Stigma Communication Surrounding PrEP: The Experiences of A Sample of Men Who Have Sex With Men

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.

Preference heterogeneity for HIV pre-exposure prophylaxis care among gay, bisexual, and other men who have sex with men in the United States: a large discrete choice experiment

Background

PrEP uptake among Black and Latino gay, bisexual, and other men who have sex with men (GBM) remains low in the United States. The design and implementation of PrEP delivery programs that incorporate the preferences of Black and Latino GBM may overcome barriers to uptake. We aimed to identify preferences for PrEP care among high-priority GBM in the U.S. with a large discrete choice experiment.

Methods

We conducted two discreet choice experiments (DCE) to elicit care preferences for (1) Starting PrEP and (2) Continuing PrEP care among GBM clinically indicated for PrEP. The DCE web-based survey was nested in a longitudinal cohort study of GBM in the U.S., implemented with video and audio directions among 16-49 year-old participants, not using PrEP, and verified to be HIV-negative. All participants were presented with 16 choice sets, with choices determined by BLGBM and PrEP implementation stakeholders. We calculated overall utility scores and relative importance and used latent class analyses (LCA) to identify classes within the Starting and Continuing PrEP DCE. Multivariable analysis was performed to identify factors associated with class membership.

Findings

Among 1514 participants, mean age was 32 years; 46·5% identified as Latino, 21·4% Black, and 25·2 White; 37·5% had an income less than USD $20,000. Two latent classes were identified for Starting PrEP: Class 1 (n=431 [28·5%]) was driven by preference for more traditional in-person care, and Class 2 (n=1083 [71·5%]) preferred flexible care options and on-demand PrEP. In a multivariable model, having a sexual health doctor (adjusted OR 0·7, CI 0·5, 0·9), having a primary care provider (OR 0·7,CI 0·5, 0·9, p= 0·023), and concerns over PrEP side effects (OR 1·1, CI 1·0,1·2, p= 0·003) were all associated with class membership.

Interpretation

The different preferences identified for PrEP care indicate the need for diverse care and formulation choices to improve PrEP uptake and persistence. Addressing these preferences and understanding the factors that shape them can inform the implementation of programs that increase PrEP uptake.

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.

Health literacy mediates the association between cognition and healthcare provider interactions among gay and bisexual men with HIV disease

Introduction: Gay and bisexual men (GBM) account for the highest rates of incident infection with HIV in the U.S., and experience social, systemic barriers to accessing and engaging in healthcare services. Interacting with healthcare providers can be a complex process for some GBM with HIV disease. The current study examined the contributions of cognition and health literacy to perceived interactions with healthcare providers among GBM with HIV disease. Methods: The sample included 100 adults with HIV disease (ages 24-75) who identified as GBM. All participants completed the Dealing with Health Professionals subscale of the Beliefs Related to Medication Adherence survey, as well as the Cogstate neuropsychological battery, self-report measures of cognitive symptoms, and well-validated measures of health literacy. Results: Worse performance-based cognition and subjective cognitive symptoms were both associated with perceived difficulties dealing with healthcare providers, but these associations were fully mediated by lower health literacy. Conclusion: Health literacy may play a role in the association between poorer cognitive functioning and difficulties navigating healthcare interactions among GBM with HIV disease. Further studies are needed to determine whether cognitive approaches to enhancing the access, understanding, and use of health information in GBM with HIV disease improves healthcare interactions and outcomes.

COVID-19 Courtesy Stigma among Healthcare Providers in India: A Study of Stigma Management Communication and its Impact

