PrEP use and stigma among a sample of older adults in Columbus,Ohio

Abstract

Introduction

Despite older adults (age ≥50 years) continuing to account for 1 in 6 new HIV diagnoses, the majority of research has focused on young adults. Assessing PrEP use and stigma among this understudied population is key to achieving the U.S.’s goals of Ending the HIV Epidemic, a federal initiative focusing on reducing new HIV infections by at least 90% by 2030.

Methods

Data for this analysis came from the Columbus Health Aging Project (N = 794). This study was designed to assess several domains of health among adults aged 50 years and older in Columbus, Ohio. Multiple logistic and linear regression models were used to examine the associations between sociodemographic factors and past 6-month PrEP use, PrEP stigma, and concurrent use of PrEP and other prevention methods, adjusting for known confounders.

Results

Overall, 93 (11.7%) participants reported past 6-month PrEP use. Transgender women (aOR = 6.90; 95% CI: 2.19, 21.72), cisgender gay men (aOR = 5.58; 95% CI: 2.49, 12.50), cisgender lesbians (aOR = 2.24; 95% CI: 1.05, 4.80), and those living with family members or roommates (aOR = 6.59; 95% CI: 3.49, 12.45) were each more likely to report past 6-month PrEP use relative to cisgender women, heterosexuals, and those living with a spouse/partner, respectively. Relative to cisgender women, PrEP-related stigma was lower among transgender women (β = −5.05; 95% CI: −8.44, −1.66) and higher among cisgender men (β = 1.96; 95% CI: 0.46, 3.46).

Conclusion

Future research should aim to continue developing a firm understanding of PrEP use and stigma among older adults to reduce HIV risk among this population and to understand unique needs of sub-populations of older adults.

Keywords

Older adults HIV PrEP pre-exposure prophylaxis stigma

Introduction

Overall, the rate of new HIV diagnoses in the U.S. has decreased over time to approximately 34,800 cases in 2019.¹ This decrease is likely attributable to two key factors: (1) treatment as prevention, or increases in sustained viral suppression among those diagnosed with HIV; and (2) more recently, among those undiagnosed with HIV, the approval and uptake of HIV preventative medications, such as pre-exposure prophylaxis (PrEP).² Even in light of recent decreases in the rate of new HIV diagnoses, disparities have persisted. For example, of all new HIV diagnoses in the United States, 68% occurred among men who have sex with men (MSM), 22% occurred due to heterosexual contact, 7% among persons who inject drugs, and ∼2% among transgender people.³ And within each of these groups, disparities continue: among MSM, 38% of new HIV diagnoses were among Black MSM and 33% were among Hispanic/Latino MSM; among transgender people, 93% were among transgender women; and among infections due to heterosexual contact, women accounted for 16% of new diagnoses while men accounted for only 7%.⁴ These data demonstrate strong, persistent disparities in new HIV diagnoses across all adults in the U.S., yet recent HIV research has largely focused on younger populations (16–29 years) even as older adults continue to account for 1 in 6 new HIV diagnoses.⁵

Among HIV-negative individuals, PrEP has been shown to be one of the most efficacious methods of reducing HIV infection risk. In fact, those who remain adherent to the medication as prescribed can expect up to a 99% reduction in risk of acquiring an HIV infection.^6,7 Despite these high rates of risk reduction, PrEP uptake has been slower than hoped, reaching only 25% of those eligible for PrEP nationally in 2020⁸ even with the implementation of several demonstration projects.^6,9,10 And as with new HIV diagnoses, PrEP prescription rates vary widely, particularly by race and ethnicity, with 66% of eligible White individuals fulfilling a prescription while only 9% of Black and 16% of Hispanic/Latinx individuals fulfilled prescriptions in 2020.⁸ However, there is sparse research on how PrEP is utilized by older adults. When research does include adults outside of the key demographic of 16–29 years of age, they are typically lumped into a single group despite differences in risk of HIV infection. For example, between 2014 and 2017, the proportion of individuals who experience risk of HIV infection and aware of PrEP increased 54% among those 18–29 years and 66% among those 30 and older yet no further break down of age is typically provided.¹¹ This lack of more nuanced analyses of age-related data is likely due to pertinacious assumptions^12,13 that older adults are not sexually active.

