The Unanticipated Benefits of PrEP for Young Black Gay, Bisexual, and Other Men Who Have Sex with Men
Abstract
Pre-exposure prophylaxis (PrEP) is effective at reducing new HIV infections among adherent users. However, there are potential benefits of PrEP beyond HIV prevention that remain understudied, particularly among young Black gay, bisexual, and other men who have sex with men (MSM). In 2018, we conducted six focus groups (n = 36) in four midwestern cities: Milwaukee, WI; Minneapolis, MN; Detroit, MI; and Kansas City, MO with current and former PrEP users who identified as Black MSM. The focus groups covered medical care and provider experiences, patterns of PrEP use and adherence, relationships while on PrEP, and PrEP stigma. Results revealed four unanticipated benefits of PrEP for young Black MSM: (1) improved engagement in medical care, (2) reduced sexual and HIV anxiety, (3) increased sexual comfort and freedom, and (4) positive sexual relationships with people living with HIV. Findings from this study fill a gap in our understanding of the potential benefits of PrEP beyond HIV prevention. Public health campaigns and messaging around PrEP should incorporate such benefits to reach young Black MSM who may be motivated by benefits beyond HIV prevention.
Keywords
Pre-exposure prophylaxis Young Black MSM Sexual anxiety Engagement in medical care Focus groupsNotes
Acknowledgements
Funding support was provided by the National Institute of Mental Health (R01-MH115764; PI: Walsh; P30-MH052776, PI: Jeffrey A. Kelly; K01-MH112412; PI: Quinn). The Authors would like to acknowledge the support and collaboration of our community partner agencies in Milwaukee, Minneapolis, Kansas City, and Detroit. Special Thanks to the Red Door Clinic in Minneapolis, the Detroit Public Health STD Clinic, Wayne State University, and University of Missouri-Kansas City, and all of the staff at the Center for AIDS Intervention Research (CAIR) who were instrumental in this research.
References
- 1.Centers for Disease Control and Prevention (CDC). HIV and African American gay and bisexual men. Atlanta, GA; 2019. https://www.cdc.gov/hiv/pdf/group/msm/cdc-hiv-bmsm.pdf. Accessed 24 Nov 2019.
- 2.Mustanski B, Morgan E, D’Augelli AR, Brikett M, Janulis P, Newcomb ME. Individual and network factors associated with racial disparities in HIV among young men who have sex with men: results from the Radar cohort study. J Acquir Immune Defic Syndr. 2018. https://doi.org/10.1097/QAI.0000000000001886.CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Hess K, Hu X, Lansky A, Mermin J, Hall HI. Lifetime risk of a diagnosis of HIV infection in the United States. Ann Epidemiol. 2017;27(4):238–43.CrossRefGoogle Scholar
- 4.Anderson PL, Glidden DV, Liu A, et al. Emtricitabine–tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 2012;4(151):151ra125.CrossRefGoogle Scholar
- 5.Donnell D, Baeten JM, Bumpus NN, et al. HIV protective efficacy and correlates of tenofovir blood concentrations in a clinical trial of PrEP for HIV prevention. J Acquir Immune Defic Syndr. 2014;66(3):340–8. https://doi.org/10.1097/qai.0000000000000172.CrossRefPubMedPubMedCentralGoogle Scholar
- 6.Whitfield THF, Jones SS, Wachman M, Grov C, Parsons JT, Rendina HJ. The impact of pre-exposure prophylaxis (PrEP) use on sexual anxiety, satisfaction, and esteem among gay and bisexual men. J Sex Res. 2019. https://doi.org/10.1080/00224499.2019.1572064.CrossRefPubMedGoogle Scholar
- 7.Golub S, Radix A, Hilley A. Developing and implementing a PrEP Demonstration/implementation hybrid in a community-based health center. In: IAPAC adherence. Miami, FL; 2014. https://www.iapac.org/AdherenceConference/presentations/ADH9_OA409.pdf. Accessed 24 Nov 2019.
