The Pre-Exposure Prophylaxis (PrEP) Care Continuum among English-Speaking Latino Sexual Minority Men in the United States (2014–2020)

Abstract

Background:

There is limited understanding of the pre-exposure prophylaxis (PrEP) care continuum specific to Latino/x gay, bisexual, and other sexual minority men (SMM) that encompasses the population residing outside of large metropolitan or urban areas.

Setting:

We examined trends and characteristics associated with the PrEP care continuum with data from the 2014–2020 cycles of the American Men’s Internet Survey, an annual online cross-sectional behavioral survey of cisgender SMM in the U.S.

Methods:

We calculated PrEP continuum outcomes overall and by year among Hispanic/Latino SMM (n=9,010). We used generalized estimating equations with Poisson links to examine (1) temporal trends (2014–2020) in each step of the PrEP continuum and PrEP use in the past year stratified by PrEP eligibility and (2) correlates of each step of the PrEP continuum in 2020 using multivariable models.

Results:

Among 2,283 Latino SMM in 2020, 84% reported PrEP awareness, 30% discussed PrEP with a provider, 15% used PrEP in the past year, and 12% were currently using PrEP. PrEP awareness increased from 52% in 2014 to 84% in 2020; and PrEP use in past year increased from 4% in 2014 to 15% in 2020. In the multivariable models, age and PrEP eligibility were associated with PrEP use in past year, and urban-rural classification was associated with current PrEP use.

Conclusions:

While the majority of Latino SMM are aware of PrEP, significant gaps remain in this population in discussing PrEP with a provider and using PrEP that require tailored strategies to enhance access to HIV prevention services.

INTRODUCTION

Gay, bisexual, and other sexual minority men (SMM) are the group at highest risk for HIV in the United States and accounted for 69 percent of all new HIV diagnoses in 2019.¹ Pre-exposure prophylaxis (PrEP) is an effective biomedical strategy for HIV prevention and can significantly reduce the risk of HIV infection among SMM when taken regularly.² While PrEP awareness and use have increased over the years, its uptake remains far less than optimal, particularly among racial/ethnic minority SMM who are disproportionately affected by HIV.^3,4

Latino SMM, for example, bear a disparate burden of new HIV diagnoses and accounted for more than 32 percent of HIV diagnoses among SMM in 2019.¹ While new HIV diagnoses among Black/African American, Asian, and White SMM decreased from 2015 to 2019 (by 5%, 16%, and 18%, respectively), the number of new diagnoses among Latino SMM remained stable.¹ Despite their elevated risk for HIV transmission, Latino SMM report comparable or lower rates of PrEP use relative to their Black or White counterparts.^3–5

To enhance PrEP use among Latino SMM requires attention to their PrEP care continuum, which defines key steps or stages toward achieving persistent PrEP uptake.⁶ These stages include PrEP awareness, discussing PrEP with a provider, PrEP initiation, and PrEP adherence.^5,6 Identification of disparities across the PrEP care continuum among Latino SMM can facilitate development of tailored strategies to address specific gaps and ultimately reduce new HIV infections.⁶ While differences across the PrEP care continuum have been identified by race/ethnicity and other sociodemographic characteristics,^3,5,7,8 few studies have examined the PrEP care continuum specific to Latino SMM that encompass the population residing outside of large metropolitan or urban areas.^3,5 A prior paper that examined trends (2013–2017) in the PrEP care continuum using data from the American Men’s Internet Survey (AMIS) found that PrEP awareness increased over the study period among all SMM, including Hispanic/Latino SMM.⁵ While the authors found differences in PrEP usage by age, population density, and health insurance status,⁵ the study’s focus on all racial/ethnic groups limited understanding of how these characteristics differ among Latino SMM to shape PrEP outcomes. Further, this paper examined PrEP outcomes only among SMM who were eligible for PrEP according to CDC guidelines.⁹ These shortcomings have implications for HIV prevention as cultural, sociodemographic, and geographic differences in the Latino SMM community can affect each phase of the PrEP care continuum and shape the overall prevalence of PrEP use and adherence. Further, a single approach to describing the PrEP care continuum for all Latino SMM overlooks the vast diversity of the population.¹⁰

This study sought to capture the stages of the PrEP care continuum among a nationwide sample of Latino SMM and examine differences by sociodemographic and geographic factors using AMIS data. We also assessed annual changes over time across indicators of the PrEP continuum from 2014 to 2020 among Latino SMM.

