Structural Barriers to Pre-exposure Prophylaxis Use Among Young Sexual Minority Men: The P18 Cohort Study

Abstract

Background: Despite decreasing rates of HIV among many populations, HIV-related health disparities among gay, bisexual and other men who have sex with men persist, with disproportional percentages of new HIV diagnoses among racial and ethnic minority men. Despite increasing awareness of HIV pre-exposure prophylaxis (PrEP), PrEP use remains low. In addition to exploring individual-level factors for this slow uptake, structural drivers of PrEP use must also be identified in order to maximize the effectiveness of biomedical HIV prevention strategies. Method: Using cross-sectional data from an ongoing cohort study of young sexual minority men (N=492), we examine the extent to which structural-level barriers, including access to health care, medication logistics, counseling support, and stigma are related to PrEP use. Results: While almost all participants indicated awareness of PrEP, only 14% had ever used PrEP. PrEP use was associated with lower concerns about health care access, particularly paying for PrEP. Those with greater concerns talking with their provider about their sexual behaviors were less likely to use PrEP. Conclusion: Paying for PrEP and talking to one’s provider about sexual behaviors are concerns for young sexual minority men. In particular, stigma from healthcare providers poses a significant barrier to PrEP use in this population. Providers need not only to increase their own awareness of and advocacy for PrEP as an effective risk-management strategy for HIV prevention, but also must work to create open and non-judgmental spaces in which patients can discuss sexual behaviors without the fear of stigma.

Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review

“…Participants with greater concerns around talking with their provider about their sexual behaviors were less likely to use PrEP [191] Online surveys and focus groups of adolescents (N = 56), most of whom were cis male (95%) and identified as gay (79%)…”

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

“…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.…”

“…A range of solutions for improving the relationship between the service users and providers were offered in the studies. These included having gay-friendly service providers and affirmative training, [77,79,80,94,100] improving long-term communication to build trust, [62,67,92,94,95,101] developing patient-centred care, [92] increasing service provider knowledge and awareness of PrEP, [62,96,101] and encouraging wider health discussions [62,78]. Key solutions included the routinisation of PrEP prescribing with electronic health record systems that could be used 'to identify potential PrEP candidates… and follow up-care', [62] and the delivery of PrEP using a shared decision-making approach between the patient and service provider, as proposed by Calabrese et al [68] and Krakower et al [57].…”

“…For example, Calabrese et al [68] stated that there was a gap for 'the development of curricula and evaluation standards for PrEP-related medical education', whilst Newman et al [120] highlighted the importance of online experiences in bringing together the gay and bisexual male (GBM) PrEP community. The third element is the identification of potential PrEP users [52,61,73,96,108,127]. This could be through existing relationships between the individuals and healthcare providers or counsellors but also through established referral systems.…”

Assisters Succeed in Insurance Navigation for People Living with HIV and People at Increased Risk of HIV in a Complex Coverage Landscape

“… 23 Moreover, PrEP-related out-of-pocket costs can vary widely depending on one's insurance, 24 and high PrEP-related costs are a barrier to PrEP use. 25–27 PrEP reduces HIV transmission for sexual encounters by >90% and for injection drug use by >70%. 28 Each HIV infection that is averted saves approximately $400,000.…”