“A Gay Man and a Doctor are Just like, a Recipe for Destruction”: How Racism and Homonegativity in Healthcare Settings Influence PrEP Uptake Among Young Black MSM
Young, Black, gay bisexual or other MSM are significantly less likely to use PrEP than their White counterparts. These disparities may be due, in part, to medical mistrust and mistreatment within the healthcare system. This study aimed to uncover how young Black MSM’s perceptions of, and experiences with, health care contribute to low engagement in the healthcare system and low PrEP utilization. In late 2017 and early 2018, we conducted six focus groups with 44 Black MSM ages 16–25 in Milwaukee. Focus group topics included participants’ knowledge and perceptions of PrEP, perceptions and stereotypes about PrEP users, and general healthcare utilization patterns and behaviors. Focus group transcripts were transcribed verbatim and coded using MAXQDA qualitative analysis software. We used a team-based approach to thematic content analysis to understand how racism and homonegativity affected healthcare access and experiences. Results from this study help to characterize what contributes to mistrust of the healthcare system and healthcare providers to negatively affect PrEP use among young Black MSM. Focus group discussions revealed how previous and anticipated negative interactions with physicians and skepticism about the healthcare system have alienated young Black MSM from the health care system and created significant barriers to PrEP. Efforts to increase PrEP uptake and must address negative and discriminatory interactions with providers and the healthcare system.
KeywordsMedical mistrust Racial disparities PrEP disparities Young adults Qualitative Racism Homonegativity
We are incredibly grateful to the young people who participated in this study and we were willing to share intimate details about their lives and healthcare experiences. This research would not have been possible without the community organizations and leaders who partner with us.
This study was funded by the National Institute of Mental Health (K01 MH112412; PI: Quinn) and supported by the National Institute of Mental Health Center Grant (P30-MH52776; PI: J. Kelly).
Compliance with Ethical Standards
Conflict of interest
The authors have no conflicts of interest to disclose.
All study procedures were in accordance with the ethical standards of the Institutional Review Board at the Medical College of Wisconsin and with the 1964 Helsinki declaration and its later amendments.
Informed consent as obtained from all individuals who participated in the study.
- 3.Krakower DS, Mimiaga MJ, Rosenberger JG, et al. Limited awareness and low immediate uptake of pre-exposure prophylaxis among men who have sex with men using an internet social networking site. PLoS ONE. 2012;7(3):e33119. https://doi.org/10.1371/journal.pone.0033119.CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Rawlings KMR, Pechonkina A. Status of Truvada for HIV pre-exposure prophylaxis (PrEP) in the United States: An early drug utilization analysis. Paper presented at: 53rd ICAAC. Denver, Co.; 2015.Google Scholar
- 9.Smith DK. By race/ethnicity, Blacks have the highest number needing PrEP in the United States, 2018. In: CROI. Boston, MA; 2018. http://www.croiwebcasts.org/console/player/37188?mediaType=slideVideo&&crd_fl=0&ssmsrq=1529425735624&ctms=5000&csmsrq=5290.
- 11.Hosek S, Rudy B, Landovitz R, et al. ATN 110: an HIV PrEP demonstration project and safety study for young men who have sex with men in the United States. In: 8th IAS Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, Canada; 2015. http://www.natap.org/2015/IAS/IAS_76.htm.
- 12.Centers for Disease Control and Prevention. HIV and Youth. Atlanta, GA; 2018. https://www.cdc.gov/hiv/pdf/group/age/youth/cdc-hiv-youth.pdf.
- 14.Cahill S, Taylor SW, Elsesser SA, Mena L, Hickson DM, Mayer KH. 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. https://doi.org/10.1080/09540121.2017.1300633.CrossRefPubMedPubMedCentralGoogle Scholar
- 16.Holloway IW, Tan D, Gildner JL, et al. Facilitators and barriers to pre-exposure prophylaxis willingness among young men who have sex with men who use geosocial networking applications in California. AIDS Patient Care STDS. 2017;31(12):517–27. https://doi.org/10.1089/apc.2017.0082.CrossRefPubMedPubMedCentralGoogle Scholar
- 29.Saldana J. The Coding Manual for Qualitative Researchers—Johnny Saldana—Google Books. SAGE Publications Ltd. https://books.google.ca/books?id=ZhxiCgAAQBAJ&printsec=frontcover#v=onepage&q&f=false. Published 2016.
- 30.Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 4th ed. Thousand Oaks, CA: Sage; 2015.Google Scholar
- 32.Wisconsin Department of Health Services. Wisconsin HIV Surveillance Annual Review Addendum: City of Milwaukee. New Diagnoses, Prevalent Cases, Syphilis Diagnoses, and HIV Testing Through December 31, 2016. Wisconsin Department of Health Services; 2017. https://www.dhs.wisconsin.gov/publications/p0/p00484a.pdf.
- 47.Gay and Lesbian Medical Association. Guidelines for care of lesbian, gay, bisexual, and transgender patients. 2006. http://www.glma.org/_data/n_0001/resources/live/Welcoming Environment.pdf.
- 49.Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States-2017 Update: a clinical practice guideline. 2017. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf.
- 51.Lim FA, Brown DV, Justin Kim SM. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: a review of best practices. Am J Nurs. 2014;114(6):24–34. https://doi.org/10.1097/01.naj.0000450423.89759.36.CrossRefPubMedGoogle Scholar