Abstract
Background
Limited access to healthcare has been associated with limited uptake of pre-exposure prophylaxis (PrEP) for HIV among men who have sex with men (MSM). This descriptive analysis examined, in a near universal healthcare setting, differences between MSM reporting using versus not using PrEP in the past 12 months.
Method
Data come from the 2017 Boston sample of the National HIV Behavioral Surveillance (NHBS) system, containing a venue-based and time-spaced sample of 530 MSM. The analysis used descriptive frequencies and tests of bivariate associations by PrEP use using Fisher’s exact test.
Results
Five hundred four respondents had data necessary to determine if PrEP was indicated, and 233 (43.9%) had an indication for PrEP. Of these 233 participants, 117 (50.2%) reported using PrEP in the past 12 months. Not being out, in terms of disclosing one’s sexual orientation to a healthcare provider, lack of health insurance, limited access to healthcare, and history of incarceration were all significantly associated with not using PrEP in the past 12 months. Race/ethnicity was not significantly associated with PrEP use in the past 12 months.
Conclusions
In the setting of Massachusetts healthcare expansion and reform, and in a sample somewhat uncharacteristic of the population of individuals experiencing difficulties accessing PrEP, structural and demographic factors remain potent barriers to PrEP uptake. Targeted PrEP expansion efforts in Massachusetts may focus on identifying vulnerable subgroups of MSM (e.g., underinsured or criminal justice system-involved MSM) and delivering evidence-based interventions to reduce stigma and promote disclosure of same-sex behavior in healthcare settings.
Similar content being viewed by others
References
Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated). https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2018-updated-vol-31.pdf. Published May 2020. Accessed August 1, 2020.
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(27):2587–99. https://doi.org/10.1056/NEJMoa1011205.
Mayer KH, Skeer M, Mimiaga MJ. Biomedical approaches to HIV prevention. Alcohol Res Health. 2010;33(3):195–202.
Mayer KH, Molina JM, Thompson MA, Anderson PL, Mounzer KC, De Wet JJ, Hare CB. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial. The Lancet. 2020;396(10246):239–54.
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. Lancet. 2016;387(10013):53–60. https://doi.org/10.1016/S0140-6736(15)00056-2.
Molina JM, Capitant C, Spire B, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015;373(23):2237–46. https://doi.org/10.1056/NEJMoa1506273.
Mayer KH, Safren SA, Elsesser SA, et al. Optimizing pre-exposure antiretroviral prophylaxis adherence in men who have sex with men: Results of a pilot randomized controlled trial of “Life-Steps for PrEP.” AIDS Behav. 2017;21(5):1350–60. https://doi.org/10.1007/s10461-016-1606-4.
Sullivan PS, Giler RM, Mouhanna F, et al. Trends in the use of oral emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis against HIV infection, United States, 2012–2017. Ann Epidemiol. 2018;28(12):833–40. https://doi.org/10.1016/j.annepidem.2018.06.009.
Sullivan PS, Sanchez TH, Zlotorzynska M, et al. National trends in HIV pre-exposure prophylaxis awareness, willingness and use among United States men who have sex with men recruited online, 2013 through 2017. J Int AIDS Soc. 2020;23(3):e25461. https://doi.org/10.1002/jia2.25461.
Nunn AS, Brinkley-Rubinstein L, Oldenburg CE, et al. Defining the HIV pre-exposure prophylaxis care continuum. AIDS. 2017;31(5):731–4. https://doi.org/10.1097/QAD.0000000000001385.
Parsons JT, Rendina HJ, Lassiter JM, Whitfield TH, Starks TJ, Grov C. Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States. J Acquir Immune Defic Syndr. 2017;74(3):285–92. https://doi.org/10.1097/QAI.0000000000001251.
Smith DK, Van Handel M, Wolitski RJ, et al. Vital Signs: Estimated Percentages and Numbers of Adults with Indications for Preexposure Prophylaxis to Prevent HIV Acquisition--United States, 2015. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6446a4.htm?s_cid=mm6446a4_w. Published November 2015. Accessed August 1, 2020.
