Structural Barriers to Pre-exposure Prophylaxis Use Among Young Sexual Minority Men: The P18 Cohort Study

Author(s): Jessica Jaiswal* , Marybec Griffin , Stuart N. Singer , Richard E. Greene , Ingrid Lizette Zambrano Acosta , Saara K. Kaudeyr , Farzana Kapadia , Perry N. Halkitis .

Journal Name: Current HIV Research

Volume 16 , Issue 3 , 2018

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Graphical Abstract:


Abstract:

Background: Despite decreasing rates of HIV among many populations, HIV-related health disparities among gay, bisexual and other men who have sex with men persist, with disproportional percentages of new HIV diagnoses among racial and ethnic minority men. Despite increasing awareness of HIV pre-exposure prophylaxis (PrEP), PrEP use remains low. In addition to exploring individual-level factors for this slow uptake, structural drivers of PrEP use must also be identified in order to maximize the effectiveness of biomedical HIV prevention strategies.

Method: Using cross-sectional data from an ongoing cohort study of young sexual minority men (N=492), we examine the extent to which structural-level barriers, including access to health care, medication logistics, counseling support, and stigma are related to PrEP use.

Results: While almost all participants indicated awareness of PrEP, only 14% had ever used PrEP. PrEP use was associated with lower concerns about health care access, particularly paying for PrEP. Those with greater concerns talking with their provider about their sexual behaviors were less likely to use PrEP.

Conclusion: Paying for PrEP and talking to one’s provider about sexual behaviors are concerns for young sexual minority men. In particular, stigma from healthcare providers poses a significant barrier to PrEP use in this population. Providers need not only to increase their own awareness of and advocacy for PrEP as an effective risk-management strategy for HIV prevention, but also must work to create open and non-judgmental spaces in which patients can discuss sexual behaviors without the fear of stigma.

Keywords: Pre-exposure Prophylaxis, PrEP, structural barriers, healthcare providers, stigma, diverse, clinicians.

