Skip to main content

Explaining the Efficacy of Pre-exposure Prophylaxis (PrEP) for HIV Prevention: A Qualitative Study of Message Framing and Messaging Preferences Among US Men Who have Sex with Men

Abstract

We investigated message comprehension and message framing preferences for communicating about PrEP efficacy with US MSM. We conducted eight focus groups (n = 38) and n = 56 individual interviews with MSM in Providence, RI. Facilitators probed comprehension, credibility, and acceptability of efficacy messages, including percentages, non-numerical paraphrases, efficacy ranges versus point estimates, and success- versus failure-framed messages. Our findings indicated a range of comprehension and operational understandings of efficacy messages. Participants tended to prefer percentage-based and success-framed messages, although preferences varied for communicating about efficacy using a single percentage versus a range. Participants reported uncertainty about how to interpret numerical estimates, and many questioned whether trial results would predict personal effectiveness. These results suggest that providers and researchers implementing PrEP may face challenges in communicating with users about efficacy. Efforts to educate MSM about PrEP should incorporate percentage-based information, and message framing decisions may influence message credibility and overall PrEP acceptability.

This is a preview of subscription content, access via your institution.

References

  1. 1.

    Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367(5):423–34.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Choopanya K, Martin M, Suntharasamai P, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083–90.

    Article  PubMed  Google Scholar 

  4. 4.

    Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587–99.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Molina JM, Capitant C, Charreau I, et al. On demand PrEP with oral TDF-FTC in MSM: results of the ANRS Ipergay trial. Conference on Retroviruses and Opportunistic Infections. Seattle, WA, 2015 [abstract 23LB].

  6. 6.

    McCormack S, Dunn D. Pragmatic open-label randomised trial of preexposure prophylaxis: the PROUD study. Conference on Retroviruses and Opportunistic Infections. Seattle, WA, 2015 [abstract 22LB].

  7. 7.

    Young I, McDaid L. How acceptable are antiretrovirals for the prevention of sexually transmitted HIV?: a review of research on the acceptability of oral pre-exposure prophylaxis and treatment as prevention. AIDS Behav. 2014;18(2):195–216.

    Article  PubMed  Google Scholar 

  8. 8.

    Eisingerich AB, Wheelock A, Gomez GB, Garnett GP, Dybul MR, Piot PK. Attitudes and acceptance of oral and parenteral HIV preexposure prophylaxis among potential user groups: a multinational study. Plos One. 2012;7(1):e28238.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Mimiaga MJ, Case P, Johnson CV, Safren SA, Mayer KH. Preexposure antiretroviral prophylaxis attitudes in high-risk Boston area men who report having sex with men: limited knowledge and experience but potential for increased utilization after education. J Acquir Immune Defic Syndr. 2009;50(1):77–83.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Bauermeister JA, Meanley S, Pingel E, Soler JH, Harper GW. PrEP awareness and perceived barriers among single young men who have sex with men. Curr HIV Res. 2013;11(7):520–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Chen YH, Raymond HF, Grasso M, Nguyen B, Robertson T, McFarland W. Prevalence and predictors of conscious risk behavior among San Franciscan men who have sex with men. AIDS Behav. 2013;17(4):1338–43.

    Article  PubMed  Google Scholar 

  12. 12.

    Golub SA, Gamarel KE, Rendina HJ, Surace A, Lelutiu-Weinberger CL. From efficacy to effectiveness: facilitators and barriers to PrEP acceptability and motivations for adherence among MSM and transgender women in New York City. AIDS Patient Care STDs. 2013;27(4):248–54.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Liu AY, Vittinghoff E, Chillag K, et al. Sexual risk behavior among HIV-uninfected men who have sex with men participating in a tenofovir preexposure prophylaxis randomized trial in the United States. J Acquir Immune Defic Syndr. 2013;64(1):87–94.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Mustanski B, Johnson AK, Garofalo R, Ryan D, Birkett M. Perceived likelihood of using HIV pre-exposure prophylaxis medications among young men who have sex with men. AIDS Behav. 2013;17(6):2173–9.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Rucinski KB, Mensah NP, Sepkowitz KA, Cutler BH, Sweeney MM, Myers JE. Knowledge and use of pre-exposure prophylaxis among an online sample of young men who have sex with men in New York City. AIDS Behav. 2013;17(6):2180–4.

