AIDS and Behavior

, Volume 23, Issue 7, pp 1721–1736 | Cite as

An Integrated Examination of County- and Individual-Level Factors in Relation to HIV Pre-exposure Prophylaxis Awareness, Willingness to Use, and Uptake Among Men Who Have Sex with Men in the US

  • Jingjing Li
  • Carla J. Berg
  • Michael R. Kramer
  • Regine Haardörfer
  • Maria Zlotorzynska
  • Travis H. SanchezEmail author
Original Paper


This study explored the extent to which county- and individual-level factors were associated with awareness, willingness to use, and use of pre-exposure prophylaxis (PrEP) among US men who have sex with men (MSM). We conducted multilevel analyses using a sample of 8338 MSM residing in 1257 US counties drawn from the 2014–2015 American Men’s Internet Survey to examine these associations, with focuses on variation in PrEP outcomes across counties and proportion variation explained by county-level factors (HIV prevalence, racial composition, median household income, income inequality, health insurance coverage). Results showed that PrEP awareness varied moderately across counties (intraclass correlation coefficients [ICC] = 7.7%), willingness to use did not vary; however, the actual use varied substantially (ICC = 20.7%). Half of the variation in awareness and use was explained by county-level factors. Higher median household income was associated with greater likelihood of awareness and use. Higher income inequality was associated with greater likelihood of PrEP awareness. Findings can inform the development of multilevel interventions to address PrEP uptake among MSM and identify communities where structural intervention is most needed.


HIV/AIDS Pre-exposure prophylaxis Men who have sex with men Uptake 



The authors would like to thank Hannah Cooper, Yongjiang Chen, Kevin Jefferson, Yenting Chen, Kathleen Krause, Catherine Prueitt, Nancy DeSousa Williams, and Blanche Greene Cramer for their valuable comments.