Due to this dearth of research among older adults there is a lack of understanding of participation in other HIV risk reduction practices (e.g. condom use) among those already using PrEP. This gap in the literature may be due in large part to misconceptions regarding sexual activity of older adults, namely that it is non-existent or occurs at levels low enough to not warrant further study.^12,13 Quite the opposite is, in fact, true, as both women and men remain sexually active well into their elderly years with 73% of adults aged 57–64 years, 53% of those aged 65–74 years, and 26% of those aged 75–85 years remaining sexually active.^12,13 As a result of this persistent stereotype, medical providers may be more reluctant to collect sexual activity history from older adults or to discuss sexual health practices such as condom use or, importantly, to communicate novel methods of preventing HIV acquisition, such as PrEP.¹⁴

In order to address this gap in the literature, we recruited a sample of older adults (aged ≥50 years) in Columbus, Ohio, United States. By examining sociodemographic characteristics of older adult PrEP and non-PrEP users, we can begin to gain a better understanding of patterns of use with the goal of reducing HIV risk among this population. This work will also advance our ability to achieve the US target goals for Ending the HIV Epidemic (EHE), a federal initiative which focuses on reducing new HIV infections in the U.S. by at least 90% by 2030.¹⁵ To this end, we analyzed data from a diverse cohort of older adults in order to: (1) assess sociodemographic characteristics associated with past 6-month PrEP use, (2) concurrency of PrEP use alongside other HIV and sexually transmitted infection (STI) prevention methods, and (3) differences in PrEP stigma across a variety of sociodemographic characteristics.

Methods

Study population

Data come from the cross-sectional survey, the Columbus Health Aging Project (CHAP). CHAP was designed to assess several domains of health (e.g. HIV/STI, substance use) and potential risk factors (e.g. stress, stigma) among adults aged 50 years and older in Columbus, Ohio. Recruitment occurred throughout the Columbus metropolitan area exclusively via Facebook and Instagram. Inclusion criteria included: (1) age ≥50 years; (2) residence in Columbus or surrounding suburbs; (3) access to a computer or smartphone to complete the online survey assessment; and (4) a working email address. Several methods were utilized in Qualtrics to ensure anonymous participants could only complete the survey once, including, automated prevention of multiple submissions, bot detection, RelevantID to prevent fraudulent submissions, and prevention of indexing on search engines. All participants were compensated $20 in the form of an Amazon gift card for their time. All study protocols and procedures were approved by The Ohio State University’s Institutional Review Board (2020B0394).

Demographic and other measures

Demographic information was self-reported by participants and included age, sex, gender identity, race/ethnicity, and sexual identity. Age was self-reported and operationalized categorically, similar to past research, as youngest old (50–64 years), middle old (65–74 years), and oldest old (≥75 years).¹⁶ Sex was reported as female, male, or intersex and coded as such. Self-reported sex assigned at birth and gender identity were combined to categorize individuals as cisgender women, cisgender men, transgender women, transgender men, or a different identity. Race and ethnicity were coded based on participant self-identification as American Indian/Alaska Native, Asian, Black, Hispanic/Latinx, Native Hawaiian/Other Pacific Islander, White, Multiracial, or a different race. The variable used in this analysis was operationalized as Black, White, Hispanic/Latinx, or a different racial identity (due to low endorsement of remaining categories). Sexual identity was operationalized as gay, lesbian, bisexual, heterosexual, or a different identity. Participants also reported whether or not they had any form of insurance (e.g. private, Medicare, Medicaid, etc.) at the time of the survey with the variable coded as such. Participants were also asked which situation best describes their current living situation, the variable operationalized as living alone, living with family members or roommates, living with a partner or spouse, or living in a long-term care facility. Living with family members or roommates were separately assessed and combined into a single category.

