Skip to main content
SpringerLink
Log in

Low Self-Perceived Need for PrEP and Behavioral Indications of MSM Who Recently Refused Daily PrEP: A Mixed Methods Study in Three U.S. Cities

  • Original Paper
  • Published:
AIDS and Behavior Aims and scope Submit manuscript

Abstract

Pre-exposure prophylaxis (PrEP) reduces sexual risk for HIV transmission by 99% when used appropriately, but remains underutilized among gay, bisexual, and other men who have sex with men (MSM). In this mixed-method study, we describe reasons for PrEP refusal associated with low self-perceived need for PrEP among MSM who recently declined daily oral PrEP when offered by a provider. Data are from a quantitative behavioral survey of MSM (N = 93) living in Atlanta, Chicago, and Raleigh-Durham, who also either responded to an in-depth interview (n = 51) or participated in one of 12 focus groups (n = 42). Themes of low self-perceived need for PrEP were: low self-perceived risk for HIV acquisition (33% of respondents); confidence in remaining HIV-negative (35%); using condoms (81%); limiting number of partners and choosing partners carefully (48%); asking partners about their HIV status before having sex (45%); engaging in safer sexual positions or oral sex (28%); being in a monogamous relationship or exclusivity with one partner (26%); and regular HIV testing (18%). Low self-perceived risk for HIV acquisition and high confidence in other prevention strategies were important factors related to low self-perceived need in MSM refusing daily oral PrEP when offered. Providers should continue to discuss the benefits of PrEP as a safe and highly effective option for HIV prevention.

Resumen

La profilaxis pre-exposición (PrEP) reduce el riesgo de transmisión sexual por el VIH en un 99% cuando se utiliza apropiadamente, pero sigue siendo subutilizada entre hombres gais, bisexuales y otros hombres que tienen sexo con hombres (HSH). En este estudio de método mixto, describimos los motivos del rechazo de la PrEP asociados a la baja necesidad autopercibida de la PrEP entre los HSH que recientemente rechazaron la PrEP oral diaria, cuando fue ofrecida por un proveedor de salud. Los datos provienen de una encuesta cuantitativa de comportamiento de los HSH (N = 93) que viven en Atlanta, Chicago y Raleigh-Durham, quienes también respondieron a una entrevista en profundidad (n = 51) o participaron en uno de los 12 grupos focales (n = 42). Los temas de baja necesidad autopercibida del uso de la PrEP fueron: el bajo riesgo auto percibido de contraer el VIH (33% de los encuestados); la confianza en seguir siendo VIH negativo (35%); utilizar condones (81%); limitar el número de parejas sexuales y elegir las parejas cuidadosamente (48%); preguntar a sus parejas sobre su estado de VIH antes de tener relaciones sexuales (45%); participar en posiciones sexuales más seguras o sexo oral (28%); estar en relación monógama o de exclusividad con una sola pareja (26%); y hacerse pruebas del VIH regularmente (18%). El bajo riesgo autopercibido de contraer el VIH y la alta confianza en otras estrategias de prevención fueron factores importantes relacionados con la baja necesidad autopercibida en los HSH que rechazaron la PrEP oral diaria cuando se les ofreció. Los proveedores de salud deben continuar el diálogo sobre los beneficios de la PrEP como una opción segura y altamente eficaz para la prevención del VIH.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Centers for Disease Control and Prevention. HIV surveillance report, vol. 34. 2021. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2023. Accessed 10 Nov 2023.

  2. Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis. 2014;14(9):820–9. https://doi.org/10.1016/S1473-3099(14)70847-3.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Liu AY, Cohen SE, Vittinghoff E, et al. Preexposure prophylaxis for HIV infection integrated with municipal- and community-based sexual health services. JAMA Intern Med. 2016;176(1):75–84. https://doi.org/10.1001/jamainternmed.2015.4683.

    Article  PubMed  PubMed Central  Google Scholar 

  4. McCormack S, Dunn DT, Desai M, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. The Lancet. 2016;387(10013):53–60. https://doi.org/10.1016/S0140-6736(15)00056-2.

