Masculine ideology and Black men who have sex with men’s interest in HIV pre-exposure prophylaxis (PrEP)

Abstract

We examined how traditional masculinity and stigma surrounding HIV pre-exposure prophylaxis (PrEP) affect PrEP interest among Black men who have sex with men (BMSM). One hundred twenty-three men attending a Black Gay Pride event completed measures assessing traditional masculinity, PrEP stigma, and PrEP interest along with two behavioral measures of interest in PrEP. Results demonstrated that avoidance of femininity directly related to interest in PrEP and indirectly through conformity to heterosexual self-presentation. Further, PrEP stigma differentially moderated both of these relationships. Interventions designed to improve engagement of PrEP for BMSM should be attentive to traditional masculinity as a barrier.

Keywords

Black men who have sex with men HIV masculinity ideology pre-exposure prophylaxis stigma

Introduction

HIV prevalence among Black men who have sex with men (BMSM) in the United States is an estimated 32%, which is four times higher than among White MSM (Eaton et al., 2018; Koblin, 2012; Rosenberg et al., 2014; Sullivan et al., 2009). If current epidemiological trends continue, one mathematical model suggests that as many as 60% of BMSM may be living with HIV by the age of 40 (Matthews et al., 2016). Pre-exposure prophylaxis (PrEP) substantially reduces the risk of HIV acquisition and provides nearly complete protection when taken daily (Baeten et al., 2012; Grant et al., 2010). However, interest and uptake of PrEP have varied among MSM, with particularly low levels of PrEP uptake observed among BMSM (Elopre et al., 2017; Snowden et al., 2017). While awareness and interest in PrEP has slowly increased, relatively few BMSM are accessing and using PrEP (Kanny et., 2019). Studies examining PrEP uptake in BMSM suggest a myriad of intrapersonal, interpersonal, institutional, and structural barriers (Eaton et al., 2017a; Ojikutu et al., 2018; Smith et al., 2012).

In qualitative research, traditional masculine ideology has emerged as a consistent theme related to HIV preventation behaviors among BMSM ( Fields et al., 2012, 2015; Malebranche et al., 2009; Murray et al., 2018), including PrEP use (Garcia et al., 2016). The theory of gender and health (Courtenay, 2000) provides a framework for examining traditional masculinity as a potential influence on PrEP use among BMSM. From this perspective, engaging in health-related behaviors is considered an indication of femininity, while performing risk behaviors, including those that place one’s health at risk, are instrumental in expressing masculinity (Courtenay, 2000). Prior studies show that avoiding femininity is related to a lack of engagement in several health-related behaviors among Black men (Campbell et al., 2012; Hawkins et al., 2017; Liburd et al., 2007). Thus, interest in and/or use of PrEP may be influenced by a desire to avoid being perceived as feminine among BMSM. Because anti-femininity is central to traditional masculinity and privileges heterosexuality, BMSM who endorse avoiding femininity may internalize the need for others to perceive them as heterosexual regardless of sexual preference. Parent et al. (2012) found that among MSM, frequency of HIV testing inversely relates to conformity to the masculine role norm of heterosexual self-presentation. Specifically, MSM higher in heterosexual self-presentation are less likely to test for HIV. Because perceptions of PrEP are linked to homosexuality (Garcia et al., 2016), heterosexual self-presentation may serve as a similar barrier to PrEP engagement.

Further, because BMSM who do not openly identify as a sexual minority may anticipate that using PrEP will expose their same-sex sexual behavior, concerns that PrEP will inadvertently disclose their sexual preference also may impact interest in PrEP. Research shows that efforts to hide a concealable stigmatized identity, such as one’s sexual preference, can influence health-related decisions leading to risk-taking and poor health outcomes (Quinn and Earnshaw, 2011; Quinn et al., 2017). Previous studies suggest that poor uptake of PrEP among some BMSM is related to the perception that PrEP use is an indication that a person is gay (Garcia et al., 2016; Ojikutu et al., 2018; Smith et al., 2012).

