The Pre-Exposure Prophylaxis-Stigma Paradox: Learning from Canada's First Wave of PrEP Users

Abstract

With the emergence of daily oral tenofovir disoproxil fumarate and emtricitabine-based pre-exposure prophylaxis (PrEP) use in Canada, questions have emerged concerning the impacts of this HIV prevention tool on gay men's social and sexual lives. We conducted small focus groups and individual qualitative interviews with 16 gay men in Toronto who were part of the ‘first wave’ of Canadian PrEP users. Participants were on PrEP for at least one year as part of a demonstration project (November 2014–June 2016). These participants accessed PrEP before regulatory approval by Health Canada in February 2016. The mean age of participants was 37.6 years (SD 11.02); 94% completed secondary education, and 69% were white. Sex-stigma emerged as a complex theme in men's accounts of PrEP use across three overlapping domains: (1) PrEP-related stigma, including discussions of concealment and stigma from friends, family, and sexual partners, (2) PrEP as a perceived tool for combating HIV-related stigma, where some men said that they no longer discussed HIV status with sexual partners, and (3) PrEP as illuminating structural stigma, where it was attributed to unmasking stigma related to sex and sexuality. For some participants, PrEP has allowed for liberating sex and a self-described return to normalcy—normal, exciting, pleasurable sex that was no longer reliant on condom use. Paradoxically, some men said that PrEP use both led them to experience stigmatizing reactions within their social and sexual networks, while also helping to remove stigma, shame, and fear related to HIV, sexuality, and sex with gay men living with HIV.

“Little Tablets of Gold”: An Examination of the Psychological and Social Dimensions of PrEP Among LGBTQ Communities

“…Our findings about stigma are consistent with previous research identifying stigma as an important factor influencing PrEP use (Arnold et al, 2017;Collins, McMahan, & Stekler, 2017;Franks et al, 2018;García & Harris, 2017;Grace et al, 2018;Haire, 2015;Liu et al, 2014;Taylor et al, 2014;Thomann et al, 2018;. In our and other studies, PrEP stigma is closely tied to stigma around HIV, "risky" sexual behavior, and sexual and gender identity (Franks et al, 2018;Grace et al, 2018;Haire, 2015). Just as we found, other researchers have observed that stigma can be an obstacle to PrEP use, but that PrEP is also an opportunity to expose and combat stigma around HIV and sexuality (Grace et al, 2018;Storholm et al, 2017).…”

“…In our and other studies, PrEP stigma is closely tied to stigma around HIV, "risky" sexual behavior, and sexual and gender identity (Franks et al, 2018;Grace et al, 2018;Haire, 2015). Just as we found, other researchers have observed that stigma can be an obstacle to PrEP use, but that PrEP is also an opportunity to expose and combat stigma around HIV and sexuality (Grace et al, 2018;Storholm et al, 2017). Additionally, we noted, as did others, that PrEP users had a sense of pride around PrEP (Grace et al, 2018).…”

“…Just as we found, other researchers have observed that stigma can be an obstacle to PrEP use, but that PrEP is also an opportunity to expose and combat stigma around HIV and sexuality (Grace et al, 2018;Storholm et al, 2017). Additionally, we noted, as did others, that PrEP users had a sense of pride around PrEP (Grace et al, 2018). Our findings add new insights about the PrEP stigma by further illuminating strategies that LGBTQ PrEP users adopt to challenge stigma and reframe conversations about PrEP use and HIV prevention.…”

“…Although previous studies have examined attitudes about PrEP uptake (Bauermeister, Meanley, Pingel, Soler, & Harper, 2013;Brooks et al, 2011;Dolezal et al, 2015;Galindo et al, 2012;García & Harris, 2017;Goedel, Halkitis, Greene, Hickson, & Duncan, 2016;Grov, Whitfield, Rendina, Ventuneac, & Parsons, 2015;Holt et al, 2012;Peng et al, 2018;Thomann, Grosso, Zapata, & Chiasson, 2018;Young, Flowers, & McDaid, 2014), and impact of PrEP on sexual risk behaviors (Freeborn & Portillo, 2018;Grov et al, 2015;Holt et al, 2012;Koester et al, 2017;Storholm, Volk, Marcus, Silverberg, & Satre, 2017), there is little understanding of the sociocultural dimensions of actual PrEP use. Most previous U.S. studies about the emotional or psychological effects of PrEP have asked participants to consider hypothetical situations or have enrolled participants of clinical trials and demonstrations projects (Gilmore et al, 2013;Grace, Jollimore, MacPherson, Strang, & Tan, 2018;Koester et al, 2017). While these studies provide insights into the experience of PrEP in controlled research and practice contexts, little is known about the real-world psychological and social effects of PrEP among LGBTQ adults who use PrEP.…”

Access to HIV Pre-exposure Prophylaxis in Practice Settings: a Qualitative Study of Sexual and Gender Minority Adults’ Perspectives

“…8,12,13 Research among potential PrEP users identifies awareness and knowledge of PrEP, costs, side effects, PrEP stigma, beliefs about HIV, and access to health care as important factors impacting uptake of PrEP. [14][15][16][17][18][19][20][21] Findings from open-label trials and demonstration projects have been similar, [22][23][24] although research in these contexts has focused on adherence and sexual behavior changes rather than uptake. [25][26][27][28][29][30] Others have studied provider barriers to PrEP implementation, finding that provider education is an important aspect of PrEP access.…”