementation study and develop a novel biomarker for pre-exposure prophylaxis (PrEP) adherence by analyzing PrEP drug levels in fingernails.

Methods

PARTNER is a 4-session motivational interviewing–based intervention that integrates video-based communication training to address drug use and HIV prevention among partnered YMSM. This study utilizes a randomized controlled trial design to compare the PARTNER intervention with an attention-matched psychoeducation control arm that provides information about HIV-risk reduction, PrEP, and substance use. Participants are randomized in a 1-to-1 ratio stratified on age disparity between partners, racial composition of the couple, and relationship length. Follow-up assessments are conducted at 3-, 6-, 9-, and 12-months postbaseline. The study recruits and enrolls 240 partnered YMSM aged between 18 to 29 years at a research center in New York City. Participants will be HIV-negative and report recent (past 30-day) drug use and condomless anal sex with casual partners; a nonmonogamous primary partner (regardless of HIV status); or a serodiscordant primary partner (regardless of sexual agreement). Primary outcomes (drug use and HIV sexual transmission risk behavior) are assessed via a Timeline Follow-back interview. Biological markers of outcomes are collected for drug use (fingernail assay), sexual HIV transmission risk (rectal and urethral gonorrhea and chlamydia testing), and PrEP adherence (dried blood spots and fingernails for a novel PrEP drug level assay).

Results

The study opened for enrollment in February 2018. Anticipated completion of enrollment is October 2021. Primary outcome analyses will begin after final follow-up completion.

Conclusions

Existing research on partnered YMSM within the framework of Couples Interdependence Theory (CIT) has suggested that relationship factors (eg, dyadic functioning and sexual agreements) are meaningfully related to drug use and HIV transmission risk. Results pertaining to the efficacy of the proposed intervention and the identification of putative moderators and mediators will substantially inform the tailoring of interventions for YMSM in relationships and contribute to a growing body of relationship science focused on enhancing health outcomes.

Trial Registration

ClinicalTrials.gov NCT03396367; https://clinicaltrials.gov/ct2/show/NCT03396367 (Archived by WebCite at http://www.webcitation.org/78ti7esTc.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13015

Experiences of Anticipated and Enacted Pre-exposure Prophylaxis (PrEP) Stigma Among Latino MSM in Los Angeles

Latino men who have sex with men (MSM) are a group critically affected by HIV. Pre-exposure Prophylaxis (PrEP) is a biomedical prevention strategy that can help reduce new infections in this population. However, PrEP use may expose users to experiences of PrEP-related stigma. In-depth interviews conducted with Latino MSM PrEP users (N = 29) were analyzed using thematic analysis to explore experiences of PrEP stigma. Six themes emerged related to anticipated and enacted PrEP stigma: (1) Perception that PrEP users engage in risky sexual behaviors; (2) PrEP-induced conflict in relationships; (3) Perception that PrEP users are HIV-positive; (4) Generational differences in attitudes toward HIV prevention; (5) Experiences of discomfort, judgment, or homophobia from medical providers; and (6) Gay stigma related to PrEP disclosure to family. Manifestations of stigma included disapproving judgment, negative labeling, rejection, and devaluing individuals. The social consequences associated with using PrEP may deter uptake and persistence among Latino MSM.