Facilitators and Barriers to Pre-Exposure Prophylaxis Willingness Among Young Men Who Have Sex with Men Who Use Geosocial Networking Applications in California

Introduction

The HIV epidemic in the US continues to disproportionately impact vulnerable and marginalized communities. While incidence remains high among gay, bisexual, and other men who have sex with men (MSM), the burden is shifting from white to black and Latino MSM. ^{1 –4} According to the CDC, ⁵ nearly half of black MSM and one quarter of Latino MSM will be diagnosed with HIV in their lifetimes (compared to one in 11 white MSM) if current infection rates continue, with a majority of those infections attributable to same-sex sexual contact. ³ The burden is also shifting from older to younger MSM (YMSM), with as many as two-thirds of new HIV infections among youth also attributable to same-sex sexual contact. ⁶ YMSM of color have been particularly affected, with HIV prevalence among these men rising according to recent estimates. ^7,8 The HIV epidemic in California largely reflects these trends. ^9,10

Some prevention efforts specifically target YMSM, ¹¹ and more are warranted; however, broader epidemiological analyses suggest that the effect of behaviorally focused HIV prevention efforts on new infections may have plateaued. ¹² Thus, in recent years, attention has turned to and enthusiasm has grown for biomedical approaches to HIV prevention. The “test and treat” model, for example, involves routinizing testing for at-risk populations, linking to care those who test positive, and ensuring care for those already positive to decrease community viral load. ^{13 –15} Pre-exposure prophylaxis (PrEP), the use of antiretroviral medications by HIV-negative individuals to prevent infection, is a newly available and promising biomedical tool. Clinical trials estimate that, when taken consistently, PrEP can reduce HIV infection risk by as much as 99%. ^{16 –18} In the years following its introduction, studies demonstrated that efficacy remains relatively high even with imperfect use (e.g., 76% reduction with five missed doses per week; 96% with three). ¹⁶ Also, concerns about PrEP use causing mutations in the HIV virus have largely been allayed. Studies have shown that drug resistance is rare enough that the potential benefit of avoiding HIV infection far outweighs the risk of seroconversion by mutated virus while on PrEP. ^{19 –21}

Understandably then, PrEP has been integrated into many new prevention efforts across the United States, including California's “Laying a Foundation for Getting to Zero” initiative. ²² Previous research, however, has found that despite increasing awareness of and interest in PrEP, uptake remains low, often as little as 1–5% of MSM report having ever taken it. ^{23 –29} While some evidence suggests this is likely to increase over time, ^30,31 remaining barriers threaten to stymie a broader uptake. Studies show that access to PrEP (i.e., its cost and the cost of health insurance coverage more broadly), the health effects of PrEP (i.e., its side effects and consequences of long-term use), and behavior change related to PrEP (i.e., medication adherence and fears that a decreased perception of risk will lead to increased risk behavior, or what is broadly referred to as “risk compensation”) remain significant barriers to uptake among MSM. ^{32 –38}

Stigma associated with taking PrEP is another barrier, with some MSM reporting being afraid of or having experienced moral judgment and shaming from their peers as well as their health providers. ^{39 –42} Concerns about stigma are not unfounded: one study showed that members of the general public expressed lower support for funding policies and programs that would facilitate access to PrEP for gay men, with gay black men receiving the least expressed support relative to expressed support for the general population. ⁴³ While some research has shown YMSM face similar stigma, ^{23,44 –46} much less is known about the barriers and facilitators to PrEP willingness and uptake for this population.

Many studies of PrEP involving MSM have emerged from preliminary investigations into its feasibility and acceptability, or clinical determinations of its efficacy. Since its approval in 2012, there have been several studies of MSM's attitudes toward PrEP and recent studies have begun to focus on correlates of PrEP uptake, given limitations of studying PrEP willingness and intentions to use PrEP. ⁴⁷ However, many of these samples of MSM trend toward older or whiter MSM, with some reporting higher levels of education and income relative to YMSM. ^{23,48 –51} As such, it remains unclear whether these data reflect the attitudes, behaviors, and experiences of YMSM, especially YMSM of color, or whether men in these samples have similar risk behavior profiles to YMSM.

Previous studies of PrEP that do involve YMSM have shown low awareness ^23,44 and moderate-to-high willingness, ^45,52 with concerns regarding accessing PrEP a commonly reported barrier. ^23,44,46 While these studies provide valuable insight into MSM's attitudes toward and use of PrEP, important questions remain unanswered for YMSM. Data on a full range of barriers and facilitators, as well as their saliency, for PrEP willingness and uptake among YMSM are lacking, as are data on the associations between sexual risk and substance use on YMSM's attitudes toward PrEP. With many YMSM seeking sexual partners through online- and smartphone-based social networking applications (hereafter referred to as GSN apps), it is imperative that this potentially high-risk population be included in future investigations. ^{53 –57}

This study explores the association between willingness to take PrEP and demographic characteristics, sexual risk, and substance use, and attitudinal factors among YMSM in California who use GSN apps. Its aim is to better understand the barriers and facilitators for PrEP willingness and uptake among a diverse sample of YMSM at risk for HIV infection, to inform multi-level intervention efforts that may improve PrEP uptake in this population.

Methods

Results

Discussion

This study examined willingness to take PrEP, and its associated facilitators and barriers, by simultaneously examining a full range of factors, including the demographic characteristics, sexual risk, and substance use behavior, and attitudes toward PrEP for a diverse group of California YMSM who use GSN apps. Previous investigations examined facilitators and barriers to PrEP uptake qualitatively; others used single-item attitudinal measures that may not fully elucidate key domains related to PrEP use. ^{23,33,44,46,64} Attitudinal factors including drug effects, perceived benefits, medical mistrust, and adherence were all significantly associated with willingness to take PrEP after adjusting for other covariates. Future efforts to educate YMSM about PrEP, and engage YMSM in PrEP screening, must pay careful attention to these factors to improve uptake within YMSM communities.

