Current HIV/AIDS Reports

, Volume 15, Issue 2, pp 190–197 | Cite as

PrEP Stigma: Implicit and Explicit Drivers of Disparity

The Science of Prevention (JD Stekler and J Baeten, Section Editors)
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Part of the following topical collections:
  1. Topical Collection on The Science of Prevention

Abstract

Purpose of Review

Despite its promise as an HIV prevention strategy, PrEP uptake remains slow, especially among highest priority populations. One factor that may be impeding implementation and driving disparities is PrEP-related stigma. This paper reviews the role of PrEP-related stigma in PrEP access, adherence, and persistence and examines its antecedents and consequences.

Recent Findings

Although PrEP stigma is often experienced at the community level (i.e., by potential and current users), it can be reinforced and even amplified by public health programs, policy, and research. PrEP stigma disproportionately impacts disadvantaged groups and impedes scalability by influencing behavior of both patients and providers.

Summary

Reducing PrEP stigma and its negative impact on the epidemic requires a significant shift in perspective, language, and programs. Such a shift is necessary to ensure broader reach of PrEP as a prevention strategy and improve its utilization by the individuals who need it most.

Keywords

Pre-exposure prophylaxis (PrEP) Stigma HIV/AIDS Sexual health Prevention Implementation 

Notes

Compliance with Ethical Standards

Conflict of Interest

Dr. Golub reports non-financial support from Gilead Sciences in the form of medication supply for an NIH-funded PrEP demonstration project, outside the submitted work.

Human and Animal Rights

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance.