METHODS

We analyzed data from the 2014–2020 cycles of AMIS, an annual cross-sectional behavioral survey of SMM. Study procedures have been documented in detail elsewhere.¹¹ Briefly, participants were recruited via convenience sampling from e-mail blasts as well as advertisements on websites and social media applications to participate in a self-administered, web-based survey. Participants in the previous year’s survey who provided email addresses were re-invited to take the survey in the subsequent year. Eligibility criteria included being aged 15 years or older, being assigned male at birth, residing in the U.S., and having ever had oral or anal sex with a man. People 15–17 years who identified as gay, homosexual, or bisexual were also eligible regardless of sexual history. Institutional Review Board approval was obtained from Emory University. Video-delivered consent information and online consent documentation was used for all participants, including those aged 15–17 (parental permission requirement was waived). Surveys were conducted in English and questions included sociodemographic characteristics, sexual behaviors, HIV/STI testing, HIV prevention service utilization, and other health outcomes.¹² Participants were not compensated for completing the survey. For the present analyses, we included participants who identified as being Hispanic/Latino/x, reported being HIV-negative or not knowing their HIV status, and had complete responses to each step in the PrEP continuum.

PrEP Outcome Measures

The following PrEP continuum outcomes were measured via self-report: having heard of PrEP “before today” (i.e. aware of PrEP); having discussed taking PrEP with a health care provider in the past 12 months; having taken PrEP in the past 12 months; and currently taking PrEP (2016–2020 only). In 2014, participants were randomly sampled on a 1:1 basis to respond to two different PrEP question sets. For this analysis, we included only those participants in 2014 randomized to the question set that was retained for use from 2015 onwards. In 2016, PrEP use in the past 12 months was not explicitly measured and was therefore approximated by reporting ever taking PrEP among those who reported discussing PrEP with a provider in the past 12 months.

Consistent with logic patterns, respondents who reported “no” to a previous step in the continuum were coded as “no” to all subsequent steps in the continuum with one exception; a small number of respondents reported using PrEP in the past 12 months but not having discussed PrEP during this period. Because it is possible for a discussion regarding PrEP greater than 12 months ago to have resulted in PrEP use in the past 12 months, we included these respondents as having used PrEP and discussed PrEP with a provider.

Other Characteristics and Behaviors

The following characteristics were assessed via self-report: age, educational attainment, housing insecurity, marital status, sexual orientation, income level, health insurance, substance use, and in 2018–2020 only, primary language (English, Spanish, or Other) and country of origin. In addition, self-reported behaviors were used to define PrEP eligibility based on CDC guidelines¹³ as either (1) having a main male sex partner who is HIV-positive or (2) having ≥2 male sex partners in the past 12 months plus condomless anal sex or an STI diagnosis in the past 12 months. HIV testing history was based on responses to questions that asked about ever having tested for HIV and, among those tested, the month and year of last test. Finally, zip code of residence was used to determine Census region of residence¹⁴ and National Center for Health Statistics urban-rural classification of county of residence.¹⁵

Analyses

First, we assessed the PrEP continuum in 2020 overall and stratified by PrEP eligibility. We used GEE with a Poisson link and robust variance to examine associations between sociodemographic characteristics and each of the following outcomes with denominators in parentheses in 2020: PrEP awareness (all respondents), discussed PrEP with provider (aware), used PrEP in past 12 months (discussed with provider), and current PrEP use (separately among those who used PrEP in past 12 months and among all respondents). To identify independent correlates, multivariable regression models were built separately for each outcome. All characteristics associated with the outcome in bivariate analyses at p<0.05 were included in the relevant multivariable model except income, which was missing for a large proportion of respondents and correlated with both age and education. For multivariable models, p-values were determined using likelihood ratio tests comparing the full model to reduced models without each individual characteristic. P-values <0.05 were considered statistically significant.

