Interpersonal and Community-Level Influences Across the PrEP Cascade Among Young Adult Latinx Men who Have Sex with Men Living in a US-Mexico Border Region: A Qualitative Study

Abstract

Latinx men who have sex with men (MSM) are an at-risk population for new HIV diagnoses. Pre-exposure prophylaxis (PrEP) is a suite of biomedical approaches to prevent HIV infection. Latinx MSM are less likely to take PrEP compared to non-Latinx White MSM. This qualitative study identified interpersonal- and community-level barriers and facilitators of PrEP among young adult Latinx MSM. Using stratified purposeful sampling, 27 Latinx men, ages 19-29 years and living in a US-Mexico border region, completed self-report demographic surveys and participated in semi-structured in-depth interviews assessing barriers and facilitators to PrEP. Directed content analysis was used to identify both a priori and emerging themes. Most participants reported that other people, including peers, friends, partners, and health care providers were both supportive and discouraging of PrEP use. Participants’ intersectional identities as members of both Latinx and LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer) communities both hindered and facilitated PrEP use.

INTRODUCTION

An estimated 1.2 million people in the United States (U.S.) were living with HIV in 2019 [1]. There are substantial HIV-related health disparities and health inequities related to sexual orientation, race/ethnicity, and age. In 2019, 70% of all HIV infections in the U.S. occurred in men who have sex with men (MSM), and Latinx MSM experienced 32.5% of HIV diagnoses [1,2]. Although overall incidence of HIV has decreased in the U.S., and new infections among MSM have decreased 9% among MSM between 2015 and 2019 [1,2], new infections among Latinx MSM and MSM between the ages of 25-34 have remained stagnant. Modeling studies suggest 1 out of 5 Latinx MSM will be diagnosed with HIV within their lifetime [3]. Collectively, these studies underscore the risk of HIV among young adult Latinx MSM.

San Diego, California is located 17 miles from the Mexican border and adjacent to the Mexican city of Tijuana. The San Ysidro border crossing is the 4th busiest in the world with an average of 90,000 people crossing the border each day [4] to work, attend school, shop, receive medical and dental care, visit family and friends, and for tourism. The U.S.-Mexico border region of San Diego is a unique health care environment, with prior research documenting that 32% of first- and second-generation immigrants in San Diego (even those with U.S. health insurance) regularly seek healthcare in both Mexico and San Diego [5]. The reasons that people of Mexican origin living in San Diego (both with and without health insurance) seek healthcare in Tijuana and other areas of Mexico are complex and include the lower cost of medical services and pharmaceuticals in Mexico, better access to pharmaceuticals in Mexico, dissatisfaction with health care provided in the U.S., the perceived need for a second opinion, seeing providers for specific conditions in each country, being denied prescription medications and referrals to specialty care by providers in the U.S., and more appreciation of the interpersonal quality of encounters with physicians in Mexico [5]. In 2019, 470 out of 100,000 people in San Diego County were living with HIV [6]. In 2015, there was a similar prevalence of HIV among MSM living in San Diego (18.0%) and Tijuana (20.2%) [7]. Viral sequence data indicate significant transmission of HIV across the U.S.-Mexican border, including among MSM [8].

Reducing the number of new HIV infections is both an objective of Healthy People 2020 and 2030 and one of the National HIV/AIDS Strategy for the United States goals [9–11]. Pre-exposure prophylaxis (PrEP) is a suite of biomedical prevention interventions that includes an oral medication (tenofovir/emtricitabine [TDF/FTC]) taken daily or an injectable medication (cabotegravir extended-release injectable suspension) taken every other month. In 2019, HIV PrEP was endorsed with a ‘grade A’ rating by the U.S. Preventive Services Task Force, indicating substantial benefit, small harms, and meeting a cost-effectiveness threshold such that most insurance plans should and must provide coverage for this intervention [12]. Currently, there are two FDA-approved PrEP oral medications available in the U.S. (brand names: Truvada and Descovy). In a landmark study, TDF/FTC was found to reduce incidence of HIV by 44% among MSM and transgender women [13]. When active drug was detected in participants’ blood—indicating high levels of adherence—efficacy increased to 92%. In a subsequent open-label trial [14], zero HIV infections were noted among participants who took TDF/FTC four or more days per week. In 2021, the U.S. Food and Drug Administration approved injectable PrEP (cabotegravir; U.S. brand name: Apretude) for adults and adolescents [15] after two large clinical trials demonstrated superior efficacy of cabotegravir to oral PrEP [16]. PrEP is recommended as a tool to prevent HIV, along with condoms and other prevention methods, especially among individuals at substantial risk of HIV acquisition [17].

Despite the strong efficacy of PrEP, uptake of it is poor, particularly among the most vulnerable groups in the U.S. The National HIV/AIDS Strategy for the United States indicates facilitating access to HIV prevention (including PrEP) services as an objective and notes that efforts should prioritize MSM, Latinx MSM, and youth aged 13-24 years [11,18]. There are a number of steps that an individual must take prior to obtaining a PrEP prescription, and individuals taking PrEP must receive regular follow-up care, as noted by various PrEP cascade and continuum models [19–23]. These models identify various steps along a PrEP continuum of care where an intervention could assist individuals, such as: 1) being at risk for HIV infection; 2) being identified as a PrEP candidate; 3) being interested in taking PrEP; 4) being linked to a PrEP program; 5) initiating PrEP medication; 6) being retained in a PrEP program, and 7) achieving adherence and persistence [23].