In early 2020, the first wave of the COVID-19 pandemic hit India, generating one of the highest rates of infection and death in the world. Meanwhile, healthcare workers experienced stigma and discrimination due to their association with COVID-19 patients. This study analyzed healthcare workers' experience of courtesy stigma in India, the communication strategies they used to manage stigma, and the impact on their mental health. A cross-sectional survey of 150 healthcare workers in India showed that almost 50% experienced discrimination due to their association with COVID-19 patients. Using Confirmatory Factor Analysis and Structural Equation Modeling, this study found that experience of discrimination was associated with perceived courtesy stigma. Two stigma management strategies (reducing offensiveness and passive acceptance) mediated the relationship between perceived courtesy stigma and perceived stress and depression. Participants also reported engaging in stigma management strategies of bonding with other healthcare professionals and passive acceptance of the stigma more than reducing stigma and displaying/disclosing stigma. We conclude that perhaps due to depletion of cognitive and emotional resources, healthcare workers engaged more in social support (bonding) and passive stigma acceptance strategies to alleviate the stress associated with providing COVID-19 patient care. Practical and theoretical implications are further discussed.

The Power of "We": Using Inclusive Pronouns in Norm-Based Messages to Promote PrEP-Related Information Seeking Among Men Who Have Sex With Men

Pre-exposure prophylaxis (PrEP) is an effective medicine preventing HIV transmission. This study designs and tests normative messages that promote PrEP-related information seeking among men who have sex with men (MSM) (n = 410). Two factors were manipulated in normative messaging: type of norm (descriptive ["people do"] vs. injunctive ["people should"]) and type of pronoun (individual "you" vs. collective "we"). The results favored the use of descriptive normative appeal and collective pronouns in normative message design. For health campaigns that target MSM's PrEP-related behaviors, this study suggests that descriptive norms may increase behavioral changes whereas injunctive norms may appear intrusive and backfire. At the same time, using inclusive agency assignment (e.g., pronouns) may encourage HIV prevention through provoking solidarity considerations.

Barriers to Pre-Exposure Prophylaxis (PrEP) use for HIV: an integrative review

OBJECTIVES

to identify and synthesize scientific evidence on the barriers and difficulties for Pre-exposure Prophylaxis (PrEP) use and compliance for HIV.

METHODS

an integrative literature review, using the MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier and Scopus (Elsevier) databases.

RESULTS

all (100%) the articles included identified that PrEP users experience some type of structural barrier related to health services such as long distance from the units, suboptimal logistics for taking pills and professional resistance to prescribing PrEP. Furthermore, 63.21% identified social barriers, such as stigma about sexuality and HIV, in addition to individual barriers such as alcohol use, adverse effects, and concerns about long-term toxicity.

CONCLUSIONS

the barriers to PrEP use are multifactorial. Effective interventions are needed to support PrEP users in accessing, complying with, and retaining health services.

Predicting and influencing PrEP use: the role of motivational and attitudinal factors

This study examined PrEP attitude and HIV risk factors associated with PrEP motivation and evaluated the efficacy of a mock public health video that addresses both motivational and stigma issues for improving PrEP uptake over a standard educational video. Gay, bisexual, and other men who have sex with men (GBMSM; N = 604) were enrolled. One-way between subject analysis of variance (ANOVA) and post-hoc comparisons revealed that GBMSM in later stages of change had significantly higher endorsement of positive PrEP attitudes, PrEP stigma, objective and perceived HIV risk, HIV worry, and valued health benefits of PrEP more. Stepwise multiple regression revealed five significant predictors of PrEP motivation: HIV worry, objective HIV risk, anticipated PrEP stigma, positive PrEP attitudes, and perceived social consequences of PrEP use. Video conditions did not differ in their impact on PrEP attitudes or motivation; however, regardless of video condition, participants experienced a pre- to post-video increase in positive PrEP attitudes and motivation. Findings suggest HIV worry, objective HIV risk, positive PrEP attitudes, and perceived PrEP health benefits are important factors to optimize PrEP motivation, which can inform secondary prevention efforts. Further study is needed on promotional PrEP campaigns that disconfirm stigmatizing PrEP misconceptions.

