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. Author manuscript; available in PMC: 2024 Feb 1.
Published in final edited form as: Arch Sex Behav. 2022 May 10;52(2):741–750. doi: 10.1007/s10508-021-02263-7

Individual, Interpersonal, and Structural Factors That Influence Intentions to Use Pre‑exposure Prophylaxis Among Sexual Minority Men in Miami

Brooke G Rogers 1,2,3, Audrey Harkness 3,4, Satyanand Satyanarayana 3, John Pachankis 5, Steven A Safren 3,6
PMCID: PMC10463180  NIHMSID: NIHMS1924304  PMID: 35536492

Abstract

Pre-exposure prophylaxis for HIV or “PrEP” holds great promise for reducing HIV incidence. However, in certain geographic settings, like Miami, a US HIV epicenter, uptake of PrEP has been paradoxically very low compared to other areas of the country. The goal of the current study was to examine factors associated with low uptake of PrEP in young sexual minority men in Miami. Qualitative data were extracted from conversations during voluntary HIV/STI counseling and testing sessions with 24 young sexual minority men, most of whom identified as racial/ethnic minorities. These sessions were completed as part of a baseline visit for a combined mental and sexual health intervention trial. Thematic analysis of transcripts revealed barriers and facilitators associated with PrEP uptake at multiple levels (individual, interpersonal, and economic and healthcare systems barriers). Individual-level themes included concerns about the safety of PrEP, risk compensation, and taking daily oral medication; and potential benefits of PrEP as a backup plan to condom use to reassure and reduce worry about HIV. Interpersonal-level themes included lack of knowledgeable and affirming medical providers, changing norms within the community around “safe sex,” and PrEP use in serodiscordant partnerships. Economic and healthcare systems barriers included challenges to accessing PrEP because of a lack of insurance and high out-of-pocket cost. These data can be used to inform the development of interventions aligned with Ending the HIV Epidemic priorities to increase PrEP use among young sexual minority men living in an HIV epicenter.

Keywords: HIV, AIDS, Sexual health, Sexual minority men, PrEP, Sexual orientation

Introduction

Men who have sex with men (MSM), including gay, bisexual, and other sexual minority men, experience nearly three quarters of new HIV diagnoses in the USA (Centers for Disease Control & Prevention, 2020).1 With the advent of preexposure prophylaxis (PrEP) and antiretroviral therapy for prevention, increased availability of HIV testing, monitoring of medication adherence among patients with HIV, and other tools, many areas in the USA and abroad have been curtailing the epidemic. The Centers for Disease Control and Prevention (CDC) has identified young Black/African-American and Hispanic/Latino MSM as disproportionately impacted by HIV with data from 2018, demonstrating that 26% of all new HIV infections occurred among Black MSM and 21% among Hispanic/Latino MSM with the majority occurring among younger men, ages 13–34 (Centers for Disease Control and Prevention, 2021a, 2021b). Furthermore, the Ending the HIV Epidemic plan for the USA has identified geographic HIV hot spots, one of which is Miami-Dade County, which leads in terms of HIV incidence in general and particularly among young sexual minority men (Fauci et al., 2019; Florida Department of Health, 2021).

The strategy of using antiretroviral (ARV) medication through daily tenofovir disoproxil fumarate/emtricitabine (e.g., Truvada) or emtricitabine and tenofovir alafenamide (e.g., Descovy), also known as pre-exposure prophylaxis (PrEP), holds tremendous promise for prevention of HIV (Grant et al., 2010, 2014; Mayer, 2014). However, since the approval of ARV as PrEP for HIV by the US Food and Drug Administration in 2012, uptake has been suboptimal among US gay, bisexual, and other MSM. It is estimated that as few as 5.8% of MSM who meet CDC indications for PrEP use the drug as of 2014 (Hoots et al., 2016). In particular, uptake has been slow for young men who identify as both sexual minority and Hispanic/Latino and/or Black who are, due to a variety of structural and societal factors that likely also fuel suboptimal PrEP uptake, those most impacted by HIV in the USA (Centers for Disease Control & Prevention, 2020). Data collected from the CDC National HIV Behavioral Surveillance showed significant disparities in PrEP awareness among Hispanic/Latino (87%) and Black (86%) compared to White MSM (95%) (Kanny et al., 2019). Discussing PrEP with a healthcare provider in the past year was also significantly less common for Hispanic/Latino and Black MSM, with White MSM being 1.2 times (95% CI 1.1–1.3) more likely to be approached by a healthcare provider about PrEP than Black or Hispanic/Latino MSM (Kanny et al., 2019). Once discussed with their healthcare provider, Black MSM (55%) and Hispanic/Latino MSM (62%) were significantly less likely to take PrEP compared to their White counterparts (68%) (Kanny et al., 2019). MSM currently using PrEP are two to four times as likely to be White as non-White (Hoots et al., 2016; Snowden et al., 2017).

Miami is a diverse city with regards to race/ethnicity, country of origin, immigration, and socioeconomic status (Conduent Healthy Communities Initiative, 2021). Miami is also a community with high HIV incidence and prevalence and poor retention along the HIV care continuum in addition to low uptake of HIV prevention services and PrEP compared to other US cities (Doblecki-Lewis et al., 2017; International Association of Providers of AIDS Care, 2019). Approximately 25,000 people in Miami-Dade County are living with HIV, and over 1000 people are diagnosed with HIV annually. Of these, most are among men, and 81.5% of all new HIV diagnoses among men are attributable to male-to-male sexual contact (Miami-Dade County, 2021). In a survey of 20 major US cities, Miami scored below the national average (1.6% compared to the average of 3.7%) in prior-year PrEP usage among MSM (Hoots et al., 2016). In an open-label demonstration trial of PrEP for MSM, participants in Miami were less likely to have protective levels of PrEP when tested via biological samples and were more likely to drop out of the study than participants in San Francisco and Washington, DC; they were also less likely to have heard about PrEP or self-refer to participate in the trial (Cohen et al., 2015; Liu et al., 2016). The rollout and implementation of PrEP in Miami have been slow, and given the high rates of HIV incidence, there is a need to understand the potential mechanisms dampening PrEP uptake.