  1. 1.
    Singh GK, Azuine RE, Siahpush M. Widening socioeconomic, racial, and geographic disparities in HIV/AIDS mortality in the United States, 1987–2011. Adv Prev Med. 2013: Article ID 657961;  https://doi.org/10.1155/2013/657961.
  2. 2.
    Lemly DC, Shepherd BE, Hulgan T, Rebeiro P, Stinnette S, Blackwell RB, et al. Race and sex differences in antiretroviral therapy use and mortality among HIV-infected persons in care. J Infect Dis. 2009;199(7):991–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Hess KL, Hu X, Lansky A, Mermin J, Hall HI. Lifetime risk of a diagnosis of HIV infection in the United States. Ann Epidemiol. 2017;27(4):238–43.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Zablotska IB, Spelman T, Grulich A. 2015–a seminal year for HIV biomedical prevention. J Int AIDS Soc. 2015;18(1):1–3.CrossRefGoogle Scholar
  5. 5.
    Eaton LA, Matthews DD, Driffin DD, Bukowski L, Wilson PA, Stall RDA. 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.CrossRefPubMedGoogle Scholar
  6. 6.
    Parsons JT, Rendina HJ, Lassiter JM, Whitfield TH, Starks TJ, Grov C. Uptake of HIV pre-exposure prophylaxis (PrEP) in a National Cohort of gay and bisexual men in the United States. JAIDS J Acquir Immune Defic Syndr. 2017;74(3):285–92.CrossRefPubMedGoogle Scholar
  7. 7.
    Kuhns LM, Hotton AL, Schneider J, Garofalo R, Fujimoto K. 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.CrossRefPubMedGoogle Scholar
  8. 8.
    Elopre L, Kudroff K, Westfall AO, Overton ET, Mugavero MJ. 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. J Acquir Immune Defic Syndr. 2017;74(1):56–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Stigma EG. Notes on the management of spoiled identity. New York: Simon & Schuster Inc; 1963.Google Scholar
  10. 10.
    Golub SA, Gamarel KE, Surace A. Demographic differences in PrEP–related stereotypes: implications for implementation. AIDS Behav. 2017;21(5):1229–35.CrossRefPubMedGoogle Scholar
  11. 11.
    Biello KB, Oldenburg CE, Mitty JA, Closson EF, Mayer KH, Safren SA, et al. The" safe sex" conundrum: anticipated stigma from sexual partners as a barrier to PrEP use among substance using MSM engaging in transactional sex. AIDS Behav. 2017;21(1):300–6.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Van der Elst EM, Mbogua J, Operario D, Mutua G, Kuo C, Mugo P, et al. High acceptability of HIV pre-exposure prophylaxis but challenges in adherence and use: qualitative insights from a phase I trial of intermittent and daily PrEP in at-risk populations in Kenya. AIDS Behav. 2013;17(6):2163–72.Google Scholar
  13. 13.
    Joint United Nations Programme on HIV/AIDS (UNAIDS). On the Fast-Track to end AIDS by 2030: Focus on location and population. Geneva: UNAIDS; 2015.Google Scholar
  14. 14.
    Baugher AR, Beer L, Fagan JL, Mattson CL, Freedman M, Skarbinski J, et al. Prevalence of internalized HIV-related stigma among HIV-infected adults in care, United States, 2011–2013. AIDS Behav. 2017;21:1–9.  https://doi.org/10.1007/s10461-017-1712-y.CrossRefGoogle Scholar
  15. 15.
    •• Haire BG. Preexposure prophylaxis-related stigma: strategies to improve uptake and adherence–a narrative review. HIV/AIDS (Auckland, NZ). 2015;7:241. This paper provides and important review and analysis of the PrEP stigma literature.Google Scholar
  16. 16.
    Calabrese SK, Underhill K. How stigma surrounding the use of HIV Preexposure prophylaxis undermines prevention and pleasure: a call to destigmatize "Truvada whores". Am J Public Health. 2015;105(10):1960–4.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Eaton LA, Kalichman SC, Price D, Finneran S, Allen A, Maksut J. 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.CrossRefPubMedGoogle Scholar
  18. 18.
    Farhat D, Greene E, Paige MQ, Koblin BA, Frye V. Knowledge, stereotyped beliefs and attitudes around HIV chemoprophylaxis in two high HIV prevalence neighborhoods in new York City. AIDS Behav. 2017;21(5):1247–55.CrossRefPubMedGoogle Scholar
  19. 19.
    •• Knight R, Small W, Carson A, Shoveller J. Complex and Conflicting Social Norms: Implications for Implementation of Future HIV Pre-Exposure Prophylaxis (PrEP) Interventions in Vancouver, Canada. PLoS One. 2016;11(1):e0146513. This qualitative study provides examples and analysis of the nature of PrEP stigma among a cohort of men under 25. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Anderson PL, Glidden DV, Liu A, Buchbinder S, Lama JR, Guanira JV, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 2012;4(151):151ra125.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Smith DK, Herbst JH, Zhang X, Rose CE. Condom effectiveness for HIV prevention by consistency of use among men who have sex with men in the United States. JAIDS J Acquir Immune Defic Syndr. 2015;68(3):337–44.CrossRefPubMedGoogle Scholar
  22. 22.
    Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. 2009;23(9):1153–62.CrossRefPubMedGoogle Scholar
  23. 23.
    MacKellar DA, Valleroy LA, Secura GM, Behel S, Bingham T, Celentano DD, et al. Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men: opportunities for advancing HIV prevention in the third decade of HIV/AIDS. JAIDS J Acquir Immune Defic Syndr. 2005;38(5):603–14.CrossRefPubMedGoogle Scholar
  24. 24.
    Young SD, Nussbaum AD, Monin B. Potential moral stigma and reactions to sexually transmitted diseases: evidence for a disjunction fallacy. Personal Soc Psychol Bull. 2007;33:789–99.CrossRefGoogle Scholar
  25. 25.