'Why aren't you on PrEP? You're a gay man': reification of HIV 'risk' influences perception and behaviour of young sexual minority men and medical providers

Public health models and medical interventions have often failed to consider the impact of reductionist HIV 'risk' discourse on how sexual minority men interpret, enact and embody biomedical knowledge in the context of sexual encounters. The aim of this study was to use an anthropological lens to examine sexual minority men's perception of HIV risk and experience within the medical system in order to examine the influence of risk discourse on their health, behaviour and social norms. In-depth interviews (n = 43) were conducted with a racially, ethnically and socioeconomically diverse sample of young sexual minority men and explored HIV-related beliefs and experiences, as well as their interactions with healthcare providers. Findings suggest that the stigmatisation of behaviours associated with HIV appears to be shaped by three key forces: healthcare provider perceptions of sexual minority men as inherently 'risky', community slut-shaming, and perceptions of risk related to anal sex positioning. Stigmatising notions of risk appear to be embodied through sexual health practices and identities vis-à-vis preferred anal sex positions and appear to influence condom use and PrEP initiation.

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.

Preferences Across Pre-Exposure Prophylaxis Modalities Among Young Men Who Have Sex with Men in the United States: A Latent Class Analysis Study

Access to daily oral pre-exposure prophylaxis (PrEP) is suboptimal among young cisgender men who have sex with men (YMSM) in the United States. Next-generation modalities that do not involve daily oral regimens may mitigate some of the barriers to PrEP use. We identified latent classes of YMSM based on health care decision-making patterns and examined associations between latent classes and access to health care and PrEP modality preferences (i.e., daily and event-driven oral, rectal douches, broadly neutralizing antibodies, subcutaneous implants, and an injectable). Between October 2020 and June 2021, we administered an online survey to 737 YMSM. Latent class analysis (LCA) identified groups of YMSM based on communication with providers, stigma and mistrust in health care, and autonomy in sexual health decisions. Logistic regression examined associations between class membership and health care access, and exploded logit regression examined associations between class membership and ranked PrEP modality preferences. LCA identified three classes: shared decision-making (high communication with providers and high autonomy); provider-led decision-making (high communication and low autonomy); and patient-driven decision-making (low communication and high autonomy). Shared decision-making was associated with higher access to health care in comparison with the other classes. Across all classes, YMSM preferred daily oral PrEP over all next-generation PrEP modalities. Preferences for daily oral PrEP over next-generation PrEP modalities were particularly marked among the patient-driven decision-making class. Shared decision-making is associated with access to health care and HIV prevention and higher acceptability of next-generation PrEP modalities, and should be considered as part of future interventions to promote use of daily oral and next-generation PrEP.

Intersectional Stigma and Prevention Among Gay, Bisexual, and Same Gender-Loving Men in New York City, 2020: System Dynamics Models

Objectives. To create causal loop diagrams that characterize intersectional stigma experiences among Black, gay, bisexual, same gender-loving, and other men who have sex with men and to identify intervention targets to reduce stigma and increase testing and prevention access. Methods. Between January and July 2020, we conducted focus groups and in-depth interviews with 80 expert informants in New York City, which were transcribed, coded, and analyzed. These qualitative insights were developed iteratively, visualized, and validated in a causal loop diagram (CLD) using Vensim software. Results. The CLD revealed 3 key feedback loops-medical mistrust and HIV transmission, serosorting and marginalization of Black and gay individuals, and family support and internalized homophobia-that contribute to intersectional HIV and related stigmas, homophobia, and systemic racism. On the basis of these results, we designed 2 novel intervention components to integrate into an existing community-level anti-HIV stigma and homophobia intervention. Conclusions. HIV stigma, systemic racism, and homophobia work via feedback loops to reduce access to and uptake of HIV testing, prevention, and treatment. Public Health Implications. The CLD method yielded unique insights into reciprocal feedback structures that, if broken, could interrupt stigmatization and discrimination cycles that impede testing and prevention uptake. (Am J Public Health. 2022;112(S4):S444-S451. https://doi.org/10.2105/AJPH.2022.306725).