The present study sought to understand attitudes toward PrEP in Miami by examining qualitative data extracted from voluntary counseling and testing (VCT) sessions for sexual risk reduction with young sexual minority men (SMM), most of whom identified as racial and ethnic minorities, who were not currently taking PrEP. Although some studies have examined barriers (e.g., medication side effects, fears of drug resistance, concerns about suboptimal adherence to daily medication, concerns about mistreatment by non-affirming providers, medical mistrust) and facilitators (e.g., free access to PrEP, free STI/HIV screening services, access to one-on-one counseling, perceived benefits of taking PrEP, and concern about getting HIV) to PrEP use among young SMM, the current study innovates by using a novel and externally valid source of qualitative data (Cahill et al., 2017; Golub et al., 2013; Holloway et al., 2017). Because discussing PrEP was a structured part of the VCT sessions, we were able to observe participants’ reactions to and considerations of starting PrEP in a naturalistic setting, a novel contribution to the literature. We used the following question to guide our analysis of VCT sessions: What are the factors that influence intentions to use PrEP among young sexual minority men living in Miami?

Method

Participants

Recruitment for the parent study primarily occurred through advertisements on social and sexual networking applications for sexual minority men. In-person recruitment included placing flyers in venues throughout Miami catering to SMM (bars, clubs, cruising areas) and in counseling centers and health offices. Active recruitment was conducted in community venues and at LGBTQ + community events. Participants in the present analysis included 24 young, cisgender men (M age = 26.67, SD = 3.71). Of these, most (87.5%) identified as gay and one identified as bisexual. Reflective of Miami’s demographics, almost all participants were identified as racial/ethnic minorities (54.2% White Hispanic, 16.7% Black/African-American; 8.3% Multiracial; 4.2% Asian) with only 16.7% of individuals identifying as White non-Hispanic. Five participants were born outside of the USA, in either Latin America or the Caribbean. To contextualize the quotes, we identified participants’ nativity in addition to age category, race, and ethnicity. To protect the identities of participants, we collapsed ages into broad age categories (as opposed to exact age) and countries of origin into regions. However, many participants shared these identities, so to identify them as separate individuals, we added randomly assigned numbers to identify distinct participants for the purpose of this manuscript. These were not their study identification numbers and are not associated with their data records. For more information on the sample, see Table 1.

Table 1.

Sample Characteristics (N = 24)

M SD
Age 26.67 3.71
N %
Born Outside of USA 5 20.83
Race/Ethnicity
White (Non-Hispanic/Latino) 4 16.67
White Hispanic/Latino 13 54.17
Black/African-American 4 16.67
Multiracial (Non-Hispanic/Latino) 1 4.17
Multiracial (Hispanic/Latino) 1 4.17
Asian 1 4.17
Sexual orientation
Gay 21 87.50
Bisexual 3 12.50
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Procedure

Data for this study were extracted from the video-recorded VCT sessions delivered as part of a randomized controlled trial (Project ESTEEM; Pachankis et al., 2019). The purpose of this 3-arm trial was to compare a 10-session cognitive behavioral minority-stress-focused treatment intended to improve SMM’s mental and behavioral health to community mental health counseling and to no therapy. To be eligible for the study, participants had to meet criteria for at least one DSM mood or anxiety disorder, not be PrEP adherent, and report at least one instance of condomless anal sex with a male partner whose HIV status was unknown or positive (unless with a main partner with known undetectable viral load) within the past 90 days. Prior to randomization, all participants received a voluntary HIV/STI counseling and testing session (VCT).

VCT was based on CDC guidelines and the control arms of large community-based RCTs (e.g., Projects RESPECT, EXPLORE, AWARE) (Kamb et al., 1998; Koblin, 2004; Metsch et al., 2013). The qualitative data were extracted from clinician–participant dialogues during the VCT session. At the beginning of the session, the clinician explained the purpose of HIV/STI testing and, with the participant’s consent, administered an OraSure Rapid HIV-1/2 antibody test. The clinician reviewed facts about HIV transmission risk and PrEP, clarifying misperceptions and engaging in a person-centered discussion to elicit the participant’s current sexual behavior and contextual drivers of sexual behavior that could lead to HIV acquisition. In a manner consistent with motivational interviewing, clinicians and participants discussed pros and cons of current sexual health practices and clinicians elicited and reinforced participants own reasons for change.

Following VCT guidelines, a personalized risk reduction plan was created, including specific, achievable goals that the participant could implement to promote sexual health and local referrals. As part of VCT, the clinician asked about PrEP as a possible component of their risk reduction plan and assessed participants’ knowledge of and interest in PrEP. Clinicians used unstructured clinical probing to further discuss participants’ knowledge, interest, or opinions about PrEP depending on participants’ responses to the initial PrEP inquiry. As such, these data represent what might occur in a naturalistic VCT session and are therefore likely to reveal “real-world” thoughts and emotions surrounding PrEP use in the community. Importantly, these sessions were not semi-structured interviews conducted for the purpose of qualitative research; therefore, standardized research probes were not implemented. By contrast, probes were guided by the clinical needs of a given participant and the overall VCT manual.

