The PrEP Cascade in a National Cohort of Adolescent Men Who Have Sex With Men

Abstract

Background: Pre-exposure prophylaxis (PrEP) has been an available biomedical intervention for at-risk adolescents for over 2 years; however, progression from awareness to uptake and adherence has been slow. In response, we map adolescent men who have sex with men (AMSM) onto the PrEP Motivation Cascade to identify stages for intervention. Methods: We analyzed PrEP-related attitudinal and behavioral data from a US national cohort of 1398 AMSM. Results: A majority of the sample (53.9%) were identified as appropriate PrEP candidates. Of those identified as appropriate candidates, 51.8% were precontemplative (stage 1; unwilling to take or believing they were inappropriate candidates for PrEP), and 48.2% reached contemplation (stage 2; willing and self-identified as appropriate candidates). Only 16.3% of candidates reached preparation (stage 3; seeing PrEP as accessible and planning to initiate PrEP), and 3.1% reached PrEP action (stage 4; prescribed PrEP). Although few of the AMSM identified as appropriate candidates were on PrEP, most users (87%) reported high adherence to 4+ doses per week (stage 5; PrEP maintenance). Factors associated with reaching later stages were being older, being out to parents, and engaging in previous HIV/sexually transmitted infection testing. Conclusions: AMSM PrEP use falls short of recommended levels. PrEP campaigns are needed to raise awareness by targeting key AMSM subgroups that underestimate the appropriateness of use. Equally important, parents and health providers of AMSM should serve educational roles to help facilitate potential PrEP uptake, by motivating adolescents and giving them the skills needed to request, fill, and adhere to a prescription.

“You Don't Want Your Parents Knowing That You're Taking Pre-exposure Prophylaxis”: Pre-exposure Prophylaxis Stigma Among Black and Latinx Adolescents

“…PrEP uptake is also important to consider for racial/ethnic minority adolescent girls because the lifetime risk of an HIV diagnosis for Black and Latinx women is significantly greater than that of White women, and Black women bear the highest burden of new HIV diagnoses after MSM (CDC, 2018a; Hess et al, 2017). Barriers to promoting adolescent PrEP include parental consent, developmental stage, PrEP adherence, adolescent willingness, and lack of physician knowledge and comfort with prescribing PrEP (Macapagal et al, 2020; Moore et al, 2019; Moskowitz et al, 2021; Taggart et al, 2019).…”

PrEParing for NextGen: Cognitive Interviews to Improve Next Generation PrEP Modality Descriptions for Young Men Who have Sex with Men

“…YMSM are at increased risk of HIV infection but are less likely to be prescribed PrEP [4,6]. Comprehensible, culturally-appropriate descriptions of next generation PrEP products are necessary to strengthen measurement accuracy, generate valid data on YMSM's preferences and acceptability across next generation PrEP modalities, and increase comparability and generalizability of findings across studies.…”

“…This trend is particularly troubling, as young MSM (YMSM; ages [13][14][15][16][17][18][19][20][21][22][23][24] account for nearly one-third of new infections among MSM in the US [4]. Despite their high PrEP need, only 3% of eligible YMSM have been prescribed PrEP, substantially lower than their older peers [5,6]; PrEP uptake among YMSM under 18 years old is even lower, contributing to continued HIV transmission among this group [2]. Among YMSM with a PrEP prescription, adherence to daily oral PrEP and retention in PrEP care is also substantially lower than adult MSM [7,8], jeopardizing the real-world impact of PrEP in this population.…”

Factors that motivate men who have sex with men in Berlin, Germany, to use or consider using HIV pre-exposure prophylaxis—A multi-methods analysis of data from a multicentre survey

“…A recent example is an analysis of data from a national, online, open-prospective observational study among MSM in Australia by Keen et al (2020), who found that PrEP use was independently associated with lower levels of HIV anxiety among PrEP-eligible men [ 54 ]. Another example is the correlation between lower perceived HIV risk and PrEP non-use or PrEP discontinuation, which has been reported in large number of studies to date (e.g., [ 31 , 51 – 53 , 56 , 58 ]). Furthermore, in a cross-sectional study of 164 HIV-negative MSM in HIV seroconcordant negative primary partnerships who were not taking PrEP, Gamarel et al (2015) found that age, education and intimacy motivations for condomless sex were associated with PrEP adoption intensions in a multivariate model based on data elicited using interview-administered survey questions and assessment scales.…”

“…To improve the implementation of PrEP, a range of authors over the past decade have proposed and refined several models of a continuum or "cascade" of PrEP care [31][32][33][34][35][36][37]. Most of the earlier models are largely based on a biomedical approach that assumes HIV prevention is the main priority in a person's sexual decision-making and therefore evaluate this decisionmaking chiefly in terms of risk [38] and in a linear fashion.…”