Information Seeking and MSM's Beliefs about PrEP and Condoms

This study examined how frequently men who have sex with men (MSM) used a selection of sources, including news media, social media, health organizations, and dating/hookup apps, for HIV information. Additionally, the study explored the extent to which MSM's efficacy beliefs about pre-exposure prophylaxis (PrEP) and perceptions of condom importance could be predicted by the sources they used. A sample of MSM (N= 969) were surveyed online. Results showed that respondents obtained information about HIV most often from HIV organizations, LGBT organizations, and dating/hookup apps, particularly the apps Growlr, Scruff, and Grindr. Use of the app Scruff was the strongest source-based predictor of beliefs about both PrEP and condoms. Implications for health promotion are discussed.

Barriers to Pre-Exposure Prophylaxis Uptake Among Online Male Sex Workers in the US

Though barriers to HIV pre-exposure prophylaxis (PrEP) uptake among gay, bisexual, and other men who have sex with men (MSM) have received substantial research attention, less is known about what factors may be affecting PrEP uptake among male sex workers (MSWs), a population at high risk of HIV. This paper presents qualitative findings regarding why a subsample of MSM engaged in exchange sex (receiving money, drugs, shelter, or other goods in exchange for sex) with partners they met on dating/hookup websites and apps had never used PrEP. Analysis revealed several barriers to PrEP uptake including lack of awareness and knowledge about PrEP, scientific and medical concerns, issues related to individual risk perception and beliefs/preferences about risk management, practical and logistical barriers, and provider-level barriers. Nuances to these barriers are discussed, particularly as they relate to the specific type of sex work participants were engaged in. Implications for interventions are also discussed.

Women Trust Their OBGYNs to Provide Preexposure Prophylaxis: An Opportunity for HIV Prevention

Objective

The objective of this study was to understand how women perceive the role of their Obstetrician and Gynecologist (OBGYN) in screening for and providing preexposure prophylaxis (PrEP) for HIV prevention.

Methods

We recruited women ages 18–45 years receiving obstetric or gynecological care at an academic medical center in the Bronx, NY. Thirty participants were enrolled: 10 seeking care for family planning, 10 seeking prenatal care, and 10 seeking care for a sexually transmitted infection. We screened participants for HIV acquisition risk using a PrEP screening tool. We conducted face-to-face, semi-structured interviews, which were audio-recorded, transcribed, and entered into Dedoose for analysis of themes using a grounded theory approach.

Results

Sixty percent of the participants were Latinx and 33% African American. Seventy percent had one or more risk factors for HIV acquisition based on the PrEP screening tool, indicating they would benefit from a PrEP discussion. Three main themes emerged from the analysis of interview data. Participants viewed OBGYNs as experts in sexual and reproductive healthcare and believed they were experts in PrEP. Participants were concerned about “PrEP stigma”, being judged by their clinicians as being sexually promiscuous if they expressed a need for PrEP. Lastly, when participants trusted their OBGYN, that trust became a facilitator for women to consider PrEP and offset stigma as a barrier to identifying patients who are candidates for PrEP.

Conclusion

Women established in care with an OBGYN are enthusiastic about having access to PrEP services incorporated into their sexual and reproductive healthcare. A universal approach to HIV prevention would avert stigma surrounding HIV care and prevention.

Communication Strategies for Discussing PrEP with Men Who Have Sex with Men

HIV continues to be a pressing problem, particularly for men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is a highly effective means of preventing HIV infection, but adoption of it by MSM has been sluggish. Though there are many reasons for PrEP's limited adoption, healthcare providers' lack of skill in communicating with MSM likely plays a role. This study employed in-depth interviews with MSM who have adopted PrEP to explore how effective patient-provider communication surrounding PrEP takes place. Findings revealed that healthcare providers utilized five strategies to communicate with their MSM patients about PrEP. These strategies included (1) disclosure of identity and personal information; (2) knowledge of information that may be relevant to MSM patients; (3) positivity; (4) relationship inquiries; and (5) remaining calm. Employing the strategies uncovered in this study may be useful in improving communication between healthcare providers and their MSM patients and may help to increase MSM's adoption of PrEP.