    Article  PubMed  Google Scholar 

  16. 16.

    Mustanski B, Ryan DT, Sanchez T, Sineath C, Macapagal K, Sullivan PS. Effects of messaging about multiple biomedical and behavioral HIV prevention methods on intentions to use among US MSM: results of an experimental messaging study. AIDS Behav. 2014;18(9):1651–60.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Underhill K, Morrow KM, Operario D, Mayer KH. Could FDA approval of pre-exposure prophylaxis make a difference? A qualitative study of PrEP acceptability and FDA perceptions among men who have sex with men. AIDS Behav. 2014;18(2):241–9.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Barash EA, Golden M. Awareness and use of HIV pre-exposure prophylaxis among attendees of a Seattle gay pride event and sexually transmitted disease clinic. AIDS Patient Care STDs. 2010;24(11):689–91.

    Article  PubMed  Google Scholar 

  19. 19.

    Mansergh G, Koblin BA, Colfax GN, et al. Preefficacy use and sharing of antiretroviral medications to prevent sexually-transmitted HIV infection among US men who have sex with men. J Acquir Immune Defic Syndr. 2010;55(2):e14–6.

    Article  PubMed  Google Scholar 

  20. 20.

    Mehta SA, Silvera R, Bernstein K, Holzman RS, Aberg JA, Daskalakis DC. Awareness of post-exposure HIV prophylaxis in high-risk men who have sex with men in New York City. Sex Transm Infect. 2011;87(4):344–8.

    Article  PubMed  Google Scholar 

  21. 21.

    Galindo GR, Walker JJ, Hazelton P, et al. Community member perspectives from transgender women and men who have sex with men on pre-exposure prophylaxis as an HIV prevention strategy: implications for implementation. Implement Sci. 2012;7:116.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Hosek S, Siberry G, Bell M, et al. The acceptability and feasibility of an HIV pre-exposure prophylaxis (PrEP) trial with young men who have sex with men (YMSM). J Acquir Immune Defic Syndr. 2013;62(4):447–56.

    Article  PubMed  Google Scholar 

  23. 23.

    Juusola JL, Brandeau ML, Owens DK, Bendavid E. The cost-effectiveness of preexposure prophylaxis for HIV prevention in the United States in men who have sex with men. Ann Intern Med. 2012;156(8):541–50.

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Krakower DS, Mimiaga MJ, Rosenberger JG, et al. Limited awareness and low immediate uptake of pre-exposure prophylaxis among men who have sex with men using an internet social networking site. Plos One. 2012;7(3):e33119.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Mansergh G, Koblin BA, Sullivan PS. Challenges for HIV pre-exposure prophylaxis among men who have sex with men in the United States. Plos Med. 2012;9(8):e1001286.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Koblin BA, Mansergh G, Frye V, et al. Condom-use decision making in the context of hypothetical pre-exposure prophylaxis efficacy among substance-using men who have sex with men: project MIX. J Acquir Immune Defic Syndr. 2011;58(3):319–27.

    Article  PubMed  Google Scholar 

  27. 27.

    CDC. CDC fact sheet: HIV and AIDS among gay and bisexual men, 2011.

  28. 28.

    Smith DK, Thigpen MC, Nesheim SR, et al. Interim guidance for clinicians considering the use of preexposure prophylaxis for the prevention of HIV infection in heterosexually active adults. MMWR. 2012;61:586.

    Google Scholar 

  29. 29.