Data reported here were collected from November 2016 to April 2018. Informed consent was obtained from all participants. The Human Subjects Committee of Yale School of Public Health and the Institutional Review Board of University of Miami approved all study procedures.

Data Analysis

The lead authors (B.G.R. and A.H.) used a mixed inductive–deductive approach to develop the initial codebook. Themes were identified from the literature to build initial code themes. Next, a review of the transcribed data of four interviews was used to build the initial codebook. The codebook included a list of possible codes, definitions of those codes, and examples to illustrate those codes. This codebook was consulted and revised throughout the coding process. Two bachelor’s level research assistants transcribed any discussion of PrEP from the recordings. Upon development of the initial codebook and transcription of the sessions, the data were coded independently (two coders assigned per transcript) by one bachelor’s level, one post-baccalaureate, and one doctoral-level research assistant. Thematic analysis was used to guide the coding process, such that after coding all transcripts, codes were organized into overarching “themes” generated by researchers after significant engagement with the data (Braun & Clarke, 2006, 2021). Through this process, the researcher must engage with the data to interpret meaning and do so in a way which is thoughtful and reflexive and acknowledge the ways in which their own identities may impact the evaluation of the data. Accordingly, consensus meetings included discussion about the meaning of participants’ words, themes, and how each coder’s own identity (e.g., age, sexual identity, ethnicity, race) and perspective may have shaped how they coded the data. The lead authors (B.G.R. and A.H.) facilitated consensus meetings after coding had been completed for approximately every five participant transcripts. During these meetings, coders reached consensus about prior coding inconsistencies and the lead authors resolved remaining discrepancies. Session transcripts were analyzed until saturation was reached (Guest et al., 2016). A total of 24 transcripts were included in the analysis.

Results

Themes related to PrEP occurred across three levels of influence: individual, interpersonal, and structural. Illustrative quotes for each theme are presented below. Importantly, participants’ comments about PrEP were shared within the context of HIV testing and counseling questions; therefore, there were not standardized questions or probes that led to the quotations. All quotations refer either directly or indirectly to participants’ thoughts, feelings, and intentions to use PrEP, given that the purpose of the conversation was to introduce participants to PrEP as an HIV prevention strategy and provide a referral if they elected to include it in their sexual health plan. Where needed, we include contextual information regarding the overall conversation or counselors’ question to help the reader situate the participant quotations. Participant demographics are reported following each quote and the list of themes by category and the classification as a facilitator or barrier are provided in Table 2.

Table 2.

Barriers and facilitators of PrEP uptake identified at multiple levels of influence

Domains Themes
Individual factors PrEP is being “tested” on the gay community and is only questionably safe (barrier)
PrEP will increase sexual risk behavior (barrier)
Taking PrEP will make it more dangerous if they acquired HIV (barrier)
Daily oral medication is a challenge (barrier)
PrEP could be used as a “backup plan” when condoms are not used (facilitator)
PrEP provides peace of mind regarding HIV (facilitator)
Social factors Medical providers are not knowledgeable about LGBTQ health or PrEP (barrier)
PrEP has changed the definition of “safe sex” among sexual minority men (facilitator)
PrEP can increase dating partner options with men who are living with HIV (facilitator)
Economic and healthcare systems factors PrEP is difficult to access because of insurance and cost (barrier)
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Level 1: Individual Factors

The first set of themes was related to individual-level factors related to personal beliefs, concerns, and reasons for taking PrEP.

PrEP Is Being “Tested” on the Gay Community and Is Only Questionably Safe

Some participants had spoken to members of the community who had warned that they should be skeptical about the safety of PrEP and had concerns about the community being targeted as test subjects. For example, when asked his thoughts about PrEP as an HIV prevention strategy, one participant stated:

“Some conspiracies [sic] theories believe that we are just the guinea pigs…because, you know it’s still new…It’s still controversial…we don’t really know like the long-term effects…They are also saying that if you don’t really need it, then don’t. You know, it’s really hard on the body, very hard on the liver, and I think your bones as well.” Multiracial, gay man, mid 30s, Caribbean Islands, Participant #1

Another man shared his fear that, although data were not yet available to show the harms related to PrEP, there would be data that would emerge later demonstrating negative health consequences of PrEP use when it was too late:

“I feel like it’s like not great for you. And, I feel like that’s one of the things that maybe like 25 years from now people are gonna be like, ‘oh God, like people taking PrEP… they’re ruining their bodies like smoking’ and things like that.” –White Hispanic, gay man, mid 20s, South America, Participant #2

PrEP Will Increase Sexual Risk Behavior

Several participants highlighted concerns about changes in sexual practices, which influenced their attitudes toward starting PrEP. Specifically, they were concerned that starting PrEP could increase the number of condomless anal sex acts or other behaviors that put them at risk for STIs despite being protected from HIV: “If I was in the same [sexual] situation it would be like ‘oh, well I’m on PrEP, so why even bother using a condom?’ I just don’t want my mentality to change like that.”—White Hispanic, gay man, mid 20s, U.S., Participant #3 Another participant described PrEP more broadly as a facilitator of increased sexual partnerships: “Um so you know when I first heard about it (PrEP), um, I was kind of against it because this is kind of giving people license to… sleep around.” – White, gay man, mid 30s, U.S., Participant #4.

