Sexually Transmitted Infection Prevention Perspectives in Black Men Who Have Sex With Men Taking Preexposure Prophylaxis in New Orleans

In a qualitative study, Black men who have sex with men engaged in preexposure prophylaxis care in New Orleans, Louisiana, described their willingness to engage in various sexually transmitted infection prevention strategies.

Abstract

Introduction

Profound sexual health disparities exist for Black men who have sex with men (MSM) in the US South, including a high prevalence of sexually transmitted infections (STIs). Sexually transmitted infection prevention strategies beyond condoms are needed for Black MSM taking preexposure prophylaxis (PrEP).

Methods

We conducted in-depth interviews with Black MSM taking PrEP in New Orleans, Louisiana. Informed by the Health Belief Model, we asked about participants' perceived susceptibility, severity, and concerns regarding STIs, and perceived benefits of STI prevention. We also asked about willingness to use various STI prevention strategies, including antibiotic prophylaxis. Interviews were audio-recorded and analyzed using applied thematic analysis.

Results

We interviewed 24 Black MSM aged 18 to 36 years; half had a recent STI diagnosis. Most participants were concerned about receiving an STI diagnosis, noting shame or disappointment; physical effects were concerning but infrequently considered. Participants described being less likely to use condoms with routine partners or those taking PrEP. Most reported being willing to engage in each of the 6 prevention strategies discussed.

Conclusions

Black MSM taking PrEP voiced concern about STIs, and many noted that they infrequently use condoms. They were willing to engage in methods focused on preventing STIs on an individual or population level.

Rates of bacterial sexually transmitted infections (STIs) have risen sharply in recent years, and persons of color and men who have sex with men (MSM) are disproportionately impacted. In the US South, including in Louisiana, these trends are often magnified.^1–4 In addition, rates of STIs have been shown to be high in those on HIV preexposure prophylaxis (PrEP).^5,6 Where these risk groups converge—in Black MSM (BMSM) engaged in HIV PrEP care in the South—sexual health disparities are profound; yet, although prior research has evaluated the relationship between HIV PrEP and STIs in MSM populations, little research has focused on STI prevention specifically in BMSM.^7,8 Additional prevention research, including efforts to determine the acceptability of prevention strategies, is needed, particularly in the wake of recent studies demonstrating the efficacy of doxycycline for bacterial STI prophylaxis.^9–11 In one prior study to evaluate the acceptability of doxycycline for STI postexposure prophylaxis, 84% of gender-diverse participants reported interest in this strategy, and African American race was associated with higher interest.¹²

As part of a larger study to design an app focused on STI prevention among BMSM,¹³ we conducted qualitative research to explore perceptions about STIs and risk reduction practices in BMSM. The purpose of this study was to describe participants' perceptions around STIs and willingness to engage in various STI prevention activities.

MATERIALS AND METHODS

We conducted a qualitative descriptive study using in-depth interviews with BMSM taking PrEP in New Orleans, Louisiana, from January 2020 to May 2021.¹⁴ Black MSM with and without an STI history, aged 18 to 35 years at the time of recruitment, and engaged in PrEP care were recruited and eligible to participate. We purposefully recruited 12 participants with recent (within 12 months) bacterial STI diagnosis and 12 without. The question guide was informed by the Health Belief Model (HBM), a widely used theoretical framework that draws connections between individuals' beliefs and health-related behaviors.¹⁵ Following the model's constructs, we included questions about participants' perceived susceptibility and perceived severity of having an STI, and about participants' perceived benefits of and their willingness and ability to engage in various STI prevention strategies, including increased testing frequency, self-examinations, partner notification and partner delivered therapy, vaccines and antibiotics prophylaxis, and peer support via a mobile Health (mHealth) application, that is, an “app” for use on a cellular phone (Table 1)^{9–11,16–25} Interviews were audio-recorded, with participants' permission. The study was approved by our local Institutional Review Board (Protocol No. 497).

TABLE 1.