[1]
CDC. HIV Surveillance Report, 2015; vol 28. http://www. cdc. gov/hiv/library/reports/hiv-surveillance.html Published November 2017. Accessed Jan 29 2018.2017.
[2]
Oster AM, Wiegand RE, Sionean C, et al. Understanding disparities in HIV infection between black and white MSM in the United States. AIDS 2011; 25(8): 1103-12.
[3]
Millett GA, Peterson JL, Flores SA, et al. Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis. Lancet 2012; 380(9839): 341-8.
[4]
Rosenberg ES, Millett GA, Sullivan PS, Del Rio C, Curran JW. Understanding the HIV disparities between black and white men who have sex with men in the USA using the HIV care continuum: a modeling study. Lancet HIV 2014; 1(3): e112-8.
[5]
Maulsby C, Millett G, Lindsey K, et al. HIV among Black men who have sex with men (MSM) in the United States: a review of the literature. AIDS Behav 2014; 18(1): 10-25.
[6]
Administration FD. FDA Approves First Medication to Reduce HIV Risk. https://www.fda.gov/ForConsumers/Consumer Updates/ ucm311821.htm Accessed August 29, 2017.2012.
[7]
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.
[8]
Marks SJ, Merchant RC, Clark MA, et al. Potential healthcare insurance and provider barriers to pre-exposure prophylaxis utilization among young men who have sex with men. AIDS Patient Care STDS 2017; 31(11): 470-8.
[9]
Myers J. A Public Health Approach to PrEP and PEP. In: Hygeine NDoMHa. Editor 2015.
[10]
Grov C, Whitfield TH, Rendina HJ, Ventuneac A, Parsons JT. Willingness to take PrEP and potential for risk compensation among highly sexually active gay and bisexual men. AIDS Behav 2015; 19(12): 2234-44.
[11]
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.
[12]
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.
[13]
Holloway IW, Dougherty R, Gildner J, et al. Brief Report: PrEP Uptake, Adherence, and Discontinuation Among California YMSM Using Geosocial Networking Applications. J Acquir Immune Defic Syndr 2017; 74(1): 15-20.
[14]
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.
[15]
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.
[16]
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.
[17]
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.
[18]
Khanna AS, Michaels S, Skaathun B, et al. Preexposure prophylaxis awareness and use in a population-based sample of young black men who have sex with men. JAMA Intern Med 2016; 176(1): 136-8.
[19]
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.
[20]
Brooks RA, Landovitz RJ, Kaplan RL, Lieber E, Lee SJ, Barkley TW. Sexual risk behaviors and acceptability of HIV pre-exposure prophylaxis among HIV-negative gay and bisexual men in serodiscordant relationships: a mixed methods study. AIDS Patient Care STDS 2012; 26(2): 87-94.
[21]
Baeten JM, Haberer JE, Liu AY, Sista N. Preexposure prophylaxis for HIV prevention: where have we been and where are we going? J Acquir Immune Defic Syndr 2013; 63(2): S122-9.
[22]
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.
[23]
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.
[24]
Chan PA, Mena L, Patel R, et al. Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities. J Int AIDS Soc 2016; 19(1): 20903.
[25]
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.
[26]
Halkitis PN, Jaiswal J, Griffin-Tomas M, Krause KD, D’Avanzo PA, Kapadia F. 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 2018. [Epub ahead Print].
[27]
Krakower DS, Mayer KH. Pre-exposure prophylaxis to prevent HIV infection: current status, future opportunities and challenges. Drugs 2015; 75(3): 243-51.
[28]
Wilton J, Senn H, Sharma M, Tan DH. Pre-exposure prophylaxis for sexually-acquired HIV risk management: a review. HIV AIDS (Auckl) 2015; 7: 125-36.
[29]
Calabrese SK, Underhill K. How stigma surrounding the use of hiv preexposure prophylaxis undermines prevention and pleasure: a call to destigmatize “truvada whores”. Am J Public Health 2015; 105(10): 1960-4.
[30]
Haire BG. Preexposure prophylaxis-related stigma: strategies to improve uptake and adherence - a narrative review. HIV AIDS (Auckl) 2015; 7: 241-9.
[31]
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.
[32]
Tellalian D, Maznavi K, Bredeek UF, Hardy WD. Pre-exposure prophylaxis (PrEP) for HIV infection: results of a survey of HIV healthcare providers evaluating their knowledge, attitudes, and prescribing practices. AIDS Patient Care STDS 2013; 27(10): 553-9.