The social ecological model (SEM) indicates that health behaviors, such as PrEP initiation and follow-up care, are influenced by a number of individual and social environmental factors [24,25]. These factors include intrapersonal, interpersonal, organizational, community, and public policy [26]. Individual and public policy barriers to PrEP initiation, follow-up care, and adherence include low PrEP awareness and knowledge [27–33], concerns about side effects [29,34,35], concerns about cost [27–34,36], and lack of PrEP access [27–34]. Individual and public policy facilitators of PrEP initiation and adherence include awareness of risk of HIV [27,28,34,37,38], prior diagnosis of another sexually transmitted infection (STI) or a sexual encounter with an HIV exposure [27,28,37,38], concern about acquiring HIV [37], less fear and anxiety and increased enjoyment during sex while on PrEP [27–29,34,36,38], availability and accessibility of PrEP [37], having health insurance [39], and having PrEP be no or low cost [37]. Individual and public policy barriers more strongly identified among Latinx MSM when compared to White MSM, include lower PrEP awareness and lower knowledge of where to obtain PrEP and how to enroll in health insurance [40]. Some Latinx MSM experience barriers to PrEP related to immigration status [41].

Multiple qualitative studies have examined interpersonal influences of PrEP initiation and adherence among non-Latinx white and African American/Black MSM, but few have been conducted in Latinx MSM. Similar to findings among non-Latinx White and African American/Black MSM, a few qualitative studies that included Latinx participants indicated they were motivated to initiate PrEP from being in an HIV serodiscordant relationship and by both peers and sex partners who provided information about PrEP [34,37,38,42]. Latinx MSM noted that communication difficulties were a barrier to HIV prevention care, including PrEP [29,41]. One study which included non-Latinx white, Latinx, and African American/Black MSM from Austin and San Antonio, Texas, found Latinx men reported fewer people in their lives who would approve of PrEP use [43]. In the study, no Latinx men reported that their family approved of PrEP use, and 24% reported that their family would disapprove of it. None of these studies have been conducted among Latinx MSM living in a U.S.-Mexico border region, which has unique interpersonal impacts on health.

There have also been few qualitative studies of community barriers and facilitators of PrEP uptake and adherence in Latinx MSM, with none conducted in a U.S.-Mexico border region. In a mixed methods study of African American/Black and Latinx MSM in Western Washington, participants reported limited community supportive services for MSM, especially for racially and ethnically diverse MSM [29]. While there is recognition that PrEP-related stigma undermines HIV prevention efforts [44], there has been limited qualitative research documenting PrEP-related stigma among Latinx populations, with only one qualitative study of Latinx MSM [27,28] and one mixed methods study which included both African American/Black and Latinx MSM [29]. Latinx MSM reported that they anticipated or experienced PrEP-related stigma from various sources including from sexual partners, friends, family, and health care providers [27,28]. Latinx MSM also reported that others believed PrEP users engaged in more risky sexual behaviors and assigned disparaging labels to them, and/or thought they were HIV-positive [27,28]. A quantitative survey of Latinx MSM also found participants believed PrEP use would result in others believing they were promiscuous or living with HIV [35]. Furthermore, in both qualitative and quantitative studies, Latinx MSM reported LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, or Queer)-related stigma impacted their initiation and adherence to PrEP. This included having concerns about LGBTQ+ stigma from medical providers [28,35]. In one study, participants reported stigma associated with sexual orientation in the Latinx community as a barrier to PrEP [41]. On the other hand, in a quantitative nationwide study of Latinx MSM in a partnered relationship in the U.S., both Latinx group membership and gay community connectedness were associated with PrEP uptake in bivariate analysis [39]. In multivariable analysis, there was a significant interaction between Latinx group membership and gay community connectedness in the prediction of PrEP uptake [39]. When the level of Latinx group membership was average, gay community connection was positively associated with PrEP uptake. On the other hand, when the level of gay community connection was average, the association between Latinx group membership and PrEP uptake was non-significant. There was an increase in the magnitude of the association between gay community connection and PrEP uptake as the level of Latinx group membership increased. Also, as gay community connection increased the association between Latinx group membership and PrEP uptake also increased [39].

No qualitative studies have evaluated interpersonal influences on PrEP uptake and adherence among young adult Latinx MSM living in a U.S.-Mexico border region, a population that remains at high risk of HIV [1] and has unique practices in obtaining health care. While there have been two qualitative/mixed methods studies documenting the impact of community stigma on PrEP use in Latinx MSM and one qualitative study that has documented other community barriers to PrEP use among Latinx MSM, none of this research has been conducted among Latinx MSM living near the U.S.-Mexico border. Based on SEM [25], the purpose of this qualitative study was to identify interpersonal- and community-level barriers and facilitators to PrEP initiation and adherence among young adult Latinx MSM living in a U.S.-Mexico border region.

METHODS

Overview

The San Diego State University Institutional Review Board approved this cross-sectional qualitative study, which followed COREQ guidelines for qualitative research [45,46] (see Supplementary Information for completed COREQ Checklist). The methodological orientation of the study was phenomenology, which is used to understand lived experiences of individuals [47]. A 3-member participatory planning group (PPG) consisting of members of the intended audience and individuals employed by the partnering federally qualified health center (FQHC) provided assistance with drafting the interview guide and referring potential participants to the study. All participants engaged in an informed consent process and provided written informed consent prior to study participation.

Participants

To be included in the study, participants were required to: 1) be age 18 to 29 years; 2) currently self-identify as male; 3) identify as gay/bisexual or report having sex with men in the past 12 months; 4) identify as Latinx; 5) self-report not living with HIV (i.e., HIV-negative); 6) reside in San Diego County, California; 7) speak English or Spanish; 8) be willing and able to provide informed consent; and 9) report at least one HIV risk factor as informed by Center for Disease Control (CDC) guidelines [48]. MSM were considered at elevated risk for HIV if they reported one of the following: 1) a sexual partner living with HIV; 2) diagnosis of a STI within the past 12 months; 3) engaging in condomless anal sex with a non-monogamous partner in the past 12 months; 4) engaging in commercial sex work in the past 12 months; 5) injection of illicit drugs and sharing of injection equipment in the past 12 months; or 6) engaging in treatment for injection drug use in the past 12 months.