In addition to attitudes about PrEP, Hispanic/Latino ethnicity and concern for contracting HIV were both significantly positively associated with willingness to take PrEP. California leads the United States in its total number of Latino residents ⁶⁵ and Latinos make up the largest number of new HIV/AIDS cases in the state. ⁶⁶ Latino YMSM may be particularly vulnerable to HIV due to lack of health insurance, language barriers, and other cultural factors that impede their ability to negotiate safer sex. ⁶⁷ Our data suggest high PrEP willingness among Latino YMSM, indicating the need for culturally and linguistically tailored programs to encourage PrEP uptake in this population.

The relationship between concern for contracting HIV and willingness has been well documented. ^32,35,38,68 These data are consistent with the Health Belief Model, which posits that perceived susceptibility is a key antecedent to behavior change, ⁶⁹ and may indicate that messaging about PrEP is reaching some of its target audience, as those who perceive themselves at greater risk display greater willingness to take PrEP. Opportunities for YMSM to reflect on engagement in risk behaviors and encouragement to assess HIV risk may be one strategy for increasing PrEP willingness. ⁷⁰ Recent efforts to characterize motivation for PrEP use consider willingness as part of the PrEP Contemplation Stage, which is an important precursor to PrEP uptake. ²⁸

Adherence to PrEP is a common concern among MSM and YMSM. ^26,34,71 Efficacy studies demonstrate that even with suboptimal adherence, PrEP can be up to 96% effective. ¹⁶ These data must be disseminated widely to YMSM and the medical providers who serve them to allay fears that missing doses forecloses a PrEP prescription. Instead, clear and accessible information about PrEP adherence, strategies for remembering to take the medication, and guidance about what to do if a dose is missed should be highlighted. In our earlier work on PrEP uptake and adherence with YMSM, we found that, although 90% of current PrEP users reported taking their medication 6–7 times/week, difficulty in remembering to take it was one of the top reasons they discontinued it. ⁷² Other research on PrEP adherence for YMSM shows that nearly two-thirds are adherent. ⁷³ These data suggest the need for further research on barriers and facilitators to PrEP adherence among YMSM to ensure optimal outcomes for users. Future developments in PrEP, such as long-term injectable formats and on-demand PrEP, may be promising solutions to address adherence concerns among YMSM. ^{52,74 –76}

Greater medical mistrust was associated with less willingness to take PrEP, highlighting the need to address wariness with the health system among YMSM. Previous research documents medical mistrust among both racial/ethnic minority and sexual minority communities. ^77,78 For example, a study of black MSM by Eaton et al. ³⁹ showed that nearly one-fifth do not trust doctors and healthcare workers. Another study by Mutchler et al. ⁷⁹ noted high levels of misconceptions and mistrust about PrEP among black YMSM and their close friends, including skepticism about the efficacy of PrEP and fears that PrEP might cause people to develop HIV. While we did not see an interaction effect by race/ethnicity in our data, the literature on medical mistrust among black communities is robust. ^{77,80 –83} Community-based agencies focused on LGB/T health have disseminated guidelines for providers to increase cultural competence in working with sexual minority men. ⁸⁴ More work should be done on increasing PrEP knowledge and attitudes in communities of color. ⁴⁶ In addition, researchers have noted the importance of attitudes among care providers when discussing PrEP with YMSM. In a recent mixed methods study of clinicians involved in the NIH-funded Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), Mullins et al. found that most thought the CDC guidelines were compatible with their practice; however, there was variability in what they considered to be appropriate characteristics for suitable candidates. ⁸⁵ Other studies highlight that providers' willingness to prescribe PrEP is associated with PrEP knowledge ⁸⁶ and experience in treating HIV-positive people, ^87,88 suggesting that resources be devoted to PrEP training for clinicians in general, since YMSM are more likely to be seen by general practitioners than HIV specialists, ⁸⁹ and PrEP navigation for YMSM patients. ⁷⁹

Previous research indicates YMSM are concerned about PrEP's long-term side effects. ^23,68 Fatigue, nausea, and headache have been documented and YMSM should be given strategies to alleviate these symptoms and encouraged to continue the medication, as side effects often resolve with a few weeks. ⁹⁰ Literature on “seasons of risk” highlights particular times when individuals may be at an elevated risk for acquiring STIs, including HIV. ⁷⁴ Providers should be attuned to these times that may elevate HIV risk for YMSM and emphasize that PrEP does not necessarily require long-term use. Rather, YMSM, in partnership with their providers, can evaluate their use of PrEP over time during routine medical visits to ensure that decisions regarding PrEP uptake and discontinuation are based on accurate risk assessment. As new evidence regarding long-term side effects of PrEP becomes available, providers should share it with their patients.

In this study, perceived benefits of PrEP, including the belief that PrEP offered effective protection against HIV and taking PrEP would decrease worry about infection, were associated with greater willingness. Popular discourse around PrEP has sometimes promoted negative images of those who use it. For instance, PrEP users have been called “irresponsible” and “promiscuous.” ⁴⁰ This messaging can be damaging to community perceptions about the benefits of PrEP. ^41,91 In response, more can be done to increase positive associations with PrEP. Reframing PrEP users as knowledgeable, responsible men who take an active role in maintaining their health may increase positive associations with PrEP. Providing empirically based, accessible information about PrEP's efficacy can also increase knowledge of its benefits, which are associated with increased willingness to take PrEP.