[33]
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): 1712-21.
[34]
Krakower D, Mayer KH. Engaging healthcare providers to implement HIV pre-exposure prophylaxis. Curr Opin HIV AIDS 2012; 7(6): 593-9.
[35]
Blumenthal J, Jain S, Krakower D, et al. Knowledge is power! Increased provider knowledge scores regarding pre-exposure prophylaxis (PrEP) are associated with higher rates of PrEP prescription and future intent to prescribe PrEP. AIDS Behav 2015; 19(5): 802-10.
[36]
Bernstein KT, Liu K-L, Begier EM, Koblin B, Karpati A, Murrill C. Same-sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches. Arch Intern Med 2008; 168(13): 1458-64.
[37]
Durso LE, Meyer IH. patterns and predictors of disclosure of sexual orientation to healthcare providers among lesbians, gay men, and bisexuals. Sex Res Soc Policy 2013; 10(1): 35-42.
[38]
Dowshen N, Binns HJ, Garofalo R. Experiences of HIV-related stigma among young men who have sex with men. AIDS Patient Care STDS 2009; 23(5): 371-6.
[39]
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.
[40]
Mimiaga MJ, Goldhammer H, Belanoff C, Tetu AM, Mayer KH. Men who have sex with men: perceptions about sexual risk, HIV and sexually transmitted disease testing, and provider communication. Sex Transm Dis 2007; 34(2): 113-9.
[41]
Eliason MJ, Schope R. Does “don’t ask don’t tell” apply to health care? Lesbian, gay, and bisexual people’s disclosure to health care providers. J Gay Lesbian Med Assoc 2001; 5(4): 125-34.
[42]
Taylor SW, Mayer KH, Elsesser SM, Mimiaga MJ, O’Cleirigh C, Safren SA. Optimizing content for pre-exposure prophylaxis (PrEP) counseling for men who have sex with men: perspectives of PrEP users and high-risk PrEP naive men. AIDS Behav 2014; 18(5): 871-9.
[43]
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.
[44]
Hubach RD, Currin JM, Sanders CA, et al. Barriers to access and adoption of pre-exposure prophylaxis for the prevention of hiv among men who have sex with men (msm) in a relatively rural state. AIDS Educ Prev 2017; 29(4): 315-29.
[45]
Kwakwa HA, Bessias S, Sturgis D, et al. Attitudes toward HIV pre-exposure prophylaxis in a United States urban clinic population. AIDS Behav 2016; 20(7): 1443-50.
[46]
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.
[47]
Koenig LJ, Lyles C, Smith DK. Adherence to antiretroviral medications for HIV pre-exposure prophylaxis: lessons learned from trials and treatment studies. Am J Prev Med 2013; 44(1)(Suppl. 2): S91-8.
[48]
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.
[49]
Hosek SG, Rudy B, Landovitz R, et al. An HIV preexposure prophylaxis demonstration project and safety study for young MSM. J Acquir Immune Defic Syndr 2017; 74(1): 21-9.
[50]
Golub SA, Gamarel KE. The impact of anticipated HIV stigma on delays in HIV testing behaviors: findings from a community-based sample of men who have sex with men and transgender women in New York City. AIDS Patient Care STDS 2013; 27(11): 621-7.
[51]
Auerbach JD, Hoppe TA. Beyond “getting drugs into bodies”: social science perspectives on pre-exposure prophylaxis for HIV. J Int AIDS Soc 2015; 18(4)(Suppl. 3): 19983.
[52]
Arnold T, Brinkley-Rubinstein L, Chan PA, et al. Social, structural, behavioral and clinical factors influencing retention in Pre-Exposure Prophylaxis (PrEP) care in Mississippi. PLoS One 2017; 12(2): e0172354.
[53]
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.
[54]
Halkitis PN, Krause KD, Vieira DL. Mental health, psychosocial challenges and resilience in older adults living with hiv. Interdiscip Top Gerontol Geriatr 2017; 42: 187-203.
[55]
Kinsey AC, Pomeroy WB, Martin CE, Sloan S. Sexual behavior in the human male. Bloomington, Indiana: Indiana University Press 1948.
[56]
Health NYSDo. What is Medicaid? https://www.health.ny.gov/ health_care/medicaid/ definition [updated November 2017].
[57]
Kuhns LM, Hotton AL, Schneider J, Garofalo R, Fujimoto K. Use of pre-exposure prophylaxis (PrEP) in young men who have sex with men is associated with race, sexual risk behavior and peer network size. AIDS Behav 2017; 21(5): 1376-82.
[58]
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.
[59]
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.
