'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

Protocol for a systematic search and critical discourse analysis of research on national HIV pre-exposure prophylaxis programmes among gay, bisexual, and other men who have sex with men

Background

HIV pre-exposure prophylaxis (PrEP) is a medication that prevents the acquisition of HIV, most commonly taken in the form of a pill. PrEP is an efficacious tool for HIV prevention, including among gay, bisexual, and other men who have sex with men (gbMSM). PrEP is often provided through formal PrEP programmes. Research on these programmes may employ discourses shaped by heteronormativity and homophobia. Given that expert language influences how HIV prevention is understood and delivered, problematic discourses in research likely extend into PrEP implementation. This study will use critical discourse analysis (CDA) to explore research on PrEP programme implementation for gbMSM. Within this literature, we will identify interpretive repertoires used to discuss gbMSM; the subject positions afforded to gbMSM; and the implications of these interpretive repertoires and subject positions for gbMSM engaging with HIV PrEP programmes.

Methods

Systematic search methods identified relevant articles through timebound searching (2012-2023) in ProQuest ASSIA, EBSCOhost PsycInfo, OVID Medline, OVID Embase, and EBSCOhost CINAHL, with forward and backward citation searching of included studies. Grey literature will be identified through ProQuest and Google Scholar. Screening will be conducted by two independent reviewers, who will conduct random partial double screening for titles and abstracts and for all full text articles. Data will be analysed and synthesised using CDA informed by critical realism (CR). CDA focuses on relationships between language and power, including how language enables inequality. The analytic process will explore the background of included studies, identify themes, and analyse external and internal relations in included studies.

Conclusions

Highlighting issues with discourses in PrEP implementation may enhance reflective engagement with assumptions underlying this research, preventing further stigmatisation of gbMSM's sexual and protective practices. As PrEP programmes become more common, diverse and inclusive perspectives in PrEP programme research may inform interventions that enhance their acceptability and implementation.

Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care

BACKGROUND

Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings.

OBJECTIVE

To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs.

DESIGN

Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018.

PARTICIPANTS

The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City.

APPROACH

Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts.

KEY RESULTS

Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers.

CONCLUSIONS

SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.

Gay community involvement and the sexual health behaviours of sexual minority men: a systematic review and directions for future research

Considerable research has examined how involvement in gay-affiliated communities is associated with sexual health behaviours in sexual minority men (i.e., gay, bisexual, and other men who have sex with men), yet findings in this domain are often contradictory and inconclusive. This systematic review aimed to (a) synthesise the related empirical literature, and (b) identify potential factors driving inconsistent findings. Peer-reviewed publications were included if they contained quantitative data and at least one measure of the statistical association between gay community involvement and sexual health behaviour. The search strategy was implemented in six databases and returned 6,409 articles, of which 86 met the inclusion criteria. There was considerable heterogeneity in how gay community involvement was assessed across studies. Although gay community involvement was consistently associated with greater engagement in protective behaviours across studies, the association between gay community involvement and risk behaviours appeared to depend on how gay community involvement was conceptualised and measured (e.g., nightlife involvement vs. political activism). Findings emphasise a need for studies that employ validated measures that reflect the multidimensional nature of gay community involvement, as well as research designs better suited to address the causal effects of community involvement on HIV/STI transmission and prevention.

Attitudes and Beliefs About HIV Treatment as Prevention Among People Who are Not Engaged in HIV Care, 2018-2019

Treatment as prevention (TasP) is an effective HIV prevention strategy. Our objectives were to explore TasP attitudes and beliefs among people with HIV (PWH) who are not engaged in care and to examine attitudes and beliefs by selected characteristics. We sampled PWH who had participated in the Medical Monitoring Project (MMP), a structured interview survey, from June 2018-May 2019 to participate in 60-minute semi-structured telephone interviews. We obtained sociodemographic and behavioral quantitative data from the MMP structured interview. We used applied thematic analysis to analyze the qualitative data and integrated the qualitative and quantitative data during analysis. Negative attitudes and beliefs, especially skepticism and mistrust, about TasP were pervasive. Only one participant who identified as female, was not sexually active, and had not heard of TasP held positive attitudes and beliefs about TasP. TasP messages should use clear and unambiguous language, address mistrust, and reach people who are not engaged in medical care.

Pre-exposure prophylaxis (PrEP) use, anticipated PrEP stigma, and bisexual identity among a Black and Hispanic/Latino sexual and gender diverse sample

Black and Hispanic/Latino sexual minority men and gender diverse (SMMGD) individuals are disproportionately impacted by the HIV epidemic. Uptake and adherence to pre-exposure prophylaxis (PrEP) is suboptimal among SMMGD Black and Hispanic/Latino individuals, but most research has approached this population as homogenous (e.g., a group operationalized as men who have sex with men). Bisexual men are less likely to disclose their sexual identity and report more mental health problems than their gay counterparts, but there is less attention to the impact of different sexual identities on PrEP use over time. We utilized data from three waves of a national longitudinal study (2020-2021) to characterize Black and Hispanic/Latino SMMGD participants' PrEP use including: 1) PrEP uptake during the study; 2) consistent PrEP use across the study; and 3) discontinuation of PrEP use since study baseline. We found bisexual men were significantly less likely than gay men to be consistent PrEP users and were more likely to discontinue PrEP use over the course of the study. Of the sample who reported PrEP use across surveys, 10% initiated PrEP during the study period, 0% of whom were bisexual. Additionally, bisexual participants reported statistically significantly higher anticipated PrEP stigma relative to gay participants. These findings have implications for HIV prevention interventions. Given the differences in PrEP experiences as a function of sexual identity, researchers and clinicians should consider the disruptive role of stigma (both biphobia and anticipated PrEP stigma) in PrEP care and adherence.

PrEP use and stigma among a sample of older adults in Columbus, Ohio

INTRODUCTION

Despite older adults (age ≥50 years) continuing to account for 1 in 6 new HIV diagnoses, the majority of research has focused on young adults. Assessing PrEP use and stigma among this understudied population is key to achieving the U.S.'s goals of Ending the HIV Epidemic, a federal initiative focusing on reducing new HIV infections by at least 90% by 2030.

METHODS

Data for this analysis came from the Columbus Health Aging Project (N = 794). This study was designed to assess several domains of health among adults aged 50 years and older in Columbus, Ohio. Multiple logistic and linear regression models were used to examine the associations between sociodemographic factors and past 6-month PrEP use, PrEP stigma, and concurrent use of PrEP and other prevention methods, adjusting for known confounders.

RESULTS

Overall, 93 (11.7%) participants reported past 6-month PrEP use. Transgender women (aOR = 6.90; 95% CI: 2.19, 21.72), cisgender gay men (aOR = 5.58; 95% CI: 2.49, 12.50), cisgender lesbians (aOR = 2.24; 95% CI: 1.05, 4.80), and those living with family members or roommates (aOR = 6.59; 95% CI: 3.49, 12.45) were each more likely to report past 6-month PrEP use relative to cisgender women, heterosexuals, and those living with a spouse/partner, respectively. Relative to cisgender women, PrEP-related stigma was lower among transgender women (β = -5.05; 95% CI: -8.44, -1.66) and higher among cisgender men (β = 1.96; 95% CI: 0.46, 3.46).

CONCLUSION

Future research should aim to continue developing a firm understanding of PrEP use and stigma among older adults to reduce HIV risk among this population and to understand unique needs of sub-populations of older adults.