Procedure

Stratified purposeful sampling [49,50] was used to recruit participants within San Diego County via several methods, including outreach and flyering at the partnering FQHC and HIV/STI testing programs, a Spanish language Latinx MSM support group, local LGBTQ+ community centers, and gay-identified/friendly coffee shops, gyms, and bars. We also used online recruitment methods, including targeted ads through Facebook and Instagram, use of geolocation social networking mobile applications tailored to sexual minority men (e.g., Grindr), and emailing a participant registry. During sampling, we aimed to include 15 participants who were PrEP naive and 15 who had previously been prescribed PrEP. Potential participants were requested to contact study personnel via email or telephone. A Spanish-English bilingual member of the study team attempted to contact each potential participant to explain the study and screen them for inclusion. An interview appointment was scheduled with those who met inclusion criteria and were interested in participating. The study team attempted to contact participants up to 5 times via phone, email, and text message. Fifty-eight potential participants responded to recruitment materials. We were unable to reach 12 (20.7%) potential participants for screening, and one (1.7%) declined to be screened. Of those who were screened, 8 (13.8%) did not meet inclusion criteria, and 8 (13.8%) canceled and did not reschedule an interview appointment. After recruiting and interviewing 17 PrEP naive participants and determining we had reached saturation in that group, we continued to recruit individuals with PrEP experience using the same methods. During screening, we identified two (3.4%) more PrEP naive participants, but did not interview them. We reached saturation in the PrEP-experienced group once we interviewed 10 PrEP-experienced participants. Twenty-seven participants (46.6%; 17 PrEP naïve and 10 PrEP-experienced) attended interview appointments, consented to participate, and completed an interview.

The research team and PPG drafted an interview guide in both English and Spanish to evaluate barriers and facilitators to PrEP initiation, follow-up, and adherence across all levels of the SEM (see Supplementary Information for example questions in English and Spanish) [25]. After the informed consent process, a trained Spanish-English bilingual research staff member with significant expertise in qualitative data collection conducted semi-structured in-depth interviews with participants in English or Spanish, according to participant preference. The interviewer, a female Research Associate, has a master’s degree in public health, a foreign medical degree, significant interest in Latinx health, and prior experience in HIV prevention research. Participants were not known to the interviewer prior to the interview and were interviewed alone and in person at a private location of their choice. There were no repeat interviews. All participants were provided a $50 gift card following completion of the interview and demographic survey.

Interviews were conducted between January 18, 2018 and August 2, 2018, and lasted between 19.2 and 66.6 minutes (mean: 30.2, standard deviation [SD]: 10.0). In addition, the research team member administered a demographic form in the participant’s preferred language assessing the following variables: age, sex assigned at birth, gender identity, sexual orientation, relationship status, ethnicity, race, primary language, native language, highest level of education, employment status, annual income in U.S. dollars, nationality, citizenship, health insurance coverage, current housing situation, stability of housing in the past 6 months, and lifetime experience with the correctional system). Interviews were audio recorded using a digital audio recorder and transcribed verbatim by other members of the research team. The interviewer took field notes. Interviews conducted in Spanish were translated to English by a bilingual, native Spanish-speaking team member with significant expertise in translation of qualitative interviews and other health-related documents. After 27 interviews were conducted (10 PrEP experienced- and 17 PrEP naive-Latinx MSM), it was determined that theoretical saturation had been achieved [51], as participants in both groups were no longer providing new information during interviews [51]. English-language transcripts were imported into NVivo for analysis [52]. Transcripts were not returned to participants for comment or correction.

Using directed content analysis [53], two authors initially reviewed all interview transcripts to understand study data and develop an initial code list of a priori themes based on levels of the SEM [25], as well as emerging themes. Using this initial codebook, the two authors (AJB, KJW) independently coded randomly selected interview transcripts, and then met to discuss differences in coding and ways to refine the codebook. This process was repeated several times until both coders reached consensus about the final codebook. Once refinement of the codebook was finalized, the coders rated each interview individually. Coders met to discuss coding of each interview until consensus was reached on all codes assigned to text in the transcripts. The two coders were not involved in data collection, and both had expertise and prior experience with coding qualitative data. A third coder was available for consultation if consensus could not be reached. This process of coding met published guidelines for evaluating and reporting intercoder reliability [54]. All coded interviews were uploaded into NVivo, each code was assigned a node to group similarly coded data, and then each code was subsequently summarized by sub-themes. Study participants did not provide feedback on the findings. Demographic data were entered into SPSS and summarized using descriptive statistics (i.e., frequencies, measures of central tendency and variability).

RESULTS

Participant Demographics

Twenty-one interviews (77.8%) were completed in English, and 6 interviews were completed in Spanish (see Table 1 for participant sociodemographic characteristics). Participants ranged in age from 19-29 years (mean: 24.1; standard deviation [SD]: 3.1). Most participants identified as: White (33.3%) or Other (44.4%) race; gay (66.7%) or bisexual (29.6%); and single (48.1%) or in monogamous relationships (37%). The majority of participants had completed at least some college (83.4%), and 66.6% reported annual income of less than $24,000 (U.S.D.). Most participants were born in the U.S. (63%) and identified as a U.S. citizen (66.7%). Most participants’ primary language was English (66.7%); however, most participants reported that their native language was Spanish (66.7%). The majority of participants (77.8%) had some form of health insurance coverage, were employed full time (51.9%), and had stable housing within the past 6 months (88.9%).

Table 1.