The present study examined the role of traditional masculinity in PrEP interest among BMSM. To our knowledge, this is the first study to assess the interactive influence of anti-femininity ideologies and stigma on PrEP interest. Using the conceptual model shown in Figure 1, the present study examined how masculinity ideology and PrEP stigma influence interest in PrEP uptake among BMSM. We hypothesized (1) that greater avoidance of femininity would relate to lower PrEP interest, (2) that conformity to the gender norm of heterosexual self-presentation would mediate this relationship, and (3) that anticipating sexual minority stigma through PrEP use would moderate this relationship both directly and indirectly. Specifically, we hypothesized that endorsing avoiding femininity will relate to greater conformity of heterosexual self-presentation. In turn, greater heterosexual self-presentation will relate to less interest in PrEP. Further, stigma will moderate both the direct and indirect effects such that those holding higher levels of anticipated sexual minority stigma will demonstrate the least interest in using PrEP.

Figure 1.

Moderated mediation model predicting PrEP interest from avoidance of femininity, mediated by heterosexual self-presentation and moderated by PrEP stigma.

Method

Participants and setting

Participants were attendees of the 2017 Black Pride Festival in Atlanta, GA, aged 18 to 64 (M = 30.9, SD = 9.88). The initial sample (n = 301) consisted of 226 men (75%) who identified as gay/same gender loving, 49 who identified as bisexual (16%), 12 who identified as heterosexual (4%), and 13 who identified as other (4%). We excluded men who were HIV positive (n = 71), as well as those who had not engaged in sex with another man in the past 6 months (n = 43), were currently using PrEP (n = 49), or who reported a race/ethnicity other than Black (n = 15). The final sample consisted of 123 sexually active, self-reported HIV-negative BMSM not currently using PrEP.

Measures

Demographic and health characteristics

Participants reported their age, race/ethnicity, sexual preference, income, and number of years of education completed. Participants reported number of times they engaged in anal intercourse as the penetrative and/or receptive partner, with and without condoms in the past 6 months, and number of male sexual partners with whom they had engaged in each behavior. Frequency of previous HIV testing and results of the most recent HIV test were assessed. Participants reported their awareness, consideration of use, and prior use of PrEP to three questions with Yes/No responses. We examined the use of marijuana, crack/cocaine, methamphetamine, and/or non-prescription drugs over the previous six months. Alcohol use was measured with the three-item consumption subscale of the Alcohol Use Disorders Identification Test (AUDIT-C; Maisto et al., 2000), which reflects frequency and quantity of alcohol consumption. AUDIT-C items were assessed on a 5-point scale (1 = Never; 5 = Daily or almost daily). Responses were averaged with higher scores indicating greater frequency and quantity of alcohol use (α = 0.76)

Sexual preference openness

Participants completed the Outness Inventory (OI; Mohr and Fassinger, 2000) an 11-item scale that assesses the degree of openness ranging from 1 (person definitely does not know about your sexual orientation status) to 7 (person definitely knows about your sexual orientation status, and it is openly talked about). Responses were averaged across items with higher scores indicating a greater degree of openness (α = 0.91).

Avoidance of femininity

The Male Role Norms Inventory-Short form (MRNI-SF; Levant et al., 2013) assessed the overall endorsement that men should avoid femininity. The avoidance of femininity subscale consists of three items, such as “Men should watch football games instead of soap operas.” Responses ranged from 1 (strongly disagree) to 6 (strongly agree) and were averaged such that higher scores indicated greater endorsement of avoidance of femininity (α = 0.84).

Heterosexual self-presentation

The Conformity to Masculine Norms Inventory-46 (CMNI-46; Parent and Moradi, 2009) examined the degree to which men conformed to the masculine gender norm of heterosexual self-presentation. The subscale contains six items that assess the importance placed on not being perceived as gay. An example item includes, “I would be furious if someone thought I was gay.” Responses were provided on a 4-point scale, 0 (strongly disagree) to 3 (strongly agree). Items were averaged with higher scores indicating greater conformity to the norm of heterosexual self-presentation (α = 0.70).

PrEP stigma

To assess anticipated stigma regarding PrEP, five modified items from the HIV Stigma Scale (Berger et al., 2001) were used. Items were adapted to assess perceptions of how others would treat one if they used PrEP. An example item includes, “If I used PrEP, I would work hard to keep it a secret.” An additional item created by the researchers was included, “If I used PrEP, people would automatically think I was gay.” Responses were provided on a 4-point scale 0 (strongly disagree) to 3 (strongly agree). Averaged across items, higher scores indicated greater anticipated stigma of PrEP (α = 0.86). We also performed a principal components factor analysis with varimax rotation. Inspection of the scree plot, component matrix, and Eigenvalues indicated that the items converged into one factor. An Eigenvalue of 3.80 accounted for 63.4% of the variance for the factor.

