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Beliefs About the End of AIDS, Concerns About PrEP Functionality, and Perceptions of HIV Risk as Drivers of PrEP Use in Urban Sexual Minority Men: The P18 Cohort Study


Using cross-sectional data from an ongoing cohort study of young gay, bisexual, and other men who have sex with men (N = 492), we examined the extent to which cognitive factors such as beliefs about the end of AIDS, concerns about the manner in which PrEP works, and perceptions about risk of contracting HIV, are related to PrEP uptake and use. While almost all participants indicted awareness of PrEP, a mere 14% had ever used PrEP. Those with lower concerns about the side effects of PrEP and greater belief that treatment and PrEP would eliminate AIDS were also more likely to have ever used PrEP. Our findings support the ongoing challenges of PrEP uptake as means of curtailing HIV in young sexual minority men, and suggest that beyond the structural factors, consideration must be given to further educating the population as a means of adjusting potentially faulty beliefs, concerns, and perceptions which may influence PrEP utilization.


Utilizando datos transversales de un estudio de cohorte en curso de jóvenes homosexuales, bisexuales y otros hombres que tienen relaciones sexuales con hombres (N = 492), examinamos la medida en que los factores cognitivos en forma de creencias sobre el fin del SIDA, las preocupaciones sobre la forma en que funciona la PrEP y las percepciones sobre el riesgo de contraer el VIH, están relacionados con la consumo y el uso de PrEP. Mientras que casi todos los participantes indicaron la toma de conciencia sobre la PrEP, sólo un 14% había usado PrEP. Aquellos con una menor preocupación por los efectos secundarios de la PrEP y una mayor creencia de que el tratamiento y la PrEP eliminaría el SIDA también fueron más propensos a haber usado PrEP. Nuestros hallazgos apoyan los desafíos actuales de la adopción de PrEP como medios para reducir el VIH en hombres jóvenes de minorías sexuales, y sugieren que más allá de los factores estructurales, se debe considerar la posibilidad de educar a la población como un medio para ajustar creencias potencialmente erróneas, que pueden influir en la utilización de la PrEP.

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  1. 1.

    Centers for Disease Control and Prevention. HIV among gay and bisexual men. 2017. Accessed 29 Aug 2017.

  2. 2.

    Federal Drug Administration. FDA approves first medication to reduce HIV risk. 2012. Accessed 29 Aug 2017.

  3. 3.

    Delaney KP, Sanchez T, Bowles K, Oraka E, DiNenno EA, Sullivan PS. Awareness and use of PrEP appear to be increasing among internet samples of US MSM. In: Paper presented at conference on retroviruses and opportunistic infections 2016, Boston, MA.

  4. 4.

    Bush S, Magnuson D, Rawlings M, Hawkins T, McCallister S, Mera Giler R. Racial characteristics of FTC/TDF for pre-exposure prophylaxis (PrEP) users in the US. In: Paper presented at: ASM Microbe/ICAAC; June 16- June 20, 2016, Boston, MA.

  5. 5.

    Myers J. A Public Health Approach to PrEP and PEP. NYC Department of Mental Health and Hygiene, 2015.

  6. 6.

    Chan PA, Rose J, Maher J, et al. A latent class analysis of risk factors for acquiring HIV among men who have sex with men: implications for implementing pre-exposure prophylaxis programs. AIDS Patient Care STDS. 2015;29(11):597–605.

    Article  Google Scholar 

  7. 7.

    Eaton LA, Driffin DD, Bauermeister J, Smith H, Conway-Washington C. Minimal awareness and stalled uptake of pre-exposure prophylaxis (PrEP) among at risk, HIV-negative, black men who have sex with men. AIDS Patient Care STDS. 2015;29(8):423–9.

    Article  Google Scholar 

  8. 8.

    Goedel WC, Halkitis PN, Greene RE, Hickson DA, Duncan DT. HIV risk behaviors, perceptions, and testing and preexposure prophylaxis (PrEP) awareness/use in Grindr-using men who have sex with men in Atlanta, Georgia. J Assoc Nurses AIDS Care. 2016;27(2):133–42.

    Article  Google Scholar 

  9. 9.

    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  Google Scholar 

  10. 10.

    Eaton LA, Matthews DD, Driffin DD, et al. A multi-US city assessment of awareness and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among Black men and transgender women who have sex with men. Prev Sci. 2017:1–12.

  11. 11.