    Smith DK, Grant RM, Weidle PJ, Lansky A, Mermin J, Fenton KA. Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR. 2011;60(3):65–8.

    Google Scholar 

  30. 30.

    Smith DK, Martin M, Lansky A, Mermin J, Choopanya K. Update to interim guidance for preexposure prophylaxis (PrEP) for the prevention of HIV infection: PrEP for injecting drug users. MMWR. 2013;62(23):463–5.

    Google Scholar 

  31. 31.

    World Health Organization. Guidance on oral pre-exposure prophylaxis (PrEP) for serodiscordant couples, men and transgender women who have sex with men at high risk of HIV: recommendations for use in the context of demonstration projects. Geneva, Switzerland: World Health Organization; 2012.

    Google Scholar 

  32. 32.

    Gilead Sciences Inc. Truvada: Risk Evaluation and Mitigation Strategy. http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM312304.pdf. Accessed 28 April 2015.

  33. 33.

    Gilead Sciences Inc. TRUVADA for a pre-exposure prophylaxis indication: training guide for healthcare providers. Foster City, CA: Gilead Sciences Inc.; 2013.

    Google Scholar 

  34. 34.

    CDC. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2014: A Clinical Practice Guideline. Atlanta, GA: CDC; 2014.

  35. 35.

    FDA. Truvada for PrEP Fact Sheet: Ensuring Safe and Proper Use. Silver Spring, MD: FDA; 2012.

  36. 36.

    Mayer K, Johnson C, Mimiaga M, Safren S, Case P. Influence of potential symptoms and perceived efficacy on the willingness to use HIV pre-exposure prophylaxis (PrEP) among Boston area men who have sex with men (MSM). 5th IAS Conference on HIV Pathogenesis and Treatment. Cape Town, South Africa, 2009 [abstract WEPEC080].

  37. 37.

    Anderson PL, Glidden DV, Liu A. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 2012;4(151):151ra125.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Newman PA, Duan N, Rudy ET, Roberts KJ, Swendeman D. Posttrial HIV vaccine adoption: concerns, motivators, and intentions among persons at risk for HIV. J Acquir Immune Defic Syndr. 2004;37(3):1393–403.

    Article  PubMed  Google Scholar 

  39. 39.

    Rothman AJ, Salovey P. Shaping perceptions to motivate healthy behavior: the role of message framing Psychol Bull. 1997;121(1):3–19.

    CAS  PubMed  Google Scholar 

  40. 40.

    Linville PW, Fischer GW, Fischhoff B. AIDS risk perceptions and decision biases. In: Pryor JB, Reeder GD, editors. The social psychology of HIV infection. Hillsdale: Erlbaum; 1993. p. 5–38.

    Google Scholar 

  41. 41.

    Edwards A, Elwyn G, Covey J, Matthews E, Pill R. Presenting risk information: a review of the effects of “framing” and other manipulations on patient outcomes. J Health Commun. 2001;6:61–82.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Gallagher KM, Updegraff JA. Health message framing effects on attitudes, intentions, and behavior: a meta-analytic review. Ann Behav Med. 2012;43(1):101–16.

    Article  PubMed  Google Scholar 

  43. 43.

    Rucker DD, Petty RE, Brinol P. What’s in a frame anyway?: a meta-cognitive analysis of the impact of one versus two sided message framing on attitude certainty. J Consum Psychol. 2008;18(2):137–49.

    Article  Google Scholar 

  44. 44.

    Golub SA, Gamarel K, Surace A, Lelutiu-Winberger C. Impact of PrEP messaging factors on comprehension, adherence motivation, and risk compensation intentions. 8th International Conference on HIV Treatment and Prevention Adherence. Miami, FL, 2013 [abstract 125].

  45. 45.

    Golub SA, Gamarel K, Surace A, Lelutiu-Weinberger CL. Critical lessons for pre-exposure prophylaxis (PrEP) messaging and program development. American Public Health Association140th Annual Meeting. San Francisco, CA, 2014 [abstract 267271].