PrEP interest

As the key outcome variable, we constructed a composite variable of PrEP interest using Bartlett factor scores (Mulaik, 2009). The Bartlett approach utilizes factors scores from a principal components factor analysis providing unbiased estimates reflecting a more accurate index of cases on a latent continuum in a population (DiStefano et al., 2009). The composite PrEP interest variable consisted of self-reported interest and two behavioral indicators of interest. Specifically, after a brief explanation of what PrEP is, participants responded to an interest item “How interested are you in taking PrEP?” on a 4-point rating scale 0 (not at all interested) to 3 (very interested). We then provided participants with two opportunities to request more information about PrEP: (a) requesting an informational brochure regarding PrEP developed by the CDC (Centers for Disease Control, 2016) and/or (b) a list of local PrEP providers within the greater Atlanta metro area. To compute factor scores a principal components factor analysis with varimax rotation was performed with the three measures of interest. Inspection of the scree plot, component matrix, and Eigenvalues indicated the items converged into one factor with an Eigenvalue of 1.99 accounting for 66.5% of the variance. The resulting Bartlett factor scores served as the composite variable of PrEP interest.

Procedure

Participant recruitment occurred during the 2017 Atlanta, GA Black Pride Festival. A research team member approached men attending the event as they walked through the event using intercept survey procedures. Approximately seventy percent of those approached agreed to participate and complete the survey. Before completing the survey, participants received an institutional review board (IRB) approved information sheet detailing the procedures, ensuring anonymity, and providing participants with contact information for research-related questions or concerns. Upon completing the survey, participants had the option of taking a CDC PrEP brochure as well as a list of local PrEP providers. Participants were compensated $5 for their participation. Staff members collecting completed surveys provided compensation and any requested informational items. The University of Connecticut IRB approved all procedures.

Data analysis

We performed descriptive analyses for socio-demographic characteristics using means for continuous variables and frequencies for categorical variables. We also conducted a median split of the endorsement of avoidance of femininity to examine demographic characteristics among men who strongly internalized the ideology versus those who do not. Next, we conducted zero-order correlations to examine bivariate relationships at p < 0.10 among the variables of interest. A moderated mediation model tested the main study hypotheses defining significance as p < 0.05. The model examined the influence of avoidance of femininity on PrEP interest with conformity to heterosexual self-presentation as a mediator and PrEP stigma as a moderator using Hayes’ PROCESS macro (model 15) in SPSS (Hayes, 2013). Hayes’ model 15 specifies moderated mediation and a test of conditional direct effects. Specifically, the model examined second stage moderation testing whether PrEP stigma moderated the second (b) path of the indirect effect, as well as the direct effect of avoidance of femininity on PrEP interest. Three covariates (participant age, sexual preference openness, and frequency of previous HIV testing) were included in the model. We probed for significance of conditional effects at the 16th, 50th, and 84th percentiles. Bootstrap samples for bias-corrected confidence intervals (CI) were set at 10,000. SPSS statistical software version 24 was used to conduct all statistical analyses.

Results

Socio-demographic characteristics

Participants reported an average of 14.6 (SD = 2.06) years of education, equivalent to some college, 2.45 (SD = 1.92) condomless anal intercourse acts in the past 6 months, and 2.36 (SD = 1.45) HIV tests over the past 12 months. Awareness of PrEP was high (88%), and 65% reported having considered using PrEP in the past, however previous PrEP use was low (5%). The only substance use reported by a majority of the sample was alcohol (92%). The mean AUDIT-C subscale score across the sample was 1.55 (SD = 0.85), suggesting the frequency and quantity of alcohol use was low. Table 1 shows socio-demographic characteristics for the sample by endorsement of femininity. For descriptive purposes we performed a median split to separate participants into high and low endorsement groups (MDN = 2, range = 1–6). Twenty-eight participants who scored at the median were excluded (M low endorsement = 1.12; M high endorsement = 3.32). BMSM who reported a higher level of endorsing the belief that men should avoid femininity were significantly more likely to conform to the gender norm of heterosexual self-presentation and reported greater anticipation of experiencing sexual minority stigma by using PrEP. The only demographic characteristic showing a significant difference among groups was income, with more men expressing low endorsement reporting earning an income.

Table 1.

Demographic and behavioral characteristics.