STI Prevention Strategies Explored With Participants and Rationale

STI Prevention Strategy	Rationale
Testing frequency	Testing for and treating STIs is an important prevention step to limit ongoing transmission, and recent findings suggest that substantial numbers of Black MSM have asymptomatic STIs but are not tested.16 Mathematical modeling has demonstrated that increasing testing frequency (e.g., from every 6 mo to every 3 mo or from every 3 mo to monthly) can further reduce the incidence rate of STIs among PrEP users.17
Conducting self-examinations	In one study, MSM who were primarily receptive partners in anal sex were more likely to present with secondary syphilis, implying an increased likelihood of undetected primary syphilis.18 This finding implies that anorectal chancres more often go unnoticed relative to penile chancres and presents an opportunity for additional prevention strategies—i.e., performance of self-examinations—to improve early detection, reduce duration of infectiousness, and limit the likelihood of transmission to partners.
Partner notification and partner-delivered therapy	Patient-delivered partner therapy has been shown to be effective in reducing the rates of recurrent chlamydia and gonorrhea infection among heterosexual adults, although experts recommend that this strategy should only be used in MSM “selectively, and with caution when other partner management strategies are impractical or unsuccessful.”19–21 Current Louisiana law allows for partners to deliver prescriptions for medications to partners.22
Biomedical prevention	Prior studies have shown that doxycycline used as preexposure or postexposure prophylaxis can prevent syphilis and chlamydia, and a recent study suggests benefit for gonorrhea prevention as well.9–11 Numerous vaccines protect against viral STIs (e.g., human papilloma virus, hepatitis A and B, Mpox), and there is potential for the meningococcal group B vaccine to prevent gonorrhea. This vaccine is being evaluated in a clinical trial currently (NCT04350138).
Peer support through mHealth	Among Black MSM, use of mHealth interventions including peer support features has been associated with improved attitudes toward condom usage and reduce episodes of condomless sex.23–25

We analyzed the interviews using applied thematic analysis.²⁶ We followed a 2-stage deductive and inductive analysis approach. First, analysts used NVivo²⁷ 12 to apply structural codes to transcripts based on the research objectives and interview guide domains. Second, selected structural coding reports were reviewed to identify content codes, and analysts applied these codes to relevant portions of the transcripts. To ensure consistency of the coding process, intercoder reliability was assessed on 20% of the transcripts, and all coding discrepancies were resolved through discussion followed by revisions to the codebook and previous transcripts. After coding was complete, tables were created to visualize code frequency and distribution across participant groups (i.e., BMSM with and without prior STI diagnosis) and to aid in identifying salient themes in the dataset.

RESULTS

We interviewed 24 self-identified, non-Hispanic BMSM taking PrEP, with a mean age of 28.5 years. Half had been diagnosed with an STI in the prior 12 months, and most (n = 16, 66.7%) had been taking PREP for more than 1 year (Table 2).

TABLE 2.

Participant Demographic Characteristics (n = 24)

Parameter	n (%)
Mean age, y	28.5
Sexual identity
Gay or homosexual	17 (70.8)
Bisexual	6 (25.0)
Queer	1 (4.2)
Duration on PrEP
3–6 mo	3 (12.5)
6–12 mo	5 (20.8)
>12 mo	16 (66.7)
Employment
Employed and not in school	18 (75.0)
Employed and in school	3 (12.5)
Unemployed and not in school	3 (12.5)
Education level
High school graduate or GED	5 (20.8)
Some college, technical, or vocational school	6 (25.0)
Technical or vocational school graduate	2 (8.3)
4-y college graduate	7 (29.2)
Some graduate school	2 (8.3)
Master's degree or above	2 (8.3)
Housing status
Own/Rent	18 (75.0)
Living with friend/relative	6 (25.0)
Income
<$15,000	7 (29.2)
$15,000–$24,999	3 (12.5)
$25,000–$34,999	7 (29.2)
$35,000–$49,999	3 (12.5)
$50,000–$74,999	3 (12.5)
≥$75,000	1 (4.2)
Health insurance status
A private health plan	10 (43.5)
Medicaid	11 (47.8)
Uninsured	3 (8.7)

Concerns About STIs

Perceived Susceptibility

Nearly all participants perceived little to no chance of getting an STI in the near future. However, many acknowledged that their sexual behavior could put them at risk if they were not careful to prevent exposure. Most explained that their low-risk perception was due to not being sexually active enough (e.g., not having multiple partners) or consciously taking steps to reduce their risk through engaging in risk-reduction methods such as using condoms or evaluating partners for signs of active infection. Several participants described learning from past STI diagnosis experiences and taking more active steps to avoid future exposure:

Because now that I had it, I know what to do and I'm gonna be more careful because I don't want to catch something I can't get rid of…Just watching who I would sleep with, watch who I lay in bed with…the condoms of course is in full effect, making sure I take my PrEP on a continuous note, and, yeah, just watching. And another thing for me, I guess inspecting people's bodies before I go and do that act, if that makes sense.—22 years old with recent STI

Perceived Severity

Participants with and without recent STIs expressed concerns about the short-term physical adverse effects of STIs, such as pain during urination, discharge, rectal bleeding, or lesions, and long-term adverse effects such as developing cancer, blindness, or infertility. Participants without a recent STI diagnosis frequently described that their concerns varied depending on the specific STI, noting differences in the length and complexity of treatment, the severity of symptoms, and risk of transmission. Sexually transmitted infections with recurring symptoms or requiring lifelong treatment caused more distress, whereas others caused less distress because, as one participant noted, “you can easily get a shot or some kind of medications” to provide a cure. One participant without recent infection noted that STIs were not something he frequently considered:

You know, there's always a bit of concern but it's not something that I'm thinking about at all times…I don't wake up in the morning, it's not, ‘oh, super gonorrhea is coming.’—32 years old without recent STI

Participants also expressed concern about the psychosocial effects of an STI diagnosis or a theoretical STI diagnosis. Men without a recent STI described potentially feeling “unclean” and the possible emotional burden of acknowledging that they had an STI. One participant said:

There's a social stigma attached to [STIs]. You know, it's something that you morally and I believe legally have to disclose to sexual partners, so I think there is some shame and guilt built in…and being perceived as like, being dirty…you tell a sexual partner and that might end that interaction.—32 years old without recent STI

Some participants expressed that an STI diagnosis was often accompanied with feelings of shock or betrayal by their partner. Both groups of men also described that they would feel disappointed, embarrassed, or depressed if they were diagnosed with an STI. Reflecting upon his own recent diagnosis, one participant said, “It made me sad. It made me feel like I failed myself.” Some men with a recent STI were mostly worried about disrupting their sex life during treatment, and several also recalled questioning both from whom they acquired the infection and to whom they may have transmitted it. Other men with a recent diagnosis noted the inevitability of getting an STI, saying that it is simply part of having an active sex life and that people should not be so hard on themselves. One participant likened it to a sports injury—although he acknowledged the need to change future behaviors:

So, it really isn't a big deal. If you play sports, you're gonna sprain an ankle. The problem is you sprained your ankle and you keep walking on it, then you got permanent damage for the rest of your damn life.—33 years old with recent STI

STI Prevention Methods

Routine Testing and Increasing Testing Frequency

Most participants had favorable views about engaging in routine STI testing. Participants said that their STI-testing behavior is based on their current risk perception or their desire to take care of themselves and others. Some said testing made them feel more confident in their overall health:

It's like I said, when you know you're preventing yourself, you feel more emotionally stronger, I guess. Or you feel more confident in knowing about your physical health and mental health. So, getting tested and taking care of yourself.—28 years old with recent STI

Most participants indicated that it would be acceptable to increase the frequency of STI testing to every 1 to 2 months, and that this would allow them to become aware of an STI diagnosis sooner and avoid unknowingly transmitting an STI to a sexual partner:

Only because, like I say, the timeframe of you waiting to go to an appointment in three months, you could've passed that on to so many other people and vice versa.—27 years old with recent STI

Some participants preferred testing every 3 months because they were accustomed to their 3-month PrEP appointments, their sexual risk did not warrant more frequent testing, or they did not want frequent needlesticks. Other participants noted that conflicting schedules or STI testing costs would make more frequent testing challenging. To support more frequent testing, participants suggested offering rapid, at-home testing, incentives, greater financial support, scheduling reminders, and improving convenience and availability of STI testing, including extended visit times, appointment-free “anytime” testing, and locations that are convenient to living or work locations to avoid rush-hour traffic.

Self-Examinations

Nearly all the participants expressed their willingness to perform a self-examination for signs of an STI if asked by a provider, including visual and physical examinations of their own throat, genitals, or rectum, and reported being comfortable with their own bodies. Many participants, however, expressed worry about the accuracy of their self-examination: “I would feel very comfortable with it. Of course, I would be paranoid that I'm not doing it right.” (30 years old without recent STI diagnosis). Some also voiced that they would be concerned about “finding something wrong” or experiencing a delay in getting into care after finding an abnormality. A few other participants said they would perform self-examinations to avoid a clinic visit, if their provider recommended it, their health demanded it, or they believed it was important for the quality of their partnerships. One participant felt performing self-examinations, particularly while in a committed relationship, ensured that both partners were also committed to each others' safety. A few participants said they would be hesitant or unwilling to perform a self-examination, primarily because of limited confidence in interpreting their observations or because of their anxiety around potential health outcomes.

