The Promise of Pre-Exposure Prophylaxis for Black Men Who Have Sex with Men: An Ecological Approach to Attitudes, Beliefs, and Barriers

Abstract

Research has demonstrated the clinical effectiveness of pre-exposure prophylaxis (PrEP) for HIV prevention, but little is known about how factors at the individual-, interpersonal-, community-, and structural levels impact PrEP use for black men who have sex with men (BMSM). We advance existing work by examining how all levels of the ecological framework must be addressed for PrEP to be successfully implemented as an effective HIV prevention approach. We interviewed 31 BMSM three times each and 17 community stakeholders once each; interviews were taped, transcribed, and analyzed using the constant comparative method. Factors that influence how BMSM experienced PrEP emerged across all levels of the ecological framework: At the individual level, respondents were wary of giving medication to healthy people and of the potential side-effects. At the interpersonal level, BMSM believed that PrEP use would discourage condom use and that PrEP should only be one option for HIV prevention, not the main option. At the community level, men described not trusting the pharmaceutical industry and described PrEP as an option for others, not for themselves. At the structural level, BMSM talked about HIV and sexuality-related stigmas and how they must overcome those before PrEP engagement. BMSM are a key population in the US National HIV/AIDS Strategy, yet few individuals believe that PrEP would be personally helpful. Our research indicates the urgent need to raise awareness and address structural stigma and policies that could be substantial barriers to the scale-up and implementation of PrEP-related services.

Characteristics of the Provider-Patient Encounter Associated With Awareness of and Willingness to Take PrEP Among Young Minority Urban Males in Baltimore City

“…The proportions of patients who expressed awareness of and willingness to take PrEP in our population were similar to those noted in other studies (Arrington-Sanders et al, 2016;Eaton, Matthews et al, 2017;Philbin et al, 2016). Being asked by a provider about sexual-related behaviors and one's sexual orientation and having been hurt by a partner increased the odds of willingness to take PrEP, as did having provider-initiated discussions about HIV/STI risk reduction and condom use.…”

“…Several studies have explored individual-level characteristics and behaviors that affect awareness of PrEP as well as willingness to take a preventive medication daily particularly among priority populations (Fallon, Park, Ogbue, Flynn, & German, 2017;Garnett et al, 2018;Holloway et al, 2017). PrEP awareness has been shown to be significantly associated with recent HIV/STI testing, perceived HIV risk, higher number of sex partners, and intermittent/lack of condom use; willingness to take PrEP has been associated with concerns about side effects, PrEP-associated stigma, and medical mistrust (Arrington-Sanders et al, 2016;Eaton, Kalichman et al, 2017;Eaton, Matthews et al, 2017;Garcia & Harris, 2017;Kwakwa et al, 2016;Philbin et al, 2016;Underhill et al, 2015). Some studies have also highlighted the potential impact of clinic-based approaches to change provider and staff behavior, such as implementing cultural competency training to reduce medical mistrust and perceived racism in clinic settings, and encouraging providers to reduce missed opportunities for talking to high-risk patients about PrEP when patients disclose information to their providers about sexual behaviors or risk (Arrington-Sanders et al, 2016;Cahill et al, 2017;Kwakwa et al, 2016).…”

Acceptability and willingness to use HIV pre-exposure prophylaxis among HIV-negative men who have sex with men in Switzerland

“…The findings of this study go beyond the known descriptions of socio-demographic characteristics of MSM either willing or not willing to use PrEP (e.g. Bil, Stolte, van der Veldt, & Davidovich, 2014 ; Philbin et al., 2014 ). The findings suggest that the acceptability of PrEP is not only determined by usefulness or expected performance.…”

Next-Generation HIV Pre-Exposure Prophylaxis Preferences Among Men Who Have Sex with Men Taking Daily Oral Pre-Exposure Prophylaxis

“…However, uptake remains suboptimal with common barriers, including lack of access to PrEP care, low HIV risk perception, cost, stigma, and concerns about side effects. [3][4][5][6][7] Those who do initiate PrEP face additional barriers to adherence and retention in care, both of which are necessary to ensure efficacy. 8 Importantly, emerging racial and ethnic disparities in PrEP care may perpetuate existing inequalities.…”