Grov C, Jonathan Rendina H, Patel VV, Kelvin E, Anastos K, Parsons JT. Prevalence of and factors associated with the use of HIV serosorting and other biomedical prevention strategies among men who have sex with men in a US nationwide survey. AIDS Behav. 2018;22(8):2743–55. https://doi.org/10.1007/s10461-018-2084-7.
Jenness SM, Goodreau SM, Rosenberg E, et al. Impact of the Centers for Disease Control’s HIV preexposure prophylaxis guidelines for men who have sex with men in the United States. J Infect Dis. 2016;214(12):1800–7. https://doi.org/10.1093/infdis/jiw223.
Baral S, Logie CH, Grosso A, Wirtz AL, Beyrer C. Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health. 2013;13:482. https://doi.org/10.1186/1471-2458-13-482.
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. https://doi.org/10.1371/journal.pone.0033119.
Brooks RA, Kaplan RL, Lieber E, Landovitz RJ, Lee SJ, 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. https://doi.org/10.1080/09540121.2011.554528.
Hannaford A, Lipshie-Williams M, Starrels JL, et al. The use of online posts to identify barriers to and facilitators of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men: A comparison to a systematic review of the peer-reviewed literature. AIDS Behav. 2018;22(4):1080–95. https://doi.org/10.1007/s10461-017-2011-3.
Liu A, Cohen S, Follansbee S, et al. Early experiences implementing pre-exposure prophylaxis (PrEP) for HIV prevention in San Francisco. PLoS Med. 2014;11(3):e1001613. https://doi.org/10.1371/journal.pmed.1001613.
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. 2018;22(4):1063–74. https://doi.org/10.1007/s10461-017-1675-z.
Pérez-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. https://doi.org/10.1521/aeap.2015.27.2.112.
Wao H, Aluoch M, Odondi GO, Tenge E, Iznaga T. MSM’s versus health care providers’ perceptions of barriers to uptake of HIV/AIDS-related interventions: Systematic review and meta-synthesis of qualitative and quantitative evidence. Int J Sex Health. 2016;28(2):151–62. https://doi.org/10.1080/19317611.2016.1153560.
Brewer RA, Magnus M, Kuo I, Wang L, Liu TY, Mayer KH. The high prevalence of incarceration history among Black men who have sex with men in the United States: Associations and implications. Am J Public Health. 2014;104(3):448–54. https://doi.org/10.2105/AJPH.2013.301786.
Zaller ND, Neher TL, Presley M, et al. Barriers to linking high-risk jail detainees to HIV pre-exposure prophylaxis. PLoS One. 2020;15(4):e0231951. Published 2020 Apr 17. doi:https://doi.org/10.1371/journal.pone.0231951
Sullivan PS, Siegler AJ. Getting pre-exposure prophylaxis (PrEP) to the people: opportunities, challenges and emerging models of PrEP implementation. Sex Health. 2018;15(6):522–7. https://doi.org/10.1071/SH18103.
Massachusetts Department of Public Health. Massachusetts Integrated HIV/AIDS Prevention and Care Plan. https://www.mass.gov/files/documents/2016/12/vz/mass-hiv-aids-plan.pdf. Published December 2016. Accessed August 1, 2020.
Massachusetts Department of Public Health. HIV/AIDS Service and Resource Guide. https://www.mass.gov/files/documents/2018/01/09/resources-guide.pdf. Published January 2018. Accessed August 1, 2020.
Kaiser Family Foundation. Election 2020: State Health Care Snapshots. https://www.kff.org/statedata/election-state-fact-sheets/. Published February 2020. Accessed August 1, 2020.
Chin M, Gurewich D, Muhr K, Posner H, Rosinski J, LaFlamme E. The Remaining Uninsured in Massachusetts: Experiences of Individuals Living without Health Insurance Coverage. https://www.bluecrossmafoundation.org/sites/default/files/download/publication/Remaining_Uninsured_Final.pdf. Published February 2016. Accessed 1 Aug 2020.
Centers for Disease Control and Prevention. National HIV Behavioral Surveillance (NHBS). https://www.cdc.gov/hiv/statistics/systems/nhbs/index.html. Updated May 2020. Accessed August 1, 2020.
US Department of Health and Human Services. US federal poverty guidelines used to determine financial eligibility for certain federal programs. https://aspe.hhs.gov/2017-poverty-guidelines. Published January 2017. Accessed August 1, 2020.
Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;32(6):959–76. https://doi.org/10.1017/s0033291702006074.
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.
Klevens RM, Martin BM, Doherty R, Fukuda HD, Cranston K, DeMaria A Jr. Factors associated with pre-exposure prophylaxis in a highly insured population of urban men who have sex with men, 2014. AIDS Behav. 2018;22(4):1201–8. https://doi.org/10.1007/s10461-017-1879-2.
Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV epidemic: A plan for the United States. JAMA. 2019;321(9):844–5. https://doi.org/10.1001/jama.2019.1343.
Doblecki-Lewis S, Liu A, Feaster D, et al. Healthcare access and PrEP continuation in San Francisco and Miami following the US PrEP demo project. J Acquir Immune Defic Syndr. 2017;74(5):531.
Patel RR, Mena L, Nunn A, et al. Impact of insurance coverage on utilization of pre-exposure prophylaxis for HIV prevention. PLoS ONE. 2017;12(5):e0178737. https://doi.org/10.1371/journal.pone.0178737.
Brinkley-Rubinstein L, Peterson M, Arnold T, et al. Knowledge, interest, and anticipated barriers of pre-exposure prophylaxis uptake and adherence among gay, bisexual, and men who have sex with men who are incarcerated. PLoS One. 2018;13(12):e0205593. https://doi.org/10.1371/journal.pone.0205593.
Meyer IH, Flores AR, Stemple L, Romero AP, Wilson BD, Herman JL. Incarceration rates and traits of sexual minorities in the United States: National Inmate Survey, 2011–2012. Am J Public Health. 2017;107(2):267–73.
Brinkley-Rubinstein L, Peterson M, Zaller ND, Wohl DA. Best practices for identifying men who have sex with men for corrections-based pre-exposure prophylaxis provision. Health & justice. 2019;7(1):1–4.
Metcalfe R, Laird G, Nandwani R. Don't ask, sometimes tell. A survey of men who have sex with men sexual orientation disclosure in general practice. Int J STD AIDS. 2015;26(14):1028–1034. https://doi.org/10.1177/0956462414565404
Oldenburg CE, Perez-Brumer AG, Hatzenbuehler ML, et al. State-level structural sexual stigma and HIV prevention in a national online sample of HIV-uninfected MSM in the United States. AIDS. 2015;29(7):837–45. https://doi.org/10.1097/QAD.0000000000000622.
Santos GM, Beck J, Wilson PA, et al. Homophobia as a barrier to HIV prevention service access for young men who have sex with men. J Acquir Immune Defic Syndr. 2013;63(5):e167–70. https://doi.org/10.1097/QAI.0b013e318294de80.
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;4(4):310–4. https://doi.org/10.1089/lgbt.2016.0068.
Rowan D, DeSousa M, Randall EM, White C, Holley L. We’re just targeted as the flock that has HIV”: Health care experiences of members of the house/ball culture. Soc Work Health Care. 2014;53(5):460–77. https://doi.org/10.1080/00981389.2014.896847.
Irvin R, Wilton L, Scott H, et al. A study of perceived racial discrimination in Black men who have sex with men (MSM) and its association with healthcare utilization and HIV testing. AIDS Behav. 2014;18(7):1272–8. https://doi.org/10.1007/s10461-014-0734-y.
Beyrer PC, Sullivan PS, Sanchez J, et al. A call to action for comprehensive HIV services for men who have sex with men. Lancet. 2012;380(9839):424–38. https://doi.org/10.1016/S0140-6736(12)61022-8.
Funding
This publication was made possible by Grant Numbers T32 AI007433 and 5P30AI060354-15 from the National Institute of Allergy and Infectious Diseases.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethical Approval
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.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Conflict of Interest
Ken Mayer has received unrestricted research grants from Gilead Sciences. The other authors have no conflicts of interest 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
About this article
Cite this article
Fitch, C., Foley, J., Klevens, M. et al. Structural Issues Associated with Pre-exposure Prophylaxis Use in Men Who Have Sex with Men. Int.J. Behav. Med. 28, 759–767 (2021). https://doi.org/10.1007/s12529-021-09986-w
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12529-021-09986-w