The low rate of use of Truvada (tenofovir disoproxil fumarate/emtricitabine) as pre-exposure prophylaxis (PrEP) among African-American men who have sex with men (MSM) may be driven in part by stigma related to intersectional identities, including being both Black and gay, aidsmap reports. Additionally, overlapping stigma toward and stereotypes about PrEP users and HIV-positive men likely inhibit the use of Truvada as prevention in this population.
Seven years after PrEP’s approval, an estimated 200,000 people, the vast majority of whom are MSM, are taking Truvada for prevention, according to Gilead Sciences, which manufactures the drug. PrEP users are predominantly white MSM older than 25. Only a small fraction of users are Black MSM—this despite the fact that the rate of new HIV infection among Black MSM is much higher than that among their white counterparts.
Publishing their findings in Social Science & Medicine, researchers conducted six focus groups in Milwaukee between late 2017 and early 2018 that included a total of 44 Black MSM. The participants were 18 to 25 years old, designated male at birth, had had sex with a man in the last two years and were HIV negative or of an unknown HIV status.
Three quarters of the participants identified as gay, 48% had a high school diploma or the equivalent and four had a college degree. More than two thirds had a full- or part-time job; half earned less than $10,000 per year. Two of the men had previously used PrEP, and eight were currently on Truvada for prevention. Each focus group included at least one man who was taking PrEP.
In the focus groups, the leaders covered five major topics, including: 1) an introduction to PrEP; 2) willingness to take PrEP or support a partner in doing so; 3) perceptions and stereotypes of individuals on PrEP; 4) perceived barriers to PrEP uptake among Black MSM; and 5) the use of health care, including barriers to access. Additionally, the men were asked how they saw their personal experiences as different from those of Black heterosexual men and white gay men.
Stigma emerged as a dominant theme, with the men saying they both anticipated and experienced negative attitudes from health care providers based on their race, sexuality or both. These factors in turn served as barriers to PrEP access. They also reported that as Black MSM, they tended to receive poorer services from the health care system, which made them more hesitant to access that system in order to obtain Truvada for prevention.
Men said they faced judgment from health care providers that they felt was driven by racial bias. Wary of negative appraisals, they said they were disinclined to disclose their sexual behaviors with men to clinicians and preferred to maintain a more traditional masculine front when seeing a health care provider in order to avoid what they feared would be homophobic attitudes.
The study participants said the use of PrEP served as a marker of gay sexual identity, one that might out them to their families—a problem that was particularly pronounced among the younger, closeted men in the study group.
Some of the study participants, in particular those taking Truvada for prevention, said that to help promote PrEP use among Black MSM, members of this community should engage in peer education and advocacy about Truvada as prevention, targeting younger men in particular. They were especially concerned that a knowledge deficit about PrEP is inhibiting its uptake among their peers.
The men commonly reported experiencing racism and various forms of social inequity—harmful effects that were compounded by homophobia. Competing priorities in life, they said, including poverty, unemployment and racial segregation, led PrEP to drop down on Black MSM’s list of priorities.
The participants tended to be of two minds about PrEP use among Black MSM. On the one hand, they were inclined to characterize those taking PrEP as “responsible” and “mature.” However, when asked who they thought should be taking Truvada for prevention, they referenced men they characterized in stigmatizing terms as promiscuous as well as men whom they said do not value themselves highly.
Considering that Truvada is used both as prevention and, among HIV-positive individuals, as treatment for the virus, the men had overlapping stigmatizing attitudes toward men taking such a pill for either purpose. Stigma toward the practice of condomless sex, which these men presumed both PrEP users and those living with HIV engage in, further linked these two groups in their minds. Condoms, they tended to feel, remained the standard, “correct” form of HIV prevention. Eschewing latex and using only Truvada for prevention, in their minds, was irresponsible and conflicted with an entrenched social norm.
In sum, the men conveyed that Black MSM may avoid PrEP because they do not want to be associated with the intersectional identity of being an African-American gay HIV-positive man.
“Multilevel interventions are needed to address the society stigmas and inequities facing young Black GBM [gay and bisexual men],” the study authors concluded. “Interventions to mitigate intersectional stigma and its consequences can cultivate environments in which young men are able to access quality health care, including PrEP, without judgment or discrimination.”
To read the aidsmap article, click here.
To read the study abstract, click here.