Promoting Pre-Exposure Prophylaxis to Gay, Bisexual, and Other Men who Have Sex with Men in the US Deep South: A Qualitative Exploration of Promotion Perceptions and Preferences

Abstract

Background:

Effective HIV pre-exposure prophylaxis (PrEP) promotion is critical to mitigate PrEP disparities, yet there are gaps in understanding how gay, bisexual, and other men who have sex with men (GBM) respond to and prefer PrEP promotion. The Deep South of the United States, a region with high HIV rates and low PrEP uptake, has unique contextual factors that stifle effective PrEP provision and uptake, which could be overcome with effective PrEP promotional messaging.

Methods:

We conducted an exploratory qualitative study grounded in Andersen’s Behavioral Model for Healthcare Utilization. We recruited HIV-negative GBM, aged 18–39 years, from social media, dating apps, and community outreach to complete semi-structured interviews to explore perceptions of and preferences for PrEP promotion. Interview transcripts were inductively and deductively coded for thematic analysis.

Results:

40 participants completed interviews (median age 28 years, 68% Black, 48% current PrEP users). Three themes emerged: 1) the role of different identities with sub-themes emphasizing diversity to reduce stigma and improve relatability, 2) interpersonal relationships, i.e., friends, partners, and family, affect PrEP promotion, and 3) reduced emphasis on HIV risk in promotions.

Conclusion:

To see behavior change for seeking PrEP knowledge and PrEP uptake, PrEP promotions must evolve to improve diversity to foster relatability and reduce stigma, harness social networks to efficiently transmit messaging, and tactfully discuss risk behaviors without compounding stigma.

Brief Summary:

A qualitative study among sexual minority men exploring PrEP promotion preferences found three main themes: the role of diverse identities, relationships affecting PrEP promotion, and reduced emphasis on HIV risk.

Introduction

Although pre-exposure prophylaxis (PrEP) prevents HIV, gay, bisexual, and other men who have sex with men (GBM), especially of color, have inequitable access to PrEP (1–3). These disparities in PrEP uptake have not sufficiently stemmed new HIV diagnoses in high priority areas, such as the Deep South of the United States (US) (1, 2, 4–6). Alabama, a priority jurisdiction in Ending the HIV Epidemic, has relatively low uptake of PrEP, especially among Black GBM, who have the highest likelihood of HIV acquisition (3, 7, 8). Intersectional stigma related to how a person experiences stigma due to overlapping identities (e.g., racial and ethnic identities, sexual and gender identities) and sexual behaviors lead to access disparities in this region, especially considering racism, homophobia, and medical mistrust (9, 10). PrEP promotional messaging may be one strategy to overcome these barriers. Black GBM living in the US mid-Atlantic region reported the need for more information and the desire to normalize PrEP use (11). More broadly, Black GBM have reported experiencing stigma from social media PrEP promotions (11, 12). While some have emphasized multi-level barriers to healthcare access in the US Deep South, there is a gap in understanding how GBM perceive and prefer PrEP promotions in the US Deep South and how this understanding can be leveraged to improve healthcare access for PrEP (13–15). PrEP promotion may occur on various platforms, content, and media; for example, digital advertisement via social media, commercials on TV or streaming services, or even physical signage such as billboards have been used to promote PrEP. Some work has demonstrated that PrEP promotion can influence behavior and motivation to use PrEP with key predictors such as PrEP knowledge, positive PrEP attitude, higher HIV risk, and low PrEP stigma (16). In an era of increasing PrEP awareness, more must be done to empower GBM to seek PrEP information and start using PrEP (17, 18).

In this study, we sought to understand how GBM in the US Deep South perceive and what they prefer to see in PrEP promotions. Given the unique context of the Deep South with high HIV incidence and disparate PrEP uptake among GBM of color, this exploratory qualitative study sought to provide richer context around how GBM interpret PrEP promotions and how they prefer for PrEP to be promoted.

