PrEP Stigma: Implicit and Explicit Drivers of Disparity
- 747 Downloads
Purpose of Review
Despite its promise as an HIV prevention strategy, PrEP uptake remains slow, especially among highest priority populations. One factor that may be impeding implementation and driving disparities is PrEP-related stigma. This paper reviews the role of PrEP-related stigma in PrEP access, adherence, and persistence and examines its antecedents and consequences.
Although PrEP stigma is often experienced at the community level (i.e., by potential and current users), it can be reinforced and even amplified by public health programs, policy, and research. PrEP stigma disproportionately impacts disadvantaged groups and impedes scalability by influencing behavior of both patients and providers.
Reducing PrEP stigma and its negative impact on the epidemic requires a significant shift in perspective, language, and programs. Such a shift is necessary to ensure broader reach of PrEP as a prevention strategy and improve its utilization by the individuals who need it most.
KeywordsPre-exposure prophylaxis (PrEP) Stigma HIV/AIDS Sexual health Prevention Implementation
Compliance with Ethical Standards
Conflict of Interest
Dr. Golub reports non-financial support from Gilead Sciences in the form of medication supply for an NIH-funded PrEP demonstration project, outside the submitted work.
Human and Animal Rights
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •• Of major importance.
- 1.Singh GK, Azuine RE, Siahpush M. Widening socioeconomic, racial, and geographic disparities in HIV/AIDS mortality in the United States, 1987–2011. Adv Prev Med. 2013: Article ID 657961; https://doi.org/10.1155/2013/657961.
- 9.Stigma EG. Notes on the management of spoiled identity. New York: Simon & Schuster Inc; 1963.Google Scholar
- 12.Van der Elst EM, Mbogua J, Operario D, Mutua G, Kuo C, Mugo P, et al. High acceptability of HIV pre-exposure prophylaxis but challenges in adherence and use: qualitative insights from a phase I trial of intermittent and daily PrEP in at-risk populations in Kenya. AIDS Behav. 2013;17(6):2163–72.Google Scholar
- 13.Joint United Nations Programme on HIV/AIDS (UNAIDS). On the Fast-Track to end AIDS by 2030: Focus on location and population. Geneva: UNAIDS; 2015.Google Scholar
- 15.•• Haire BG. Preexposure prophylaxis-related stigma: strategies to improve uptake and adherence–a narrative review. HIV/AIDS (Auckland, NZ). 2015;7:241. This paper provides and important review and analysis of the PrEP stigma literature.Google Scholar
- 19.•• Knight R, Small W, Carson A, Shoveller J. Complex and Conflicting Social Norms: Implications for Implementation of Future HIV Pre-Exposure Prophylaxis (PrEP) Interventions in Vancouver, Canada. PLoS One. 2016;11(1):e0146513. This qualitative study provides examples and analysis of the nature of PrEP stigma among a cohort of men under 25. CrossRefPubMedPubMedCentralGoogle Scholar
- 23.MacKellar DA, Valleroy LA, Secura GM, Behel S, Bingham T, Celentano DD, et al. Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men: opportunities for advancing HIV prevention in the third decade of HIV/AIDS. JAIDS J Acquir Immune Defic Syndr. 2005;38(5):603–14.CrossRefPubMedGoogle Scholar
- 29.Mack N, Odhiambo J, Wong CM, Agot K. Barriers and facilitators to pre-exposure prophylaxis (PrEP) eligibility screening and ongoing HIV testing among target populations in Bondo and Rarieda, Kenya: results of a consultation with community stakeholders. BMC Heal Serv Res. 2014;14:231.CrossRefGoogle Scholar
- 30.•• Peng P, Su S, Fairley CK, et al. A global estimate of the acceptability of pre-exposure prophylaxis for HIV among men who have sex with men: a systematic review and meta-analysis. AIDS Behav. 2017; https://doi.org/10.1007/s10461-017-1675-z. This meta-analysis reviews PrEP acceptability studies internationally.
- 31.Tangmunkongvorakul A, Chariyalertsak S, Amico KR, Saokhieo P, Wannalak V, Sangangamsakun T, et al. Facilitators and barriers to medication adherence in an HIV prevention study among men who have sex with men in the iPrEx study in Chiang Mai, Thailand. AIDS Care. 2013;25(8):961–7.CrossRefPubMedGoogle Scholar
- 36.Harawa N et al. Engaging Black Men Who Have Sex with Men (BMSM) in Los Angeles in HIV Pre-Exposure Prophylaxis (PrEP). 2016. California HIV/AIDS Policy Centers. http://chipts.ucla.edu/about/chiptspolicycore/.
- 37.Black AIDS Institute. Black Lives Matter: What’s PrEP got to do with it? April 2016. http://blackprep.org/assets/16-prep-report.pdf
- 40.US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. Available at http://www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf
- 49.•• Jenness SM, Sharma A, Goodreau SM, Rosenberg ES, Weiss KM, Hoover KW, et al. Individual HIV Risk versus population impact of risk compensation after HIV Preexposure prophylaxis initiation among men who have sex with men. PloS one. 2017;12(1):e0169484. This modeling study examines the impact of changes in condom use among PrEP users and demonstrates that risk compensation may actually result in decreased HIV incidence. CrossRefPubMedPubMedCentralGoogle Scholar
- 52.Oldenburg CE, Nunn AS, Montgomery M, Almonte A, Mena L, Patel RR, et al. Behavioral Changes Following uptake of HIV pre-exposure prophylaxis among men who have sex with men in a clinical setting. AIDS Behav. 2017; https://doi.org/10.1007/s10461-017-1701-1.
- 58.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.CrossRefPubMedPubMedCentralGoogle Scholar
- 69.Smith DK, Van Handel M, Wolitski RJ, Stryker JE, Hall HI, Prejean J, et al. Vital signs: estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV acquisition—United States, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(46):1291–5.CrossRefPubMedGoogle Scholar