- 8.Koester KA, Erguera XA, Kang Dufour M-S, et al. “Losing the Phobia:” understanding how HIV Pre-exposure prophylaxis facilitates bridging the serodivide among men who have sex with men. Front Public Health. 2018. https://doi.org/10.3389/fpubh.2018.00250.CrossRefPubMedPubMedCentralGoogle Scholar
- 9.Carlo Hojilla J, Koester KA, Cohen SE, et al. Sexual behavior, risk compensation, and HIV prevention strategies among participants in the San Francisco PrEP demonstration project: a qualitative analysis of counseling notes. AIDS Behav. 2016. https://doi.org/10.1007/s10461-015-1055-5.CrossRefPubMedGoogle Scholar
- 10.Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States-2017 update: a clinical practice guideline. 2017. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf. Accessed 24 Nov 2019.
- 11.Sullivan PS, Peterson J, Rosenberg ES, et al. Understanding racial HIV/STI disparities in black and white men who have sex with men: a multilevel approach. PLoS ONE. 2014;9(3):e90514.CrossRefGoogle Scholar
- 12.Harawa NT, Greenland S, Bingham TA, et al. Associations of race/ethnicity with HIV prevalence and HIV-related behaviors among young men who have sex with men in 7 urban centers in the United States. J Acquir Immune Defic Syndr. 2004;35(5):526–36.CrossRefGoogle Scholar
- 13.Sullivan PS, Purcell DW, Grey JA, et al. Patterns of racial/ethnic disparities and prevalence in HIV and syphilis diagnoses among men who have sex with men, 2016: a novel data visualization. Am J Public Health. 2016. https://doi.org/10.2105/AJPH.2018.304762.CrossRefGoogle Scholar
- 14.Bauermeister JA, Carballo-Diéguez A, Ventuneac A, Dolezal C. Assessing motivations to engage in intentional condomless anal intercourse in HIV risk contexts (“bareback sex”) among men who have sex with men. AIDS Educ Prev. 2009. https://doi.org/10.1521/aeap.2009.21.2.156.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Gamarel KE, Golub SA. Intimacy motivations and pre-exposure prophylaxis (PrEP) adoption intentions among HIV-negative men who have sex with men (MSM) in romantic relationships. Ann Behav Med. 2014;49(2):177–86.CrossRefGoogle Scholar
- 16.Malebranche DJ, Fields EL, Bryant LO, Harper SR. Masculine socialization and sexual risk behaviors among Black men who have sex with men: a qualitative exploration. Men Masculinities. 2009;12(1):90–112.CrossRefGoogle Scholar
- 17.Clark A, Mayben JK, Hartman C, Kallen MA, Giordano TP. Conspiracy beliefs about HIV infection are common but not associated with delayed diagnosis or adherence to care. AIDS Patient Care STDS. 2008;22(9):753–9.CrossRefGoogle Scholar
- 18.Bogart LM, Thorburn S. Are HIV/AIDS conspiracy beliefs a barrier to HIV prevention among African Americans? J Acquir Immune Defic Syndr. 2005;38(2):213–8.CrossRefGoogle Scholar
- 19.Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr. 2001;28(1):47–58.CrossRefGoogle Scholar
- 20.Whetten K, Leserman J, Whetten R, et al. Exploring lack of trust in care providers and the government as a barrier to health service use. Am J Public Health. 2006;96(4):716–21.CrossRefGoogle Scholar
- 21.Quinn KG, Dickson-Gomez J, Zarwell M, Pearson B, Lewis M. “A gay man and a doctor are just like, a recipe for destruction”: how racism and homonegativity in healthcare settings influence PrEP uptake among young Black MSM. AIDS Behav. 2019;23(7):1951–63. https://doi.org/10.1007/s10461-018-2375-z.CrossRefPubMedGoogle Scholar
- 22.Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. 4th ed. Thousand Oaks: Sage; 2015.Google Scholar
- 23.Saldana J. The coding manual for qualitative researchers. 3rd ed. Thousand Oaks, CA: Sage; 2016.Google Scholar
- 24.Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa.CrossRefGoogle Scholar
- 25.Dangerfield DT, Ober AJ, Smith LR, Shoptaw S, Bluthenthal RN. Exploring and adapting a conceptual model of sexual positioning practices and sexual risk among HIV-negative black men who have sex with men. J Sex Res. 2018. https://doi.org/10.1080/00224499.2018.1433287.CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016. https://doi.org/10.1056/NEJMoa1600693.CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. J Am Med Assoc. 2016. https://doi.org/10.1001/jama.2016.5148.CrossRefGoogle Scholar
- 28.Bavinton BR, Pinto AN, Phanuphak N, et al. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV. 2018. https://doi.org/10.1016/S2352-3018(18)30132-2.CrossRefPubMedGoogle Scholar
- 29.Smith DK. By race/ethnicity, blacks have the highest number needing PrEP in the United States, 2018. In: CROI. Boston, MA; 2018. http://www.croiwebcasts.org/console/player/37188?mediaType=slideVideo&&crd_fl=0&ssmsrq=1529425735624&ctms=5000&csmsrq=5290. Accessed 24 Nov 2019.
