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. Author manuscript; available in PMC: 2019 Nov 1.
Published in final edited form as: Stigma Health. 2017 Sep 18;3(4):330–337. doi: 10.1037/sah0000102

Health Care Discrimination, Sex Behavior Disclosure, and Awareness of Pre-Exposure Prophylaxis Among Black Men Who Have Sex With Men

Jessica L Maksut 1, Lisa A Eaton 1,2, Elizabeth J Siembida 1, Chanee D Fabius 1, Alison M Bradley 1
PMCID: PMC6334285  NIHMSID: NIHMS905790  PMID: 30662952

Abstract

Background

Perceived healthcare-related discrimination and disclosure of same-sex sex behaviors to healthcare providers may act as barriers to awareness of pre-exposure prophylaxis (PrEP) for Black/African-American men who have sex with men (BMSM). Given the elevated rates of HIV transmission among young BMSM in particular, age is likely an important factor for determining the correlates of PrEP awareness unique to BMSM of different ages.

Method

147 BMSM (M age = 30.6 years, SD = 10.3 years) located in the Southeastern United States were recruited from gay-identified bars, clubs, bathhouses, parks, and street locations, via online classifieds (e.g., Craigslist) and social media (e.g., Facebook). Participants completed surveys that included questions about demographic characteristics, perceived healthcare-related discrimination, disclosure of same-sex sex behavior to healthcare providers, and PrEP awareness.

Results

Perceived healthcare-related discrimination was significantly, negatively associated with PrEP awareness, and same-sex sex behavior disclosure to healthcare providers was significantly, positively related to awareness of PrEP among BMSM. A moderation analysis, with participant age as the moderator, revealed that higher perceived healthcare-related discrimination was significantly, negatively associated with PrEP awareness beginning at 30.2 years of age, and that the relationship strengthened as age increased.

Discussion

Perceived healthcare-related discrimination plays a particularly important role in PrEP awareness for BMSM who are 30 years of age and older. Discrimination in healthcare settings may impact BMSM’s ability, particularly those who are older, to access PrEP information. Healthcare professionals must establish procedures for identifying appropriate patients for PrEP, and prioritize addressing the psychosocial factors that impede PrEP awareness for their BMSM patients.

Keywords: HIV, age, Black men who have sex with men, PrEP, healthcare-related discrimination

Introduction

New technologies for preventing HIV infection have emerged, most notably, pre-exposure prophylaxis (PrEP). PrEP, which received approval by the FDA in 2012, offers promise in reducing disease incidence, particularly among groups at elevated risk for HIV, such as men who have sex with men (MSM; Hall et al., 2008; Maulsby et al., 2014; Millett, Flores, Peterson, & Bakeman, 2007). Previous researchers have argued that PrEP is “the beginning of the end of AIDS” (Havlir & Beyrer, 2012, p. 685), and that it offers exciting, albeit challenging, opportunities for HIV prevention (Young & McDaid, 2013). While efforts to promote PrEP to MSM have demonstrated modest progress (Hood et al., 2016), reductions in HIV incidence by using PrEP will require a much greater proportion of those at highest risk for HIV infection to both access and be adherent to the medication (Kelley et al., 2015). Moreover, limited research has been done to understand facilitators of PrEP awareness, uptake, and adherence in various populations of MSM at elevated risk for HIV, including Black/African-American MSM (BMSM; Snowden, Chen, McFarland, & Raymond, 2016).

While there have been a number of clinical trials (e.g., Grant et al., 2010) that have demonstrated that PrEP – specifically, tenofovir disoproxil fumarate/emtricitabine, or Truvada® – is an efficacious HIV prevention option for MSM, it is concerning that there remains a limited understanding of PrEP awareness and/or uptake among BMSM. For example, PrEP use among BMSM, the sociodemographic group that is most heavily impacted by the U.S. HIV epidemic, continues to lag (Eaton, Driffin, Bauermeister, Smith, & Conway-Washington, 2015; Millett, Peterson, Wolitski, & Stall, 2006; Young & McLeod, 2013). Furthermore, trials of PrEP among MSM tend to suffer from low representation of BMSM in their samples (Perez-Figueroa, Kapadia, Barton, Eddy, & Halkitis, 2015). However, preliminary results from the HTPN 073 study, a phase I open label PrEP trial among BMSM, demonstrate a high interest in, uptake of, and adherence to PrEP among BMSM (Wheeler et al., 2016). Structural (e.g., racism, homophobia, economic differences) and cultural (e.g., perceived healthcare-related discrimination, medical mistrust) factors that are pertinent drivers of health outcomes and health behaviors for BMSM must be strongly considered when assessing the impact and delivery of PrEP for BMSM (Mayer, Pace, Siberry, Hazra, & Kapogiannis, 2013; Holden, McGregor, Blanks, & Mahaffey, 2012). It is clear that additional studies of PrEP awareness, uptake, and use among this disproportionately affected population are urgently needed.