Provider-Patient Communication on Pre-Exposure Prophylaxis (Prep) for HIV Prevention: An Exploration of Healthcare Provider Challenges

Pre-exposure prophylaxis (PrEP) is a once-daily pill prescribed by healthcare providers to protect patients from contracting HIV. Current data suggests that a minority of healthcare providers have ever prescribed it to clinically-eligible patients. The present study employed a social ecological framework to understand the factors that influence providers' engagement in patient-centered communication regarding PrEP. Semi-structured interviews (N = 20) with physicians, physician assistants, and nurse practitioners working in primary and specialty care practices in Western New York were thematically analyzed to understand provider-based PrEP communication challenges. Although participants never prescribed PrEP, all had clinical experience with patient populations at risk for HIV, such as people who inject drugs, men who have sex with men, transgender women, and people who exchange sex for resources. Results revealed three themes affecting provider engagement in PrEP-related discussions, which emerged across three levels of the social ecological model. At the individual level, challenges affecting provider engagement in patient-centered discussions included lacking PrEP knowledge to educate and counsel patients and discomfort with prescribing PrEP based on its perceived newness. At the interpersonal level, participants expressed varying degrees of discomfort discussing HIV risk behaviors with patients. At the organizational level, providers expressed that time constraints and managing concurrent health conditions were competing clinical priorities. Findings indicate expanding implementation efforts will require multilevel interventions that target potential PrEP-adopting healthcare providers to mitigate the perceived and real challenges surrounding provider-patient communication on PrEP for HIV prevention. Practical implications are discussed.

Academic Detailing to Increase Prescribing of HIV Pre-exposure Prophylaxis

Although HIV pre-exposure prophylaxis can decrease new cases of HIV by up to 99%, many patients who could benefit from pre-exposure prophylaxis never receive prescriptions for it. Because pre-exposure prophylaxis is indicated for patients who do not have an infectious disease, increasing pre-exposure prophylaxis prescribing by primary care and generalist clinicians represents a key element of the Ending the HIV Epidemic in the U.S. initiative. This review provides an overview of academic detailing and how it is currently being used to increase pre-exposure prophylaxis prescribing. Academic detailing is outreach education that engages with clinicians in 1-to-1 or small group interactions focused on identifying and addressing an individual clinician's needs to increase their use of evidence-based practices. Academic detailing has been proven in multiple previous research studies, and the principles required for successful implementation include interactivity, clinical relevance of content, and focus on defined behavior change objectives. Clinician barriers to pre-exposure prophylaxis prescribing may occur in the domains of knowledge, attitudes, or behavior, and academic detailing has the potential to address all of these areas. State and local health departments have developed academic detailing programs focused on pre-exposure prophylaxis prescribing and other elements of HIV prevention-sometimes describing the approach as public health detailing. Few studies of academic detailing for pre-exposure prophylaxis have been published to date; rigorous evaluation of HIV-specific adaptations and innovations of the approach would represent an important contribution. In the setting of the COVID-19 pandemic, interest in virtual delivery of academic detailing has grown, which could inform efforts to implement academic detailing in rural communities and other underserved areas. Increasing this capacity could make an important contribution to Ending the HIV Epidemic in the U.S. and other HIV prevention efforts.

‘Access necessitates being seen’: Queer visibility and intersectional embodiment within the health information practices of queer community leaders

Navigating healthcare infrastructures is particularly challenging for queer-identifying individuals, with significant barriers emerging around stigma and practitioner ignorance. Further intersecting, historically marginalised identities such as one’s race, age or ability exacerbate such engagement with healthcare, particularly the access to and use of reliable and appropriate health information. We explore the salience of one’s queer identity relative to other embodied identities when navigating health information and care for themselves and their communities. Thirty semi-structured interviews with queer community leaders from South Carolina inform our discussion of the role one’s queer visibility plays relational to the visibility of other identities. We find that leaders and their communities navigate these intersectional visibilities through unique and iterative approaches to health information seeking, sharing and use predicated upon anti-queer, racist, ableist and misogynistic sentiments. Findings can inform queer-inclusive, intersectionally informed interventions by health and information professionals such as non-profit advocacy organisations and medical librarians.