Partner Discussions and Notification

Nearly all participants said they have had conversations with partners about STI testing, usually to disclose STI test results or diagnoses.

I just showed him my results. And he was, he just felt like showing me his. Yeah, it was, it was like an honest discussion as far as us saying, hey, you know leading into this, let's look at each other's results, let's see what's our status.—36 years old without recent STI

Most explained that STI testing and having these conversations were a part of maintaining their overall health or part of the partnership vetting process. Other participants shared reasons to test and discuss STI testing with partners, such as experiencing symptoms of an STI or meeting someone from dating apps—as the latter introduced an added level of unfamiliarity with both the person and their risk behavior.

My last experience, I was having sex with one person in particular, and I had some side effects not long afterwards…I called him up and I had the conversation. They were pretty supportive. They told me that they would get tested and yeah. So, it was hard and scary… But, it was something that I did and it was cool.—31 years old with recent STI

Numerous participants indicated that they would tell their partners to get tested and/or abstain from sex while they were being treated. Some participants described a sense of moral obligation to disclose their diagnoses and advise their partners to abstain and get tested themselves. Meanwhile, a few expressed that these discussions were pointless because people lie and information disclosed may not be trustworthy, and others noted reasons for not having conversations about STI testing with their partners, such as a lack of perceived need due the nature of the relationship, and issues around trust, fear, and prioritizing self.

I would just not tell him [if I were to get a new STI diagnosis], and if it was something serious I would try to find a way to end the relationship […] I would feel like they, you know, maybe after I'm treated and cured I'd [tell them to get tested], I might, but I would have to get myself straightened out first.—36 years old without recent STI

In addition, a few participants expressed an unwillingness or discomfort with having STI discussions with their partners because they did not feel it was appropriate to tell their partner what to do with their bodies or health. However, a few participants also pointed out that, regardless of whether they disclose or initiate these discussions with their partners, their partners may not adhere to their advice or instruction.

Partner-Delivered Treatment

Most participants said that they were comfortable and willing to deliver STI treatment to their partners. Some expressed altruistic motivations in doing so, such that they would be contributing to STI prevention efforts, particularly if this would reduce visit fatigue or clinic strain, missed treatments, or transmission. Despite their willingness, a few feared that delivering treatment to their partner may greatly and/or permanently alter the relationship:

I mean the only uncomfortable thing about the aspect is the fact that the relationship probably would be lost.—31 years old without recent STI

A few men thought that this strategy would not be advantageous or that they would not be comfortable delivering STI treatment to their partners. Their concerns focused on the potential for exploitation, that is, those attempting to accumulate medications for selfish reasons; or because their partner may have other health concerns that may be missed if they did not visit a provider for testing; or possible difficulties with partner tracing.

Participants who were willing to receive treatment from a partner felt that it was the responsible thing to do:

[Interviewer: And, how would you feel if someone did that for you?] I would feel the same way. I would think it was responsible as hell to be honest.—31 years old with recent STI

Biomedical Prevention

Most participants said that they would take an antibiotic for STI prevention as an extra safety net. Many indicated their willingness to take an antibiotic once a day, primarily because it would be easy to add another pill to their daily PrEP regimen. Others, however, wanted to take an antibiotic only before or after sex or on-demand. These participants wanted to avoid taking medication and any short- and long-term adverse effects.

Similarly, the majority of participants stated that they would be willing to take an STI vaccine, to serve as an extra layer of protection:

Well, like I said, anyone can make mistakes and slip up…If partner goes and does it, which I see it happen all the time. Someone cheats…and then that other person…has to suffer because someone else stepped out of the relationship. So, that would just be—would make me feel more comfortable.—33 years without recent STI

Some participants, however, voiced hesitation about biomedical STI prevention. These participants explained that their willingness depends, in part, on the antibiotic or vaccine adverse effects and efficacy—and for vaccines, how long it has been available and what side effects have been documented:

See like I would wait until they've been around for a while before I jumped into it. Like I don't want to be the guinea pig.—27 years old without recent STI

Participants expressed that having a full understanding of both the short- and long-term adverse effects will be critical in their decision making.