In recent years, PrEP feasibility and acceptability among MSM have been increasingly investigated; however, while studies of this kind that target young MSM exist (Hosek et al., 2013), the same is not true for their older counterparts, despite evidence that age is an important factor in PrEP awareness and uptake (e.g., Golub et al., 2013; Gamarel & Golub, 2015). Factors such as disease epidemiology (e.g., younger BMSM have higher HIV incidence than older BMSM; Prejean et al., 2011) and cost effectiveness (e.g., PrEP is most cost-effective for younger, at risk MSM; Paltiel et al., 2009) have likely driven the strong focus on PrEP uptake among youth populations. However, it is important to note that, although HIV incidence may be highest among young BMSM, cohorts of older BMSM face the highest rates of HIV prevalence (Matthews et al., 2016). The lack of focus on older BMSM in PrEP implementation studies likely impacts healthcare providers’ evaluations of their older BMSM patients’ need for accessing PrEP, which may in turn affect uptake of this prevention strategy (Arnold et al., 2012).

Age may be an important factor in determining the degree to which BMSM experience mistrust of healthcare. Medical mistrust, or beliefs regarding mistrust in the medical establishment, has been shown to be especially pertinent to BMSM in need of healthcare services, given its significant, negative relationship with their utilization of those services; however, there is evidence in related literatures that medical mistrust, and related perceived healthcare-related discrimination, may act as a more serious barrier to engaging in healthcare among older Black adults in general (Hammond, 2011) perhaps due to longer history of interacting with the medical establishment. The overwhelming majority of studies that have explored the relationships between medical mistrust, perceived healthcare-related discrimination, and utilization of healthcare services among BMSM have demonstrated a significant relationship between these variables (e.g., Eaton et al., 2015; Trivedi & Ayanian, 2006). According to a study by Eaton and her colleagues (2015), the relationship between perceived healthcare-related discrimination and time since last physical examination among HIV negative BMSM was negative and significant, and the relationship was fully mediated by global medical mistrust. With respect to PrEP, perceived healthcare-related discrimination may be significantly, negatively associated with PrEP awareness, and this relationship may differ by age, as older individuals may be less trustful of the medical community than their younger counterparts.

It is also important to acknowledge that implicit bias on behalf of healthcare providers due to ageist beliefs regarding at what age BMSM may be or not be a good PrEP candidate is a potential barrier to older BMSM’s awareness of this HIV prevention tool. In spite of the fact that sexual health remains an important area for individuals across the lifespan, healthcare professionals routinely avoid engaging in discussions with their patients around sex-related concerns (Taylor & Gosney, 2011) which, for older BMSM, lack of sexual health communication with providers may act as a barrier to PrEP awareness, and may be compounded by healthcare providers’ implicit biases that are motivated by racism or homophobia. A study by Calabrese and her colleagues (2014) revealed that, relative to White MSM, BMSM were rated by healthcare professionals as more likely to engage in increased unprotected sexual intercourse if prescribed PrEP, which, in turn, was associated with reduced willingness to discuss PrEP with BMSM patients. It is possible that race-related beliefs, paired with ageist thoughts regarding sexual health, may position older BMSM such that they are least likely to be engaged by healthcare providers about PrEP.

It is known that healthcare providers are critical gatekeepers of information regarding sexual health and HIV prevention strategies for MSM (Underhill, 2014). Along these lines, healthcare providers are crucial for linking MSM who are at risk for HIV to PrEP (Blumenthal et al., 2015). Previous studies indicate that PrEP knowledge among healthcare providers is generally high, but that their experiences prescribing PrEP are often limited, and their willingness to adopt PrEP implementation guidelines is variable (Tripathi, Ogbuanu, Monger, Gibson, & Duffus, 2012; White, Mimiaga, Krakower, & Mayer, 2012; Karris, Beekmann, Mehta, Anderson, & Polgreen, 2014). Furthermore, MSM’s willingness to disclose same-sex sex behaviors, or other HIV risk behaviors, to healthcare professionals may be a critical piece in their gaining awareness of and access to PrEP. There is evidence that non-disclosure limits opportunities for providers to identify patients for whom this HIV prevention strategy may be appropriate, as well as to initiate discussions regarding information about PrEP (Khawcharoenporn, Kendrick, & Smith, 2012; Underhill, 2014).