Additionally, we examined temporal trends in each step of the PrEP continuum with denominators in parentheses as follows: PrEP awareness (among all respondents), discussed PrEP with provider (among those aware), used PrEP in past 12 months (among those who discussed with provider), and current PrEP use (among those who used PrEP in past 12 months, for 2016–2020 only). In addition, we examined temporal trends (2014–2020) in the proportion of all respondents who reported PrEP use in the past 12 months, stratified by CDC PrEP eligibility guidelines and urban-rural classification given the importance of these variables in determining access to PrEP. We used generalized estimating equation (GEE) with a Poisson link, exchangeable correlation matrix, and robust variance, accounting for repeat participation across survey years. Regression models treated survey year as a linear independent variable. Resulting prevalence ratios (PRs) and associated 95% confidence intervals (CIs) represent per-year changes in each outcome.

Analyses were conducted in R Studio version 1.4.1717, apart from temporal trend analyses, which were conducted using Stata version 16.1.

RESULTS

Population Characteristics

Of the total 72,931 AMIS surveys completed from 2014–2020, 11,265 (15.4%) respondents identified as Hispanic/Latino. Among Hispanic/Latino respondents, 10,383 (92.2%) reported being HIV-negative or unknown status, of whom 9,010 (86.8%) had complete PrEP continuum data and were included in this analysis. The remainder were missing ≥1 PrEP continuum element (n=805, 7.8%) or were randomly assigned to the alternative PrEP question set in 2014 (n=568, 5.5%).

Sociodemographic characteristics, HIV testing history, sexual behaviors, and substance use behaviors for Latino SMM are presented in Table 1. About half of participants were ages 15–24 years, a majority had completed at least some college or a two-year/technical degree, and most were stably housed in the past 12 months. Most identified as gay (n=6,525, 74%) and reported having only male sex partners in the past 12 months (n=7,712, 86%). Participants primarily resided in the South (n=3,422, 38%) and West (n=3,361, 37%) regions of the U.S., and two-thirds resided in the central (n=4,211, 47%) or fringe (n=1,763, 20%) counties of large metropolitan areas. About half had tested for HIV in the past 12 months and were eligible for PrEP based on CDC guidelines. Among 5,231 respondents from 2018–2020 survey years, 4,659 (89%) reported English as their primary spoken language and 4,431 (85%) were born in the United States. Characteristics were similar between the overall sample (2014–2020) and 2020 alone.

Table 1.

Characteristics of Latino sexual minority men of negative or unknown HIV status participating in the American Men’s Internet Survey, 2014–2020