SocioDemographic Characteristics of Study Participants (n=27)

Characteristic	Number of Participants	Percent
Sex Assigned at Birth (n = 27)
Male	27	100.0
Gender by which Participant Identifies (n = 27)
Male	27	100.0
Sexual Orientation (n = 27)
Gay	18	66.7
Bisexual	8	29.6
Queer	1	3.7
Relationship Status *
Single	13	48.1
Legally married	1	3.7
Monogamous relationship	10	37.0
Sexually active with more than one person	4	14.8
Other: In a relationship but have multiple sex partners	1	3.7
Identify as Hispanic or Latino (n = 27)
Yes	27	100.0
Race (n = 27)
Black/African American	1	3.7
White	9	33.3
Other**	12	44.4
Not sure/prefer not to respond	5	18.5
Primary Language (n = 27)
English	18	66.7
Spanish	7	25.9
Both English and Spanish	2	7.4
Native Language (n = 27)
English	8	29.6
Spanish	18	66.7
Portuguese	1	3.7
Highest Level of Education Completed (n=25)
Less than high school	1	4.2
High school or GED	3	12.5
Some college	6	25.0
College graduate	7	29.2
Some graduate work (no degree to date)	3	12.5
Graduate/Professional	4	16.7
Employment Status *
Full-time (≥30 hours per week)	14	51.9
Part-time (<30 hours per week)	7	25.9
Unemployed	3	11.1
Student	6	22.2
Annual Income in U.S. Dollars
<$6,000	5	18.5
$6,000-$11,999	3	11.1
$12,000-$17,999	5	18.5
$18,000-$23,999	5	18.5
$24,000-$29,999	3	11.1
$30,000-$59,999	6	22.2
Country of Birth (n = 27)
United States	17	63.0
Mexico	9	33.3
Brazil	1	3.7
Identify as a U.S. Citizen (n = 27)
Yes	18	66.7
Health Insurance Coverage *
No health insurance	6	22.2
Private insurance or HMO	10	37.0
Medicare	1	3.7
Medicaid	7	25.9
I have health insurance, but unsure what type	2	7.4
Other health insurance	2	7.4
Current Housing (n = 27)
Rent a house or apartment	13	48.1
Live with friends, family, or sex partner and pay them rent	10	37.0
Live with friends, family, or sex partner without paying rent	3	11.1
Other: Live with family	1	3.7
Unstable Housing in Past 6 Months (n = 27)
Yes	3	11.1
No	24	88.9
Identifies as Having Been in the Correctional System During Lifetime (n = 27)
Yes	2	7.4

^*Participants could select more than one answer

^**9 participants who endorsed “other” race provided text responses indicating Latinx heritage (e.g., Hispanic, Mexican, Mexicano, Guatemalan); 1 participant indicated they were “mixed” race

Interpersonal-level Influences on PrEP

Peer and Family Influences.

As summarized in Table 2, most participants recalled initially hearing about PrEP from individuals in their social networks, particularly from peers who used PrEP. Participants described learning from their social networks about PrEP’s purpose and efficacy, as well as where and how to access it: “Back in 2014 my friend was on it. He kept saying, ‘I’m on Truvada.’ I was like, ‘What’s that?’ He told me what it was…and then I started hearing more and more about it…from other people.” (P7, PrEP-experienced).

Table 2.

Summary of Interpersonal and Community Barriers and Facilitators to PrEP Initiation and Adherence.

Subtheme	Barriers and Facilitators to PrEP Initiation and Adherence
Interpersonal
Peers and Family Influences	• Gained awareness about PrEP’s purpose and efficacy through their social networks (e.g., peers who also used PrEP)  • Sought additional information about PrEP to make an informed decision on using PrEP after learning about it from their peers  • Friends and family members sometimes provided inaccurate information about PrEP  • Experienced emotional and instrumental support from peers, partners, and family to get PrEP-related care
Health Care Provider Influences	• Expressed having positive experiences with health care providers overall  • Described that health care providers provided information about sexual health including information about PrEP such as efficacy, side effects, and how to access it  • Expressed being comfortable discussing sexual health with health care providers who they perceived to be familiar with gay men’s health  • Described their health care providers’ lack of knowledge about PrEP  • Expressed fear of judgment and discrimination about disclosing their sexual orientation and sexual health related needs to health care providers
Stigma from Peers, Family, and Healthcare Providers	• Expressed that their family, friends, and partners discouraged them from accessing PrEP due to side-effects and being in a monogamous relationship  • Expressed that their health care providers were opposed to PrEP and unwilling to prescribe it to them
Community
San Diego	• Reported that structural characteristics (e.g., difficulty using public transit) in the San Diego area serve as barriers to initiating PrEP  • Described difficulty accessing PrEP due to resources being located far away from where they live
LGBTQ+ Community	• Described learning about PrEP through community outreach via social media and dating platforms  • Indicated that a LGBTQ+-friendly neighborhood in San Diego encouraged MSM to use PrEP  • Expressed concerns regarding how PrEP use is stigmatized in the San Diego MSM community and the greater LGBTQ+ community
Latinx Community	• Expressed how the Latinx community or culture discourages seeking healthcare services or taking any medications  • Reported that masculinity and machismo in Latinx culture prevent men from seeking healthcare services, especially from male health care providers
Intersectionality	• Expressed how intersectional identities were a source of community and how LGBTQ+ and Latinx MSM support groups assist with learning and accessing/adhering to PrEP  • Expressed concerns regarding how Latinx culture and religious practices prevented open dialogue regarding sexual orientation  • Described how PrEP stigma in the LGBTQ+ community and sexual orientation stigma in the Latinx community can make PrEP use among Latinx MSM more difficult

Other participants described how initially learning about PrEP from peers led them to further research the medication on their own, which enabled them to make informed decisions about whether or not to access PrEP: “I had never heard of PrEP and it turns out that an older friend of mine…told me “Oh, the guy I go out with takes PrEP” and I was like “oh, okay”, acting like I knew what it was. Of course I was checking what PrEP was on my phone so that I could continue the conversation…And I looked it up [PrEP]..that’s how I knew what PrEP was…I never knew more than the condom, that it was the way to protect yourself.” (P29, PrEP-naive).

Some participants shared how peers actively encouraged them to initiate PrEP: “I met friends that were on it, and they told me ‘Hey, you should get on it, it’s just to prevent infections and HIV’.” (P27, PrEP-experienced). Another participant described how friends can provide important logistical information related to accessing PrEP, such as where to get a prescription: “A friend can recommend it, if you have LGBT friends that have already taken it. They can give you references on what clinic to go to, or what program to take.” (P14, PrEP-experienced).

