Research Article: Sex, PrEP, and Stigma: Experiences with HIV Pre-exposure Prophylaxis Among New York City MSM Participating in the HPTN 067/ADAPT Study

Date Published: November 15, 2017

Publisher: Springer US

Author(s): Julie Franks, Yael Hirsch-Moverman, Avelino S. Loquere, K. Rivet Amico, Robert M. Grant, Bonnie J. Dye, Yan Rivera, Robert Gamboa, Sharon B. Mannheimer.


The HPTN 067/Alternative Dosing to Augment Pre-Exposure Prophylaxis Pill Taking (ADAPT) study evaluated daily and non-daily dosing schedules for oral pre-exposure prophylaxis (PrEP) to prevent HIV. A qualitative sub-study including focus groups and in-depth interviews was conducted among men who have sex with men participating in New York City to understand their experience with PrEP and study dosing schedules. The 37 sub-study participants were 68% black, 11% white, and 8% Asian; 27% were of Hispanic/Latino ethnicity. Mean age was 34 years. Themes resulting from qualitative analysis include: PrEP is a significant advance for HIV prevention; non-daily dosing of PrEP is congruent with HIV risk; and pervasive stigma connected to HIV and risk behavior is a barrier to PrEP adherence, especially for non-daily dosing schedules. The findings underscore how PrEP intersects with other HIV prevention practices and highlight the need to understand and address multidimensional stigma related to PrEP use.

Partial Text

Oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) as pre-exposure prophylaxis (PrEP) to prevent HIV acquisition was approved by the FDA in 2012 [1] and has the potential to alter the trajectory of the US epidemic if used by those at substantial risk for HIV, including men who have sex with men (MSM) [2, 3]. However, only about 4% of MSM surveyed in the 2014 National HIV Behavioral Surveillance had taken PrEP in the last 12 months, a much lower proportion than the 25% estimated to meet behavioral indications for PrEP [4]. Some potential barriers to use of the currently approved daily PrEP regimen, such as the need for long-term adherence to a daily medication [5, 6], users’ concerns about medication toxicity [7–10], and cost [9–11], may be mitigated by nondaily PrEP regimens [12–16]. Contextual factors, notably users’ perceptions and experiences of social attitudes about PrEP [17–20], can also influence its use. While perceived social norms concerning PrEP use and how PrEP fits into sexual practices have been explored hypothetically in qualitative research among people who would be potentially eligible to take PrEP [21–24], to date there is limited qualitative research exploring experiences using open-label PrEP [18, 25–27], particularly for non-daily dosing [19].

As shown in Table 3, 37 of the 179 Harlem HPTN 067 study participants completed either a FG (N = 31) or an IDI (N = 6). Participants in the qualitative sub-study had a mean age of 34 years. One IDI participant identified as gender queer; the remaining 36 sub-study participants identified as MSM. Sub-study participants were 68% black, 11% white, and 8% Asian; 27% identified as ethnically Hispanic or Latino. Sixty-eight percent were unemployed. Sub-study participants reported a mean of 5.7 sexual partners (range 1–25) and a mean of 9.1 instances of condomless intercourse (range 0–55) in the 3 months preceding study randomization. Sub-study participants did not differ significantly from other main study participants in demographic characteristics and in reported sexual behavior (data not shown). Consistent with the approach of recruiting participants around the time of their final study follow-up visit, sub-study participants had higher retention in scheduled follow-up study visits as compared to other main study participants (mean retention 96.5% vs 82.9%; p < 0.001).Table 3Qualitative sub-study participant demographicsFG (n = 31)IDI (n = 6)Total (n = 37)Mean age343634Gender identity MSM31 (100%)5 (83%)36 (97%) Gender queer0 (0%)1 (17%)1 (3%)Race Black21 (68%)4 (67%)25 (68%) White3 (10%)1 (17%)4 (11%) Asian3 (10%)0%3 (8%) Othera4 (13%)1 (17%)5 (14%)Hispanic ethnicity9 (29%)1 (17%)10 (27%)Unemployed20 (65%)5 (83%)25 (68%)Educational level Less than high school7 (23%)1 (17%)8 (22%) High school9 (29%)3 (50%)12 (32%) Technical training2 (6%)2 (33%)4 (11%) Some college6 (19%)0%6 (16%) College7 (23%)0%7 (19%)aIncludes European (2), not defined (2), and Native American (1) The mainly black MSM participants in the Harlem HPTN067/ADAPT qualitative sub-study saw PrEP as a valuable addition to their existing HIV prevention strategies, which were based in part on their ability to discern risk in their partners and adjust their behavior accordingly. Participants commonly described a heightened awareness of prevention while taking PrEP and adopting additional protective behaviors, perhaps in part due to the regular counseling and HIV testing they received as part of study participation. At the same time, a minority of participants reported increased willingness to engage in sexual encounters that might put them at risk for HIV, similar to the reductions in condom use among some PrEP patients that has been noted in clinical practice settings [38]. The experience of recognizing and correcting increased risk behavior while on PrEP has been identified in other qualitative studies of PrEP use [39], highlighting that individual prevention practices are responsive to both perceptions of situation-specific risk and the internalization of support for practicing prevention behaviors [40, 41]. As PrEP uptake in the US grows, the need for interventions to support its effective use becomes ever more urgent. The qualitative data presented here highlight critical areas of needed support, including integrating PrEP into other prevention strategies, adherence interventions for dosing schedules that are congruent with patterns of sexual activity and intensifying efforts to counter PrEP-related stigma. The findings are particularly relevant in characterizing PrEP-using experiences of Black MSM—a crucial population for HIV prevention efforts in the US.   Source:


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