    Auerbach JD, Parkhurst JO, Caceres CF. Addressing social drivers of HIV/AIDS for the long-term response: conceptual and methodological considerations. Global Public Health. 2011;6(Suppl 3):S293–309.

    Article  Google Scholar 

  12. 12.

    Brooks RA, Landovitz RJ, Regan R, Lee S-J, Allen VC Jr. Perceptions of and intentions to adopt HIV pre-exposure prophylaxis among black men who have sex with men in Los Angeles. Int J STD AIDS. 2015;26(14):1040–8.

    Article  Google Scholar 

  13. 13.

    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.

    Article  Google Scholar 

  14. 14.

    Dolezal C, Frasca T, Giguere R, et al. Awareness of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) is low but interest is high among men engaging in condomless anal sex with men in Boston, Pittsburgh, and San Juan. AIDS Educ Prev. 2015;27(4):289–97.

    Article  Google Scholar 

  15. 15.

    Perez-Figueroa RE, Kapadia F, Barton SC, Eddy JA, Halkitis PN. Acceptability of PrEP uptake among racially/ethnically diverse young men who have sex with men: the P18 study. AIDS Educ Prev. 2015;27(2):112–25.

    Article  Google Scholar 

  16. 16.

    Lee C, Ayers SL, Kronenfeld JJ. The association between perceived provider discrimination, healthcare utilization and health status in racial and ethnic minorities. Ethn. Dis. Summer. 2009;19(3):330–7.

    Google Scholar 

  17. 17.

    Nelson AR, Stith AY, Smedley BD. Unequal treatment: confronting racial and ethnic disparities in health care (full printed version). Washington: National Academies Press; 2002.

    Google Scholar 

  18. 18.

    Mead H, Cartwright-Smith L, Jones K, Ramos C, Woods K, Siegel B. Racial and ethnic disparities in US health care: a chartbook. New York: The Commonwealth Fund; 2008.

    Google Scholar 

  19. 19.

    LaVeist TA, Nickerson KJ, Bowie JV. Attitudes about racism, medical mistrust, and satisfaction with care among African American and white cardiac patients. Med Care Res Rev. 2000;57(Suppl 1):146–61.

    Article  Google Scholar 

  20. 20.

    Institute of Medicine Committee on U, Eliminating R, Ethnic Disparities in Health C. In: Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): National Academies Press (US); 2003.

  21. 21.

    Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995:80–94.

    Article  Google Scholar 

  22. 22.

    Brandon DT, Isaac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc. 2005;97(7):951–6.

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    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.

    Article  Google Scholar 

  24. 24.

    LaVeist TA, Isaac LA, Williams KP. Mistrust of health care organizations is associated with underutilization of health services. Health Serv Res. 2009;44(6):2093–105.

    Article  Google Scholar 

  25. 25.

    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.

    Article  Google Scholar 

  26. 26.

    Brooks RA, Allen VC, Jr., Regan R, Mutchler MG, Cervantes-Tadeo R, Lee SJ. HIV/AIDS conspiracy beliefs and intention to adopt preexposure prophylaxis among black men who have sex with men in Los Angeles. Int J STD AIDS. 2017:956462417727691.

  27. 27.

    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.

    Article  Google Scholar 

  28. 28.

    Eaton LA, Driffin DD, Smith H, Conway-Washington C, White D, Cherry C. Psychosocial factors related to willingness to use pre-exposure prophylaxis for HIV prevention among Black men who have sex with men attending a community event. Sex Health. 2014;11(3):244–51.

    Article  Google Scholar 

  29. 29.

    Bain A, Wong CA, Slap G, et al. Common and costly hospitalizations among insured young adults since the Affordable Care Act. J Adolesc Health. 2016;59(1):61–7.

    Article  Google Scholar 

  30. 30.

    Kalichman SC, Eaton L, Cain D, Cherry C, Pope H, Kalichman M. HIV treatment beliefs and sexual transmission risk behaviors among HIV positive men and women. J Behav Med. 2006;29(5):401–10.

    Article  Google Scholar 

  31. 31.

    Kalichman SC, Eaton L, Kalichman MO, Cherry C. Medication beliefs mediate the association between medical mistrust and antiretroviral adherence among African Americans living with HIV/AIDS. J Health Psychol. 2017;22(3):269–79.

    Article  Google Scholar 

  32. 32.

    Kalichman SC, Eaton L, Kalichman MO, Grebler T, Merely C, Welles B. Race-based medical mistrust, medication beliefs and HIV treatment adherence: test of a mediation model in people living with HIV/AIDS. J Behav Med. 2016;39(6):1056–64.