Characteristics	Avoidance of femininity
	Low endorsementn = 53N (%) / M (SD)	High endorsementn = 42N (%) / M (SD)	t / X²
Age	28.5 (8.5)	29.6 ( 8.8)	−0.65
Education in years	14.8 (2.1)	14.1 (2.1)	1.58
Income			5.65*
<30,000	17^A (33%)	24^B (57%)
⩾30,000	35^A (67%)	18^B (43%)
Degree of sexual preference openness	4.51 (1.94)	3.80 (1.91)	1.78⁺
HIV testing frequency	2.3 (1.2)	2.4 (1.5)	−0.28
Condomless anal intercourse	2.8 (2.8)	2.2 (1.0)	1.16
Alcohol use	1.50 (0.98)	1.65 (0.83)	−0.80
Marijuana use	31 (59%)	22 (54%)	0.22
Crack/cocaine use	3 (6%)	3 (7%)	0.09
Meth	0 (0%)	2 (5%)	2.64
Non-prescription drug use	1 (2%)	2 (5%)	0.71
Heterosexual self-presentation	0.63 (0.59)	1.16 (0.51)	−4.68***
PrEP stigma	0.34 (0.48)	0.78 (0.65)	−3.59**
Outcome variable

p < 0.10; *p < 0.05; **p < 0.01.;***p < 0.001. ^A,Bdiffer significantly at p = 0.05.

Zero-order correlations of model constructs

Table 2 provides zero-order correlations, means, standard deviations, and minimum and maximum scores of the moderated mediation model variables. As expected, avoidance of femininity demonstrated significant positive relationships with heterosexual self-presentation (r = 0.45, p < 0.001), and PrEP stigma (r = 0.31, p = 0.001). Heterosexual self-presentation evidenced a significant negative relationship with the degree of openness of sexual preference (r = −0.28, p = 0.002), and a significant positive relationship with PrEP stigma (r = 0.42, p < 0.001). Interest in PrEP demonstrated marginally significant relations to heterosexual self-presentation (r = 0.17, p = 0.08), PrEP stigma (r = 0.18, p = 0.06) and frequency of HIV testing (r = 0.19, p = 0.05). Avoidance of femininity was not correlated with PrEP interest.

Table 2.

Correlations, means, and standard deviations of model constructs.

Variable	PrEPInterest	Avoidance of femininity	Heterosexual self-presentation	PrEP Stigma	Sexual preference openness	Frequency of HIV testing
PrEP interest	1	0.09	0.17⁺	0.18⁺	0.09	0.19⁺
Avoidance of femininity		1	0.45***	0.31**	−0.17⁺	0.04
Heterosexual self-presentation			1	0.42***	−0.28**	0.06
Stigma				1	−0.11	0.01
Sexual preference openness					1	0.08
Frequency of HIV testing						1
Variable	Mean	S.D.	Min	Max
Avoidance of femininity	2.07	1.13	1.00	6.00
Heterosexual self-presentation	0.89	0.59	0.00	2.33
PrEP Stigma	0.57	0.61	0.00	2.33

p < 0.10; *p < 0.05; **p < 0.01; ***p < 0.001. Min: Minimum score; Max: Maximum score.

Moderated mediation model

Table 3 and Figure 2 show the results of conditional process modeling examining the relationship between traditional masculinity, PrEP stigma, and PrEP interest. Greater endorsement of avoidance of femininity related to less interest in PrEP, b = −0.35, SE = 0.14, p = 0.02 supporting our first hypothesis regarding the direct relation between avoidance of femininity and PrEP interest. This relationship was qualified by an interaction with PrEP stigma b = 0.61, SE = 0.17, p < 0.001, and we found partial support for our third hypothesis by probing the interaction at the 16th, 64th, and 84th percentile. Among men low in avoidance of femininity, holding low levels of stigma related to greater interest in PrEP, whereas holding higher levels of stigma related to lower interest in PrEP. Unexpectedly, among men high in avoidance of femininity, holding low levels of stigma related to lower interest in PrEP, whereas holding higher levels of stigma related to greater interest in PrEP (see Figure 3). We also found partial support for our second hypothesis. Examining the mediating role of heterosexual self-presentation demonstrated an inconsistent indirect relationship between endorsing avoidance of femininity and interest in PrEP. Here avoidance of femininity related to conformity to heterosexual self-presentation b = 0.20, SE = 0.05, p < 0.001 as predicted; however contrary to our prediction, heterosexual self-presentation related to increased interest in PrEP b = 0.97, SE = 0.28, p = 0.002. This finding was qualified by an interaction with PrEP stigma b = −0.97, SE = 0.35, p < 0.01. Figure 4 provides a visual representation of the interaction of heterosexual self-presentation and PrEP stigma with a negative conditional indirect effect (−0.0.20, SE = 0.10) 95% CI [−0.41, −0.005]. Probing the interaction at the 16th, 64th, and 84th percentile, we found as predicted, that as stigma increased among men reporting higher heterosexual self-presentation, interest in PrEP decreased. Unexpectedly, those low in heterosexual self-presentation and low in stigma demonstrated significantly less interest in PrEP.