PrEP use and other sexual health measures

Consistent with past studies, PrEP use was self-reported by participants and coded as any use in the past 6-months or no use in the past 6-months.^2,17–19 Participants also reported whether they: (1) discussed PrEP with their medical provider; and (2) were recommended to use PrEP by their medical provider. Each of these variables was coded as a binary no/yes variable. PrEP stigma was measured using a previously validated 11-item scale where each item was measured using a 5-point Likert scale.²⁰ Scoring was done by summing responses across items into a single PrEP stigma score, ranging from 11 to 55 (alpha = 0.86).

Participants were also asked to self-report the use of any HIV/STI prevention methods in the past 6-months, including: condoms, withdrawal/pull-out, spermicidal foam/jelly/cream/film/suppository, diaphragm, female condom/vaginal pouches, or no methods used. The survey question was asked such that participants were able to select all that applied (not mutually exclusive) while each method was separately operationalized as a dichotomous variable.

Statistical analyses

Bivariate associations initially examined sociodemographic differences in PrEP use using chi-squared analyses, Fisher’s exact tests, and ANOVAs as appropriate. Multivariable logistic regression models were then utilized to assess the associations between sociodemographic characteristics and PrEP use. Next, multivariable linear regression models were used to examine: (1) the association between concurrent PrEP use and participation in other sexual risk reduction practices; and (2) the association between sociodemographic characteristics and the PrEP stigma scale. Individuals self-reporting as sexually inactive (n = 12) were not included in analyses regarding PrEP use but were included in analyses examining PrEP stigma. Reference categories were chosen to represent those at lowest risk or least exposed. Statistical significance was established at alpha <0.05. All analyses were performed in StataBE 17.0.

Results

Table 1 presents demographic and other variables stratified by whether or not the participant self-reported any PrEP use in the past 6-months. Overall, 172 (21.7%) participants were recommended by their medical providers to take PrEP with 87 (50.6%) reporting use following this recommendation. An additional six reported use via other means (e.g. friends) for a total of 93 (11.7%) participants reporting past 6-month PrEP use. The majority of PrEP users were youngest old age (50–64 years; n = 51, 54.8%), followed by those in the middle old age category (65–74 years; n = 41, 44.1%), and then those in the oldest old age category (≥75 years; n = 1, 1.1%). PrEP use varied widely by gender identity with cisgender men reporting the highest levels of PrEP use (n = 34, 36.6%) followed by cisgender women (n = 31, 33.0%), transgender women (n = 15, 16.1%), and those identifying as a different identity (n = 13, 14.0%). No transgender men reported PrEP use. Regarding other demographic characteristics, the majority of those reporting PrEP use in the past 6-months were White (n = 60, 64.5%), identified as gay or lesbian (n = 66, 71.0%), and were living with family members or roommates (n = 61, 65.5%). The majority of PrEP users also reported having some form of insurance (n = 89, 96.7%).

Table 1.

Demographic attributes of the Columbus Health Aging Project, 2021 (N = 794).