Methods

Approach:

We approached this work through a phenomenological lens to understand how GBM participants interpret and respond to PrEP promotional messaging with a key focus on how their lived experiences affect this perception (19). We grounded this study in the Andersen Behavioral Model of Healthcare Utilization (ABM) to understand the predisposing factors, enabling resources, and need that influence how PrEP promotion perception and preference (Figure 1) (20).

Figure 1.

Andersen’s Behavioral Model of Healthcare Utilization with interview topics mapped to constructs.

Sampling:

We completed this study in Birmingham, Alabama, a city with high HIV incidence, from 2022–2023 (5). Eligible participants self-identified as 1) a cisgender man who reported sex with men, 2) age 18 through 39 years old, and 3) self-reported HIV-negative status (4, 5). We sought to recruit at least 50% Black GBM and at least 10% Hispanic GBM to ensure representation of groups most affected by HIV in the region (4, 5). We purposively sampled through social media, dating apps, community-based organizations outreach, and established local participant registries. All participants were recruited from Alabama.

Data Collection:

We based initial interview guide topics on literature review and investigator experience, mapping to ABM constructs in Figure 1, and iteratively revised based on interviewer feedback (supplemental file). Three interviewers (two Black cisgender women and one White cisgender woman) with experience in qualitative interviewing for HIV prevention research with sexual minority men conducted private semi-structured interviews with probing as necessary, either in-person or remotely using a secure video conferencing platform. Interviews were audio recorded and transcribed verbatim by a secure transcription service. Authors reviewed the recordings and transcripts for fidelity and completeness.

Data Analysis:

Two authors (RMG and GM) coded transcripts using NVivo software to organize the analysis (Lumivero, Denver, CO, US). The lead coder (RMG) had similar lived experiences to participants, contributing to reflexivity in this work, allowing a greater contextual understanding while maintaining objectivity (21). Coders employed thematic analysis and coded both inductively and deductively based on a priori codes from the literature (22). Coders iteratively revised the codebook and compared coding schemes to ensure interrater reliability, having strong intercoder agreement with Cohen’s Kappa of 0.85 (23). The final codebook is provided in the supplement. We operationalized codes and subcodes based on the constructs, assembled these into themes with subthemes, and mapped back to the framework.

Ethics:

The institutional review board at the University of Alabama at Birmingham approved this study, and each participant consented to their participation.

Results

Forty GBM completed interviews. The median age was 28 years (range 20–38). Most participants identified as Black (n=27, 68%), and 11 (28%) identified as White. Ten percent (n=4) identified as Hispanic. Just over half of participants (52.5%) were not currently using PrEP. Education and income levels varied across participants. Table 1 shows complete sociodemographic data.

Table 1.

Sociodemographic and PrEP use of participants, N=40

Median Age, Years (Range)	28 (20–38)
Race n (%)
Black	27 (67.5%)
White	11 (27.5%)
Other	2 (5.0%)
Ethnicity n (%)
Hispanic	4 (10%)
Non-Hispanic	36 (90%)
Highest Education Completed n (%)
High School Diploma or Equivalent	8 (20%)
Some College – did not graduate	6 (15%)
Associate degree	5 (12.5%)
Bachelor’s degree	14 (35%)
Graduate or Professional Degree	7 (70%)
Annual Personal Income n (%)
<$25,000	6 (15%)
$25,000–$49,999	20 (50%)
$50,000–$74,999	9 (22.5%)
>$75,000	3 (7.5%)
Prefer not to answer	2 (5%)
PrEP Use n (%)
Never	14 (35%)
Prior	7 (17.5%)
Current	19 (47.5%)

From these data, we report three themes, with subthemes, that emerged: 1) the role of identity in PrEP promotion, 2) the impact of relationships on PrEP promotion, and 3) reduced emphasis on HIV risk. Our results mapped to three main ABM constructs: Predisposing factors, Enabling Resources, and Need. Each theme and subtheme map to ABM constructs with supporting quotes (Table 2), and Figure 2 shows sub-themes mapped onto the ABM construct model.