- 30.Huang H, Zhu W, Smith DK, Harris N, Hoover KW. HIV preexposure prophylaxis by race and ethnicity—United States, 2014–2016. MMWR Morb Mortal Wkly Rep. 2018;67:1147–50.CrossRefGoogle Scholar
- 31.Quinn K, Bowleg L, Dickson-Gomez J. “The fear of being Black plus the fear of being gay”: the effects of intersectional stigma on PrEP use among young Black gay, bisexual, and other men who have sex with men. Soc Sci Med. 2019. https://doi.org/10.1016/j.socscimed.2019.04.042.CrossRefPubMedGoogle Scholar
- 32.Petroll AE, Mosack KE. Physician awareness of sexual orientation and preventive health recommendations to men who have sex with men. Sex Transm Dis. 2011;38(1):63–7. https://doi.org/10.1097/OLQ.0b013e3181ebd50f.CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Gilbert KL, Ray R, Siddiqi A, et al. Visible and invisible trends in black men’s health: pitfalls and promises for addressing racial, ethnic, and gender inequities in health. Annu Rev Public Health. 2016;37:295–311. https://doi.org/10.1146/annurev-publhealth-032315-021556.CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Milam J, Jain S, Dubé MP, et al. Sexual risk compensation in a pre-exposure prophylaxis demonstration study among individuals at risk of HIV. J Acquir Immune Defic Syndr. 2019. https://doi.org/10.1097/QAI.0000000000001885.CrossRefPubMedGoogle Scholar
- 35.Eaton LA, Matthews DD, Bukowski LA, et al. Elevated HIV prevalence and correlates of PrEP use among a community sample of Black men who have sex with men. J Acquir Immune Defic Syndr. 2018;79(3):339–46. https://doi.org/10.1097/QAI.0000000000001822.CrossRefPubMedPubMedCentralGoogle Scholar
- 36.Hightow-Weidman LB, Magnus M, Beauchamp G, et al. Incidence and correlates of STIs among black men who have sex with men participating in the HPTN 073 PrEP study. Clin Infect Dis. 2019. https://doi.org/10.1093/cid/ciy1141.CrossRefPubMedGoogle Scholar
- 37.Millett G, Peterson J, Wolitski R, Stall R. Greater risk for HIV infection of black men who have sex with men: a critical literature review. Am J Public Health. 2006;96(6):1007–19.CrossRefGoogle Scholar
- 38.Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The impact of patient race on clinical decisions related to prescribing HIV pre-exposure prophylaxis (PrEP): assumptions about sexual risk compensation and implications for access. AIDS Behav. 2014;18(2):226–40.CrossRefGoogle Scholar
- 39.Gandhi M, Spinelli MA, Mayer KH. Addressing the sexually transmitted infection and HIV syndemic. JAMA. 2019;321(14):1356–8.CrossRefGoogle Scholar
- 40.Race K. Click here for HIV status: shifting templates of sexual negotiation. Emot Space Soc. 2010. https://doi.org/10.1016/j.emospa.2010.01.003.CrossRefGoogle Scholar
- 41.Parsons JT, Schrimshaw EW, Wolitski RJ, et al. Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation. AIDS. 2005. https://doi.org/10.1097/01.aids.0000167348.15750.9a.CrossRefPubMedGoogle Scholar
- 42.Golub SA, Tomassilli JC, Parsons JT. Partner serostatus and disclosure stigma: implications for physical and mental health outcomes among HIV-positive adults. AIDS Behav. 2009. https://doi.org/10.1007/s10461-008-9466-1.CrossRefPubMedGoogle Scholar
- 43.Bourne A, Hickson F, Keogh P, Reid D, Weatherburn P. Problems with sex among gay and bisexual men with diagnosed HIV in the United Kingdom. BMC Public Health. 2012. https://doi.org/10.1186/1471-2458-12-916.CrossRefPubMedPubMedCentralGoogle Scholar