In addition to describing informational support related to PrEP use, many participants described how emotional and instrumental support from partners, friends, and family helped them to obtain PrEP-related care. For example, participants stated that family and friends encouraged them to look after their own health, adhere to PrEP, and/or attend follow-up appointments. One participant described how his partner encourages him to take PrEP on schedule when he is away from home: “My partner’s always on top of it because he’s also taking an HIV medication. So, he’s always telling me…or I’m in LA and then I’m like ‘hey remind me… And he’s like ‘okay, I’ll text you’… it helps a lot.” (P27, PrEP-experienced). Another participant explained the role his brother plays in supporting his use of PrEP: “…because my brother is also gay,…I think he is always…aware, of whether I’m dating someone, or whether I’m monogamous with someone, to make sure I take care of myself” (P8, PrEP-experienced), while a third participant recounted how his friends encourage his use of PrEP: “I’ve told my girl friends that I take PrEP, and they’re like, oh, I’m so happy for you! That’s great! And I’m happy you’re being safe. And…that makes me feel great, that somebody…is proud that I’m taking care of myself” (P56, PrEP-experienced). Finally, a few participants also noted that they saw taking PrEP as a way of protecting their sexual partners as well as themselves, which motivated them to engage in PrEP-related care, including adhering to a daily regimen and accessing timely refills: “When I had to renew it [PrEP], because I had run out, I felt happy with myself because it was the first time I was doing something good for myself and for the partner or for the person with whom I was going to have sex with. Then I went ahead and took the medication every day. I had to have a motivation so that I would not forget to take it.” (P14, PrEP-experienced).

Although most participants indicated that their social networks facilitated their use of PrEP, participants also recounted multiple ways in which their family, friends, and partners discouraged them from accessing and remaining adherent to PrEP. For example, participants’ peers did not always provide accurate or useful information about PrEP: “friends who think that…if you’re on it, you may mentally think…it’s a suitable substitute for a condom, when in actuality, it isn’t really.” (P7, PrEP-experienced). A few participants stated that their loved ones discouraged them from taking PrEP due to concerns about side effects: “My boyfriend would bring up the cons…like, “don’t forget it might affect your liver, so, just keep trying it, see how you feel.” (P11, PrEP-experienced). Likewise, a few participants noted their partners dissuaded them from taking PrEP due to their being in a monogamous relationship: “After I was taking it for the first couple of years… he talked me out of it, because he said…if we’re gonna be monogamous that it wasn’t necessary. And I think…retrospectively, it’s probably not the smartest thing to do.” (P8, PrEP-experienced).

Furthermore, participants who were not out to their families expressed concern that using PrEP would inadvertently disclose their sexual orientation. One participant explained how this concern might negatively impact PrEP adherence: “If you have family members or you’re with family members that are anti-gay or something like that…if they saw you taking it, or if you had to tell them what it was, you might feel pressure not to take it just because you don’t want your family to label you or just talk down upon you about it.” (P1, PrEP-experienced). This issue was particularly salient for participants who lived with their family members:

Some folks like myself aren’t…out in the open with my family, right? I also live with my family…This medication…might raise some flags with some people or might raise some questions. That might discourage someone from taking PrEP. I know it would definitely discourage me if I knew I ran a risk of coming out to my family inadvertently just because of this. (P49, PrEP-naive).

Indeed, several participants mentioned that their parents and family members stigmatized the use of PrEP by MSM: “One of the people…in my personal life, that doesn’t like the whole PrEP idea is actually my mom…She was just like, well why don’t they just not have sex in the first place?” (P55, PrEP-experienced).

Healthcare Provider Influences.

Most participants indicated they received information about sexual health and/or about PrEP from their medical providers, including information about PrEP efficacy, side effects, and access. Participants noted that seeing health care providers who are knowledgeable about PrEP helps MSM to learn about the medication and facilitates receipt of PrEP-related care. For example, one participant noted, “If it wasn’t for, my doctors who were like, ‘you should be on PrEP,’ just telling me straight up, ‘you should be on PrEP,’…I don’t think I’d know about it and if I’d have access to it.” (P55, PrEP-experienced). Another participant described how his physician convinced him to initiate PrEP by describing its benefits and anticipated cost:

I went to the doctor and I got tested, and it came back negative, and then my doctor said, ‘you should go on PrEP’ and I was like, ‘what’s PrEP?’ So, she explained to me, and I was like ‘wow, I didn’t even know that existed,’ and she’s like ‘yeah it’s 99.9% that you won’t catch it,’ and I was like, ‘interesting,’ I was like ‘sure,’ and she was like ‘your insurance covers it,’ I was like ‘cool’, so I went on it, and I’ve been on it ever since. (P18, PrEP-experienced).

Most participants noted that they had positive relationships with specific healthcare providers, or had favorable experiences with other medical staff. Participants explained how these positive relationships and experiences facilitated their use of PrEP. Some participants reported finding doctors who were not judgmental of their sexual orientation or sexual behaviors, which made talking about sexual health and PrEP more comfortable:

She’s like, ‘before you get on PrEP, we do have to do screening for STDs, HIV and all of those things’ and we did them, and, it was very nice, she was very nice, comforting, she didn’t judge, she did, there was no sense of being like ‘oh my gosh, it’s a gay man, or it’s somebody who’s Latino.’ There was nothing of that, she was very straightforward, she was very professional, very nice, she answered all of the questions that I had. (P56, PrEP-experienced).

In general, participants reported feeling comfortable discussing sexual health needs, including PrEP, with healthcare providers when they perceived that the providers were especially familiar with the health needs of gay men. One participant stated, “Being able to have health care professionals that understand the life of a gay man makes it very easy to talk about your issues and what things you may need as a gay man that otherwise…doctors don’t know.” (P8, PrEP-experienced), while another shared:

He is known as the “urologist for gay people”. He is not gay though, but his advertisement says that he treats a specific population and treats you as a friend. It is a young doctor who does not seem to be one that judges you…[he] inspires confidence that he will treat you in a certain way (P29, PrEP-naive)

Although some participants were able to obtain PrEP easily from their physicians, other participants stated that their physicians lacked knowledge regarding PrEP, or had to refer them to another provider or a specialist to obtain a prescription. One participant shared, “I had a doctor, she was a primary care doctor, who didn’t even know…whether she could even prescribe it [PrEP].” (P8, PrEP-experienced).