Behavioral Intentions to Use Patient Portals to Disclose HIV and Other Sexually Transmitted Infection Testing Histories with Sexual Partners Among U.S. Sexual Minority Men

Disclosure of HIV and other sexually transmitted infection (HIV/STI) testing history to sexual partners is low among gay, bisexual, and other U.S. sexual minority men (SMM). Patient portals (PP) could increase HIV/STI testing history disclosure. This study estimated the predictive validity of the Enhancing Dyadic Communication (EDC) latent construct for perceived behavioral intentions to use PP for HIV/STI test disclosures. A randomized subset of SMM completed the Patient Portal Sexual Health Instrument as part of the 2018 American Men's Internet Survey. Multivariable logistic regression models estimated associations between EDC and intentions to use PP for test disclosures. Among a sample of 1,509 SMM aged 15 to 77 years, EDC was associated with intentions to use PP to disclose test history with main partners (aOR 2.17; 95% CI 1.90 to 2.47) and non-main partners (aOR 2.39; 95%CI 2.07 to 2.76). Assessing EDC could be useful in clinical settings for interventions encouraging patients to communicate with partners about testing.

Socio-Sexual Experiences and Access to Healthcare Among Informal PrEP Users in the Netherlands

The aim of this qualitative study was to explore the experiences of informal PrEP users regarding access to PrEP and PrEP-related healthcare, community responses, sexual behavior and well-being. We interviewed 30 men who have sex with men (MSM) in semi-structured online interviews between March and August 2018. Interviews were analyzed using interpretive description. Informal PrEP users were well informed about the use of PrEP, but sometimes did not make use of renal testing. Participants reported a lack of PrEP knowledge among healthcare providers, which limited their access to PrEP and put them at risk, as they received incorrect information. Although some participants reported negative reactions from potential sex partners, most received positive reactions and were sometimes seen as more desirable sex partners. PrEP healthcare services should not only be accessible to formal PrEP users, but also to PrEP users who procure PrEP informally.

Identity cues influence sexual minorities' anticipated treatment and disclosure intentions in healthcare settings: Exploring a multiple pathway model

The present work experimentally examines how identity cues that signal minority inclusion contribute to sexual minorities' (SM) healthcare visit expectations. We find that minority representation cues reduced SM's (N = 188) expectations of a healthcare provider's bias and increased perceived provider cultural competency which was, in turn, associated with lower anticipated identity-based devaluation and greater sexual orientation disclosure comfort. Providers' diversity-valuing statements had mixed effects highlighting the importance of more concrete indicators of inclusion in this context. This work suggests that a lack of identity safety cues in healthcare settings may contribute to disparate health outcomes for sexual minority populations.

Validation of the HIV Pre-exposure Prophylaxis Stigma Scale: Performance of Likert and Semantic Differential Scale Versions

Stigma regarding HIV pre-exposure prophylaxis (PrEP) is commonly implicated as a factor limiting the scale-up of this highly effective HIV prevention modality. To quantify and characterize PrEP stigma, we developed and validated a brief HIV PrEP Stigma Scale (HPSS) among a group of 279 men who have sex with men (MSM). Scale development was informed by a theoretical model to enhance content validity. We assessed two scale versions, Semantic Differential and Likert, randomizing the order in which scales were presented to participants. Both scales demonstrated high internal consistency. The Likert scale had substantially better construct validity and was selected as the preferred option. Scale scores demonstrated construct validity through association with constructs of interest: healthcare distrust, HIV knowledge, perceived proportion of friends/partners on PrEP, perceived community evaluation of PrEP, and perceived effectiveness of PrEP. The scale accounted for 25% of the total variance in reported willingness to be on PrEP, indicating the substantial role PrEP stigma may have on decisions to initiate PrEP. Given increased efforts to roll-out PrEP, having a valid tool to determine the level and types of PrEP stigma in individuals, groups, and communities can help direct implementation plans, identify goals for stigma reduction, and monitor progress over time.