	Total	No PrEP use^a	PrEP use^a	p-value^b
	(n = 794)	(n = 701)	(n = 93)	p-value^b
Age, n (%)
Youngest old (50–64 Years)	454 (57.3)	403 (57.6)	51 (54.8)	0.882
Middle old (65–74 Years)	290 (41.7)	290 (41.4)	41 (44.1)
Oldest old (≥75 Years)	8 (1.0)	7 (1.0)	1 (1.1)
Sex assigned at birth, n (%)
Female	371 (49.7)	313 (47.9)	58 (63.0)	0.006
Male	375 (50.3)	341 (52.1)	34 (37.0)	0.006
Gender, n (%)
Cisgender women	330 (41.6)	299 (42.7)	31 (33.3)	<0.001
Cisgender men	360 (45.3)	326 (46.5)	34 (36.6)
Transgender women	25 (3.2)	10 (1.4)	15 (16.1)
Transgender men	27 (3.4)	27 (3.9)	0 (0.0)
Different identity	52 (6.6)	39 (5.6)	13 (14.0)
Race and ethnicity, n (%)
Black	297 (37.4)	271 (38.7)	26 (28.0)	0.034
White	411 (51.8)	351 (50.1)	60 (64.5)
Hispanic/Latinx	49 (6.2)	47 (6.7)	2 (2.2)
Multiracial or different race	37 (4.7)	32 (4.6)	5 (5.4)
Sexual identity, n (%)
Gay	214 (26.7)	184 (26.3)	30 (32.3)	<0.001
Lesbian	180 (22.7)	144 (20.5)	36 (38.7)
Bisexual	52 (6.6)	48 (6.9)	4 (4.3)
Heterosexual	317 (39.9)	299 (42.7)	18 (19.4)
Different identity	31 (3.9)	26 (3.7)	5 (5.4)
Living situation, n (%)
With spouse/Partner	326 (40.6)	308 (43.4)	18 (19.4)	<0.001
Alone	169 (21.1)	156 (22.0)	13 (14.0)
With family/Roommate	269 (33.5)	208 (29.3)	61 (65.6)
Long-term care	14 (1.7)	14 (2.0)	0 (0.0)
Other	25 (3.1)	24 (3.4)	1 (1.1)
Any form of insurance, n (%)	610 (77.7)	521 (75.2)	89 (96.7)	<0.001
Discussed PrEP with medical provider, n (%)	232 (61.1)	85 (29.8)	87 (95.6)	<0.001
Recommended PrEP by medical provier, n (%)	172 (45.7)	85 (29.8)	87 (95.6)	<0.001
PrEP stigma Scale, mean (SD.)	34.9 (7.9)	35.0 (7.9)	34.7 (8.1)	0.709

^aIn the past 6 months.

^bCalculated via either chi-square analyses or Student’s t-test, as appropriate.

Table 2 presents multivariable regression models assessing the relationships between past 6-month PrEP use and select sociodemographic characteristics among our sample of older adults ≥50 years (n = 734). We observed that, compared to cisgender women, transgender women (aOR = 6.90; 95% CI: 2.19, 21.72) were more likely to report PrEP use. Gay participants (aOR = 5.58; 95% CI: 2.49, 12.50), lesbian participants (aOR = 2.24; 95% CI: 1.05, 4.80), those living with family or roommates (aOR = 6.59; 95% CI: 3.49, 12.45), and those with insurance of any form (aOR = 19.56; 95% CI: 5.31, 72.12) were also more likely to use PrEP relative to heterosexuals, those living with a spouse or partner, and those without insurance, respectively. Conversely, Black participants were less likely than White participants to report PrEP use (aOR = 0.53; 95% CI: 0.30, 0.95).

Table 2.

Multivariable regression models assessing past 6-month PrEP use and select sociodemographic variables, 2021 (n = 734).

Characteristic	OR (95% CI)
Age
Youngest Old (50–64 Years)	Ref
Middle Old (65–74 Years)	1.00 (0.59, 1.71)
Oldest Old (≥75 Years)	0.93 (0.09, 9.89)
Gender
Cisgender women	Ref
Cisgender men	0.53 (0.24, 1.19)
Transgender women	6.90*** (2.19, 21.72)
Transgender men	^a
Different identity	1.75 (0.70, 4.36)
Sexual identity
Heterosexual	Ref
Gay	5.58*** (2.49, 12.50)
Lesbian	2.24* (1.05, 4.80)
Bisexual	2.17 (0.55, 8.52)
Different identity	1.80 (0.50, 6.57)
Race/Ethnicity
White	Ref
Black	0.53* (0.30, 0.95)
Hispanic/Latinx	0.38 (0.08, 1.77)
Multiracial or different race	1.33 (0.40, 4.40)
Living situation
With spouse/Partner	Ref
Alone	1.34 (0.61, 2.98)
With family/Roommate	6.59*** (3.49, 12.45)
Long-term care	^a
Other	1.43 (0.17, 12.34)
Insurance status
No insurance	Ref
Insurance of any form	19.56*** (5.31, 72.12)

*p ≤ 0.05; **p ≤ 0.01; **p ≤ 0.001.