  46. 46.

    NVivo 9. Doncaster, Australia, 2012.

  47. 47.

    Thorne S, Kirkham SR, MacDonald-Emes J. Interpretive description: a noncategorical qualitative alternative for developing nursing knowledge. Res Nurs Health. 1997;20(2):169–77.

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Thorne S. Interpretive description. Walnut Creek: Left Coast Press, Inc.; 2008.

    Google Scholar 

  49. 49.

    Thorne S, Kirkham SR, O’Flynn-Magee K. The analytic challenge in interpretive description. Int J Qual Methods. 2004;3(1):1–11.

    Google Scholar 

  50. 50.

    Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description—the poor cousin of health research? BMC Med Res Methodol. 2009;9:52.

    Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001;322(7294):1115–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  52. 52.

    Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758–72.

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Golub SA, Kowalczyk W, Weinberger CL, Parsons JT. Preexposure prophylaxis and predicted condom use among high-risk men who have sex with men. J Acquir Immune Defic Syndr. 2010;54(5):548–55.

    Article  PubMed  PubMed Central  Google Scholar 

  54. 54.

    Helweg-Larsen M, Shepperd JA. Do Moderators of the optimistic bias affect personal or target risk estimates? A review of the literature. Pers Soc Psychol Rev. 2001;5(1):74–95.

    Article  Google Scholar 

  55. 55.

    Klein CTF, Helweg-Larsen M. Perceived control and the optimistic bias: a meta-analytic review. Psychol Health. 2002;17:437–46.

    Article  Google Scholar 

  56. 56.

    Lipkus IM, Klein WM, Rimer BK. Communicating breast cancer risks to women using different formats. Cancer Epidemiol Biomark Prev. 2001;10(8):895–8.

    CAS  Google Scholar 

  57. 57.

    Moxey A, O’Connell D, McGettigan P, Henry D. Describing treatment effects to patients. J Gen Intern Med. 2003;18(11):948–59.

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Petty RE, Priester JR, Brinol P. Mass media attitude change: implications of the elaboration likelihood model of persuastion. In: Bryant J, Zillman D, editors. Media effects: advances in theory and research. Mahwah: Lawrence Erlbaum Associates; 2002. p. 155–98.

    Google Scholar 

  59. 59.

    Smith SM, Petty RE. Message framing and persuasion: a message processing analysis. Pers Soc Psychol Bull. 1996;22(3):257–68.

    Article  Google Scholar 

  60. 60.

    Petty RE, Cacioppo JT. The elaboration likelihood model of persuasion. Adv Exp Soc Psychol. 1986;19:123–205.

    Article  Google Scholar 

  61. 61.

    Kuhn KM. Communicating uncertainty: framing effects on responses to vague probabilities. Org Behav Hum Decis Process. 1997;71(1):55–83.

    Article  Google Scholar 

Download references

Acknowledgments

We are grateful to the study participants, Project Weber, Miriam Community Access, the Yale Center for Interdisciplinary Research on AIDS, the Lifespan/Tufts/Brown Center for AIDS Research, Melissa Guillen, Genevieve Ilg, Bobby Ducharme, and Dr. Caroline Kuo for help during the implementation of this study. This study was supported by the National Institute of Mental Health, #5K01MH093273 (PI: Underhill).

Author information

Affiliations

Authors

Corresponding author

Correspondence to Kristen Underhill.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Underhill, K., Morrow, K.M., Colleran, C. et al. Explaining the Efficacy of Pre-exposure Prophylaxis (PrEP) for HIV Prevention: A Qualitative Study of Message Framing and Messaging Preferences Among US Men Who have Sex with Men. AIDS Behav 20, 1514–1526 (2016). https://doi.org/10.1007/s10461-015-1088-9

Download citation

Keywords

  • Pre-exposure prophylaxis
  • HIV prevention
  • Men who have sex with men
  • Message framing
  • Health communication