Facilitators and Barriers of Pre-exposure Prophylaxis (PrEP) Uptake Among Rural Men who have Sex with Men Living in the Midwestern U.S

Facilitators and barriers of Pre-exposure Prophylaxis (PrEP) uptake have been established in prior studies; however, most of these studies comprise samples of MSM from metropolitan cities and hypothetical PrEP use. There is a dearth of literature on the uptake factors among rural U.S. MSM who are prescribed PrEP. Thirty-four rural Midwestern MSM who currently take PrEP participated in semi-structured telephone interviews about their barriers and facilitators to their PrEP use. Interviews were analyzed using an inductive thematic analysis approach. There were four barriers: (1) lack of rural dissemination of PrEP information, (2) concern about side and adverse effects of using PrEP, (3) cost of PrEP uptake and engagement, and (4) lack of access to PrEP care and PrEP care quality. Individual and social facilitators that participants utilized to overcome these barriers are discussed. Findings elevate the importance of multilevel interventions that address PrEP adoption from a patient, provider, and healthcare system perspective.

Older Versus Younger Men Who Have Sex with Men: Awareness of and Potential Barriers to the Use of Pre-Exposure Prophylaxis (PrEP) Medication to Prevent the Transmission of HIV

Purpose:

This paper compares younger (aged 18–39; n=197) and older (ages 50+; n=53) MSM to determine their familiarity with PrEP, willingness to learn more about PrEP, perceptions of stigma relating to PrEP use, and perceptions of barriers to PrEP adoption.

Methods:

A purposive sample of diverse MSM completed 15-minute questionnaires. Younger and older MSM were compared using Student’s t-tests and odds ratios for bivariate analyses, and multivariate logistic regression and multiple regressions for analyses controlling for key demographic characteristics.

Results:

Compared to younger MSM, older MSM were more aware of PrEP, more likely to know another PrEP user, less interested in learning more about PrEP, and more averse to using existing resources to learn more about PrEP. Older men perceived less stigma relating to PrEP and fewer obstacles needing to be overcome in order to give serious consideration to PrEP adoption. These differences remained when race, educational attainment, sexual orientation, and HIV serostatus were controlled.

Conclusions:

There is a “good news/bad news” situation with respect to older MSM and PrEP. They were more aware of PrEP, less likely to associate stigma with PrEP use or PrEP users, and anticipated fewer barriers to PrEP adoption. They were also less interested than their younger counterparts in learning more about PrEP and expressed less comfort using existing sources of information to learn more about PrEP. Age-appropriate PrEP educational campaigns are advisable in order to reach older MSM and encourage more of them to consider PrEP adoption.

PrEP and sexual well-being: a qualitative study on PrEP, sexuality of MSM, and patient-provider relationships

Most new diagnoses of HIV in the United States are among men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is a medication that mitigates risk of HIV acquisition and requires regular STI testing and prescription refills with PrEP providers. Because PrEP care monitors sexual behavior, there is a need to understand how PrEP providers approach sexual health care for MSM patients. In this study, semi-structured qualitative interviews were conducted with 20 MSM in Atlanta, Georgia with current or past prescriptions for PrEP. Data were analyzed with thematic analysis using four major steps: (1) code and codebook development, (2) assigning codes to segments of interviews, (3) code-based and comparative analysis methods, and (4) developing thematic findings. Findings from interviews about changes in sexuality while using PrEP include decreased anxiety surrounding sex, increased feelings of control over personal health, and experiencing less stigma towards sexual partners with HIV. Participants indicated needs for tailored health advice based on individual sexual preferences, sexual health care free from stereotypical assumptions, and improved access to PrEP providers identifying as gay men or who practice in LGBT-friendly settings. Study findings support a call for a gain-frame approach to sexual health in PrEP care for MSM.

Brief Report: PrEPTECH: A Telehealth-Based Initiation Program for HIV Pre-exposure Prophylaxis in Young Men of Color Who Have Sex With Men. A Pilot Study of Feasibility

BACKGROUND

In the United States, young men who have sex with men (YMSM) of color represent a high number of new HIV diagnoses annually. HIV pre-exposure prophylaxis (PrEP) is effective and acceptable to YMSM of color; yet, PrEP uptake is low in those communities because of barriers including stigma, cost, adherence concerns, and medical distrust. A telehealth-based approach to PrEP initiation may be a solution to those barriers. This pilot study investigates one such intervention called PrEPTECH.