^aCells empty.

Table 3 utilized adjusted logistic regression models to examine concurrent use of PrEP and other methods of HIV transmission prevention, adjusting for sociodemographic characteristics. Those reporting withdrawal or pull-out methods (aOR = 3.48; 95% CI: 1.87, 6.47), use of spermicidal foam or jellies (aOR = 2.52; 95% CI: 1.14, 5.60), or use of female condom or vaginal pouches (aOR = 11.16; 95% CI: 5.08, 24.50) were each significantly more likely to report concurrent PrEP use relative to those who did not use these methods. Participants reporting no use of any other HIV prevention method, relative to those reporting use of at least one other prevention method, were also significantly less likely to report using PrEP (aOR = 0.02; 95% CI: 0.002, 0.14). Those reporting use of condoms or diaphragms were no more or less likely to concurrently use PrEP.

Table 3.

Multivariable logistic regression models assessing concurrent use of other prevention methods a PrEP, 2021 (n = 700).

	Past 6-month PrEP use^a
Other prevention methods	Assigned female at birth
Condoms	1.19 (0.70, 2.03)
Withdrawal/Pull-out	3.48*** (1.87, 6.47)
Spermicidal foam/jelly/etc	2.52* (1.14, 5.60)
Diaphragm	3.42 (0.61, 19.37)
Female condom or vaginal pouch	11.16*** (5.08, 24.50)
None	0.02*** (0.002, 0.14)

^*p ≤ 0.05; **p ≤ 0.01; **p ≤ 0.001.

^aRelative to no PrEP use in the past 6-months; adjusted for age category, gender, sexual identity, race and ethnicity, and insurance status.

Table 4 reports results from multivariable linear regression models assessing the relationships between PrEP stigma and select sociodemographic characteristics (n = 743). Those in the oldest old age category (≥75 years) relative to those in the middle age category (60–64 years) reported higher levels of PrEP stigma (β = 9.16; 95% CI: 3.80, 14.53). Compared to cisgender women, both transgender women (β = −5.05; 95% CI: −8.44, −1.66) and those identifying as a different identity (β = −2.67; 95% CI: −5.07, −0.27) reported lower PrEP stigma while cisgender men reported higher PrEP stigma (β = 1.96; 95% CI: 0.46, 3.46). Compared to heterosexuals, lesbians reported significantly higher PrEP stigma (β = −1.68; 95% CI: 0.03, 3.32). Regarding race and ethnicity, compared to White participants, Hispanic/Latinx participants reported greater PrEP stigma (β = 4.93; 95% CI: 2.60, 7.36) while those identifying as Multiracial or as a different race/ethnicity reported lower PrEP stigma (β = −3.87; 95% CI: −6.65, −1.10). Those living with family members or roommates reported greater PrEP stigma compared to those living with a spouse or partner (β = 1.54; 95% CI: 0.17, 2.91).

Table 4.

Multivariable linear regression model assessing PrEP stigma and select sociodemographic variables, 2021 (n = 743).

Characteristic	All participants
Age
Youngest old (50–64 Years)	Ref
Middle old (65–74 Years)	−0.60 (−1.76, 0.57)
Oldest old (≥75 Years)	9.16*** (3.80, 14.53)
Gender
Cisgender women	Ref
Cisgender men	1.96** (0.46, 3.46)
Transgender women	−5.05** (−8.44, −1.66)
Transgender men	−1.12 (−4.82, 2.57)
Different identity	−2.67* (−5.07, −0.27)
Sexual identity
Heterosexual	Ref
Gay	0.42 (−1.15, 1.99)
Lesbian	1.68* (0.03, 3.32)
Bisexual	2.43 (−0.26, 5.13)
different identity	−2.43 (−5.44, 0.59)
Race/Ethnicity
White	Ref
Black	1.24 (−0.03, 2.52)
Hispanic/Latinx	4.93*** (2.50, 7.36)
Multiracial or different identity	−3.87** (−6.65, −1.10)
Living situation
With spouse/Partner	Ref
Alone	−0.02 (−1.52, 1.49)
With family/Roommate	1.54* (0.17, 2.91)
Long-term care	3.00 (−1.85, 7.84)
Other	0.84 (−3.12, 4.80)
Insurance status
No insurance	Ref
Insurance of any form	0.97 (−0.46, 2.39)
PrEP use^a
No	Ref
Yes	0.61 (−1.07, 2.28)

^*p ≤ 0.05; **p ≤ 0.01; **p ≤ 0.001.