    Article  Google Scholar 

  33. 33.

    Graham J, Bennett IM, Holmes WC, Gross R. Medication beliefs as mediators of the health literacy-antiretroviral adherence relationship in HIV-infected individuals. AIDS Behav. 2007;11(3):385–92.

    Article  Google Scholar 

  34. 34.

    Brooks RA, Kaplan RL, Lieber E, Landovitz RJ, Lee S-J, Leibowitz AA. Motivators, concerns, and barriers to adoption of preexposure prophylaxis for HIV prevention among gay and bisexual men in HIV-serodiscordant male relationships. AIDS Care. 2011;23(9):1136–45.

    Article  Google Scholar 

  35. 35.

    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  Google Scholar 

  36. 36.

    Kesler MA, Kaul R, Myers T, et al. Perceived HIV risk, actual sexual HIV risk and willingness to take pre-exposure prophylaxis among men who have sex with men in Toronto, Canada. AIDS Care. 2016;28(11):1378–85.

    Article  Google Scholar 

  37. 37.

    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;1–13.

  38. 38.

    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.

    Article  Google Scholar 

  39. 39.

    Halkitis PN, Cook S, Ristuccia A, et al. Psychometric analysis of the life worries scale for a new generation of sexual minority men: the P18 cohort study. Health Psych. 2017

  40. 40.

    Arnett JJ. Emerging adulthood. A theory of development from the late teens through the twenties. Am Psychol. 2000;55(5):469–80.

    CAS  Article  Google Scholar 

  41. 41.

    Fishbein M. A theory of reasoned action: some applications and implications. 1979.

  42. 42.

    Green EC, Murphy E. Health belief model. The Wiley Blackwell encyclopedia of health, illness, behavior, and society. New York: Wiley; 2014.

    Google Scholar 

  43. 43.

    Montano DE, Kasprzyk D. Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. 2015; 95–124.

  44. 44.

    D’Avanzo PA, Barton SC, Kapadia F, Halkitis PN. Personality and its relation to mental and psychosocial health in emerging adult sexual minority men: the P18 cohort study. Behav Med. 2017;43(3):191–9.

    Article  Google Scholar 

  45. 45.

    Kinsey AC, Pomeroy WB, Martin CE, Sloan S. Sexual behavior in the human male. Philadelphia: Saunders; 1948.

    Google Scholar 

  46. 46.

    New York State Department of Health. Blueprint on ending the AIDS epidemic. NY: Albany; 2015.

    Google Scholar 

  47. 47.

    Midi H, Sarkar S, Rana S. Collinearity diagnostics of binary logistic regression model. J Interdiscip Math. 2010;13(3):253–67.

    Article  Google Scholar 

  48. 48.

    Garnett M, Hirsch-Moverman Y, Franks J, Hayes-Larson E, El-Sadr WM, Mannheimer S. Limited awareness of pre-exposure prophylaxis among black men who have sex with men and transgender women in New York city. AIDS Care 2017:1–9.

  49. 49.

    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  Google Scholar 

  50. 50.

    Garfinkel DB, Alexander KA, McDonald-Mosley R, Willie TC, Decker MR. Predictors of HIV-related risk perception and PrEP acceptability among young adult female family planning patients. AIDS Care. 2017;29(6):751–8.

    Article  Google Scholar 

  51. 51.

    Laufer FN, O’Connell DA, Feldman I, Zucker HA. Vital signs: increased medicaid prescriptions for preexposure prophylaxis against HIV infection—New York, 2012–2015. MMWR. 2015;64(46):1296–301.

    PubMed  Google Scholar 

  52. 52.

    Levison JH, Regan S, Khan I, Freedberg KA. Foreign-born status as a predictor of engagement in HIV care in a large US metropolitan health system. AIDS Care. 2017;29(2):244–51.

    Article  Google Scholar 

  53. 53.

    Philbin MM, Parker CM, Parker RG, Wilson PA, Garcia J, Hirsch JS. The promise of pre-exposure prophylaxis for black men who have sex with men: an ecological approach to attitudes, beliefs, and barriers. AIDS Patient Care STDS. 2016;30(6):282–90.

    Article  Google Scholar 

  54. 54.

    Underhill K, Morrow KM, 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. 2016;20(7):1514–26.

    Article  Google Scholar 

  55. 55.

    Krakower D, Ware N, Mitty JA, Maloney K, Mayer KH. HIV providers’ perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study. AIDS Behav. 2014;18(9):1712.