Peer Support

Nearly all participants believed that peer support, for example, sharing of experiences within a community of BMSM, would be beneficial in preventing STIs. Hearing peers' challenges and success stories was thought to be relatable and comforting. Participants highlighted that talking with others who have shared experiences can create support and offer a sense of community.

…coming from another person telling you what they been doing, what affected them, and what went from there, and how it bettered their life, and bettered their partner, bettered their sexuality…hearing it from somebody else it would basically up their spirits for them.—29 years old without recent STI

More than half of the participants expressed interest in having access to social support through an app. Participants highlighted that a benefit of a social support app is allowing individuals to build a support network by connecting with new people who are having similar experiences. The app will allow for people to educate one another and share experiences:

It would give people someone to talk to when they have concerns about anything. It wouldn't leave people to feel like they have no one to go to, no one they could talk to.—25 years old with recent STI

Participants described that the type of peer interactions within the app would influence their interest in using it. They want apps that are user-friendly and that include a location setting to allow connections with people in close geographic proximity and ways to create mentor-type relationships. Participants said that they also want privacy and explained the importance of being able to post or engage with other app users with a level of anonymity.

One-third of participants indicated limited interest in using a mobile app, primarily because they are not proficient with technology, they did not think an app could provide support, or an app would not provide additional support beyond existing websites.

DISCUSSION

This study aimed to shed light on STI perceptions and concerns among BMSM PrEP users in New Orleans, Louisiana, as well as to ascertain willingness to participate in STI prevention strategies in this population. We found that participants were concerned about physical effects of STIs as well as the social or emotional effects such as shame, stigma, or feeling “unclean.” Our findings suggest that participants with recent STIs may have heightened tolerance for an STI diagnosis and were bothered by the inconvenience of stopping sex during or after treatment. Most participants recognized the importance of being tested for STIs and communicating with partners about their test results and/or getting tested for STI, and some reported that they have made or would make changes in sexual behavior after an STI diagnosis.

Similar to other qualitative research among MSM, participants conveyed that condoms were no longer used routinely,²⁸ although encouragingly, they reported that other STI prevention strategies were desired. In other studies, the HBM has been used—including among MSM—to explain the uptake of health interventions such as vaccines for STIs,^29–31 and the use of HBM in this study yielded valuable information about BMSM's perceptions of prevention strategies and inclination to engage in these strategies in the future. Participants were generally willing to engage in all strategies presented to them, and our findings revealed important considerations and caveats for these strategies. For example, participants were generally willing to increase STI testing frequency but need it to be convenient and inexpensive. They thought that mHealth-based social support would be useful provided the app maintained privacy and the support came from those who lived locally and were respectful. They were also willing to engage in biomedical prevention strategies but needed reassurance about adverse effects and safety. This take-away may be particularly useful as we learn more about the potential for antibiotics and vaccines to prevent STIs.^9–12

One prior study has explored correlates of STI risk factors in BMSM engaged in PrEP care, finding that those with prior STIs and those needing more time with counselors to perform care coordination activities were more likely to have an incident STI,⁸ but we are not aware of other studies that focus specifically on STI prevention in BMSM on PrEP. More recent data do show acceptability of STI prevention, specifically doxycycline postexposure prophylaxis, among African Americans.¹²

We interviewed a very specific population—BMSM engaged in PrEP care—to better understand what STI prevention strategies might be feasible or acceptable in this population. We focused on this population as the demographic group subject to the greatest sexual health disparities and because our community partners have conveyed to us that specific intervention strategies should be tailored to this group specifically. A different group of BMSM may have shared different perspectives or have different preferences for STI prevention strategies.

In conclusion, BMSM on PrEP voiced concern about STIs, but many noted that condom use was no longer the norm. Most notably, they were concerned about STIs and willing to engage in methods focused on prevention on an individual (e.g., biomedical strategies) or population level (e.g., increased testing frequency or partner notification and treatment delivery). Participants conveyed important caveats and concerns that should be considered to optimize each strategy. The findings from these interviews are particularly relevant in the current landscape as STI rates continue to soar and new STI prevention strategies are being investigated and implemented.