Taking PrEP Will Make It More Dangerous if They Acquired HIV

When asked about potential concerns with taking PrEP, several participants expressed fears that taking PrEP would result in more resistance or virulence if they did acquire HIV:

“So I feel like I would always be thinking like is there like a super strain that is, you know, that because I’m taking this medication now, you know, is something that like, is there going to be a huge epidemic that’s going to affect all these people. Even though I know nothing about the science or even that be possible, or whatever, but I would think about that.” –White, gay man, early 30s, U.S., Participant #5

Daily Oral Medication Is a Challenge

Some participants described themselves as avoiding taking medication and were not interested in taking PrEP as a daily oral medication:

“Ya know overall I’m not very big on like taking medicine. Like a lot of people are like oh I feel whatever like Tylenol really quickly just pop a pill. I’m not like that so but…and I’m just not the taking medicine type” – White Hispanic, gay man, mid 20s, U.S., Participant #6

Other men were open to taking medication, but had concerns about their ability to take a pill daily:

“Number one for me is about the commitment. One of the things is that I have to take it every day…sometimes I rush out of school and I forget my wallet, I forget things…so like I’m not able to… cause I want to make sure I would be able to take it every day…if I do get on it, I don’t wanna miss a day” - Black, gay man, mid 20s, Caribbean Islands, Participant #7

PrEP Could Be Used as a “Backup Plan” When Condoms Are Not Used

Participants acknowledged that intentions to use condoms sometimes are not enacted as a result of arousal, attraction, substances, and/or difficulties with condom negotiation, which influenced their perceptions that PrEP could be beneficial. Some specifically saw PrEP as a useful strategy when substances were involved and decision-making was therefore impaired. For example, one participant explained, “If you’re going out for a night of drinking and you don’t remember a condom or whatever then yeah in that aspect it [PrEP] will be good.” -Black, gay man, mid 20s, U.S., Participant #8.

Another participant expressed his preference for condomless sex and how PrEP could help keep him safe when he did not use condoms:

“I think that it’s more like me not really thinking clearly in the heat of the moment and then like condomless sex is better…Yeah and I just like in the moment… I don’t think about the risks or consequences…Which is why I should be on PrEP because of that.” –White Hispanic, gay man, mid 20s, U.S., Participant #2

PrEP Provides Peace of Mind Regarding HIV

For many participants, positive attitudes toward PrEP were shaped by seeing PrEP as a way of reducing HIV risk and mental distress caused by worrying about potential HIV infection. As one participant said when considering the potential benefits of PrEP, “At least I can have the ease of mind that I won’t get HIV.”—White Hispanic, gay man, early 20s, U.S., Participant #9 Another described the benefits of PrEP as, “Just the peace of mind knowing that you’re taking care of yourself.” -White Hispanic, gay man, Caribbean Islands, Participant #10.

Level 2: Interpersonal Factors

A second set of themes was related to the social factors and interpersonal exchanges participants experienced around PrEP use. Participants were concerned about non-affirming, discriminatory, or judgmental reactions from medical providers. They were also considering how PrEP use may alter (or already has altered) their interactions with potential sexual partners including reducing condom use and increasing the likelihood that they would consider serodiscordant partnerships.

Medical Providers Are Not Knowledgeable About LGBTQ Health or PrEP

Many participants anticipated that they would receive non-affirming responses from providers if they were to ask for PrEP. Several participants mentioned that they did not think that they could ask providers for PrEP either because of their perceptions that providers lacked knowledge about PrEP or because they feared stigma related to disclosure of their sexual orientation and behaviors in discussing PrEP. For example, one participant explained the difficulties of identifying a PrEP provider due to the disclosures he would need to make related to his sexual identity and sexual behavior in that context, and, by extension, the potential judgment he would face from his primary care medical provider:

“It’s like weird, like you don’t want certain people to know certain things about you. That is not that she doesn’t know I’m gay or anything, I just don’t want her to know. ‘Oh, what is he doing that he needs PrEP?’” - Black, gay man, early 20s, U.S., Participant #11

Other participants felt uncomfortable bringing up the conversation about sexual health, HIV prevention, and PrEP with their doctors. They tried to assess whether their providers would be affirming of their LGBTQ + identity and whether they could disclose their sexual identity and/or HIV risk status to have the conversation about PrEP. Often, participants’ primary care provider was not someone they felt would be affirming of their identity or with whom they could have a conversation about getting on PrEP. As one participant noted when considering whether he could ask his doctor for PrEP:

“I mean like I have a doctor through my insurance, but… like… I didn’t feel, it’s not that I feel uncomfortable with him but like you know as a gay man like you always are, you wanna know that, you know your doctor is somebody that you can like really talk to about things…And I didn’t, like I didn’t really get that vibe from him.” - White, gay man, mid 30s, U.S., Participant #4

One participant voiced concerns about sharing information about his sexual health or asking for PrEP from a primary care provider who also sees other members of his family:

“Participant: She’s also my mom’s doctor. Counselor: Ok yeah so is that another thing that kind of gets in the way of asking her? Are you worried she’ll tell your mom or…?

Participant: Not so much that she’ll tell my mom. Yeah it just feels weird.”—Black, gay man, early 20 s, U.S., Participant #11

Several participants were discouraged from PrEP use by their doctors, who advised them that PrEP was not appropriate for them or suggested their behavior was not “risky enough” to warrant PrEP use:

“The first time I ever asked for information [about PrEP] and so the individual he’s describing I guess giving me the counseling you know we’re talking like, ‘oh ok like yeah I’m not really like super promiscuous, I’m not nightclubbing anymore you know having random hookups.’ Um, so that was when they were like, ‘well, then you’re pretty safe.’” - White Hispanic, gay man, mid 20s, U.S., Participant #6

PrEP Has Changed the Definition of “Safe Sex” Among Sexual Minority Men

Participants commented on PrEP and community norms around PrEP. Some noted how PrEP had changed norms around condom use and made it more difficult to assert condom use with casual partners, which in turn affected their own thoughts about using PrEP. Others commented on how common it had become to ask about PrEP status prior to a sexual encounter. All participants, despite not being on PrEP, were highly aware of community norms and beliefs around PrEP, which may have influenced their own feelings about using it for HIV prevention. Participants commented on how PrEP has changed condom use norms: “The problem I have… the problem I encounter with PrEP here…is people who are on PrEP… I’m a firm believer in condoms…but people who use PrEP they don’t want to so…so that’s a problem…to me personally.” – Black, gay man, mid 20 s, Caribbean Islands. Participant #7.