	2014–2020 (n=9,010)		2020 (n=2,283)
Characteristic	N	Percent*	N	Percent*
Age (years)
15–19	1,981	22%	338	15%
20–24	2,819	31%	881	39%
25–29	1,877	21%	673	29%
30–39	1,205	13%	239	10%
≥40	1,128	13%	152	7%
Education (highest level attained)
Less than high school	659	7%	86	4%
High school diploma or equivalent	1,798	20%	542	24%
Some college (includes 2-year/technical)	3,238	37%	897	40%
College or beyond	3,165	36%	745	33%
Housing status (past 12 months)
Stable	7,428	82%	2024	89%
Not stable/homeless	775	9%	226	10%
No Answer/Refused	807	9%	33	1%
Sexual identity
Gay	6,525	74%	1,667	73%
Bisexual	1,984	23%	536	24%
Straight	110	1%	20	1%
Don’t know/not sure	65	1%	19	1%
Something else	93	1%	35	2%
Gender(s) of sex partners (past 12 months)
Men only	7,712	86%	1,961	86%
Men and women	1,298	14%	322	14%
Income (USD/year) (2015–20 only)
<20,000	1,349	17%	317	14%
20,000 – 39,999	1,857	23%	575	25%
40,000 – 74,999	1,970	24%	549	24%
≥75,000	1,822	22%	579	25%
Don’t Know/Not Sure/Refused	1,107	14%	262	11%
Census region of residence **
Northeast	1,209	13%	278	12%
Midwest	962	11%	244	11%
South	3,422	38%	855	37%
West	3,361	37%	879	39%
US dependent area	56	<1%	27	1%
Urban-rural classification of residence ***
Large, central metro	4,211	47%	1,031	46%
Large, fringe metro	1,763	20%	434	19%
Medium/small metro	2,505	28%	670	30%
Non-core/rural	474	5%	120	5%
Primary language (2018–20 only)
English	4,659	89%	2,015	88%
Spanish	563	11%	259	11%
Another language	33	0.6%	7	0.3%
Country/Region of birth (2018–20 only) †
United States	4,431	85%	1,927	85%
Mexico	368	7%	172	8%
Caribbean±	60	1%	23	1%
Central America†	122	2%	51	2%
South America‡	203	4%	77	3%
Spain	7	0.1%	0	0%
Country in another region	29	0.6%	12	0.5%
Has health insurance	6999	86%	1789	82%
HIV testing history
Last test ≤ 12 months ago	4,795	55%	1,128	50%
Last test >12 months ago	1,441	17%	518	23%
Never tested	2,485	28%	609	27%
PrEP eligible ¶	4,554	51%	1,290	57%
Anal sex without a condom with male partner (past 12 months)	6,209	79%	1,644	80%
Methamphetamine Use (ever)	252	3%	63	3%
Injection Drug Use (ever)	179	2%	45	2%

^*Percentages for each category are calculated using the total number of observations for whom data is available for the respective variable.

^**Based on the United States Census Bureau Region Scheme

^***Based on the National Center for Health Statistics Urban – Rural Classification Scheme for Counties

^†Caribbean includes: Cuba, Dominican Republic, and Jamaica. Central America includes: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama. South America includes: Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, and Venezuela.

^¶Based on CDC guidelines: (1) reported a main sex partner who is HIV-positive or (2) reported two or more sex partners in the past 12 months and either (a) condomless anal sex in the past 12 months or (b) diagnosis of an STI in the past 12 months.

2020 PrEP Continuum

Figure 1 presents the PrEP continuum in 2020, overall (Panel A) and stratified by PrEP eligibility (Panel B). Overall, 84% (n=1,912) reported being aware of PrEP, 30% (n=677) discussed PrEP with a healthcare provider in the past 12 months (35% of aware), 15% (n=346) used PrEP in the past 12 months (51% of discussed), and 12% (n=263) were currently using PrEP (76% of PrEP use in past 12 months). PrEP-eligible respondents were more likely to report each outcome along the continuum than those not eligible for PrEP (p<0.0001 for all), including higher current PrEP use (18% vs. 3%, respectively). PrEP continuum outcomes in 2020 stratified by sociodemographic characteristics are presented in Table 1, Supplemental Digital Content.

Figure 1.