    Article  Google Scholar 

  5. Volk JE, Marcus JL, Phengrasamy T, et al. No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clin Infect Dis. 2015;61(10):1601–3. https://doi.org/10.1093/cid/civ778.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Finlayson T, Cha S, Xia M, et al. Changes in HIV preexposure prophylaxis awareness and use among men who have sex with men—20 urban areas, 2014 and 2017. MMWR Morb Mortal Wkly Rep. 2019;68(27):597–603. https://doi.org/10.15585/mmwr.mm6827a1.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Pitasi MA, Beer L, Cha S, et al. Vital signs: HIV infection, diagnosis, treatment, and prevention among gay, bisexual, and other men who have sex with men—United States, 2010–2019. MMWR Morb Mortal Wkly Rep. 2021;70(48):1669–75. https://doi.org/10.15585/mmwr.mm7048e1.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Cahill S, Taylor SW, Elsesser SA, Mena L, Hickson D, Mayer KH. Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts. AIDS Care. 2017;29(11):1351–8. https://doi.org/10.1080/09540121.2017.1300633.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Ojikutu BO, Bogart LM, Higgins-Biddle M, et al. Facilitators and barriers to pre-exposure prophylaxis (PrEP) use among Black individuals in the United States: results from the National Survey on HIV in the Black Community (NSHBC). AIDS Behav. 2018;22(11):3576–87. https://doi.org/10.1007/s10461-018-2067-8.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Whitfield THF, Parsons JT, Rendina HJ. Rates of pre-exposure prophylaxis use and discontinuation among a large U.S. national sample of sexual minority men and adolescents. Arch Sex Behav. 2020;49(1):103–12. https://doi.org/10.1007/s10508-019-01602-z.

    Article  PubMed  Google Scholar 

  11. Kamitani E, Wichser ME, Adegbite AH, et al. Increasing prevalence of self-reported HIV preexposure prophylaxis use in published surveys: a systematic review and meta-analysis. AIDS. 2018;32(17):2633–5. https://doi.org/10.1097/QAD.0000000000001983.

    Article  PubMed  Google Scholar 

  12. Sullivan PS, Whitby S, Hipp P, Juhasz M, DuBose S, McGuinness P, Smith DK. Trends in PrEP inequity by race and census region, United States, 2012–2021. Paper presented at: AIDS 2022. https://programme.aids2022.org/Abstract/Abstract/?abstractid=12943. Accessed 21 Oct 2023.

  13. The White House. National HIV/AIDS strategy for the United States 2022–2025: Washington, DC; 2021. https://www.whitehouse.gov/wp-content/uploads/2021/11/National-HIV-AIDS-Strategy.pdf. Accessed 2 Feb 2023.

  14. Sullivan PS, Satcher Johnson A, Pembleton ES, et al. Epidemiology of HIV in the USA: epidemic burden, inequities, contexts, and responses. The Lancet. 2021;397(10279):1095–106. https://doi.org/10.1016/S0140-6736(21)00395-0.

    Article  Google Scholar 

  15. Kota KK, Mansergh G, Stephenson R, Hirshfield S, Sullivan P. Sociodemographic characteristics of HIV pre-exposure prophylaxis use and reasons for nonuse among gay, bisexual, and other men who have sex with men from three US cities. AIDS Patient Care STDS. 2021;35(5):158–66. https://doi.org/10.1089/apc.2020.0261.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Elopre L, Ott C, Lambert CC, et al. Missed prevention opportunities: why young, Black MSM with recent HIV diagnosis did not access HIV pre-exposure prophylaxis services. AIDS Behav. 2021;25(5):1464–73. https://doi.org/10.1007/s10461-020-02985-0.

    Article  PubMed  Google Scholar 

  17. Owens C, Hubach RD, Williams D, et al. Facilitators and barriers of pre-exposure prophylaxis (PrEP) uptake among rural men who have sex with men living in the Midwestern U.S. Arch Sex Behav. 2020;49(6):2179–91. https://doi.org/10.1007/s10508-020-01654-6.

    Article  PubMed  Google Scholar 

  18. Hojilla JC, Vlahov D, Crouch PC, Dawson-Rose C, Freeborn K, Carrico A. HIV pre-exposure prophylaxis (PrEP) uptake and retention among men who have sex with men in a community-based sexual health clinic. AIDS Behav. 2018;22(4):1096–9. https://doi.org/10.1007/s10461-017-2009-x.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Mojtabai R, Olfson M, Mechanic D. Perceived need and help-seeking in adults with mood, anxiety, or substance use disorders. Arch Gen Psychiatry. 2002;59(1):77–84. https://doi.org/10.1001/archpsyc.59.1.77.

    Article  PubMed  Google Scholar 

  20. Horne R, Cooper V, Gellaitry G, Date HL, Fisher M. Patients’ perceptions of highly active antiretroviral therapy in relation to treatment uptake and adherence: the utility of the necessity-concerns framework. J Acquir Immune Defic Syndr. 2007;45(3):334–41. https://doi.org/10.1097/QAI.0b013e31806910e3.

