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.
Purpose
Disparities persist in HIV infection among Black and Latino men who have sex with men (BLMSM) and Black and Latina transgender women (BLTW). Increasing uptake and subsequent consistent use of pre-exposure prophylaxis (PrEP), an effective biomedical strategy for preventing HIV acquisition, can dramatically reduce HIV incidence in these populations. The purpose of this study was to explore reasons for PrEP discontinuation among BLMSM and BLTW living in Los Angeles County to inform the development of support services for these populations to remain persistent with their PrEP regimen.
Methods
In-depth, semi-structured interviews were conducted with 15 BLMSM and 7 BLTW who reported either temporary or indefinite PrEP discontinuation. A thematic analysis approach was used to analyze qualitative data.
Results
Four themes emerged related to reasons for PrEP discontinuation, including: (1) lower perceived HIV risk related to changes in sexual behavior; (2) structural or logistical barriers (e.g., lapse or loss of health insurance, cost, difficulty navigating complex medical systems); (3) anticipated and experienced medication side effects, with a sub-theme of interactions between PrEP and feminizing hormone medications; and (4) challenges with medication adherence.
Conclusions
PrEP is an important prevention tool for BLMSM and BLTW, particularly during periods of heightened HIV risk. However, both individual (e.g., inability to adhere to medication, changes in HIV sexual risk behaviors) and structural/logistical (e.g., loss of insurance, navigating complex medical systems) factors can cause temporary or indefinite PrEP discontinuation. Additional support services, beyond those offered by medical providers, are needed to help BLMSM and BLTW PrEP users overcome barriers to discontinuation and assist them to remain persistent with their PrEP regimen. We describe potential options for support services such as PrEP case management, expanded PrEP navigation services, or text messaging services.
IPV was more likely to be reported at visits when PrEP interruptions were also reported, which may have implications for sustained adherence to PrEP. Within PrEP delivery programs, there may be opportunities to assess individual safety and well-being to bolster adherence.
Summary
Few data exist on oral human papillomavirus (HPV) prevalence in female sex workers (FSWs). Information regarding oral sex practices of 185 Peruvian FSWs, 18–26 years of age, was obtained via survey and compared with HPV testing results of oral rinse samples. Oral HPV prevalence was 14/185 (7.6%); four (28.9%) HPV genotypes were carcinogenic. One hundred and eighty-two participants reported having had oral sex; 95% reported condom use during oral sex with clients and 9.5% with partners. Women who had oral sex more than three times with their partners in the past month were more likely to have oral HPV than women who had oral sex three times or less (P = 0.06). Ten (71.4%) women with oral HPV were HPV-positive at the cervix; conversely 8.3% of women with cervical HPV were HPV-positive in the oral cavity. The prevalence of oral HPV was relatively low, considering the high rates of oral sex practiced by these women.
In the United States, HIV disproportionally affects Black and Latina transgender women (BLTW). Preexposure prophylaxis (PrEP) is a proven biomedical method for preventing HIV acquisition. However, the social stigma attached to using PrEP may deter uptake and persistence of PrEP among BLTW, two highly vulnerable populations. The purpose of this study was to explore the experiences of PrEP stigma among BLTW who are using PrEP in Los Angeles County. Methods: In-depth, semistructured interviews were conducted with BLTW PrEP users (N = 19) to explore experiences of anticipated, enacted, and internalized PrEP stigma within the context of their unique social and contextual factors. A thematic analysis approach was used in the analysis of qualitative data. Results: We noted an underlying theme of HIV stigma related to participants' identification as trans women that served as the social context for other experiences. In addition, our data revealed five themes related to the experience of using PrEP. Three themes were specifically related to PrEP stigma and included: (1) Perception that BLTW PrEP users are HIV-positive; (2) perception that BLTW PrEP users engage in elevated sexual risk behaviors; and (3) negative labels ascribed to BLTW PrEP users. A fourth theme identified was the positive experiences of social support after PrEP disclosure reported by BLTW. Our fifth theme identified involved the dissemination of PrEP information by BLTW to friends/peers and sex partners. Conclusion: BLTW experience PrEP stigma within the context of PrEP disclosure. This experience is underscored by existing experiences of HIV stigma connected to their identity as trans women. PrEP providers should prepare BLTW to use selective disclosure practices when revealing their PrEP use to help minimize experiences of PrEP stigma or potential physical harm. PrEP implementation programs should also support peer-to-peer PrEP education programs for transgender women to promote positive views of PrEP and help facilitate PrEP uptake in this population.
Two hundred female sex workers (FSWs) in Lima, Peru were randomized to receive HPV4 vaccine in the standard (0, 2, 6 months) or a modified schedule (0, 3, 6 months). One hundred and eighty four (92%) participants completed 3 doses of vaccine. Baseline seropositive rates were 58% for HPV6, 22.5% for HPV11, 41.5% for HPV16, and 13% for HPV18. The final geometric mean antibody titer (GMT) following vaccination was significantly greater for women who were seropositive at baseline compared to seronegative women: HPV6 (GMT ratio=2.3, p<0.01), HPV11 (GMT ratio=2.7, p<0.01), HPV16 (GMT ratio=1.3, p=0.04), and HPV18 (GMT ratio=2.4, p<0.01)). Antibody titers in the modified schedule were not inferior to those in the standard schedule, suggesting the modified schedule may be paired with required STD visits. Although all women benefit from vaccination, administration at a younger age and before sexual debut is needed to achieve maximum protection from vaccine.
Summary
Female sex workers (FSWs) are at high risk of human papillomavirus (HPV) infection. Questionnaires were administered to 200 FSWs aged 18–26 years in Lima, Peru, to gather risk behaviours, and cervical swab samples were collected for Pap smears and HPV DNA testing as part of a longitudinal study. Participants reported a median of 120 clients in the past month, and 99.2% reported using condoms with clients. The prevalence of any HPV in cervical samples was 66.8%; 34 (17.1%) participants had prevalent HPV 16 or 18, and 92 (46.2%) had one or more oncogenic types. Fifteen women had abnormal Pap smears, 13 of which were HPV DNA positive. Fewer years since first sex was associated with oncogenic HPV prevalence in a model adjusted for previous sexually transmitted infection (STI) status and condom use with partners (prevalence ratio = 0.77, 95% confidence interval [CI] = 0.60–0.97). Our data confirm the high rates of HPV transmission among FSWs in Peru, highlighting the need for early and effective strategies to prevent cervical cancer.
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