- 44.Rohleder P, McDermott DT, Cook R. Experience of sexual self-esteem among men living with HIV. J Health Psychol. 2017. https://doi.org/10.1177/1359105315597053.CrossRefPubMedGoogle Scholar
- 45.Kinsler JJ, Wong MD, Sayles JN, Davis C, Cunningham WE. The effect of perceived stigma from a health care provider on access to care among a low-income HIV-positive population. AIDS Patient Care STDS. 2007;21(8):584–92.CrossRefGoogle Scholar
- 46.Sayles JN, Wong MD, Kinsler JJ, Martins D, Cunningham WE. The association of stigma with self-reported access to medical care and antiretroviral therapy adherence in persons living with HIV/AIDS. J Gen Intern Med. 2009;24(10):1101–8.CrossRefGoogle Scholar
- 47.Logie C, Gadalla TM. Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care. 2009. https://doi.org/10.1080/09540120802511877.CrossRefPubMedGoogle Scholar
- 48.Mahajan AP, Sayles JN, Patal VA, et al. Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS. 2008;22(Suppl 2):S67–79.CrossRefGoogle Scholar
- 49.Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, Mqeketo A. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med. 2007;64(9):1823–31.CrossRefGoogle Scholar
- 50.Quinn K, Voisin DR, Bouris A, et al. Multiple dimensions of stigma and health related factors among young black men who have sex with men. AIDS Behav. 2017;21(1):207–16. https://doi.org/10.1007/s10461-016-1439-1.CrossRefPubMedPubMedCentralGoogle Scholar
- 51.Hosek SG, Rudy B, Landovitz RJ, et al. An HIV pre-exposure prophylaxis (PrEP) demonstration project and safety study for young MSM. J Acquir Immune Defic Syndr. 2016;74(1):1. https://doi.org/10.1097/QAI.0000000000001179.CrossRefGoogle Scholar
- 52.Serota DP, Rosenberg ES, Lockard AM, et al. Beyond the biomedical: preexposure prophylaxis failures in a cohort of young black men who have sex with men in Atlanta, Georgia. Clin Infect Dis. 2018. https://doi.org/10.1093/cid/ciy297.CrossRefPubMedPubMedCentralGoogle Scholar
- 53.Smith DK, Toledo L, Smith DJ, Adams MA, Rothenberg R. Attitudes and program preferences of African–American urban young adults about pre-exposure prophylaxis (PrEP). AIDS Educ Prev. 2012;24(5):408–21.CrossRefGoogle Scholar
- 54.Chicago PrEP Working Group. PrEP4Love. AIDS Foundation of Chicago. prep4love.com. Published 2018. Accessed 19 Nov 2019.Google Scholar
- 55.Biello KB, Oldenburg CE, Mitty JA, et al. The “Safe Sex” conundrum: anticipated stigma from sexual partners as a barrier to PrEP use among substance using MSM engaging in transactional sex. AIDS Behav. 2017;21(1):300–6. https://doi.org/10.1007/s10461-016-1466-y.CrossRefPubMedPubMedCentralGoogle Scholar
- 56.Golub SA. PrEP stigma: implicit and explicit drivers of disparity. Curr HIV/AIDS Rep. 2018;15:190–7. https://doi.org/10.1007/s11904-018-0385-0.CrossRefPubMedPubMedCentralGoogle Scholar
- 57.Cahill S, Taylor SW, Elsesser SA, Mena L, Hickson DM, 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.CrossRefPubMedPubMedCentralGoogle Scholar
- 58.Harper GW, Jadwin-Cakmak L, Cherenak E, Wilson P. Critical consciousness-based HIV prevention interventions for black gay and bisexual male youth. Am J Sex Educ. 2019;14(1):109–133. https://doi.org/10.1080/15546128.2018.1479668.CrossRefGoogle Scholar