Study Aims

The present study had three primary aims. Our first aim was to determine the extent to which BMSM in our sample were aware of PrEP. In line with previous studies’ findings (e.g., Kelley et al., 2015), it was hypothesized that their awareness of PrEP would be low. Secondly, it was examined whether perceived healthcare-related discrimination, disclosure of same-sex sex behavior to a healthcare provider, and participants’ age were related to PrEP awareness among BMSM. For this second aim, it was hypothesized that (1) perceived healthcare-related discrimination would be significantly, negatively related to PrEP awareness among BMSM, (2) disclosure of same-sex sex behavior to a healthcare provider would be significantly, positively related to PrEP awareness, and that (3) participants’ age would be significantly, negatively related to PrEP awareness. Our third and final aim was to determine whether participants’ age moderated the relationship between perceived healthcare-related discrimination and PrEP awareness, as well as the relationship between disclosure of same-sex sex behavior to a healthcare provider and PrEP awareness.

Methods

Participant Recruitment and Data Collection

Participants in the current study were recruited from gay-identified bars, clubs, bathhouses, parks, and street locations; from online classifieds; and on social media (e.g., Facebook, Black Gay Chat, Jack’d). Screening for inclusion criteria was conducted prior to study enrollment, and participants who were recruited at LGBT-friendly and other in-person locations were screened when recruiters approached them at the abovementioned venues. Participants recruited through online classifieds or social media were screened over the phone using telephone screening software. Men were eligible for study participation if they reported condomless anal sex with a male partner in the past year, an HIV negative or unknown status, and were at least 18 years of age. After the initial screening, participants attended an in-person appointment at the study research site and provided written consent. During the appointment, participants completed a survey assessment that utilized Audio Computer Assisted Interviewing (ACASI) software. Individuals were compensated $30 for participating in the study.

One-hundred and fifty-four participants met inclusion criteria and completed the survey assessment between January 2012 and March 2014. Seven participants did not identify as Black/African American, and were therefore removed from all further analyses. Those participants who identified as bi- or multi-racial, including Black/African American, were retained in analyses (N = 147). All study procedures were approved by <blinded for peer review> Institutional Review Board.

Measures

Demographic variables

Participants were asked to report on their age, years of education, employment status, income level, race/ethnicity, and sexual orientation (i.e. whether they identified as same gender loving/gay, bisexual, or heterosexual).

Perceived healthcare-related discrimination

In order to determine participants’ perceptions of discrimination, they were asked six questions. The first three questions focused on their perception of discrimination due to their race, and included items such as “In the past year, do you think you have been mistreated by healthcare providers because of your race?” and “In the past year, do you think your healthcare isn’t as good as others because of your race?” The last three questions focused on participants’ perception of discrimination due to their sexual orientation, and included items such as “In the past year, do you think you have been ignored by healthcare providers because of your sexual orientation?” and “In the past year, do you think your healthcare isn’t as good as others because of your sexual orientation?” Participants were asked to answer either yes or no to each question, and participants were scored with a 1 for a yes response and a 0 for a no response. These items were adapted from a study by Wilson and Yoshikawa (2007). Given that race-based and sexual orientation-based discrimination in the healthcare setting were found to be highly collinear (r = .72), participants’ scores were summed across all six items to create one perceived discrimination variable (Cronbach’s α = .90).

Disclosure of same-sex sex behavior

Participants were asked if they had ever talked with a medical doctor, nurse, or other healthcare professional about having sex with men. Participants answered this question by responding yes or no.

PrEP awareness

Awareness of PrEP – taking antiretroviral medications (i.e., Truvada) to prevent HIV infection – was assessed in order to gauge the extent to which men were aware of recent HIV prevention advancements. Participants were first given a brief description of PrEP – specifically, “PrEP is when HIV-negative people take anti-HIV medications (anti-retroviral medications like Truvada) BEFORE HAVING SEX to prevent HIV infection” – and were encouraged to ask clarification questions to the study staff who administered the surveys. Upon PrEP being defined for them, participants were asked whether they had previously heard of PrEP, and answered either yes or no.

Analysis

All data analyses were performed using PAWS Statistics, version 22.0 (SPSS, Inc., Chicago, IL), as well as the PROCESS macro for SPSS (Hayes, 2011). For any variable included in the analyses, less than 5% of the data were missing. In the moderation analyses, estimates were based on 10,000 bootstrapping replicates.

Descriptive statistics were conducted to obtain frequencies and percentages for the categorical variables, as well as means, standard deviations, and ranges for the continuous variables. For inferential statistics, both bivariate and multivariable analyses were performed using the following variables: age, perceived healthcare-related discrimination, disclosure of same-sex sex behavior, and PrEP awareness. Pearson correlations, t-tests, and Chi-squared (χ2) tests were performed to identify significant associations among the abovementioned variables of interest. Moderation analyses were performed to identify the nature of the relationships between the independent (i.e., perceived healthcare-related discrimination, disclosure of same-sex sex behavior) and dependent variable (i.e., PrEP awareness). To examine whether participant age moderated the relationships between (a) perceived healthcare-related discrimination and PrEP awareness, and (b) disclosure of same-sex sex behavior and PrEP awareness, two separate regression models were constructed. In Model 1, the interaction term for perceived healthcare-related discrimination × age was examined. Similar steps were repeated in Model 2 using the interaction term for disclosure of same-sex sex behavior × age.