HIV pre-exposure prophylaxis continuum among Latino sexual minority men reporting HIV-negative or unknown status, American Men’s Internet Survey 2020

Trends in PrEP Continuum

Overall, awareness of PrEP increased from 52% in 2014 to 84% in 2020 (PR=1.06, 95%CI=1.05–1.06; p<0.0001); having discussed PrEP with a provider in the past 12 months increased from 13% to 30% (PR=1.14, 95%CI=1.12–1.17; p<0.0001); and PrEP use in the past 12 months increased from 4% to 15% (PR=1.18, 95%CI=1.14–1.22; p<0.0001) (Figure 2, Panel A). Current PrEP use increased from 8% in 2016 to 12% in 2020 (PR=1.07, 95%CI=1.02–1.12; p=0.01). In stratified analyses, PrEP use in the past 12 months increased significantly among both PrEP eligible (6% in 2014 to 23% in 2020) and ineligible respondents (2% to 5%) (p≤0.01 for both; Figure 2, Panel B). Similarly, contingent on the previous step in the continuum, having discussed PrEP increased from 25% in 2014 to 35% in 2020 among those aware (PR=1.08, 95%CI=1.06–1.10; p<0.0001); PrEP use in the past 12 months increased from 31% in 2014 to 51% in 2020 among those who had discussed PrEP with a provider (PR=1.03, 95%CI=1.01–1.06; p=0.02); and current PrEP use remained stable from 2016–2020 among those who had used PrEP in the past 12 months (range=76–87%; PR=0.98, 95%CI=0.96–1.00; p=0.09). We conducted sensitivity analyses adjusting for age for all PrEP outcomes described above, which produced similar results.

Figure 2.

Trends in the HIV pre-exposure prophylaxis continuum among Latino sexual minority men reporting HIV-negative or unknown status, American Men’s Internet Survey 2014–2020¹

¹ Descriptive prevalence data are presented in Supplemental Table 3

Correlates of PrEP Outcomes

Table 2 presents the final multivariable models for each step in the PrEP continuum in 2020. In bivariate analyses (see Table 2, Supplemental Digital Content) being aged 20 years and over (vs. 15–19), having higher levels of education, identifying as gay (vs. bisexual/straight), residing in metropolitan areas of any size (vs. non-core/rural counties), speaking English as a primary language, and being eligible for PrEP were associated with PrEP awareness (p<0.05). Education and PrEP eligibility remained associated with PrEP awareness in the multivariable model (Table 2; p<0.0001 and p=0.02, respectively).

Table 2.

Characteristics associated with each step of the PrEP continuum among HIV-negative and unknown HIV status Latino sexual minority men, American Men’s Internet Survey, 2020¹