The work was supported by the National Institutes of Health (Emory Center for AIDS Research, P30AI050409) and the MAC AIDS Fund.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed as part of the American Men’s Internet Survey study involving human participants were conducted in accordance with the ethical standards of the Emory University Institutional Review Board (IRB) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Eaton LA, et al. A multi-US city assessment of awareness and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among black men and transgender women who have sex with men. Prev Sci. 2017;18(5):505–16.CrossRefGoogle Scholar
  2. 2.
    Wu H, et al. Uptake of HIV preexposure prophylaxis among commercially insured persons—United States, 2010–2014. Clin Infect Dis. 2016;64(2):144–9.CrossRefGoogle Scholar
  3. 3.
    Hoots BE, et al. Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men–20 US cities, 2014. Clin Infect Dis. 2016;63(5):672–7.CrossRefGoogle Scholar
  4. 4.
    Elopre L, et al. Brief report: the right people, right places, and right practices: disparities in PrEP access among African American men, women, and MSM in the deep south. JAIDS J Acquir Immune Defic Syndr. 2017;74(1):56–9.CrossRefGoogle Scholar
  5. 5.
    Hosek S, et al. High rates of HIV/STIs with low PrEP uptake: baseline data from the POSSE project for black young MSM in the Chicago House/Ball community. AIDS Res Hum Retrovir. 2016;32:373.CrossRefGoogle Scholar
  6. 6.
    Parsons JT, et al. Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States. Jaids. 2017;74(3):285–92.Google Scholar
  7. 7.
    Kuhns LM, et al. 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.CrossRefGoogle Scholar
  8. 8.
    Eaton LA, et al. Stigma and conspiracy beliefs related to pre-exposure prophylaxis (PrEP) and interest in using PrEP among black and white men and transgender women who have sex with men. AIDS Behav. 2017;21(5):1236–46.CrossRefGoogle Scholar
  9. 9.
    Oldenburg CE, et al. State-level structural sexual stigma and HIV prevention in a national online sample of HIV-uninfected MSM in the United States. AIDS. 2015;29(7):837–45.CrossRefGoogle Scholar
  10. 10.
    Andersen RM, Davidson PL. Improving access to care Changing the US health care system: key issues in health services policy and management. San Francisco: Jossey-Bass; 2014.Google Scholar
  11. 11.
    Kelley CF, et al. Applying a PrEP continuum of care for men who have sex with men in Atlanta, Georgia. Clin Infect Dis. 2015;61(10):1590–7.CrossRefGoogle Scholar
  12. 12.
    Pingel ES, et al. It’s just not for me: exploring low prep uptake among young black men who have sex with men in the southern united states. London: BMJ Publishing Group Ltd; 2017.Google Scholar
  13. 13.
    Cahill S, et al. Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts. AIDS Care. 2017;29(11):1351–8.CrossRefGoogle Scholar
  14. 14.
    Pulsipher CA, Montoyo JA, Plant A, Curtis P, Holloway IW, Leibowitz AA. Addressing PrEP disparities among young gay and bisexual men in California. Los Angeles: California HIV/AIDS Research Program; 2016.Google Scholar
  15. 15.
    Andersen R, Newman NF. Societal and individual determinants of medical care utilization in the United States. Milbank Q. 2005;8:4. Scholar
  16. 16.
    Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1–10.CrossRefGoogle Scholar
  17. 17.
    Rolle C-P, et al. Challenges in Translating PrEP Interest into Uptake in an Observational Study of Young Black MSM. JAIDS J Acquir Immune Defic Syndr. 2017;76(3):250–8.CrossRefGoogle Scholar
  18. 18.
    Neaigus A, et al. Multilevel risk factors for greater HIV infection of black men who have sex with men in New York City. Sex Transm Dis. 2014;41(7):433–9.CrossRefGoogle Scholar
  19. 19.
    White AW. The role of social and cultural factors on preventive health services use among young, rural, African American men: a narrative inquiry. Alabama: University of Alabama Libraries; 2017.Google Scholar
  20. 20.
    Luo H, et al. The relationship between county-level contextual characteristics and use of diabetes care services. J Public Health Manag Pract. 2014;20(4):401.CrossRefGoogle Scholar
  21. 21.
    Frew PM, et al. An integrated service delivery model to identify persons living with HIV and to provide linkage to HIV treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. JMIR Public Health Surveill. 2015;1(2):e16.CrossRefGoogle Scholar
  22. 22.
    Ransome Y, et al. The relationship between higher social trust and lower late HIV diagnosis and mortality differs by race/ethnicity: results from a state-level analysis. J Int AIDS Soc. 2017;20(1):21442.CrossRefGoogle Scholar
  23. 23.
    Strauss BB, et al. Exploring patterns of awareness and use of HIV pre-exposure prophylaxis among young men who have sex with men. AIDS Behav. 2017;21(5):1288–98.CrossRefGoogle Scholar
  24. 24.
