Barriers to PrEP Uptake in Two Spirit, Gay, Bisexual, Trans and Queer Men, and Non-Binary People in Canada

Abstract

Background: Indigenous and ethnoracial minority Gay, Bisexual, Trans, Queer men, Two-Spirit, and non-binary (GBTQ2S+) people in Canada are often underrepresented in PrEP uptake within GBTQ2S+ population samples due to health and social inequities. We sought to determine barriers to PrEP use for sub-populations of HIV-negative GBT2Q based on ethnoracial identity and gender diversity. Method: Participants self-completed the national, online, anonymous, community-based Sex Now 2019 behavioural surveillance survey. Recruitment occurred via GBTQ2S+-oriented sex-seeking apps, websites, and social media from November 2019 to February 2020 (pre-COVID). Participants completed questions on demographics and PrEP-related barriers (e.g., low self-perceived HIV risk, cost, judgement from healthcare providers). Multivariable confounder bootstrapped (1000 iterations) logistic regression models assessed differences in various barriers to PrEP by ethnoracial identity, and stratified by cisgender/gender-diverse identity; possible confounders included age, income, and sexual orientation, if significantly correlated with the outcome. Beta coefficients (β) with 95% confidence intervals (CI) are presented. Results: Of 1137 HIV-negative Indigenous and ethnoracial minority GBTQ2S+ participants (85.5% cisgender men, 14.5% gender-diverse), 17.2% were Black/African/Caribbean, 29.2% were Indigenous, 20.0% were Latinx, 28.9% were East/Southeast Asian, and 21.9% were Arab/South Asian. Four ethnoracial differences in PrEP-related barriers were identified. First, low self-perceived HIV risk was less likely to be reported by Latinx (15.6% versus 23.2%, β=-0.75, CI [-1.41,-0.15]) and Arab/South Asian (17.8% versus 22.8%, β=-0.53, CI [-1.10,-0.056]) participants. Second, disliking taking pills was less likely to be reported by Arab/South Asian participants (8.7% versus 16.4%, β=-0.61, CI [-1.29,-0.11]). Third, cost as a barrier was less likely to be reported by Indigenous participants (19.9% versus 28.9%, β=-0.61, CI [-1.16,-0.11]). Fourth, judgement from healthcare providers was less likely reported by gender-diverse South Asian participants (8.0%, β=-1.54, CI [-22.33,-0.024]) versus all other gender-diverse participants (23.6%). Conclusion: Commonly reported PrEP barriers for Indigenous and ethnoracial minority GBTQ2S+ were self-perceived risk, cost, and judgement from healthcare providers. However, specific ethnoracial groups, intersecting with gender diversity, experienced these less. Although this data cannot encapsulate all PrEP barriers faced by these communities, it highlights the need for culturally-appropriate and gender-affirming health promotion strategies, new PrEP prevention efforts, and healthcare provider capacity-building to improve equitable PrEP implementation.

Brief Report: Outcomes of Individuals Using HIV Postexposure Prophylaxis-In-Pocket (“PIP”) for Low-Frequency, High-Risk Exposures in Toronto, Canada

“…Significant barriers to PEP remain. 3,4 PEP requires an individual to present to an ED or urgent care facility in a timely manner, at which time they may receive a "starter pack" containing only a few days of ARVs along with a referral to a dedicated PEP provider who will provide further care and determine whether the remainder of ARVs is needed. Those who require a full 28-day course of medication may then face additional challenges because ARVs are expensive and not universally covered for PEP in many jurisdictions, including Ontario.…”

“…3 Additional low-barrier biomedical HIV prevention options would be helpful for individuals who have a low frequency of unanticipated exposures. 3,4…”

“…3 Additional low-barrier biomedical HIV prevention options would be helpful for individuals who have a low frequency of unanticipated exposures. 3,4 HIV postexposure prophylaxis-in-pocket ("PEP-in-Pocket" or "PIP") involves prospectively identifying individuals with a very low frequency of higher-risk HIV exposures and providing them with a prescription for 28-days of PEP, along with instructions on when to initiate medications and how to follow-up with care. We previously described PIP care in a cohort of individuals who fit these criteria.…”