Outcome (Denominator)	Aware of PrEP (Total)		Discussed with provider (Aware)		PrEP use in past 12 mos (Discussed)		Current PrEP use (Use in past 12 mos)		Current PrEP use (Total)
	aPR (95% CI)2	P	aPR (95% CI)2	P	aPR (95% CI)2	P	aPR (95% CI)2	P	aPR (95% CI)2	P
Age (years)		0.56		0.0009		0.03		n/a		<0.0001
15 – 19	0.93 (0.73, 1.18)		0.41 (0.26, 0.66)		0.51 (0.26, 1.00)		-		0.14 (0.05, 0.36)
20 – 24	1.05 (0.86, 1.28)		0.87 (0.64, 1.17)		0.72 (0.50, 1.04)		-		0.53 (0.34, 0.82)
25 – 29	1.06 (0.87, 1.30)		0.91 (0.68, 1.21)		0.85 (0.59, 1.22)		-		0.74 (0.49, 1.13)
30 – 39	1.04 (0.83, 1.30)		0.88 (0.62, 1.24)		1.11 (0.73, 1.68)		-		1.08 (0.68, 1.71)
≥ 40	Ref		Ref		Ref		-		Ref
Education Level		0.03		0.14		n/a		n/a		0.12
Less than high school	0.76 (0.58, 1.02)		0.84 (0.48, 1.47)		-		-		1.20 (0.58, 2.49)
High school or equivalent	0.83 (0.72, 0.95)		0.76 (0.59, 0.98)		-		-		0.65 (0.42, 0.98)
Some college/2-year/trade	0.93 (0.83, 1.04)		0.86 (0.72, 1.03)		-		-		0.80 (0.60, 1.06)
College and beyond	Ref		Ref		-		-		Ref
Gay (vs. bisexual/straight3)	1.11 (0.99, 1.24)	0.06	1.22 (1.00, 1.50)	0.05	-	n/a	-	n/a	1.85 (1.27, 2.69)	0.0005
Insured (vs. uninsured)	-	n/a	1.23 (0.98, 1.55)	0.07	-	n/a	-	n/a	1.76 (1.16, 2.69)	0.005
PrEP Eligible (vs. ineligible)	1.12 (1.02, 1.23)	0.02	2.41 (1.99, 2.92)	<0.0001	1.59 (1.18, 2.15)	0.001	-	n/a	5.05 (3.44, 7.40)	<0.0001
Urban-rural classification of residence		0.60		0.40		0.37		0.02		0.06
Large, central metro	Ref		Ref		Ref		Ref		Ref
Large, fringe metro	0.99 (0.87, 1.12)		0.91 (0.73, 1.13)		0.84 (0.63, 1.14)		1.07 (0.77, 1.48)		0.82 (0.58, 1.15)
Medium/small metro	0.99 (0.89, 1.10)		0.90 (0.75, 1.09)		0.81 (0.63, 1.05)		0.80 (0.58, 1.11)		0.66 (0.47, 0.91)
Non-core/rural	0.86 (0.69, 1.08)		0.75 (0.48, 1.16)		0.94 (0.52, 1.69)		1.06 (0.56, 2.10)		0.73 (0.37, 1.44)
Primary language other than English (vs. English)	0.87 (0.74, 1.02)	0.08	-	n/a	-	n/a	-	n/a	-	n/a

¹Descriptive prevalence data are presented in Supplemental Table 1

²aPR: adjusted prevalence ratios; CI: confidence intervals; Estimates from multivariable regression models that included all characteristics associated with the relevant outcome in bivariate analyses at p<0.05. Housing status, U.S. census region, and country of birth were not significantly associated with any outcome in bivariate analyses and are therefore not included here. In addition, income was associated with being aware of PrEP (p=0.0008) and current PrEP use among total respondents (p=0.01) but was missing for a substantial proportion of participants and therefore excluded from multivariable models.

³Participants who identified with a different category other than bisexual or straight were not included in this analysis.

In bivariate analyses, respondents who were aware of PrEP were more likely to report having discussed PrEP with a provider in the past 12 months as age and education level increased and if they identified as gay, had health insurance, were eligible for PrEP, and lived in large metropolitan areas (see Table 2, Supplemental Digital Content). Age and PrEP eligibility remained significantly associated with discussing PrEP with a provider in the multivariable model (Table 2; p=0.0009 and p<0.0001, respectively).

PrEP use in the past 12 months was associated with increasing age, PrEP eligibility, and living in the center of a large metropolitan area among those who had discussed PrEP with a provider in bivariate analyses (see Table 2, Supplemental Digital Content). Age and PrEP eligibility remained significantly associated with past-year PrEP use in the multivariable model (Table 2; p=0.03 and 0.001, respectively).

Among those who reported PrEP use in the past 12 months, only urban-rural classification was associated with current PrEP use, with those in medium/small metropolitan areas less likely to report current use than other groups (p=0.02) (Table 2).