    Article  PubMed  Google Scholar 

  21. Underhill K, Guthrie KM, Colleran C, Calabrese SK, Operario D, Mayer KH. Temporal fluctuations in behavior, perceived HIV risk, and willingness to use pre-exposure prophylaxis (PrEP). Arch Sex Behav. 2018;47(7):2109–21. https://doi.org/10.1007/s10508-017-1100-8.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gelaude D, Denson D. “Why you putting this drug in your body to fight off something that you don’t have?” Perceptions about PrEP use among Black and Latino men who have sex with men in the U.S. South. J Homosex. 2023;70(5):900–16. https://doi.org/10.1080/00918369.2021.2005998.

    Article  PubMed  Google Scholar 

  23. Lockard A, Rosenberg ES, Sullivan PS, et al. Contrasting self-perceived need and guideline-based indication for HIV pre-exposure prophylaxis among young, Black men who have sex with men offered pre-exposure prophylaxis in Atlanta, Georgia. AIDS Patient Care STDS. 2019;33(3):112–9. https://doi.org/10.1089/apc.2018.0135.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Newman PA, Guta A, Lacombe-Duncan A, Tepjan S. Clinical exigencies, psychosocial realities: negotiating HIV pre-exposure prophylaxis beyond the cascade among gay, bisexual and other men who have sex with men in Canada. J Int AIDS Soc. 2018;21(11):e25211. https://doi.org/10.1002/jia2.25211.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Yi S, Tuot S, Mwai GW, et al. Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis. J Int AIDS Soc. 2017;20(1):21580. https://doi.org/10.7448/IAS.20.1.21580.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Zimmermann HM, Eekman SW, Achterbergh RC, et al. Motives for choosing, switching and stopping daily or event-driven pre-exposure prophylaxis—a qualitative analysis. J Int AIDS Soc. 2019;22(10):e25389. https://doi.org/10.1002/jia2.25389.

    Article  PubMed  PubMed Central  Google Scholar 

  27. van Dijk M, Duken SB, Delabre RM, et al. PrEP interest among men who have sex with men in the Netherlands: covariates and differences across samples. Arch Sex Behav. 2020;49(6):2155–64. https://doi.org/10.1007/s10508-019-01620-x.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Kuhns LM, Hotton AL, Schneider J, Garofalo R, Fujimoto K. Use of pre-exposure prophylaxis (PrEP) in young men who have sex with men is associated with race, sexual risk behavior and peer network size. AIDS Behav. 2017;21(5):1376–82. https://doi.org/10.1007/s10461-017-1739-0.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Gallagher T, Link L, Ramos M, Bottger E, Aberg J, Daskalakis D. Self-perception of HIV risk and candidacy for pre-exposure prophylaxis among men who have sex with men testing for HIV at commercial sex venues in New York City. LGBT Health. 2014;1(3):218–24. https://doi.org/10.1089/lgbt.2013.0046.

    Article  PubMed  Google Scholar 

  30. Centers for Disease Control and Prevention: US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States—2021 update: a clinical practice guideline. 2021. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf. Accessed 13 Aug 2023.

  31. Golub SA, Myers JE. Next-wave HIV pre-exposure prophylaxis implementation for gay and bisexual men. AIDS Patient Care STDS. 2019;33(6):253–61. https://doi.org/10.1089/apc.2018.0290.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Golub SA, Fikslin RA, Goldberg MH, Peña SM, Radix A. Predictors of PrEP uptake among patients with equivalent access. AIDS Behav. 2019;23(7):1917–24. https://doi.org/10.1007/s10461-018-2376-y.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Huang W, Lockard A, Kelley CF, et al. From declining PrEP to PrEP initiation as “first nature”—what changes PrEP initiation decisions among young, Black MSM. AIDS Care. 2022;34(3):284–93. https://doi.org/10.1080/09540121.2021.1960946.

    Article  PubMed  Google Scholar 

  34. Centers for Disease Control and Prevention. HIV surveillance report, 2018 (updated), vol. 31. 2020. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2020. Accessed 6 Mar 2023.

  35. Mansergh G, Kota KK, Carnes N, Gelaude D. Brief report: refusal of daily oral PrEP: implementation considerations and reported likelihood of using various HIV prophylaxis products in a diverse sample of MSM. J Acquir Immune Defic Syndr. 2023;92(3):212–6. https://doi.org/10.1097/QAI.0000000000003134.

    Article  PubMed  Google Scholar 

  36. Schreier M. Qualitative content analysis in practice. SAGE Publications; 2012. pp. 1–280.

  37. O’Connor C, Joffe H. Intercoder reliability in qualitative research: debates and practical guidelines. Int J Qual Methods. 2020;19:1609406919899220.