Participants who did not mind or preferred using condoms as a method of HIV prevention and for sexual health expressed frustration at how condom negotiation had become more difficult in the context of PrEP. For participants who were less assertive in their communication style, PrEP was seen as a way of protecting their sexual health that would be easier to enact than condom negotiation:

“When it comes to sex, I’m kind of subjecting myself to what the other person wants so I let them take the reins in that aspect of it. And I feel like that’s why saying I’m going to increase using condoms isn’t realistic unless I change my perspective on sexual relationships.” - White Hispanic, gay man, mid 20s, South America, Participant #12

PrEP Can Increase Dating Partner Options with Men Who Are Living with HIV

Participants held positive attitudes toward PrEP when they considered situations in which they may enter serodiscordant sexual relationships or for other potential exposures:

“And I mean that’s great too because say you are with someone who is positive and you’re not and you are like kind of maybe able to share that moment, or experience, or intimacy without hurting yourself or harming yourself…” - Multiracial, gay man, mid 30s, Caribbean Islands, Participant #1

Participants also identified the benefits of using PrEP with casual sex partners of unknown status, “Just in case somebody that I had sex with doesn’t know their status or just doesn’t even tell me at all.” –White, gay man, early 30 s, U.S., Participant #13.

Level 3: Economic and Healthcare Systems Barriers

The third set of themes was related to economic and healthcare system-related structural barriers to taking PrEP. Although PrEP was available through clinic providers in Miami, participants noted that lack of health insurance, primary care providers, and the financial cost of PrEP made it difficult to access.

PrEP Is Difficult to Access Because of Insurance and Cost

Participants had significant concerns about health insurance coverage including feasibility of obtaining and paying for PrEP. Several participants were either uninsured, underinsured, or recently insured, and, as a result, they did not attend regular medical visits or have a primary care doctor:

“I mean the only thing is like when…when PrEP and stuff like that it’s just like you need a doctor. For me in the back of my head that just means like money and things that I may not necessarily have access to like health insurance stuff like that.” - White Hispanic, gay man, early 20s, Caribbean Islands, Participant #10

Some who had health insurance questioned whether their insurance companies would cover PrEP due to anticipated discriminatory policies: “You have a lot of health care insurances that are very homophobic and reject the claim first of… and the ones that do, uh, accept the claim, its costs about seven… somewhere between 500 and 1,000 dollars.”—Multiracial Hispanic, gay man, early 20 s, U.S., Participant #14.

Given suboptimal insurance coverage and concerns about using insurance, if available, participants found themselves balancing the benefits of PrEP with the real or anticipated financial costs of the medication: “So it’s a bit pricey…PrEP could save so many people to reduce the risk of transmission almost completely, but it’s such an expensive medication to get.”—Multiracial Hispanic, gay man, early 20 s, U.S., Participant #14.

Although many participants identified perceived and actual barriers to obtaining PrEP, participants also identified community resources and organizations within the greater Miami area that could facilitate their use of PrEP by offsetting the cost of PrEP or providing it for free. A few men noted that they were aware of programs through pharmaceutical companies and insurance companies that could help support use of PrEP by reducing or eliminating cost barriers. For example, when asked about how he would obtain PrEP one participant explained: “There are certain ways to pay for it; there are certain companies and institutions that help you pay for it if it isn’t covered.” –White Hispanic, gay man, mid 20 s, South America, Participant #12.

Discussion

Young SMM in the current study described barriers and facilitators to PrEP use at multiple levels, including individual, interpersonal, and structural. Further research is needed to determine the degree to which addressing one or more of these types of multi-level components would be needed to optimize PrEP uptake in young sexual minority men in Miami. Reflective of the diversity in Miami, participants in the current study were inclusive of individuals born outside of the USA and most participants identified as racial/ethnic minorities. Importantly, the themes identified in this analysis were in the context of voluntary HIV/STI counseling and testing sessions. This unique source of qualitative data provides a window into young sexual minority men’s real-world experiences with PrEP decision-making, a new contribution to the literature on PrEP among young SMM.

Individual-level factors including attitudes, beliefs, and opinions about PrEP were similar to those noted in prior research including viewing PrEP as a “backup plan” to condoms for anal sex and fears of risk compensation (Golub et al., 2013; Holloway et al., 2017; Patrick et al., 2017). At the individual level, there were also concerns about taking PrEP daily and potential negative health consequences. It is likely that “on-demand” or “2–1–1” PrEP will soon become a standard option for PrEP use in the USA, eliminating the requirement to take PrEP daily. The IPERGAY study, a trial of oral tenofovir/emtricitabine (e.g., Truvada) taken as a double dose 24 to 2 h before a potential sexual exposure and then one pill for 2 days following a potential sexual exposure, resulted in high levels of efficacy—and demonstrated an 86% reduction in the risk of HIV among individuals taking Truvada (Molina et al., 2015). Although US clinical guidelines for PrEP use do not currently recommend this prescription pattern, studies are currently investigating ways to improve daily PrEP adherence among young MSM or to find alternate schedules, dosages, or means of PrEP administration including injectable or other longer-lasting options for PrEP (Greene et al., 2017; John et al., 2018; Meyers et al., 2018).