Another participant echoed this issue, reporting,

Then once I did get my insurance, l never met up with a doctor to request it, ‘cause you know it’s hard, they don’t know anything about it, so they would say, “well I’m probably not best doctor, so you should, look somewhere else.” (P11, PrEP-experienced).

Furthermore, some participants expressed reluctance in discussing their sexual orientation and sexual health needs with their physicians due to fear of judgement and discrimination. For example, one participant stated, “I know sometimes a lot of my friends that are LGBT, they feel uncomfortable disclaiming their sexual orientation with their doctor for fear of being judged” (P1, PrEP-experienced), while another explained, “I had the experiences where…doctors could be judgy. I don’t feel comfortable sometimes asking a doctor when it’s about my…sexual health.” (P13, PrEP-experienced). Furthermore, another participant reflected that fear of discrimination can discourage MSM away from seeking medical care altogether, stating “that’s why a lot of people don’t go to the doctor, because they feel like the doctors are gonna ask questions and…they’re gonna…judge you (P56, PrEP-experienced). One participant further explained how this fear inhibits PrEP initiation among MSM who do seek medical care:

If you go to a particular clinic, many times because of the fear of how they are going to see you, you do not disclose your sexual preference. So, I think that also slows you down a bit and you say like “hmm I don’t feel safe,” and if you don’t feel safe you don’t go for it [PrEP].” (P29, PrEP-naive).

A few participants even relayed that their physicians were overtly opposed to patients’ use of PrEP:

My doctor didn’t really agree with the medicine or the way that it was being used… he actually said that he didn’t want to prescribe it, because he felt that it…was against his morals or philosophy to provide that sort of treatment…because he believed that the best way to prevent STI or HIV was just to be in a monogamous relationship. (P10, PrEP-naive).

Finally, participants described a number of ways in which staff members at clinics and LGBTQ+ centers help MSM to learn about and obtain PrEP. A few participants noted that staff provide information about PrEP at LGBTQ+ centers and booths at Pride festivals, such as one participant who stated, “…I went to get tested at the community center. After I was tested, while I was waiting for the results…a staff member from…the community clinic talked to me about PrEP.” (P05, PrEP-naive). Similarly, a few patients explained that sexual health coordinators or navigators working at community clinics helped them access and adhere to PrEP by arranging appointments, providing reminders about appointments, and checking in about side effects:

He would call places for me. I went to his office, he called on my behalf and didn’t stop until he arranged an appointment with the doctor for me. He would always call me on the weekends before starting [PrEP], ‘hey, remember you have your appointment, don’t you miss it.’ He would also call me to see how I was feeling and to see if there were any side effects. I liked it a lot, to have that emotional and personal support, that I was not alone (P14, PrEP-experienced).

Community-level Influences on PrEP Initiation and Adherence

Participants described multiple ways in which their communities impacted their awareness and use of PrEP. First, participants described how the structural characteristics of San Diego, such as the county’s layout and accessibility of public transit, serve as barriers to PrEP initiation. Some participants noted that it can be difficult to access available PrEP services in San Diego because many of these resources are located far away from where they live, in a part of San Diego where parking is difficult, or in a part of San Diego that is difficult to get to without a car. As one participant explained, “the barriers [to PrEP] that I have right now, that I live far away from like Hillcrest so that’s where the center of PrEP is in San Diego (P55, PrEP-experienced).” Another participant echoed this concern: “it’s kinda far from me….I live in East County….and he’s at the Sports Arena clinic, so he keeps wanting me to set up an appointment, but that’s the barrier, it’s kind of far.” (P7, PrEP-experienced).

Other community influences included those of the LGBTQ+ and Latinx communities. Participants’ intersectional identities as Latinx gay, bisexual, and MSM were particularly salient in their navigation of sexual healthcare and engagement in sexual health behaviors. Many noted that community norms and values of both Latinx and LGBTQ+ communities influenced their comfort and willingness to use PrEP for HIV prevention, and intersection of these norms sometimes presented challenging situations related to sexual health in general, and PrEP use in particular.

LGBTQ+ Community Influences.

First, participants reported that aspects of the LGBTQ+ community differentially facilitated and discouraged the use of PrEP. Participants mentioned numerous ways in which the LGBTQ+ community encouraged PrEP use. For example, some participants stated they learned about PrEP due to community outreach on social media (e.g., Facebook), dating applications (e.g., Grindr) tailored for the gay community, and YouTube; and outreach conducted in gay-friendly areas (e.g., gay bars, Pride events) in San Diego. One participant recalled, “there was a lot of ads about PrEP on like social media sites, or online dating sites like Grindr” (P11, PrEP-experienced), while another shared, “on Grindr they do have a little bit of promo about PrEP…keeping it in mind as you’re about to maybe engage in sex for yourself.” (P13, PrEP-naive). One participant noted that establishments in a local LGBTQ+-friendly neighborhood in San Diego encourage MSM to use PrEP:

The Hillcrest area is very supportive of it [PrEP], because they have it at all their bars, on the T.V.s that they have there, they always have little PrEP fliers about it, they even have like PrEP parties. (P18, PrEP-experienced).

Additionally, some participants explained that MSM may be more likely to learn about, access, and take PrEP if they are aware of others in the LGBTQ+ community who use PrEP, or if PrEP use is perceived as normative in the LGBTQ+ community. Participants noted, “it’s becoming more popular in the LGBT community for men to be on PrEP” (P27, PrEP-experienced), and “I believe that in the LGBTQ community, PrEP, it’s everywhere. Like you hear it everywhere. You know someone that has taken PrEP.” (P23, PrEP-naive).