METHODS

We enrolled 25 HIV-uninfected YMSM, aged 18-25 years, from the San Francisco Bay Area into a 180-day longitudinal study between November 2016 and May 2017. Participants received cost-free PrEP services through telehealth [eg, telemedicine visits, home delivery of Truvada, and sexually transmitted infection testing kits], except for 2 laboratory visits. Online survey assessments querying PrEPTECH features and experiences were administered to participants at 90 and 180 days.

RESULTS

Eighty-four percent of participants were YMSM of color. Among the 21 who completed the study, 11 of the 16 who wanted to continue PrEP were transitioned to sustainable PrEP providers. At least 75% felt that PrEPTECH was confidential, fast, convenient, and easy to use. Less than 15% personally experienced PrEP stigma during the study. The median time to PrEP initiation was 46 days. Sexually transmitted infection positivity was 20% and 19% at baseline and 90 days, respectively. No HIV infections were detected.

CONCLUSIONS

Telehealth programs such as PrEPTECH increase PrEP access for YMSM of color by eliminating barriers inherent in traditional clinic-based models.

Long-term retention in pre-exposure prophylaxis care among men who have sex with men and transgender women in the United States

INTRODUCTION

Retention in HIV pre-exposure prophylaxis (PrEP) care in real-world settings, outside of controlled trials or demonstration projects, remains poorly understood.

METHODS

We evaluated retention in PrEP care outcomes among men who have sex with men (MSM) and transgender women prescribed PrEP through March 2017 at three clinical sites in the United States (US): Jackson, Mississippi; Providence, Rhode Island; and St. Louis, Missouri. We determined retention rates by attendance of clinical visits every three months, per US Centers for Disease Control and Prevention (CDC) guidelines, as well as by the timing of patients' actual clinical visits. Multivariable analyses examined demographic and behavioural factors associated with retention.

RESULTS

From 2013 to 2015, 282 MSM and transgender women were prescribed PrEP; 82% attended a follow-up visit. Based on CDC recommendations, 56% of patients were retained in PrEP care at the first follow-up visit, having attended a visit three months after initiation. However, 76% had a follow-up visit within eight months. Thirty-percent were retained at 12 months by CDC criteria, but 62% were retained when using a 16-month endpoint. Self-reported adherence was strongly correlated with retention. In multivariable analyses, younger age was associated with decreased odds of retention at initial follow-up, and completing college was associated with increased odds of retention at 16 months. Eight participants were newly diagnosed with HIV; six were African American, and seven were under 30 years of age.

CONCLUSIONS

Measuring retention in PrEP care using three-month follow-up intervals may underestimate true retention. Nevertheless, retention in PrEP care is suboptimal in real-world settings and should be the focus of future interventions.

Stigma and Shame Experiences by MSM Who Take PrEP for HIV Prevention: A Qualitative Study

Pre-exposure prophylaxis (PrEP) uptake has been extremely low among key groups. PrEP-related stigma and shaming are potential barriers to uptake and retention in PrEP programs. There is a lack of literature describing PrEP stigma. In order to fill this gap, we recruited online 43 HIV-negative Men who have Sex with Men (MSM) who use PrEP. Semistructured interviews were conducted to explore their perceptions and experience of stigma related to PrEP use. Data were analyzed using Strauss and Corbin's grounded theory and constant comparison techniques to enhance understanding of the lived experiences of MSM who use PrEP. The participants experienced PrEP stigma as rejection by potential/actual partners, stereotypes of promiscuity or chemsex, and labeling of both the user and the medication. They connected PrEP stigma with HIV stigma, generational differences, moralization of condom use, and inability to embrace one's own sexuality. These findings point to a need to develop tailored interventions to address PrEP-related stigma and shaming for individuals, health-care professionals, and the MSM community-at-large.