    Article  Google Scholar 

  38. Strauss A, Corbin J. Basics of qualitative research: Techniques and procedures for developing grounded theory. 2nd ed. Thousand Oaks: Sage Publications, Inc; 1998.

    Google Scholar 

  39. McFarland W, Chen YH, Nguyen B, et al. Behavior, intention or chance? A longitudinal study of HIV seroadaptive behaviors, abstinence and condom use. AIDS Behav. 2012;16(1):121–31. https://doi.org/10.1007/s10461-011-9936-8.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Vallabhaneni S, Li X, Vittinghoff E, Donnell D, Pilcher CD, Buchbinder SP. Seroadaptive practices: association with HIV acquisition among HIV-negative men who have sex with men. PLoS ONE. 2012;7(10):e45718. https://doi.org/10.1371/journal.pone.0045718.

    Article  ADS  CAS  PubMed  PubMed Central  Google Scholar 

  41. Paz-Bailey G, Mendoza MC, Finlayson T, et al. Trends in condom use among MSM in the United States: the role of antiretroviral therapy and seroadaptive strategies. AIDS. 2016;30(12):1985–90.

    Article  PubMed  Google Scholar 

  42. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. “Barebacking” in a diverse sample of men who have sex with men. AIDS. 2002;16(4):653–9.

    Article  PubMed  Google Scholar 

  43. Trost SL, Onwubiko UN, Wilson DB, Holland DP, Chamberlain AT. Health care-seeking behaviors and perceptions of provider-initiated discussion of pre-exposure prophylaxis among PrEP-naive HIV-negative men who have sex with men in Atlanta, Georgia. Open Forum Infect Dis. 2020;7(5):ofaa165.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Wilton J, Kain T, Fowler S, et al. Use of an HIV-risk screening tool to identify optimal candidate for PrEP scale-up among men who have sex with men in Toronto, Canada: disconnect between objective and subjective HIV risk. J Int AIDS Soc. 2016;19(1):20777.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Mansergh G, Sullivan PS, Kota KK, Daskalakis D. Pre-exposure prophylaxis in the era of emerging methods for men who have sex with men in the USA: the HIV Prevention Cycle of Care model. Lancet HIV. 2023;10(2):e134–42. https://doi.org/10.1016/S2352-3018(22)00309-5.

    Article  CAS  PubMed  Google Scholar 

  46. Kelley CF, Kahle E, Siegler A, et al. Applying a PrEP continuum of care for men who have sex with men in Atlanta, Georgia. Clin Infect Dis. 2015;61(10):1590–7.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Chan PA, Nunn A, van den Berg JJ, et al. A randomized trial of a brief behavioral intervention for PrEP uptake among men who have sex with men at increased risk for HIV infection. J Acquir Immune Defic Syndr. 2021;87(3):937–43. https://doi.org/10.1097/QAI.0000000000002671.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

CDC Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Funding

This work was supported by the U.S. Centers for Disease Control, under Contract No. 200-2013-57341.

Author information

Author notes

  1. Paula M. Frew

    Present address: Merck & Co., Inc., Kenilworth, NJ, USA

Authors and Affiliations

  1. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, MS H18-3, Atlanta, GA, USA

    Krishna Kiran Kota, Deborah Gelaude, Neal Carnes & Gordon Mansergh

  2. Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA

    Krishna Kiran Kota

  3. Research Support Services, Inc., Evanston, IL, USA

    Alisú Schoua-Glusberg

  4. Emory University School of Medicine, Atlanta, GA, USA

    Paula M. Frew & Laura Randall

  5. Emory University Rollins School of Public Health, Atlanta, GA, USA

    Paula M. Frew & Laura Randall

  6. American Institutes for Research, Arlington, VA, USA

    Bryan Gale & Valerie Betley

Authors
  1. Krishna Kiran Kota
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deborah Gelaude
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Neal Carnes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alisú Schoua-Glusberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Paula M. Frew
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Laura Randall
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Bryan Gale
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Valerie Betley
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Gordon Mansergh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Krishna Kiran Kota.

Ethics declarations

Competing Interests

The authors report there are no competing interests to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kota, K.K., Gelaude, D., Carnes, N. et al. Low Self-Perceived Need for PrEP and Behavioral Indications of MSM Who Recently Refused Daily PrEP: A Mixed Methods Study in Three U.S. Cities. AIDS Behav (2024). https://doi.org/10.1007/s10461-024-04276-4

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10461-024-04276-4

Keywords

Search

Navigation