Table 2.

Themes and sub-themes mapped to ABM constructs with exemplar quotes.

Theme	Sub-theme	Construct	Exemplar Quotes
The role of identity in PrEP promotions	Diversity of persons presented	Enabling Resource	“I think a perfect PrEP ad would include not just one particular type of person, not just a gay man, but of course all types of people...not just something related to sexual relations.” (28, White, current PrEP user) “I think a lotta heterosexual people don’t really look at PrEP as something for them, but HIV is something that is not just within the LGBTQ community” (26, Black, current PrEP user) “Regardless of what the person looks like, what their race is, what their style is, whether they look feminine or masculine, or if they identify as bear, twink, jock, or any of that other stuff...I feel like having a wider variety of people...would be better because then it seems more inclusive” (31, White, current PrEP user) “Certain things don’t really have a look, per se, but students, certain professional careers, people who enjoy different hobbies... ‘hey, if my counterparts are doing this, if they’re taking this, it might be beneficial for me to do it as well” (34, Black, current PrEP user)
	Relatability improves promotion perception	Enabling Resource	“People who look like me, people who do the things I do, they’re using this product, this thing, and it’s protecting them and working for them. Maybe it’s something that will work for me too” (32, White, current PrEP user) “You want to see yourself in whatever you do and whatever you see.... say, ‘OK, I’m gonna get on this. I’m gonna do this and I’m gonna stick to this...I think it’s very important for everybody to see a representation of themselves” (23, Black, never used PrEP)
	Singular identities in promotions are stigmatizing	Predisposing Factor	“Most of [PrEP promotions] are honestly and truly is set around Black, gay men, so it just seems like you get this disease from a Black, gay man...like it’s a targeted group, a targeted demographic, always...so protect yourself from this group of individuals” (29, Black, never used PrEP) “It was just like, wow, why us...even though the majority of [HIV] is coming from the gay community and you really wanna try and help them out, it’s like no, don’t single ‘em out. Make it inclusive, so make it seem like it’s a straight and gay problem.” (27, Black, current PrEP user) “I feel like there still needs to be specific outreach to the Black, LGBTQ men, but...I don’t want it to make it seem like it’s a targeted ad just for us...I love to see diversity, but don’t forget about these LGBTQ, Black men” (23, Black, former PrEP user)
Relationships affecting PrEP promotion	Interpersonal relationships facilitate PrEP promotion	Enabling Resource	“I think I would prefer receiving [the message] from someone I know. It makes it more personal...’oh, I know this person. If it’s coming from them, I can probably trust them.” (24, Hispanic, former PrEP user) “I’d rather have friends talk to me about it rather than family...that goes back to that closed off family. Partners, I think, and friends need to be the ones that talk about [PrEP] the most.” (27, White, former PrEP user)
	Communities are a natural avenue for PrEP promotion	Enabling Resource	“Some community leaders can get to a certain type of community that maybe the business can’t, or maybe even the news or social media can’t, so I think it would be actually great.” (23, Black, never used PrEP) “I wish [community leaders] would talk about [PrEP] more, instead of it always coming from just a medical professional...they’re gonna hear it from someone they look up to, someone that they trust, someone that they see as a leader in the community, and they would take their message, their word, take that in and take it to heart.” (38, White, current PrEP user). People who are in different communities and not necessarily within the LGBT community, they can still be allies and be a voice and amplify voices.” (23, Black, former PrEP user)
Reduced emphasis on HIV risk	Objective risk measures in promotions must be mitigated to prevent stigma	Need	“When hearing [HIV] statistics, especially specifically or solely about LGBTQ community, it’s a little hard to hear, or hard to swallow. I think it promotes the stigma... that just turns me off and makes me want to turn the station...it could certainly do that, without it, in a tactful way that doesn’t make people feel dirty.” (32, White, former PrEP user). “I don’t think it needs to be the front line...Don’t use a scare tactic. I think people just shut out scare tactics.” (27, White, former PrEP user). “Like not necessarily ethnicities, but maybe genders, I would say including statistics, like males and females’ chances...who’s rate is a little bit higher when it comes to HIV?” (27, Black, never used PrEP).