Table 3.

Moderated mediation analysis of PrEP interest among BMSM.

Outcome: Heterosexual self-presentation
Predictors		b	SE	t	LLCI	ULCI
(intercept)		1.12	0.26	4.33***	0.61	1.64
Avoidance of femininity		0.20	0.05	4.03***	0.10	0.30
Age		−0.01	0.01	−1.06	−0.02	0.01
Sexual preference openness		−0.07	0.03	−2.54*	−0.13	−0.02
Frequency of HIV testing		0.02	0.04	0.67	−0.05	0.09
Outcome: PrEP interest
Predictors		b	SE	t	LLCI	ULCI
(intercept)		−1.14	0.51	−2.23*	−2.16	−0.12
Avoidance of femininity		−0.35	0.14	−2.44*	−0.63	−0.06
Heterosexual self-presentation		0.97	0.28	3.41**	0.41	1.54
PrEP stigma		0.27	0.35	0.78	−0.42	0.97
Avoidance of femininity × PrEP stigma		0.61	0.17	3.62***	0.28	0.95
Heterosexual self-presentation × PrEP stigma		−0.97	0.35	−2.65**	−1.69	−0.24
Age		−0.001	0.01	−0.07	−0.03	0.02
Sexual preference openness		0.07	0.05	1.34	−0.03	0.17
Frequency of HIV testing		0.15	0.06	2.29*	0.02	0.28
Conditional direct effects of avoidance of femininity on PrEP interest
Stigma (percentile)		b	SE	t	LLCI	ULCI
16th	0.00	−0.35	0.14	−2.44*	−0.63	−0.06
50th	0.33	−0.14	0.11	−1.30	−0.36	0.07
84th	1.17	0.37	0.14	2.68**	0.10	0.65
Conditional indirect effects of avoidance of femininity on PrEP interest
Stigma (percentile)			b	SE	LLCI	ULCI
Hetero	16th	0.00	0.20	0.08	0.05	0.38
Hetero	50th	0.33	0.13	0.06	0.03	0.27
Hetero	84th	1.17	−0.03	0.07	−0.17	0.13
Index of moderated mediation
		Index	SE	LLCI	ULCI
Stigma		−0.20	0.10	−0.41	−0.005

Notes. R² = 0.22, F (8, 93) = 3.32, p < 0.01; *p < 0.05; **p < 0.01; ***p < 0.001. b: unstandardized coefficient; LLCI: Lower level confidence interval; ULCI: upper level confidence interval. Conditional indirect effect confidence intervals in bold do not encompass zero.

Figure 2.

Statistical model of the present study.

Figure 3.

Relation between anticipated PrEP stigma and PrEP interest at different levels of avoidance of femininity.

Figure 4.

Relation between anticipated PrEP stigma and PrEP interest at different levels heterosexual self-presentation.

Discussion

To our knowledge, the present study is the first to examine the interactive influence of masculinity and anticipated PrEP stigma on PrEP interest. Results supported our hypothesis that greater avoidance of femininity would relate to lower PrEP interest and there was partial support for our hypothesis that anticipating sexual minority stigma through PrEP use would moderate the relationship between avoidance of femininity and PrEP interest. However, our results are tempered by two substantial unexpected findings. First, contrary to our expectation, heterosexual self-presentation positively mediated the relationship between avoiding femininity and PrEP interest. Second, anticipated stigma produced an unexpected inverse effect on the direct relationship between avoiding femininity and PrEP interest. The relationships demonstrated in the present study suggest that expressing traditional masculinity may lead to distancing from behaviors associated with femininity, such as a preventive health behavior in general and PrEP for HIV in particular. However, in some cases, aspects of masculinity, such as presenting oneself as heterosexual socially, may improve engagement in PrEP. Further, holding stigmatized beliefs regarding PrEP may indicate boundary conditions of these effects.