    Weinstock H, Dale M, Linley L, Gwinn M. Unrecognized HIV infection among patients attending sexually transmitted disease clinics. Am J Public Health. 2002;92:280–3.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Earnshaw VA, Smith LR, Chaudoir SR, Lee IC, Copenhaver MM. Stereotypes about people living with HIV: implications for perceptions of HIV risk and testing frequency among at risk populations. AIDS Educ Prev. 2012;24:574–81.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Golub SA, Gamarel KE. The impact of anticipated HIV stigma on delays in HIV testing behaviors: findings from a community-based sample of men who have sex with men and transgender women in new York City. AIDS Patient Care STDs. 2013;27(11):621–7.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Gallagher T, Link L, Ramos M, Bottger E, Aberg J, Daskalakis D. Self-perception of HIV risk and candidacy for pre-exposure prophylaxis among men who have sex with men testing for HIV at commercial sex venues in new York City. LGBT Health. 2014;1(3):218–24.CrossRefPubMedGoogle Scholar
  29. 29.
    Mack N, Odhiambo J, Wong CM, Agot K. Barriers and facilitators to pre-exposure prophylaxis (PrEP) eligibility screening and ongoing HIV testing among target populations in Bondo and Rarieda, Kenya: results of a consultation with community stakeholders. BMC Heal Serv Res. 2014;14:231.CrossRefGoogle Scholar
  30. 30.
    •• Peng P, Su S, Fairley CK, et al. A global estimate of the acceptability of pre-exposure prophylaxis for HIV among men who have sex with men: a systematic review and meta-analysis. AIDS Behav. 2017;  https://doi.org/10.1007/s10461-017-1675-z. This meta-analysis reviews PrEP acceptability studies internationally.
  31. 31.
    Tangmunkongvorakul A, Chariyalertsak S, Amico KR, Saokhieo P, Wannalak V, Sangangamsakun T, et al. Facilitators and barriers to medication adherence in an HIV prevention study among men who have sex with men in the iPrEx study in Chiang Mai, Thailand. AIDS Care. 2013;25(8):961–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Blake HC, Turan JM, Atkins G, Kempf MC, Clay OJ, Raper JL, et al. Interpersonal mechanisms contributing to the association between HIV-related internalized stigma and medication adherence. AIDS Behav. 2017;21(1):238–47.CrossRefGoogle Scholar
  33. 33.
    Darlington CK, Hutson SP. Understanding HIV-related stigma among women in the southern United States: a literature review. AIDS Behav. 2017;21(1):12–26.CrossRefPubMedGoogle Scholar
  34. 34.
    Liu A, Cohen S, Follansbee S, Cohan D, Weber S, Sachdev D, et al. Early experiences implementing pre-exposure prophylaxis (PrEP) for HIV prevention in San Francisco. PLoS Med. 2014;11(3):e1001613.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Garcia J, Parker C, Parker RG, Wilson PA, Philbin M, Hirsch JS. Psychosocial implications of homophobia and HIV stigma in social support networks: insights for high-impact HIV prevention among black men who have sex with men. Health Educ Behav. 2016;3(2):217–25.CrossRefGoogle Scholar
  36. 36.
    Harawa N et al. Engaging Black Men Who Have Sex with Men (BMSM) in Los Angeles in HIV Pre-Exposure Prophylaxis (PrEP). 2016. California HIV/AIDS Policy Centers. http://chipts.ucla.edu/about/chiptspolicycore/.
  37. 37.
    Black AIDS Institute. Black Lives Matter: What’s PrEP got to do with it? April 2016. http://blackprep.org/assets/16-prep-report.pdf
  38. 38.
    Underhill K. Intimacy, condom use, and pre-exposure prophylaxis (PrEP) acceptability among men who have sex with men (MSM) in primary partnerships: a comment on Gamarel and Golub. Ann Behav Med. 2015;49(2):151–3.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Celum CL, Delany-Moretlwe S, McConnell M, Van Rooyen H, Bekker LG, Kurth A, et al. Rethinking HIV prevention to prepare for oral PrEP implementation for young African women. J Int AIDS Soc. 2015;18(4Suppl 3):20227.PubMedPubMedCentralGoogle Scholar
  40. 40.
    US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. Available at http://www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf
  41. 41.
    Kowalewski MR, Henson KD, Longshore D. Rethinking perceived risk and health behavior: a critical review of HIV prevention research. Health Educ Behav. 1997;24(3):313–25.CrossRefPubMedGoogle Scholar
  42. 42.
    MacKellar DA, Valleroy LA, Secura GM, Behel S, Bingham T, Celentano DD, et al. Perceptions of lifetime risk and actual risk for acquiring HIV among young men who have sex with men. AIDS Behav. 2007;11(2):263–70.CrossRefPubMedGoogle Scholar
  43. 43.
    Karris MY, Beekmann SE, Mehta SR, Anderson CM, Polgreen PM. Are we prepped for preexposure prophylaxis (PrEP)? Provider opinions on the real-world use of PrEP in the United States and Canada. Clin Infect Dis. 2014;58(5):704–12.CrossRefPubMedGoogle Scholar
  44. 44.
    Blackstock OJ, Moore BA, Berkenblit GV, Calabrese SK, Cunningham CO, Fiellin DA, et al. A cross-sectional online survey of HIV pre-exposure prophylaxis adoption among primary care physicians. J Gen Intern Med. 2017;32(1):62–70.CrossRefPubMedGoogle Scholar
  45. 45.
    Tripathi A, Ogbuanu C, Monger M, Gibson JJ, Duffus WA. Pre-exposure prophylaxis for HIV infection: healthcare providers’ knowledge, perception, and willingness to adopt future implementation in the southern US. South Med J. 2012;105(4):199–206.CrossRefPubMedGoogle Scholar
  46. 46.
    Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Jenness SM, Goodreau SM, Rosenberg E, Beylerian EN, Hoover KW, Smith DK, et al. Impact of the centers for disease Control's HIV preexposure prophylaxis guidelines for men who have sex with men in the United States. J Infect Dis. 2016;214(12):1800–7.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Volk JE, Marcus JL, Phengrasamy T, Blechinger D, Nguyen DP, Follansbee S, et al. No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clin Infect Dis. 2015;61(10):1601–3.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    •• Jenness SM, Sharma A, Goodreau SM, Rosenberg ES, Weiss KM, Hoover KW, et al. Individual HIV Risk versus population impact of risk compensation after HIV Preexposure prophylaxis initiation among men who have sex with men. PloS one. 2017;12(1):e0169484. This modeling study examines the impact of changes in condom use among PrEP users and demonstrates that risk compensation may actually result in decreased HIV incidence. CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Alaei K, Paynter CA, Juan SC, Alaei A. Using preexposure prophylaxis, losing condoms? Preexposure prophylaxis promotion may undermine safe sex. AIDS. 2016;30(18):2753–6.CrossRefPubMedGoogle Scholar
  51. 51.
    Cáceres CF, O'Reilly KR, Mayer KH, Baggaley R. PrEP implementation: moving from trials to policy and practice. Journal of the International AIDS Society. 2015;18(4Suppl 3):20222.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Oldenburg CE, Nunn AS, Montgomery M, Almonte A, Mena L, Patel RR, et al. Behavioral Changes Following uptake of HIV pre-exposure prophylaxis among men who have sex with men in a clinical setting. AIDS Behav. 2017;  https://doi.org/10.1007/s10461-017-1701-1.
  53. 53.
    Kojima N, Davey DJ, Klausner JD. Pre-exposure prophylaxis for HIV infection and new sexually transmitted infections among men who have sex with men. AIDS. 2016;30(14):2251–2.CrossRefPubMedGoogle Scholar
  54. 54.
    Scott HM, Klausner JD. Sexually transmitted infections and pre-exposure prophylaxis: challenges and opportunities among men who have sex with men in the US. AIDS Res Ther. 2016;13(1):5.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Harawa NT, Holloway IW, Leibowitz A, Weiss R, Gildner J, Landovitz RJ, et al. Serious concerns regarding a meta-analysis of preexposure prophylaxis use and STI acquisition. AIDS. 2017;31(5):739–40.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Schmidt MI, Duncan BB, Bang H, Pankow JS, Ballantyne CM, Golden SH, et al. Identifying individuals at high risk for diabetes. Diabetes Care. 2005;28(8):2013–8.CrossRefPubMedGoogle Scholar
  57. 57.
    Pérez-Figueroa RE, Kapadia F, Barton SC, Eddy JA, Halkitis PN. Acceptability of PrEP uptake among racially/ethnically diverse young men who have sex with men: the P18 study. AIDS Educ Prev. 2015;27(2):112–25.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The impact of patient race on clinical decisions related to prescribing HIV pre-exposure prophylaxis (PrEP): assumptions about sexual risk compensation and implications for access. AIDS Behav. 2014;18(2):226–40.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Bogart LM, Catz SL, Kelly JA, Benotsch EG. Factors influencing physicians’ judgments of adherence and treatment decisions for patients with HIV disease. Med Decis Mak. 2001;21(1):28–36.CrossRefGoogle Scholar
  60. 60.
    Stone VE. Physician contributions to disparities in HIV/AIDS care: the role of provider perceptions regarding adherence. Curr HIV/AIDS Rep. 2005;2:189–93.CrossRefPubMedGoogle Scholar
  61. 61.
    Malebranche DJ, Peterson JL, Fullilove RE, Stackhouse RW. Race and sexual identity: perceptions about medical culture and healthcare among black men who have sex with men. J Natl Med Assoc. 2004;96(1):97–107.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Valentine JA. Impact of attitudes and beliefs regarding African American sexual behavior on STD prevention and control in African American communities: unintended consequences. Sex Transm Dis. 2008;35(12):S23–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Grant RM, Koester KA. What people want from sex and preexposure prophylaxis. Curr Opin HIV AIDS. 2016;11(1):3–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Soames Job RF. Effective and ineffective use of fear in health promotion campaigns. Am J Public Health. 1988;78(2):163–7.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Blumberg SJ. Guarding against threatening HIV prevention messages: an information-processing model. Health Educ Behav. 2000;27(6):780–95.CrossRefPubMedGoogle Scholar
  66. 66.
    Hastings G, MacFadyen L. The limitations of fear messages. Tob Control. 2002;11(1):73–5.CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Hastings G, Stead M, Webb J. Fear appeals in social marketing: strategic and ethical reasons for concern. Psychol Mark. 2004;21(11):961–86.CrossRefGoogle Scholar
  68. 68.
    Golub SA, Operario D, Gorbach PM. Pre-exposure prophylaxis state of the science: empirical analogies for research and implementation. Curr HIV/AIDS Rep. 2010;7(4):201–9.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Smith DK, Van Handel M, Wolitski RJ, Stryker JE, Hall HI, Prejean J, et al. Vital signs: estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV acquisition—United States, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(46):1291–5.CrossRefPubMedGoogle Scholar
  70. 70.
    American College of Obstetricians and Gynecologists. Reproductive life planning to reduce unintended pregnancy. Committee Opinion No. 654. Obstet Gynecol. 2016;127:e66–9.CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Department of PsychologyHunter College and Graduate Center of the City University of New York (CUNY)New YorkUSA

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