Figure 2.

Sub-themes mapped to constructs of Andersen’s Behavioral Model of Healthcare Utilization.

Theme 1: The Role of Identity in PrEP Promotions

The identities presented in the PrEP promotion could improve perception through relatability, or it could cause the viewer to internalize anticipated stigma related to the promotion.

Sub-theme 1.1: Diversity of persons presented

Participants felt that a diverse representation of identities in a promotion was very important, serving as an enabling resource (Table 2). To many participants, diversity meant including multiple racial and ethnic identities, multiple sexual and gender identities, and different age groups. Some participants felt that current PrEP promotions are often viewed as excluding persons who do not identify as Lesbian, Gay, Bisexual, Transgender, or Queer/Questioning, plus other (LGBTQ+). In fact, many participants felt that increased diversity in PrEP promotions would make more people realize that PrEP is for all persons. It would serve as an inconspicuous call-to-action for persons to see PrEP as an HIV prevention strategy available for themselves. One participant remarked that promoters should, “make [the promotion] inclusive, make it seem like straight people can get HIV as well too.” (27, Black, never used PrEP).

Participants also commented on the representation of physical appearances and other aspects that an individual may consider central to their identity. Often under-recognized, identities in the LGBTQ+ community go beyond sexual or gender identity. Specifically, there is considerable intracommunity tribalism with subcultural identities among LGBTQ+ persons, and these subcultural identities may also contribute to stigma even within the community of GBM.(24–27) Representation of these identities in PrEP promotion also matters in how promotions may be perceived. Other participants furthered the notion that varied physical presentation in PrEP promotions is important. One participant stated, “just seeing everyday people type-deal rather than just someone who is doing a modeling career” (27, White, former PrEP user). Other parts of a person’s identity, aside from physical presentation, could be included to improve perception. In fact, one participant discussed how certain aspects may not have a particular physical presentation but could be conveyed as a part of a person’s identity. Participants spoke to how a person may relate to a promotion, improving their perception, and possibly leading to behavior change.

Sub-theme 1.2: Relatability improves promotion perception

Many participants felt that relatability helped to convey the utility of PrEP to the promotion viewers, an enabling resource (Table 2). One participant stated, “it’s all about relatability when it comes down to these advertisements” (22, Black, former PrEP user). PrEP promotions that featured persons who the viewer could relate to would encourage the viewer to explore using PrEP or get more information about PrEP. Another participant evoked the same idea in their interview and said, “If I see somebody that looks like me or identifies as me, I feel more inclined… to do that, look into it, or participate in it.” (24, White, former PrEP user). Participants not only believed that relatability was important for promotion perception; they also remarked how relatability influenced behavior change and the likelihood to pursue PrEP. Moving beyond simply being aware of PrEP, relatability meant that participants felt supported in their behavior change.

Sub-theme 1.3: Singular identities in promotions are stigmatizing

As a predisposing factor, many participants also suggested that how a person sees themselves in a promotion could lead to internalized stigma (Table 2). These participants felt that seeing only one type of person with a singular identity could be stigmatizing, especially considering racial identities. Particularly, participants felt that seeing gay, Black men frequently in these ads intimated that PrEP, or even HIV, was only relevant to gay, Black men. Many participants felt that seeing only one type of sexual or gender identity in PrEP promotions was stigmatizing and would be confusing as to who could use PrEP. Moreover, participants noted the compounding intersectionality of stigma from their racial identity and sexual identity. One participant stated, “Because there are people that look like me, they feel like they can say and stigmatize it a little more… Bein’ gay in the Black community is one of the most stigmatizing things ever.” (26, Black, current PrEP user).