Because health care engagement is considered a feminine behavior (Courtenay, 2000), men who endorse and internalized normative masculinity may be hesitant to engage in HIV prevention strategies that require them to interact with the health care system. This is because some men may fear that doing so will result in a loss of their manhood (Lichtenstein, 2004; Vandello et al., 2008). Further, racial minority men, as well as men who engage in same-sex sexual behaviors, are more reluctant to engage in preventive behaviors than racial majority men or those who do not engage in same-sex sexual behavior (Vandello et al., 2018). Thus, the negative relationship found between avoiding femininity and PrEP interest may be explained as a means of avoiding behaviors that could violate prescriptions of traditional masculine ideology (Campbell et al., 2012; Hawkins et al., 2017). Further, this finding quantitatively supports previous qualitative research that shows traditional masculinity among BMSM corresponds with less interest in PrEP (Garcia et al., 2015, 2016).

Anticipated PrEP stigma moderated the direct effect of avoiding femininity on PrEP interest. When endorsement of avoiding femininity was low, those who held lower levels of stigma reported greater interest in PrEP, while those high in stigma reported the least amount of interest, in line with our hypothesis. However, when endorsement of avoiding femininity was high, an increase in stigma related to increased interest in PrEP, contrary to our hypothesis. This may explain why previous studies indicate high interest in PrEP among BMSM while use remains low (Eaton et al., 2015; Rolle et al., 2017). It may be the case that these men are aware of the benefits of PrEP for preventing HIV and its ability to support normative masculine behaviors (e.g. sex without a condom; Zeglin, 2015); yet they are also aware of its close association with gay men. This undesired association likely outweighs the perceived benefits of PrEP, leading to high interest but low uptake of PrEP.

The unexpected inconsistent moderated mediation via heterosexual self-presentation likely demonstrates boundary conditions for PrEP interest and use. Those who seek to avoid femininity by presenting as heterosexual, and do not hold stigmatized views of PrEP, may view PrEP as a means of ensuring they do not have to disclose their same-sex sexual behavior as a result of becoming HIV positive. Illustrated in Figure 4, as anticipated stigma increases among those moderate to high in the gender norm, indicating a belief that they will be stigmatized from using PrEP, interest in PrEP decreases. This finding may help explain a previous study finding that BMSM PrEP users report higher levels of internalized homophobia than those who do not use PrEP (Eaton et al., 2017b). Studies of internalized homophobia link the construct to greater adherence to gender roles (Salvati et al., 2018) and a preoccupation with appearing masculine among sexual minority men (Sánchez and Vilain, 2012). Thus, heterosexual self-presentation may be a mechanism by which internalized homophobia relates to increased use of PrEP by some BMSM. Future research should directly investigate this proposed relation through longitudinal designs.

The present study has limitations that should be considered when interpreting the results. First, the cross-sectional design prevents the inference of any causal relationships. Second, because a convenience sample was used from a Black Pride event, the sample may not be representative of BMSM. The sample likely does not include men who are most likely to endorse masculinity ideology or hold the stigmatized beliefs examined in the study. As the present study was conducted in one city within the southeastern U.S., results may not generalize to BMSM in other geographical areas, specifically where traditional masculinity ideology may not have as strong an influence on the behavior of Black men (Levant and Richmond, 2007). Although participants were informed of anonymity, social desirability may have influenced responses. Further, due to the stigma around PrEP, the responses to our behavioral measures may have been muted. Future research should attempt to replicate the present relationships with BMSM who are less connected to the gay community than those attending a Gay Pride event.

Findings from this study provide a nuanced view of the influence anticipated stigma and masculinity have on BMSM’s interest in PrEP. Messages promoting PrEP should be more inclusive of persons who are at high risk of HIV regardless of sexual preference. This could serve to reduce the stigmatized beliefs held by some BMSM that PrEP is a clear indicator of being a sexual minority. Further, intervention research among BMSM should include critical consciousness components to transform gender norms. Such components, which have been shown to reduce detrimental influences of gender norms, have been effective in changing men’s engagement in HIV-related behaviors such as improving uptake of HIV testing (Fleming et al., 2016). Determining the effects of critical consciousness and other approaches to transforming gender norms on PrEP interest should be a research priority.

Footnotes

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.

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 of Mental Health [T32MH074387]; and the National Institute for Allergy and Infectious Diseases [T32AI102623]. The authors declare that there is no conflict of interest.

ORCID iDs

Redd Driver

Seth C Kalichman

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