On the other hand, some participants stated that PrEP use is also stigmatized in the San Diego MSM community. For example, one participant stated, “You know there is a lot of stigma around HIV and PrEP. Especially in the LGBTQA community. You know people talk around and say bad things about each other.” (P12, PrEP-naive). Another participant described his perception that PrEP was a “taboo” subject in the gay community: “But even with some of my gay friends they, we really don’t talk about that [PrEP]…which I think it’s one of the things that it’s crazy that we’re in the gay community but we don’t talk about certain things like that (P56, PrEP-experienced).” In particular, participants described the stigma linking PrEP use to being seen as promiscuous or unsafe in one’s sex life: “in the gay community… there is a saying that if you’re take it [PrEP], you’re pretty much sleeping around, which is a lie.” (P18, PrEP-experienced) and “my friend said that when you see on a Grindr profile that someone’s on PrEP, it’s like clear that they’re a slut.” (P7, PrEP-experienced).

Latinx Community Influences.

Many participants described the role of the Latinx community, faith, and culture on decisions related to PrEP use. In particular, participants noted that some aspects of the Latinx community or culture made it more difficult to access PrEP. A few participants noted that Latinx culture sometimes discourages seeking health care services or taking medication more generally. One participant observed, “I always feel that medication and doctor visits and hospitals in Latino communities is just like, oh I’d rather die, I don’t want to go to the doctor.” (P27, PrEP-experienced), while another participant described how perceived invincibility can dissuade individuals from seeking care: “I think another thing just coming from a Hispanic community, I think it’s also…’oh, it won’t happen to me’ like ‘I don’t need healthcare. I’m strong, my body will take it. I’m not sick, I don’t need medicine’.” (P49, PrEP-naive). Furthermore, some participants highlighted value placed on masculinity and machismo in Latinx culture, and explained this can prevent men from seeking health care services from male providers. “There’s people that prefer a female [physician.. because they’re embarrassed…to look weak in front of another male.” (P27, PrEP-experienced).

General Community Stigma.

Furthermore, participants described how stigma from the general San Diego community can discourage MSM from using PrEP. Due to heterosexism and homophobia, participants were worried about certain groups in their communities finding out if they used PrEP, such as individuals at their workplace:

Because I work in a pre-school, a lot of the parents live in this area. When I knew I had to get a refill, I tried to hide the pill bottle or get really close to talk quietly with the person or just show the pharmacist the medicine I needed and tried not to respond. One of those times, there was a child that pointed at me saying “the teacher.” And I was embarrassed, because in the first place a lot of people have stereotypes that if you are gay and work with kids you are a pedophile. So, I tried to keep my sexual orientation away from my professional life. (P11, PrEP-experienced).

The Role of Intersectionality in PrEP Use.

Participants frequently reported feeling tension between different aspects of their identities as Latinx MSM. Participants stated that Latinx culture and religious practices discouraged open discussion regarding sexual orientation, which they perceived as limiting their ability to discuss sexual health. In particular, participants explained that the Latinx community stigmatizes being gay, being bisexual, and MSM, which can prevent Latinx MSM from discussing their sexuality and sexual health needs and concerns with others, including peers, family, and healthcare professionals. Many participants expressed challenges associated with their intersecting identities (e.g., Latinx MSM). One participant reflected on the isolation and lack of support that Latinx MSM can experience related to discussing their sexual health: “As a Latino, one doesn’t have the trust to tell our parents [about PrEP use] because that’s not normal, or they [parents] don’t accept it. Then you don’t have anyone to tell. (P14, PrEP-experienced).” Other participants discussed the emotional difficulties of not living up to cultural expectations of their community, particularly the value placed on masculinity/machismo, and reflected on how these cultural norms affect Latinx MSM’s willingness to discuss their sexual health or seek sexual health services. One participant explained:

…being queer in the Latino community it’s difficult cause just because you have the stereotype of you have to be the caretaker of your family. You have to get married to women, you have to have kids. You have to be, it’s like Machismo…And if you are queer or LGBT that in the eyes of your family and other members of Latino community…you are not doing what you’re supposed to do. You are not living up to what you’re supposed to live up to. (P1, PrEP-experienced).

Another participant shared similar challenges:

As a young Latino gay man, it’s just kind of intimidating to look for those things [PrEP] just because in the Latino community being gay is not seen as something that is, something to brag about…In the Latino community everything has to be masculine and masculine has power…I think the Latino community is so concerned with masculine and it’s driven by men, and it’s like men cannot cry, men cannot do this, men cannot be weak. (P56, PrEP-experienced).

Furthermore, one participant explicitly described how PrEP stigma in the LGBTQ+ community can interact with sexual orientation stigma in the Latinx community to make PrEP use for Latinx MSM in San Diego especially fraught: “In Latino culture, this stigma of just being gay is so strong. So just by being gay and Latino, you have enough with that. So plus that on top of that, going to PrEP…it’s difficult for them to process it. It’s difficult for us to process it…just saying that I’m gay and I’m on PrEP, so it’s like, I’m already breaking the rules.” (P23, PrEP-naive).

However, participants explained their intersectional identities also served as a source of community, camaraderie, and informational support. In particular, participants described existing community support groups for LGBTQ+ individuals, including groups specifically for Latinx gay and bisexual men. Participants explained ways in which these community groups assist Latinx MSM in learning more about sexual health and PrEP, accessing PrEP, and receiving support in adhering to PrEP. One participant described how a support group provided him with information about PrEP use, and comfortable space to discuss sexual health:

It was just like a…support group for men, Black and Latino men who identify as gay or bisexual…going to that group, having that space where we were able to share all kinds of things…that was really cool and that’s how I was able to learn more about it [PrEP]. (P13, PrEP-naive).