Participants highlighted that even though there are high rates of HIV in the LGBTQ+ community, PrEP should be promoted more inclusively. Further, more participants reported that they recognize higher HIV incidence among GBM, but that should not invite singled-out identities in promotions. One participant did not like promotions to mention identities “at risk for HIV,” saying, “I fear that that would turn into stigma” (24, Hispanic, former PrEP user). It was clear that singular identities would increase stigma, yet it was also clear that representation still matters tremendously for effective PrEP promotion. Participants reported mixed perceptions regarding internalized stigma from PrEP promotions. The internalized stigma is also related to their need for PrEP or their perceived HIV risk. One participant described this as “At first, I felt just like…a little ashamed ‘cause I was like, ‘damn, they low key talking about me.” (23, Black, former PrEP user).

Some participants expressed often feeling targeted by social media, and this would be stigmatizing. One participant reported that PrEP promotions appear on his social media and inadvertently disclosed his identity, or “outed” him to a colleague. He not only felt stigmatized by the promotion but also targeted by promotions.

“If I watch one queer-related video, I see PrEP commercials more, and that was pointed out by a heterosexual woman who was watching YouTube videos with me. She was like, ‘Oh, I never get these. I never see these commercials.’ She was like, ‘They must be keepin’ track of you ‘cause I never see these.” And I’m like, ‘I see them every day,’ so it does make me feel a little bit targeted.” (26, Black, never used PrEP).

Theme 2: Relationships affecting PrEP promotion.

Many participants reported that some relationships were more easily amendable than others for discussing PrEP promotions, such as with friends or sex-partners rather than with family members, but that depended on their comfort discussing sexual topics with their family.

Sub-Theme 2.1: Interpersonal relationships facilitate PrEP promotion

Interpersonal relationships, particularly among friends or sex-partners, operate as an enabling resource to facilitate promoting PrEP or sharing information about PrEP (Table 2). Many participants reported feeling more confident in the promotional message and having more trust if the promotion was delivered from a close contact. In doing so, this would improve the positive emotion attached to the message and reinforce the role of trust in enabling relationships for PrEP promotion. These interpersonal promotions would foster comfort and a sense of protection. One participant remarked how it would make him feel happy to hear the message from a friend. He stated, “I’d be happy, like that’s my guy…delivering the message. Like, I see you doing your big one.” (24, Black, never used PrEP). This participant described a sense of endearment, beyond just protection or trust, to foster a favorable perception of the message.

Some participants reported that they felt their family could be a viable avenue to promote PrEP, depending on whether family members were affirming without stigma and were knowledgeable about PrEP. One participant, who felt supported by his family, stated, “I talk to my mom about it…my mom is getting ready to talk to my nephews about it.” (26, Black, former PrEP user). Other participants did not think that their family would be open to learning about or discussing PrEP with a recurring consideration that it would intimate a person is sexual thus should not discuss with family, described as, “[It’s] a little weird to me. Because you’re only taking PrEP if you’re hooking up…are you telling your mom about your hook up?” (37, White, former PrEP user). Contrasting this, other participants found value in using familial relationships to promote PrEP in a way that is gender-inclusive, centering PrEP efficacy around protecting family members. One participant described a hypothetical promotion: “‘My son is turning 16, 17. My daughter is turning 16, 17. Let’s talk to them about [PrEP]. I know they’re very sexually active. I don’t want anything to happen.” (24, Black, never used PrEP).

Sub-Theme 2.2: Communities are a natural avenue for PrEP promotion

Participants felt that relationships built within and among community members, community leaders, and community organizations would effectively enable PrEP promotion to be considered trustworthy, mapping to the Enabling Resources of the ABM (Table 2). Many participants noted that the community leaders would be the first step. One participant stated, “coming from a leader, you’d think of it as a reliable source or a trustworthy source.” (31, White, current PrEP user). Furthermore, these leaders could reach community members that other outlets were unable to reach. Community leadership is not necessarily an official role, as one participant noted that influencers should promote PrEP; a local celebrity or leader who could express their own personal experience would be impactful in promoting PrEP. One participant stated, “Maybe they’re not a local celebrity, but they are someone prominent… being like, ‘I take PrEP every day,’ I think that would be really impactful.” (32, White, current PrEP user). Some community members would be more likely to respond or trust PrEP promotions that came from community leaders or other community members more so than a medical professional.