Additionally, many participants reported concerns about taking any type of medication due to mistrust of medical providers. Medical mistrust is a significant barrier to ARV and PrEP medication adherence (Cahill et al., 2017; Dale et al., 2016). Future interventions to increase PrEP uptake among racially and ethnically diverse young MSM should be conducted with an awareness of cultural mistrust of medication use among historically marginalized communities and seek to address these factors as part of the intervention approach.

At the interpersonal level, many of the men in this study felt that they did not have providers who were LGBTQ-affirming or knowledgeable about PrEP. These views likely reflect a true unmet need in the community. Despite being perceived as a liberal enclave of the USA, in many ways, Miami lags behind other metropolitan cities within the USA with regards to awareness, policies, and advocacy efforts for LGBTQ residents (Human Rights Campaign, 2018). These larger sociopolitical influences affect individuals’ comfort in asking for medical services related to sexual minority status, discussing sexual practices, and asking for preventive health measures such as PrEP (Mustanski et al., 2018; Pachankis et al., 2015). Additionally, at the interpersonal level, participants were concerned with how peers and potential sexual partners view PrEP. Research has demonstrated the importance of social norms for health behaviors suggesting the potential relevance of addressing social norms for PrEP uptake. The findings also highlight PrEP stigma within the community as a relevant factor to address in future PrEP uptake interventions. A recent study found that PrEP stigma was highest in areas with high HIV incidence and a high proportion of racial minorities (Mustanski et al., 2018). Given the racial and ethnic diversity of Miami and this sample, addressing stigma within the community seems an important next step to shift social norms and increase PrEP uptake.

At the structural level, there were several barriers to accessing PrEP. These included concerns about financial costs, lack of health insurance coverage, and lack of available venues for receiving PrEP. At the time of writing, there are ongoing efforts in Miami to increase access to PrEP for all key populations affected by HIV through several local and national initiatives. For example, Miami-Dade Department of Health’s “Getting to Zero” initiative was established shortly after these data were collected and aimed to increase availability and affordability of PrEP to residents (Miami-Dade County HIV/AIDS “Getting to Zero” Task Force Final Report, 2017). The new national “Ready Set PrEP” program, aligned with the “Ending the HIV Epidemic” plan, is another structural intervention that seeks to ensure cost does not impede PrEP access (Fauci et al., 2019; U.S. Department of Health and Human Services, 2022). As this program is rolled out, we will learn more about implementation challenges and successes related to such an intervention.

The strengths of this study must be interpreted considering its limitations. A potential limitation of our study is that data analyzed were collected at a single visit, so we are unable to evaluate how these views may have changed over time or as a result of the VCT sessions. Examination of the longitudinal effects of VCT, including change over time in intentions to use PrEP, would have implications beyond research, as VCT is the standard of care for HIV/STI testing. Another potential limitation is the focus on Miami and young sexual minority men may not be representative or generalizable to other regions or older age cohorts.

Conclusion

Our findings illuminate multiple individual, interpersonal, and structural issues that contribute to low PrEP uptake and may be leveraged as intervention targets to slow increasing rates of HIV among this subpopulation. By examining “real-world” conversations in the context of VCT, our study uniquely examines issues around PrEP that may help explain the slow uptake in Miami. In order to ensure that disparities in PrEP use narrow, more work needs to be done to intervene on the barriers and enhance facilitators that may help increase PrEP uptake and reduce HIV incidence among this subpopulation.

Acknowledgements

We would like to acknowledge and thank Kyle Hafkey and Christopher Albright for help with coding the data. We would also like to thank Kyle Hafkey, Jacqueline Rodriguez, and Emily Deutsch for their help transcribing the audio files.

Funding

This work was supported by the National Institute of Mental Health under R01MH109413 (Pachankis). Author time was also supported by the National Institute of Mental Health under Grant F31MH113481 (Rogers) and K23MD015690 (Harkness); the National Institute of Allergy and Infectious Disease and Providence/Boston Center for AIDS Research (CFAR) P30AI042853 (Rogers); and the National Institute on Drug Abuse under Grant 9K24DA040489 (Safren).

Footnotes

Code availability Not applicable.

Conflict of interest Dr. Brooke Rogers receives scientific funding from Gilead Sciences #IN-US-276–5463 to implement PrEP in the correctional setting. Dr. Steven Safren receives royalties from Oxford University Press, Springer/Humana Press, and Guilford Publications for books that focus on different CBT and motivational interviewing approaches. Dr. John Pachankis and Dr. Audrey Harkness receive royalties from Oxford University Press for books related to LGBTQ-affirmative mental health treatments. There are no other conflicts of interest to report.

Ethics Approval Approval was obtained from the Human Subjects Committee of Yale University and the Institutional Review Board of the University of Miami.

Consent to Participate All participants provided consent to participate in the study.

Consent to Publish All participants provided consent to research processes and publishing of their data.

Informed Consent All participants provided written informed consent prior to study participation. The study procedures and materials were approved by The Human Subjects Committee of Yale University School of Public Health and the Institutional Review Board of the University of Miami.

1

We use men who have sex with men (MSM) and sexual minority men (SMM) throughout the article. In describing our own work, we use the term SMM, which represents the identities of the participants in our study, all of whom identified as SMM. However, in referring to others’ work, we use the term that reflects their original language.

Availability of data and material

Data will not be made available.