Another participant shared how a support group for Latinx MSM has encouraged his own PrEP use:

I wanted to get involved more with the Latino group. As Latinos, we don’t have that sense of sexual education as to how to protect ourselves and take care of ourselves. I wanted to learn, that way I could teach my friends that there are medications. That day I went to movie night, we had food but before that I had already taken my pill. When I got there, I was excited to tell them “Hey I just took PrEP”. They were all clapping and said “that’s good that you started the medicine, it will help you.” (P14, PrEP-experienced).

DISCUSSION

The purpose of this qualitative study was to identify interpersonal- and community-level barriers and facilitators to PrEP initiation and adherence among young adult Latinx MSM living in a U.S-Mexico border region. Similar to other previous studies in Latinx and other populations of MSM [27,28,37,42], most participants in the current study, including those who had never taken PrEP and those who had, indicated that other people supported their use of PrEP. It was common for participants to report that peers had provided important informational support and had raised their awareness of PrEP or provided logistical information on how to access PrEP. Also consistent with previous research [27,28,34,37,38,42], participants indicated peers motivated them to take PrEP or to do further research about PrEP on their own. Once participants had decided to take PrEP, some reported that partners, friends, and family provided other types of emotional and instrumental support for PrEP adherence, such as encouragement and reminders. Some participants reported they were motivated to take PrEP by the desire to protect their sexual partners. As noted in other studies of non-Latinx white and African American/Black MSM [34,37,38,42], health care providers who were knowledgeable about PrEP were a critical source of information for most study participants and could motivate participants to initiate PrEP. Finally, participants in the present study mentioned that staff at clinics were helpful in facilitating PrEP awareness, initiation, and PrEP-related health care.

On the other hand, participants also mentioned that other people, including family, friends, partners, and even healthcare providers discouraged them from initiating and adhering to PrEP. In addition to providing inaccurate information, other people expressed concerns about PrEP side effects to the participant. Similar to findings among African American/Black MSM [34], study participants mentioned that when in a monogamous relationship, their sexual partners dissuaded them from continuing to take PrEP. Finally, several participants indicated that family members stigmatized the use of PrEP, and that participants had concerns that using PrEP would lead to inadvertent disclosure of their sexual orientation to their family. This finding is similar to a prior qualitative study in Texas which found that no Latinx MSM study participant reported family support for taking PrEP [43]. Similar to experiences reported by African-American/Black MSM [42], participants also mentioned experiences with physicians who lacked knowledge regarding PrEP, or held limiting or judgmental beliefs about whether to prescribe PrEP. Participants in the present study described that Latinx MSM frequently anticipate that health care providers will stigmatize them for their sexual orientation, and that some Latinx MSM avoid obtaining or discussing sexual health care for fear of judgment and discrimination, which aligns with prior research among African American/Black and Latinx MSM who reported experiencing homophobia, judgment, and discomfort from medical providers [28,38,42]. Unlike prior research, a few participants in the current study reported that they had encountered physicians who were overtly opposed to the participant’s use of PrEP and unwilling to prescribe it.

This is the first study to specifically assess community-level influences on PrEP in a U.S.-Mexico border region. Participants identified structural characteristics in the border county of San Diego, including the vast geographic area of the county (4,526 square miles) [55], the lack of accessibility of PrEP services from public transportation, and the need to have a car to drive to PrEP services, as barriers to PrEP initiation. Participants reported multiple community influences on their PrEP-related decisions, including the LGBTQ+ community, Latinx community, and the general community of San Diego. Participants indicated that the LGBTQ+ community both facilitated and discouraged use of PrEP. Participants reported learning about PrEP from LGBTQ+-focused social media and dating applications. Similar to other studies among MSM [27,28,38,44], participants reported PrEP use can be stigmatized by other members of the LGBTQ+ community. Similar to previous findings [56,57], participants reported that Latinx culture discourages seeking healthcare and taking medication, and the cultural values of masculinity and machismo serve as barriers to seeking health care. Like a prior study which found that higher levels of perceived community homophobia were associated with lower levels of PrEP uptake [58], participants mentioned that anticipated and actual LGBTQ+ stigma in society and community can make it more difficult for them to use PrEP.

Finally, with respect to community-level influences on PrEP awareness and use, participants described intersectionality they experienced as members of both Latinx and LGBTQ+ communities and how it impacted PrEP use. Like the concept of sexual silence noted by others [59], participants reported that Latinx culture and religious practices were a barrier to discussion of their sexual orientation, which made it uncomfortable to discuss their sexual health with peers, family, or health care providers. Furthermore, similar to the findings of another study [41], some participants perceived that LGBTQ+ stigma was common in Latinx culture, making the discussion of sexual health or PrEP very difficult. These findings may conflict with a prior nationwide cross-sectional quantitative study of partnered Latinx MSM which found that both Latinx group membership and gay community connectedness (and the interaction between the two) were associated with PrEP uptake [39]. Participants in the current study also described how their intersectional identities strengthened the support they received, and that services which were specifically designed for LGBTQ+ Latinx community members were important for maintaining sexual health.

While our qualitative study’s findings regarding community barriers in a border region and intersectional influences on PrEP use are novel, it does have limitations. First, although participants in our study were diverse in many ways, they were recruited from one county in southern California, in the U.S. Thus, it is not clear that the results of the study would generalize to Latinx sexual minority men in other areas of the U.S. or outside the U.S. Given that qualitative research is exploratory, additional research is needed to investigate relationships between community and interpersonal factors and PrEP-related behaviors.

CONCLUSIONS

In conclusion, our study found there were important interpersonal and community influences on Latinx MSM’s ability to initiate and obtain care for PrEP, with peers, members of the LGBTQ+ community, health care providers, and family both facilitating and discouraging PrEP use. Positive interactions with peers and health care providers seem to be essential in PrEP initiation. Participants reported that their intersectional identities as Latinx and LGBTQ+ both hindered and facilitated use of PrEP. Future peer-based interventions should be developed and evaluated to specifically meet the needs of Latinx MSM.

Availability of Data and Material:

Not applicable.