Community promotion could go beyond just LGBTQ+ communities and increase HIV prevention promotion through allyship with other communities to reduce stigma. Other communities thought to be ideal included healthcare groups, advocacy groups, and LGBTQ+ community groups, such as ballroom houses: “I feel like people in ballrooms specifically could help with that community when it comes to actually spreading the word,” (23, Black, former PrEP user).

Community-based promotion, however, depended on the community context or the community in question. Some participants noted there were challenges in religious organizations promoting PrEP due to stigma, as one participant remarked, “My pastor’s known me since I was 12 years old…I would not ask him [to promote PrEP] just simply because I know his beliefs.” (26, Black, current PrEP user). Others noted that some persons may not engage in community promotion, or be responsive to such promotion, due to concerns of disclosing their sexual identity. Summarizing this, one participant stated, “if someone who is not out to other people, they would be hesitant to get a flyer from them because they don’t want to be known.” (33, Asian, current PrEP user).

Theme 3: Reduced emphasis on HIV risk

Many participants felt that including risk measures or discussion in PrEP promotions acknowledged the disparity in HIV diagnoses among GBM, but it could simultaneously perpetuate stigma and stereotypes about GBM. Contrasting this, some GBM felt that HIV statistics should be included in PrEP promotions and could also demonstrate to heterosexual persons that they are also at risk for HIV. However, participants felt that persons who have higher chances of acquiring HIV, especially GBM, were already aware of their HIV risk and promoting it would be harmful. This notion of how HIV risk is incorporated into PrEP promotion maps to the Need construct of ABM (Table 2).

Participants highlighted the perceived stigma when discussing rates of HIV among GBM or LGBTQ persons and described how hearing this makes them feel stigmatized and less receptive to the promotion. Other participants noted that such promotions mentioning risk come across as judgmental, stating, “I think that it could be a turn off for some people just to see it ‘cause it is a little judgy.” (37, White, current PrEP user). Other participants agreed that the initial impact of risk promotion would be aversive and not improve awareness or uptake.

Still, few GBM felt that including objective risk discussion would help improve risk perception as the first step to understanding the need for PrEP. One participant stated, “If you talk about the risk of getting HIV might get people more interested in wanting to get PrEP. ‘Cause a lot of people don’t even know about the risks.” (24, Hispanic, former PrEP user). To potentially reduce stigma, some participants felt that including rates based on gender, rather than ethnicities, in certain regions may help to demonstrate the need for PrEP without being overtly stigmatizing.

Discussion:

This study included a sample of GBM most affected by the HIV epidemic in the Southern US: a young, Black-majority cohort who are largely not using PrEP. We identified three major themes with subthemes that map back to the key constructs in ABM. Taking a phenomenological view, this work expands the literature by focusing on understanding the lived experiences of Southern GBM, how they perceived PrEP promotions, and what they preferred in PrEP promotions. PrEP promotion can improve awareness, as demonstrated with sex-positive promotion campaigns such as #PrEP4Love featured in Chicago, IL, USA (28, 29). It is unknown how similar campaigns would perform in the US Deep South. Our work is the first to qualitatively explore PrEP promotion in a setting with high levels of homophobia and racism, while centering PrEP messaging and promotion around how Southern GBM perceive and prefer PrEP promotions. These findings add much needed context into how PrEP promotions should be designed and delivered.