    Strauss BB, et al. Exploring patterns of awareness and use of HIV pre-exposure prophylaxis among young men who have sex with men. AIDS Behav. 2017;21(5):1288–98.CrossRefGoogle Scholar
  25. 25.
    Miller WC, et al. Community viral load as a measure for assessment of HIV treatment as prevention. Lancet Infect Dis. 2013;13(5):459–64.CrossRefGoogle Scholar
  26. 26.
    Baral S, et al. Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health. 2013;13:482.CrossRefGoogle Scholar
  27. 27.
    Sanchez T, et al. The annual American men’s internet survey of behaviors of men who have sex with men in the United States: 2014 Key indicators report. JMIR Public Health Surveill. 2016;2(1):e23.CrossRefGoogle Scholar
  28. 28.
    Sanchez TH, et al. The annual American men’s internet survey of behaviors of men who have sex with men in the United States: protocol and key indicators report 2013. JMIR Public Health Surveill. 2015;1(1):e3.CrossRefGoogle Scholar
  29. 29.
    US Department of Housing and Urban Development. USPS ZIP Code Crosswalk 2018 [cited 2018].
  30. 30.
    Sullivan, P.S. AIDSVu: An interactive online surveillance mapping resource to improve HIV prevention in the US. In Medicine 2.0 Conference. JMIR Publications Inc., Toronto, Canada, 2013.Google Scholar
  31. 31.
    US Census Bureau. American Community Survey estimates of county-level variables. Maryland: USCB; 2014.Google Scholar
  32. 32.
    US Public Health Service. Pre-exposure prophylaxis for the prevention of HIV infection in the United States-2014: a clinical practice guide. Maryland: US Public Health Service; 2014.Google Scholar
  33. 33.
    Ingram DD, Franco SJ. 2013 NCHS urban-rural classification scheme for counties. 2014.Google Scholar
  34. 34.
    Yitzhaki S. Relative deprivation and the Gini coefficient. Q J Econ. 1979;93(2):321–4.CrossRefGoogle Scholar
  35. 35.
    Raudenbush SW, Bryk AS. Hierarchical linear models: applications and data analysis methods, vol. 1. Thousand Oaks: Sage; 2002.Google Scholar
  36. 36.
    Belsley DA. A guide to using the collinearity diagnostics. Comput Econ. 1991;4(1):33–50.Google Scholar
  37. 37.
    Merlo J, et al. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. J Epidemiol Community Health. 2006;60(4):290–7.CrossRefGoogle Scholar
  38. 38.
    Khanna AS, 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.CrossRefGoogle Scholar
  39. 39.
    Mayer KH, Krakower DS. If PrEP decreases HIV transmission, what is impeding its uptake? Clin Infect Dis. 2015;61(10):1598Á600.CrossRefGoogle Scholar
  40. 40.
    Tempalski B, et al. Identifying which place characteristics are associated with the odds of recent HIV testing in a large sample of people who inject drugs in 19 US metropolitan areas. AIDS Behav. 2018;1:18. Scholar
  41. 41.
    Moss JL, Reiter PL, Brewer NT. Correlates of human papillomavirus (HPV) vaccine coverage: a state-level analysis. Sex Transm Dis. 2015;42(2):71.CrossRefGoogle Scholar
  42. 42.
    Cooper RA, et al. Poverty, wealth, and health care utilization: a geographic assessment. J Urban Health. 2012;89(5):828–47.CrossRefGoogle Scholar
  43. 43.
    Kirby JB, Kaneda T. Neighborhood socioeconomic disadvantage and access to health care. J Health Soc Behav. 2005;46(1):15–31.CrossRefGoogle Scholar
  44. 44.
    Adinan J, et al. Individual and contextual factors associated with appropriate healthcare seeking behavior among febrile children in Tanzania. PLoS ONE. 2017;12(4):e0175446.CrossRefGoogle Scholar
  45. 45.
    Merchant RC, et al. Preferences for HIV pre-exposure prophylaxis (PrEP) information among men-who-have-sex-with-men (MSM) at community outreach settings. J Gay Lesbian Ment Health. 2016;20(1):21–33.CrossRefGoogle Scholar
  46. 46.
    Frye V, et al. Neighborhood-level correlates of consistent condom use among men who have sex with men: a multi-level analysis. AIDS Behav. 2010;14(4):974–85.CrossRefGoogle Scholar
  47. 47.
    Hannaford A, et al. The use of online posts to identify barriers to and facilitators of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men: a comparison to a systematic review of the peer-reviewed literature. AIDS Behav. 2018;22(4):1080–95.CrossRefGoogle Scholar
  48. 48.
    Rendina HJ, et al. Distinguishing hypothetical willingness from behavioral intentions to initiate HIV pre-exposure prophylaxis (PrEP): findings from a large cohort of gay and bisexual men in the US. Soc Sci Med. 2017;172:115–23.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Jingjing Li
    • 1
    • 3
  • Carla J. Berg
    • 1
  • Michael R. Kramer
    • 2
  • Regine Haardörfer
    • 1
  • Maria Zlotorzynska
    • 2
  • Travis H. Sanchez
    • 2
    Email author
  1. 1.Department of Behavioral Sciences and Health EducationEmory University School of Public HealthAtlantaUSA
  2. 2.Department of EpidemiologyEmory University School of Public HealthAtlantaUSA
  3. 3.Department of Epidemiology, School of Health SciencesWuhan UniversityWuhanPeople’s Republic of China

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