References

  1. Braun V, & Clarke V (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. 10.1191/1478088706qp063oa [DOI] [Google Scholar]
  2. Braun V, & Clarke V (2021). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology, 18(3), 328–352. 10.1080/14780887.2020.1769238 [DOI] [Google Scholar]
  3. Cahill S, Taylor SW, Elsesser SA, Mena L, Hickson D, & Mayer KH (2017). 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, 29(11), 1351–1358. 10.1080/09540121.2017.1300633 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Centers for Disease Control and Prevention. (2020). HIV Surveillance Report 2018 (updated). 31, 119. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html [Google Scholar]
  5. Centers for Disease Control and Prevention. (2021a, September 23). HIV and African American Gay and Bisexual Men [Fact Sheet]. https://www.cdc.gov/hiv/group/msm/bmsm.html
  6. Centers for Disease Control and Prevention. (2021b, September 28). HIV and Hispanic/Latino Gay and Bisexual Men. https://www.cdc.gov/hiv/group/msm/hispanic-latino.html
  7. Cohen SE, Vittinghoff E, Bacon O, Doblecki-Lewis S, Postle BS, Feaster DJ, Matheson T, Trainor N, Blue RW, Estrada Y, Coleman ME, Elion R, Castro JG, Chege W, Philip SS, Buchbinder S, Kolber MA, & Liu AY (2015). High interest in pre-exposure prophylaxis among men who have sex with men at risk for HIV-infection: Baseline data from the US PrEP Demonstration Project. Journal of Acquired Immune Deficiency Syndromes, 68(4), 439–448. doi: 10.1097/QAI.0000000000000479 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Conduent Healthy Communities Initiative. (2021). Miami Matters: Measuring what matters in Miami-Dade County. Summary Data for County: Miami-Dade. http://www.miamidadematters.org/?module=demographicdata&controller=index&action=index&id=414&sectionId= [Google Scholar]
  9. Dale SK, Bogart LM, Wagner GJ, Galvan FH, & Klein DJ (2016). Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV. Journal of Health Psychology, 21(7), 1311–1321. 10.1177/1359105314551950 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Doblecki-Lewis S, Liu A, Feaster D, Cohen SE, Cardenas G, Bacon O, Andrew E, & Kolber MA (2017). Healthcare access and PrEP continuation in San Francisco and Miami following the U.S. PrEP Demo Project. Journal of Acquired Immune Deficiency Syndromes, 74(5), 531–538. doi: 10.1097/QAI.0000000000001236 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Fauci AS, Redfield RR, Sigounas G, Weahkee MD, & Giroir BP (2019). Ending the HIV epidemic: A plan for the United States. Journal of the American Medical Association, 321(9), 844–845. 10.1001/jama.2019.1343 [DOI] [PubMed] [Google Scholar]
  12. Florida Department of Health. (2021, March 5). HIV Data Center. http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/index.html
  13. Golub SA, Gamarel KE, Rendina HJ, Surace A, & Lelutiu-Weinberger CL (2013). From efficacy to effectiveness: Facilitators and barriers to PrEP acceptability and motivations for adherence among MSM and transgender women in New York City. AIDS Patient Care and STDs, 27(4), 248–254. 10.1089/apc.2012.0419 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Grant RM, Anderson PL, McMahan V, Liu A, Amiko KR, & Mehrota M (2014). Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: A cohort study. The Lancet Infectious Diseases, 14, 820–829. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(14)70847-3/fulltext [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, Goicochea P, Casapía M, Guanira-Carranza JV, Ramirez-Cardich ME, Montoya-Herrera O, Fernández T, Veloso VG, Buchbinder SP, Chariyalertsak S, Schechter M, Bekker L-G, Mayer KH, Kallás EG, …, Glidden DV (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 363(27), 2587–2599. 10.1056/NEJMoa1011205 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Greene GJ, Swann G, Fought AJ, Carballo-Diéguez A, Hope TJ, Kiser PF, Mustanski B, & D’Aquila RT (2017). Preferences for long-acting pre-exposure prophylaxis (PrEP), daily oral PrEP, or condoms for HIV prevention among U.S. men who have sex with men. AIDS and Behavior, 21(5), 1336–1349. doi: 10.1007/s10461-016-1565-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Guest G, Bunce A, & Johnson L (2016). How many interviews are enough?: An experiment with data saturation and variability. Field Methods, 18(1). doi: 10.1177/1525822X05279903 [DOI] [Google Scholar]
  18. Holloway IW, Tan D, Gildner JL, Beougher SC, Pulsipher C, Montoya JA, Plant A, & Leibowitz A (2017). 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 and STDs, 31(12), 517–527. 10.1089/apc.2017.0082 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Hoots BE, Finlayson T, Nerlander L, Paz-Bailey G, Wortley P, Todd J, Sato K, Flynn C, German D, Fukuda D, Doherty R, Wittke C, Prachand N, Benbow N, Jimenez AD, Poe J, Sheu S, Novoa A, Al-Tayyib A, …, Xia M (2016). Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men—20 US cities, 2014. Clinical Infectious Diseases, 63(5), 672–677. 10.1093/cid/ciw367 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Human Rights Campaign. (2018). Municipal Equality Index: A Nationwide Evaluation of Municipal Law. https://assets2.hrc.org/files/assets/resources/MEI-2018-FullReport.pdf?_ga=2.29913657.78760684.1548103971-223189626.1548103971
  21. International Association of Providers of AIDS Care. (2019). Fast Track Cities: Miami-Dade. http://www.fast-trackcities.org/data-visualization/miami