Many participants perceived singular identities (e.g., only gay, Black cisgender men) in PrEP promotions as stigmatizing, which made the promotion less impactful since participants felt less responsive to these promotions. This stigma acted as a predisposing factor interfering with responding to the promotion to engage PrEP services or seek additional PrEP knowledge, especially among sexual minority identities and racial minority identities, two identity components that historically have been marginalized in the Deep South. Although inclusion in this study focused on sexual behaviors (i.e., prior sex with men), sexual identity, such as, gay, bisexual, same-gender-loving, or straight were not quantified in our data, but most participants discussed how their lived experiences as a sexual minority person influenced their perceptions. Consistent with prior literature, we show that singular identities are stigmatizing.(11, 12) Diverse representation, however, transformed stigma, as a predisposing factor, into relatability, as an enabling resource, and expanded into aspects such body types, tribalism, and professional roles. Thus, our findings advance the prior notions of diversity and inclusion to support a broader sense of diversity to foster relatability. Understanding that PrEP promotion requires public health resources, PrEP promotions should be intentional to include a broader representation to improve PrEP promotion perception and normalize PrEP. Furthermore, having diverse identities in the promotion meant that other communities would identify with the promotion and realize that PrEP would be protective for them as well. PrEP promotions should refocus how identities are featured in PrEP promotions to harness this opportunity to improve relatability.

Interpersonal relationships, as an enabling resource, reinforced GBM as generally trusting friends or partners more than family for PrEP promotion. GBM considered PrEP promotions shared through an interpersonal relationship to be vetted, and the information would be actionable. Beyond trustworthiness, sharing promotions also fostered a sense of protection and care within a relationship dyad or community, potentially strengthening the relationship. As a communication strategy, social network theory states that information efficiently transmits through established relationships, which is supported by our findings in this work.(30, 31s) Communities are primed to promote PrEP through multiple levels, i.e., the members, leaders, and organizations, and incorporating success stories into a community context would connect the trustworthiness and relatability of an effective PrEP promotion. Faith-based organizations may hold considerable social capital in the Black, Southern communities, supporting utilization of faith-based leaders to support HIV prevention; however, religious dogma that supports homophobia and sex-related stigma may preclude this effectiveness, consistent with prior data and as noted by participants.(32s, 33s) Indeed, community leaders can act as key opinion leaders to filter and ensure delivery important messaging to a community, but modern social media has allowed promotion directly to community members using tailored analytics and big data.(34s-38s) This underlies the potential for PrEP messaging to leverage existing social networks, so PrEP promotion campaigns should be designed to harness social networks for targeted information dissemination through trusted channels.

Many GBM did not prefer risk-based framing, instead preferring gain-framed PrEP messaging similar to other studies.(39s) Regarding the ABM framework, objective need in PrEP promotions often manifests as HIV statistics and messages about risk behaviors, especially focusing on sexual minority or racial minority communities. Communication theories often used in health promotion, such as the activation model or extended parallel process model (EPPM), posit that risk is a key feature in health promotion messaging, leading to increased awareness as the first step in behavior change.(40s) In these theories, to successfully lead to behavior changes, viewers must appraise threat, or risk, in the promotion. While the intention of such is to improve risk awareness, GBM frequently reported that this was aversive, which would lead to ignoring the promotion altogether. Many GBM reported that they were aware of their HIV risk, so PrEP promotions that reinforced HIV risk among sexual minority men missed the opportunity to instead promote PrEP access or knowledge. Promotions mentioning risk or statistics instead compound perceived stigma, making GBM less likely to engage or respond to the promotion. PrEP promotion designers should carefully consider how HIV statistics and risk behavior are incorporated into the promotion messing or avoid these altogether.

In summary, PrEP promotion can affect each step in the PrEP continuum. Despite increasing awareness, PrEP promotions that lead to action are critically needed. Our work demonstrates that many aspects of current PrEP promotions do not appeal to current GBM and reduces the promotion’s impact on improving knowledge or uptake. To meet GBM preferences for PrEP promotions and improve its reach, promotions should significantly change to include diversity to foster representation and relatability and reduce stigma through interpersonal connections and community to foster trust to improve message delivery and impact.