DISCUSSION

Latino SMM in the U.S. experienced significant increases in all steps of the PrEP continuum (PrEP aware, PrEP discussion with provider, PrEP use in past 12 months, and current PrEP use) over the 7-year period from 2014 to 2020. However, while the majority of Latino SMM were aware of PrEP, only 12 percent of Latino SMM with HIV-negative or unknown status were currently using PrEP in 2020. Encouragingly, a greater proportion of Latino SMM who met CDC PrEP eligibility criteria reach each step of the continuum than Latino SMM who did not meet criteria. However, PrEP use was low and remained relatively stagnant among non-eligible Latino SMM despite potential benefits to this group. While PrEP eligibility criteria seeks to encourage uptake among individuals who are at high risk of getting HIV,¹³ it may contribute to misleading perceptions about HIV risk or about who can benefit from PrEP, posing barriers to uptake, particularly in racial/ethnic minority communities disproportionately affected by HIV. Further, factors including age and urbanicity of residence were associated with different steps across the PrEP continuum in 2020 among Latino SMM. Our findings illustrate major gaps across the PrEP continuum and point to opportunities to increase PrEP use in specific subgroups of Latino SMM across the U.S.

While PrEP awareness among Latino SMM increased significantly from 2014 to 2020, the most notable increase occurred between 2014 and 2016. This increase aligns with the CDC’s release of clinical PrEP guidelines to health care providers in 2014¹³ as well as strengthened efforts to raise PrEP awareness among SMM.^16,17 Although the majority (84%) of Latino SMM were aware of PrEP by 2020, only 30 percent had discussed PrEP with a provider in this same year. These data underscore that despite being increasingly aware of PrEP, Latino SMM encounter persistent barriers to the referral to and receipt of PrEP services.^18,19 Structural issues, including inequitable access to health services, as well as stigma and other psychosocial factors among Latino SMM may contribute to this disparity between PrEP awareness and PrEP discussion with a provider.^19,20 As PrEP referrals and discussions tend to occur in healthcare settings, alternative strategies to enhance the accessibility of PrEP services (e.g., community-based approaches) might reduce this gap in Latino SMM who may be less likely to have health insurance or a regular healthcare provider.^21,22

Alongside overall increases in PrEP awareness and PrEP discussions with a provider, our results indicated that PrEP use in the last 12 months significantly increased from 4 percent in 2014 to 15 percent in 2020. The steady increase in PrEP use may be attributed to increased awareness of PrEP alongside increase acceptance of its use. Additionally, persistent efforts to reduce costs associated with PrEP and increase its accessibility even for those without health insurance may have facilitated uptake.²³ Still, lower prevalence of current PrEP use among uninsured Latino SMM point to remaining challenges in ensuring uptake among subgroups who encounter barriers to accessing health services.

As PrEP eligibility was associated with differences across each step in the PrEP continuum in 2020, ensuring that individuals at high risk for HIV, including Latino SMM, are aware of the specific indications for PrEP is important for enhancing awareness and subsequent PrEP use. Yet, even among those who were PrEP eligible, less than one in five Latino SMM reported current PrEP use in 2020. The limited numbers of PrEP eligible Latino SMM who are using PrEP suggests a barrier to PrEP delivery that may widen HIV disparities. Further, many SMM who do not meet CDC PrEP eligibility guidelines may remain at risk for HIV or may benefit from PrEP.²⁴ Hence, identifying and understanding specific barriers to PrEP delivery for all Latino SMM should remain an important focus for future research.

Our results demonstrated that younger Latino SMM were less likely to be aware of PrEP, discuss PrEP with a provider, and report PrEP use in the last 12 months. These findings align with prior research that has documented age as a barrier to PrEP access in Latino and other SMM populations.^18,25 While younger SMM populations are less likely to be eligible for PrEP,²⁶ emerging adults aged 18–25 years are the age group with the lowest rate of PrEP uptake even among those who meet CDC PrEP eligibility.²⁷ Facilitating PrEP use in Latino SMM will require attention to age and to developmentally appropriate considerations during transitions from adolescence to adulthood in communities who may traditionally lack access to health and preventive services. As younger Latino SMM have unique needs, social and economic norms, and preferences related to understanding and obtaining HIV prevention services,²⁷ efforts to develop culturally sensitive and tailored services for Latino SMM across the PrEP continuum are critical to achieving greater PrEP uptake.

