Gendered Social Institutions and Preventive Healthcare Seeking for Black Men Who Have Sex with Men: The Promise of Biomedical HIV Prevention

Abstract

Research on gender and health, including research conducted among Black men who have sex with men (BMSM), has primarily focused on how gender norms and roles shape healthcare engagement. Here we advance that work by demonstrating how a broader theorization of gender, particularly one that moves beyond gender norms and performance to incorporate structures such as the healthcare system and the labor market, can facilitate an understanding of how gender affects preventive healthcare seeking among BMSM, particularly the uptake of pre-exposure prophylaxis (PrEP), a promising approach to alleviate HIV disparities. This article is based on a year-long ethnographic study conducted in New York City with BMSM (n = 31; three interviews each) and community stakeholders (n = 17). Two primary findings emerged: (1) the labor market systematically excluded the men in our sample, which limited their ability to access employer-sponsored healthcare. Such discrimination may promote overt demonstrations of masculinity that increase their HIV vulnerability and decrease healthcare seeking, and (2) healthcare systems are not structured to promote preventive healthcare for men, particularly BMSM. In fact, they constrained men's access to primary providers and were usually tailored to women. Applying a structural, gendered lens to men's health-in addition to the more frequently researched individual or interpersonal levels-provides insight into factors that affect healthcare seeking and HIV prevention for BMSM. These findings have implications for the design of policies and institutional reforms that could enhance the impact of PrEP among BMSM. Findings are also relevant to the management of chronic disease among men more broadly.

Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men

“…17 Patients who might be interested in PrEP report feeling that interactions with providers are ''scripted'' in ways that do not allow full disclosure of sexual behavior or concerns. 18 Men of color are particularly likely to report that providers make false assumptions about their heterosexuality, or relate that fears of ''transgressing'' masculine norms in health care settings limit their access to preventive care. 18 However, even if PrEP assessment tools were widely disseminated and providers were taught how to administer them effectively, data suggest that there would still be a fundamental problem with this strategy for identifying appropriate PrEP candidates stemming from a disconnect in data about HIV transmission.…”

“…18 Men of color are particularly likely to report that providers make false assumptions about their heterosexuality, or relate that fears of ''transgressing'' masculine norms in health care settings limit their access to preventive care. 18 However, even if PrEP assessment tools were widely disseminated and providers were taught how to administer them effectively, data suggest that there would still be a fundamental problem with this strategy for identifying appropriate PrEP candidates stemming from a disconnect in data about HIV transmission. For a given individual patient, there is no denying that as the number of risk factors (e.g., number of partners, number of sex acts) increases, their risk for HIV exposure increases as well.…”

Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Men Who Have Sex with Men (MSM): A Scoping Review on PrEP Service Delivery and Programming

“…The microsystem level represents where individuals participate directly with their surroundings and should therefore include the following three key elements. Firstly, information should be provided on how to access PrEP to address current structural barriers and challenges, [ 52 , 57 , 68 , 70 , 73 , 85 , 94 , 97 , 101 , 108 , 114 – 117 ] such as cost, [ 113 , 118 , 119 ] geography, [ 83 ] and stigma [ 78 , 82 , 120 ]. Secondly, general education about PrEP should be made accessible across a range of media, to a broad geographic and culturally diverse audience.…”

“…A surprising finding was the lack of open discussion that was experienced during consultations. From the perspective of the service user, conversations around sexual behaviour were missed as they were seen to be difficult, [62,67,80] uncomfortable, [61,97] or as a consequence of the service providers' failure to take complete histories [56,60,68,78,79,86,96]. Some studies reported the lack of disclosure of sexual activity [80,82,99] and PrEP use [80,82,99], due to concerns for privacy and confidentiality, perceived stigma, fear of negative repercussions and embarrassment.…”

“…When service users were able to disclose their previous and current sexual behaviours this was due to a 'positive rapport with staff' [55,77,82,92,100,101]. Other conversation topics noted informal PrEP use, [102] missed pills, [92] risk reduction and counselling, [55,62] testing, [86] HIV prevention, wider sexual health and sexual orientation, [62,80,81,97] systemic barriers such as lack of primary care practices, adherence and medication refills, [62,97] drug use [101] and lack of healthcare support [94,103]. As has been shown, research evidences service provision and initiation of PrEP, however the discontinuation of PrEP was only reported in three studies [57,63,104].…”