^aIn the past 6-months.

Discussion

We examined past 6-month PrEP use in a diverse sample of older adults (≥50 years) in Columbus, Ohio. We noted broad differences based on sociodemographic characteristics with 11.7% of all participants reporting past 6-month PrEP use while 50.6% of participants who had been recommended PrEP by their medical provider reported past 6-month use. Differences were observed based on sex assigned at birth and gender identity influenced by a high amount of PrEP use among transgender women in our study. We also observed that gay or lesbian participants, those living with family members or roommates, and those with insurance of any form were each more likely to report past 6-month PrEP use while Black participants were less likely to report use than White participants. Participants reported concurrent use of PrEP alongside other prevention methods including withdrawal or pull-out, spermicidal foam/jelly, and female condoms or vaginal pouches, however, those reporting no use of any other prevention methods were also less likely to use PrEP. Broad differences also existed with regards to PrEP stigma among our sample of older adults with cisgender men, Hispanic/Latinx participants, and those living with family members or roommates reporting the highest levels of PrEP stigma. Taken together, these results suggest broad differences in PrEP usage and stigma patterns among older adults, a population need of further research to better target HIV interventions at specific sub-groups rather than assuming a homogenous population as is often done with older adults.

The majority of research on PrEP has examined use among young adults (aged 16–29 years) given their elevated experiences of risk of HIV acquisition,²¹ however, this belies the fact that older adults remain sexually active^12,13 and that 1 in 6 new HIV diagnoses are among those 50 years and older.⁵ Our data note two key differences between older adults and other key populations of interest. First, although racial disparities continue to persist, recent work suggests that gains have been made in parity of PrEP use between White individuals and persons of color, particularly among Black individuals with some data suggesting nearly double the rate of use between 2016 and 2020 among all adults.^2,22,23 In our sample, however, we continue to observe strong disparities in use with Black older adults half as likely to report past 6-month PrEP use relative to White older adults, findings which may suggest more focused PrEP awareness and education programs are needed among the population of older adults. Second, the latest data by the CDC reports that, overall, only 25% of those eligible for PrEP fulfilled prescriptions as recommended by their provider,²⁴ however, our data here suggest this may be much higher among older adults with 50.6% of our sample reporting PrEP use following medical provider recommendations. These results suggest that although more concentrated PrEP awareness is needed among sub-populations of older adults, when provided a recommendation older adults may be more likely than other populations to uptake PrEP use. Future research should aim to better understand patterns and consistency of PrEP use among this population as experiences of HIV risk are persistent among older adults.

Even in light of PrEP use, other forms of risk reduction (e.g. diaphragms, female condoms) may continue to be used among older adults given their prior knowledge and past experience of older methods of HIV and STI prevention, particularly as PrEP does not protect against STIs. Reasons for continued use of older methods may be a reluctance among older populations to discuss their sexual history with their medical provider or may be due to a lack of equitable access to healthcare, both of which may result in reduced knowledge regarding newer HIV prevention methods such as PrEP.^12,25–27 Here, we observed that those using other methods of prevention including withdrawal or pull-out, spermicidal foams and jellies, and female condoms or vaginal pouches are more likely to report concurrent use of PrEP suggesting that at least some are informed regarding newer methods of HIV prevention. This concurrent use is also particularly interesting as the majority of our sample, due to their age, are unlikely to be concerned about risk of pregnancy and may instead be attempting to further reduce experiences of HIV or STI risk alongside their PrEP use. On the other end of the spectrum, however, are vastly lower odds of PrEP use among those who report no other method of prevention use suggesting either lack of concern or knowledge regarding prevention methods. Unfortunately, our data are lacking in additional survey measures which may disentangle these disparate patterns of PrEP and other prevention method use, patterns which should be explored by future research in order to understand experiences of both HIV and STI risk among older adults.