[60]
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.
[61]
Smith DK, Mendoza MC, Stryker JE, Rose CE. PrEP awareness and attitudes in a national survey of primary care clinicians in the United States, 2009–2015. PLoS One 2016; 11(6): e0156592.
[62]
Calabrese SK, Magnus M, Mayer KH, et al. Putting PrEP into practice: lessons learned from early-adopting US providers’ firsthand experiences providing HIV pre-exposure prophylaxis and associated care. PLoS One 2016; 11(6): e0157324.
[63]
Karris MY, Beekmann SE, Mehta SR, Anderson CM, Polgreen PM. Are we prepped for preexposure prophylaxis (PrEP)? Provider opinions on the real-world use of PrEP in the United States and Canada. Clin Infect Dis 2013; 58(5): 704-12.
[64]
Sabin JA, Riskind RG, Nosek BA. health care providers’ implicit and explicit attitudes toward lesbian women and gay men. Am J Public Health 2015; 105(9): 1831-41.
[65]
Malebranche DJ, Peterson JL, Fullilove RE, Stackhouse RW. Race and sexual identity: perceptions about medical culture and healthcare among black men who have sex with men. J Natl Med Assoc 2004; 96(1): 97-107.
[66]
King HL, Keller SB, Giancola MA, et al. Pre-exposure prophylaxis accessibility research and evaluation (PrEPARE Study). AIDS Behav 2014; 18(9): 1722.
[67]
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.
[68]
Arnold EA, Hazelton P, Lane T, et al. A qualitative study of provider thoughts on implementing pre-exposure prophylaxis (PrEP) in clinical settings to prevent HIV infection. PLoS One 2012; 7(7): e40603.
[69]
Dorell CG, Sutton MY, Oster AM, et al. Missed opportunities for HIV testing in health care settings among young African American men who have sex with men: implications for the HIV epidemic. AIDS Patient Care STDS 2011; 25(11): 657-64.
[70]
Klitzman RL, Greenberg JD. Patterns of communication between gay and lesbian patients and their health care providers. J Homosex 2002; 42(4): 65-75.
[71]
Sanchez NF, Rabatin J, Sanchez JP, Hubbard S, Kalet A. Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. Fam Med 2006; 38(1): 21-7.
[72]
Kennamer JD, Honnold J, Bradford J, Hendricks M. Differences in disclosure of sexuality among African American and White gay/bisexual men: implications for HIV/AIDS prevention. AIDS Educ Prev 2000; 12(6): 519-31.
[73]
Hinchliff S, Gott M, Galena E. ‘I daresay I might find it embarrassing’: general practitioners’ perspectives on discussing sexual health issues with lesbian and gay patients. Health Soc Care Community 2005; 13(4): 345-53.
[74]
Fields EL, Bogart LM, Smith KC, Malebranche DJ, Ellen J, Schuster MA. “I always felt I had to prove my manhood”: Homosexuality, masculinity, gender role strain, and HIV risk among young Black men who have sex with men. Am J Public Health 2015; 105(1): 122-31.
[75]
Millett GA, Flores SA, Peterson JL, Bakeman R. Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors. AIDS 2007; 21(15): 2083-91.
[76]
Garofalo R, Mustanski B, Johnson A, Emerson E. Exploring factors that underlie racial/ethnic disparities in HIV risk among young men who have sex with men. J Urban Health 2010; 87(2): 318-23.
[77]
Lelutiu-Weinberger C, Golub SA. Enhancing PrEP access for black and Latino men who have sex with men. J Acquir Immune Defic Syndr 2016; 73(5): 547-55.
[78]
Mayer KH, Hosek S, Cohen S, et al. Antiretroviral pre-exposure prophylaxis implementation in the United States: a work in progress. J Int AIDS Soc 2015; 18(4)(Suppl. 3): 19980.
[79]
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.
[80]
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.
[81]
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.
[82]
Doblecki-Lewis S, Liu A, Feaster D, et al. Healthcare access and PrEP continuation in San Francisco and Miami after the US PrEP demo project. J Acquir Immune Defic Syndr 2017; 74(5): 531-8.
[83]
Alstead M, Campsmith M, Halley CS, Hartfield K, Goldbaum G, Wood RW. Developing, implementing, and evaluating a condom promotion program targeting sexually active adolescents. AIDS Educ Prev 1999; 11(6): 497-512.


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Article Details

VOLUME: 16
ISSUE: 3
Year: 2018
Page: [237 - 249]
Pages: 13
DOI: 10.2174/1570162X16666180730144455

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