    Article  Google Scholar 

  56. 56.

    Blackstock OJ, Moore BA, Berkenblit GV, et al. A cross-sectional online survey of HIV pre-exposure prophylaxis adoption among primary care physicians. J Gen Intern Med. 2017;32(1):62–70.

    Article  Google Scholar 

  57. 57.

    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.

    Article  Google Scholar 

  58. 58.

    Maloney KM, Krakower DS, Ziobro D, Rosenberger JG, Novak D, Mayer KH. Culturally competent sexual healthcare as a prerequisite for obtaining preexposure prophylaxis: findings from a qualitative study. LGBT Health. 2017.

  59. 59.

    King HL, Keller SB, Giancola MA, et al. Pre-exposure prophylaxis accessibility research and evaluation (PrEPARE Study). AIDS Behav. 2014;18(9):1722.

    Article  Google Scholar 

  60. 60.

    Krieger N. Theories for social epidemiology in the 21st century: an ecosocial perspective. Int J Epidemiol. 2001;30(4):668–77.

    CAS  Article  Google Scholar 

  61. 61.

    Halkitis PN. Out in time: gay men across the generations. New York: Oxford University Press; 2019.

    Google Scholar 

  62. 62.

    Halkitis PN. Of gay men, generations, and listening. Chelsea Now 2016.

  63. 63.

    Halkitis PN. The AIDS generation: stories of survival and resilience. New York: Oxford University Press; 2013.

    Book  Google Scholar 

  64. 64.

    Halkitis PN, Kupprat SA, Hampton MB, et al. Evidence for a syndemic in aging HIV-positive gay, bisexual, and other MSM: implications for a holistic approach to prevention and health care. Annal Anthropol Pract. 2012;36(2):365–86.

    Article  Google Scholar 

  65. 65.

    Nelson KM, Gamarel KE, Pantalone DW, Carey MP, Simoni JM. Sexual debut and HIV-related sexual risk-taking by birth cohort among men who have sex with men in the United States. AIDS Behav. 2016;20(10):2286–95.

    Article  Google Scholar 

  66. 66.

    Das M, Chu PL, Santos G-M, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5(6):e11068.

    Article  Google Scholar 

  67. 67.

    Oster AM, Johnson CH, Le BC, et al. Trends in HIV prevalence and HIV testing among young MSM: five United States cities, 1994–2011. AIDS Behav. 2014;18(3):237–47.

    Article  Google Scholar 

  68. 68.

    Greene RE, Luong A, Barton S, Kapadia F, Halkitis PN. Assessing gaps in the HIV care continuum in a sample of gay, bisexual, and other YMSM: the P18 cohort study. JANAC. 2018.

  69. 69.

    Schroder KE, Carey MP, Vanable PA. Methodological challenges in research on sexual risk behavior: II. Accuracy of self-reports. Ann Behav Med. 2003;26(2):104–23.

    Article  Google Scholar 

  70. 70.

    Mera Giler R, Mangnuson D, Trevor H, Bush S, Rawlings K, McCallister S. Changes in Truvada (TVD) for HIV pre-exposure prophylaxis (PrEP) utilization in the United States:(2012–2016). In: Paper presented at 9th international AIDS society conference on HIV science 2017.

  71. 71.

    Marks L. Sexual chemistry: a history of the contraceptive pill. New Haven: Yale University Press; 2010.

    Google Scholar 

  72. 72.

    Calabrese SK, Magnus M, Mayer KH, et al. “Support your client at the space that they’re in”: HIV pre-exposure prophylaxis (PrEP) prescribers’ perspectives on PrEP-related risk compensation. AIDS Patient Care STDS. 2017;31(4):196–204.

    Article  Google Scholar 

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This work is funded by the National Institute on Drug Abuse, Grant # 1R01DA025537 and 2R01DA025537.

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Correspondence to Perry N. Halkitis.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written consent was obtained from all participants. The study possesses a federal Certificate of Confidentiality.

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Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Numbers 1R01DA025537 and 2R01DA025537. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Halkitis, P.N., Jaiswal, J., Griffin-Tomas, M. et al. Beliefs About the End of AIDS, Concerns About PrEP Functionality, and Perceptions of HIV Risk as Drivers of PrEP Use in Urban Sexual Minority Men: The P18 Cohort Study. AIDS Behav 22, 3705–3717 (2018).

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  • PrEP
  • Cognition
  • Gay and bisexual
  • Sexual minority
  • HIV
  • Belief
  • Concern
  • Risk perception
  • End of AIDS