Stigma related to PrEP use is a key barrier to uptake and consistent use of the medication as prescribed.²⁸ Past research has noted some of these key barriers include community-based “slut-shaming,” the shaming of individuals for their sexual behaviors or practices, and the equation of a sexual minority identity with HIV risk or promiscuity by medical providers,^28,29 yet little to no work has examined PrEP-related stigma among older adults. A sample of young adults in Chicago using the same PrEP stigma scale as our study noted that White participants reported lower levels of PrEP-related stigma relative to Black and Hispanic/Latinx participants.²⁰ In our sample of older adults we continue to observe lower stigma among White participants compared to Hispanic/Latinx participants but we found no difference between White and Black participants, findings which may be attributable to either generational differences in attitudes related to HIV prevention³⁰ or, more simply, better communication regarding the use of PrEP in the intervening 5 year period between studies. We also noted lower PrEP-associated stigma and higher rates of PrEP use among transgender women in our sample, an encouraging finding given their experiences of risk of HIV acquisition.^31,32 An interesting finding not previously reported in the literature was also observed, namely, relative to those living with a spouse or partner, those living with family members or roommates have elevated PrEP stigma but also are more likely to report past 6-month PrEP use. Our hypothesis here is that this may be a more direct form of community-based “slut-shaming” by one’s family or roommates (e.g. the need to hide medications), individuals whose opinions often matter more than those of the broader community. Perhaps the result here is more family-based PrEP stigma, even if that family is chosen as is often the case among sexual and gender minority populations.³³ Or, alternatively, these are lived experiences of stigma among those who take PrEP rather than imagined experiences of stigma among those considering or avoiding uptake of PrEP. To continue to reduce PrEP-related stigma and subsequently increase rates of PrEP use, future research should more closely examine the impact of the opinions of close ties on personal perception of PrEP.

Our study should be considered in light of its limitations. First, data are cross-sectional and thus limited in not being able to examine causal relationships. Second, the data rely on self-report measures, including PrEP use and are subject to social desirability biases in reporting its use. Next, this sample is limited in geography so results may only reflect the local population of Columbus rather than being representative of the entire population of older adults. We also did not assess specific reasons for concurrent prevention method use which would have helped to clarify our findings. And despite our efforts to recruit a sample that was diverse in sex and gender, we were limited in our analyses by having too few intersex or transgender men reporting PrEP use to include here.

Even in light of these limitations, we observed a novel set of findings among a diverse sample of older adults. First, we noted that transgender women, cisgender gay men, and those living with family members or roommates were each more likely to use report past 6-month PrEP use relative to cisgender women, heterosexuals, and those living with a spouse or partner, respectively. We also observed, alongside PrEP, concurrent use of various prevention methods including withdrawal or pull-out, spermicidal foams and jellies, and female condoms or vaginal pouches. Finally, we observed lower PrEP-related stigma among populations who experience the highest risk of HIV acquisition while also observing novel, elevated PrEP stigma among those living with family members or roommates. Future research should aim to continue to develop a better understanding of PrEP use and stigma among older adults to further reduce HIV risk among this under-studied population and to understand unique needs of sub-populations of older adults.

Footnotes

Authors contributions

EM led design of the survey and collection of the data, conceived of the paper concept, led statistical analyses, and led writing of the paper. CD assisted with statistical analyses and writing of the paper. JR and BF assisted with writing of the paper and critical review of the methods used.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors have no conflicts to declare.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Drug Abuse (K01DA046716 and K08DA045575).

Ethics and consent to participate

Informed consent was obtained from all participants and all study protocols and procedures were approved by The Ohio State University’s Institutional Review Board (2020B0394).

Code availability

Standard software (Stata) and code were used in this publication, no custom code was necessary to utilized to complete these analyses.

ORCID iD

Ethan Morgan

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