Our results pointed to urbanicity of residence as a potential factor that may pose challenges to accessing PrEP. Specifically, Latino SMM residing in the central counties of large metropolitan areas had greater PrEP use in the last 12 months relative to those residing in medium/small metropolitan areas. As resources and PrEP information may be more widely available in urban settings, Latino SMM outside of larger urban communities may require additional support in accessing health and social services.^28–30 Given the growing scarcity of health care services in rural communities,³¹ innovative models of delivering health services to Latino SMM and other communities outside of urban areas are necessary to reduce PrEP access barriers. Notably, methods such as TelePrEP³² deliver PrEP services via smartphone, laptop, or tablet and offer discreet and ways to receive PrEP that do not require travel to clinics or in-person settings. These models must consider the distinct cultural, social, financial, and structural factors that characterize Latino SMM communities in rural and less developed contexts. As the Latino population has increased over the past decade in non-traditional and non-urban settlement locations in the U.S.,^33–35 ensuring that rural communities are intentionally included in HIV treatment and prevention strategies will be critical for reducing PrEP-related disparities in Latino SMM.

Our study demonstrated significant improvements across the PrEP continuum from PrEP awareness to PrEP use between 2014 and 2020. Despite the increase in the percent of Latino SMM currently using PrEP, a considerable proportion of Latino SMM remain unengaged in PrEP services. Racial and ethnic disparities in PrEP uptake have been well documented in the U.S. with Latino SMM experiencing lower rates of PrEP uptake relative to their White counterparts.³ Further, PrEP access inequities due to sociodemographic factors, including education, age, and urbanicity^7,36 have been previously identified in the U.S. and persisted within our sample of Latino SMM. As overall progress in HIV prevention and PrEP uptake highlights uneven gains, greater attention to factors that limit PrEP access among Latino SMM and specific subgroups are needed. Multisectoral approaches that involve deliberate collaboration among various stakeholder and community groups may help address the complex and multilevel challenges to ensuring that PrEP is available and accessible to Latino SMM in culturally relevant and acceptable ways. Such efforts will warrant thoughtful consideration of the diverse perspectives and preferences of all Latino SMM.

This study is subject to several limitations. Data were based on self-report, which may be subject to bias. Our sample of Latino SMM is based on a convenience sample and does not represent all Latino SMM in the U.S. or online samples of Latino SMM. Data on the racial identities of participants were incomplete, which limited our ability to assess participants across ethnoracial identities. While questions related to PrEP slightly changed over time, our analyses were not sensitive to assumptions associated with such changes. Our analyses did not consider PrEP adherence or persistence, which are key issues in ensuring PrEP effectiveness.³⁷ Additionally, approximately half of Latino SMM in our sample (2014–2020) were PrEP eligible, which is higher than recent national estimates that suggest that about a third of Hispanic/Latino SMM are eligible for PrEP.²⁶ AMIS’s use of slightly different criteria in which duration or continuation of sexual partnerships with an HIV-positive male partner is not considered in determining eligibility as it is for the CDC criteria may potentially explain this difference. Hence, while our sample may overrepresent Latino SMM who may be at higher risk for HIV transmission, our study raises an important question regarding the relevance of risk eligibility criteria for Latino communities with high overall HIV incidence. Our sample only included Latino SMM who were able to complete the survey in English. Future analyses are needed to characterize PrEP-related outcomes among linguistically diverse Latino SMM with attention to other social and behavioral characteristics such as length of time residing in the U.S. and preferred language.

CONCLUSIONS

PrEP use is increasing among Latino SMM across the U.S. While the vast majority of Latino SMM are aware of PrEP, significant gaps remain in this population in discussing PrEP with a provider and using PrEP. Achieving adequate uptake of PrEP and reducing disparities in HIV transmission in Latino SMM will require greater understanding of the specific challenges faced by Latino SMM in PrEP access and use. Our findings call attention to the social and structural contexts in which Latino SMM are situated that may influence opportunities for accessing PrEP.