  22. John SA, Whitfield THF, Rendina HJ, Parsons JT, & Grov C (2018). Will gay and bisexual men taking oral pre-exposure prophylaxis (PrEP) switch to long-acting injectable PrEP should it become available? AIDS and Behavior, 22(4), 1184–1189. 10.1007/s10461-017-1907-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Kamb ML, Fishbein M, John M Douglas J, Rhodes F, Rogers J, Bolan G, Zenilman J, Hoxworth T, Malotte CK, Iatesta M, Kent C, Lentz A, Graziano S, Byers RH, Peterman TA, & Group, for the Project RESPECT Study Group. (1998). Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. Journal of the American Medical Association, 280(13), 1161–1167. 10.1001/jama.280.13.1161 [DOI] [PubMed] [Google Scholar]
  24. Kanny D, Jeffries WLI, Chapin-Bardales J, Denning P, Cha S, Finlayson T, Wejnert C, & National HIV Behavioral Surveillance Study Group. (2019). Racial/ethnic disparities in HIV preexposure prophylaxis among men who have sex with men—23 urban areas, 2017. Morbidity and Mortality Weekly Report, 68, 801–806. 10.15585/mmwr.mm6837a2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Koblin BA (2004). Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: The EXPLORE Randomised Controlled Study. The Lancet, 364(9428), 41–50. 10.1016/S0140-6736(04)16588-4 [DOI] [PubMed] [Google Scholar]
  26. Liu AY, Cohen SE, Vittinghoff E, Anderson PL, Doblecki-Lewis S, Bacon O, Chege W, Postle BS, Matheson T, Amico KR, Liegler T, Rawlings MK, Trainor N, Blue RW, Estrada Y, Coleman ME, Cardenas G, Feaster DJ, Grant R, …, Kolber MA (2016). HIV pre-exposure prophylaxis integrated with municipal and community based sexual health services. JAMA Internal Medicine, 176(1), 75–84. 10.1001/jamainternmed.2015.4683 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Local Data: Miami (Miami-Dade County). (2021). AIDSVu. https://aidsvu.org/local-data/united-states/south/florida/miami/
  28. Mayer KH (2014). Antiretroviral chemoprophylaxis: State of evidence and the research agenda. Clinical Infectious Diseases, 59(Suppl 1), S47–S51. 10.1093/cid/ciu322 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Metsch LR, Feaster DJ, Gooden L, Schackman BR, Matheson T, Das M, Golden MR, Huffaker S, Haynes LF, Tross S, Malotte CK, Douaihy A, Korthuis PT, Duffus WA, Henn S, Bolan R, Philip SS, Castro JG, Castellon PC, …, Colfax GN (2013). Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: The AWARE Randomized Clinical Trial. Journal of the American Medical Association, 310(16), 1701–1710. 10.1001/jama.2013.280034 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Meyers K, Wu Y, Brill A, Sandfort T, & Golub SA (2018). To switch or not to switch: Intentions to switch to injectable PrEP among gay and bisexual men with at least twelve months oral PrEP experience. PLoS ONE. 10.1371/journal.pone.0200296 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Miami-Dade County HIV/AIDS “Getting to Zero” Task Force Final Report. (2017). http://getting2zeromiami.com/wp-content/uploads/2017/02/Strategic-Action-Recommendations-revised-for-2.13.17-v2.pdf
  32. Molina J-M, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, Tremblay C, Le Gall J-M, Cua E, Pasquet A, Raffi F, Pintado C, Chidiac C, Chas J, Charbonneau P, Delaugerre C, Suzan-Monti M, Loze B, Fonsart J, … for the ANRS IPERGAY Study Group. (2015). On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. New England Journal of Medicine, 373, 2232–2246. 10.1056/NEJMoa1506273 [DOI] [PubMed] [Google Scholar]
  33. Mustanski B, Ryan DT, Hayford C, Phillips G, Newcomb ME, & Smith JD (2018). Geographic and individual associations with PrEP stigma: Results from the RADAR cohort of diverse young men who have sex with men and transgender women. AIDS and Behavior, 22(9), 3044–3056. 10.1007/s10461-018-2159-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Pachankis JE, Hatzenbuehler ML, Hickson F, Weatherburn P, Berg RC, Marcus U, & Schmidt AJ (2015). Hidden from health: Structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey. AIDS, 29(10), 1239–1246. 10.1097/QAD.0000000000000724 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Pachankis JE, McConocha EM, Reynolds JS Winston R, Adeyinka O, Harkness A, Burton CL, Behari K, Sullivan TJ, Eldahan AI, Esserman DA, Hatzenbuehler ML, & Safren SA (2019). Project ESTEEM protocol: A randomized controlled trial of an LGBTQ-affirmative treatment for young adult sexual minority men’s mental and sexual health. BMC Public Health, 19, 1086. 10.1186/s12889-019-7346-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Patrick R, Forrest D, Cardenas G, Opoku J, Magnus M, Phillips G, Greenberg A, Metsch L, Kharfen M, LaLota M, & Kuo I (2017). Awareness, willingness, and use of pre-exposure prophylaxis among men who have sex with men in Washington, DC and Miami-Dade County, FL: National HIV Behavioral Surveillance, 2011 and 2014. Journal of Acquired Immune Deficiency Syndromes, 75(Suppl 3), S375–S382. 10.1097/QAI.0000000000001414 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Snowden JM, Chen Y-H, McFarland W, & Raymond HF (2017). Prevalence and characteristics of users of pre-exposure prophylaxis (PrEP) amongst men who have sex with men, San Francisco, 2014 in a cross-sectional survey: Implications for disparities. Sexually Transmitted Infections, 93(1), 52–55. 10.1136/sextrans-2015-052382 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. U.S. Department of Health and Human Services. (2022). Ready, Set, PrEP. https://readysetprep.hiv.gov/

Associated Data

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Data Availability Statement

Data will not be made available.

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