The moderator variable, age, was mean-centered in the moderation analyses, and the effect of the independent variables in both Model 1 (perceived healthcare-related discrimination) and Model 2 (disclosure of same-sex sex behavior) were measured at the three levels of the moderator variable: the mean age of the sample (30.6 years), plus one standard deviation (40.9 years), and minus one standard deviation from the mean (20.3 years). This is an approach that has been routinely used in previous research (Aiken & West, 1991). Finally, given that the moderation effect was statistically significant at the p < .05 level in Model 1, the Johnson-Neyman (J-N) procedure was employed (Preacher, Curran, & Bauer, 2006). The J-N procedure provides information about the percent of cases in the data with values of the moderator above or below the points of transition in significance. In sum, the J-N procedure was used to determine at what value of the moderator for the effect of perceived healthcare-related discrimination on PrEP awareness became significant (i.e., the “threshold”).

Results

Demographic Variables

A total of 147 BMSM residing in the southeastern United States were included in the present analysis. Participants were, on average, 30.6 years of age (SD = 10.3). Of the total sample, 101 (68.7%) identified as gay, homosexual, or same gender loving; 44 (29.9%) identified as bisexual, and the remaining two (1.4%) identified as straight or heterosexual. Seventy-two (49.0%) BMSM reported annual incomes equal to or less than $10,000, and 31 (21.1%) reported having received a college degree (Table 1).

Table 1.

Descriptive statistics for the sample of 147 Black men who have sex with men (BMSM) located in the Atlanta, GA metropolitan area.

Variable M (range) SD
Age 30.61 (18–59) 10.28
Education 1.92 (1–5) 1.03
Income 2.27 (1–7) 1.66
N %
Sexual Orientation
 Gay/homosexual/same gender loving 101 68.7
 Bisexual 44 29.9
 Straight/heterosexual 2 1.4
Race/Ethnicity
 African American/Black only 131 89.1
 Bi- or multi-racial, including African American/Black 16 10.9
Disclosure of Same-Sex Sex Behavior
 Yes, I have talked to my doctor about having sex with men 68 46.3
 No, I have not talked to my doctor about having sex with men 79 53.7
Perceived Race- and Sexual Orientation-Based Healthcare-Related Discrimination
 Yes, both race- and sexual-orientation-based discrimination 25 17.0
 Yes, race-based discrimination only 10 6.8
 Yes, sexual orientation-based discrimination only 11 7.5
 Neither race- nor sexual orientation-based discrimination 101 68.7
Awareness of PrEP
 Yes, I have heard of PrEP 51 34.7
 No, I have not heard of PrEP 96 65.3
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Note. Men who identified as straight/heterosexual were included in the analysis if they reported at least one instance of engaging in male-to-male sexual contact in the last year.

Healthcare Discrimination, Sex Behavior Disclosure, and PrEP awareness

With respect to perceived healthcare-related discrimination, 46 (31.2%) participants reported having experienced racial ethnic identity-based or sexual orientation-based healthcare-related discrimination. Further, 68 participants (46.3%) indicated that they had talked with a healthcare provider about having sex with men. The remaining 79 (53.7%) participants had not spoken with a healthcare provider about having sex with men. Fifty-one (34.7%) participants indicated that they had heard of PrEP, while the remaining 96 (65.3%) were unaware of PrEP.

Regression Analyses Between Discrimination, Disclosure, and Age

The results of the present study indicate that age and perceived healthcare-related discrimination were significantly, positively correlated (r = .34), suggesting that as age increased, individuals’ perceived healthcare-related discrimination did as well. Further, BMSM who had not heard of PrEP were significantly older in age (t = 3.63, df = 146, p < .001). BMSM who had not heard of PrEP scored significantly higher on the perceived healthcare-related discrimination measure (t = 2.83, df = 146, p < .01), and were less likely to have talked to healthcare providers about having sex with men (X2 = 5.77, df = 146, p < .05). Moreover, individuals who had talked with their healthcare providers about sex with men scored significantly lower on the perceived healthcare-related discrimination measure (t = 3.16, df = 146, p < .01).

Main Effects in the Logistic Regression Models

In Model 1, both perceived healthcare-related discrimination (β = −2.84, SE = 1.44, p = .05, CI: −5.66, −.02) and age (β = −.07, SE = .03, p = .02, CI: -.13, -.01) were significantly associated with PrEP awareness. Further, in Model 2, both disclosure of same-sex sex behavior (β = .82, SE = .40, p = .04, CI: .04, 1.60) and age (β = −.05, SE = .02, p = .02, CI: −.09, −.01) were significantly associated with PrEP awareness (Table 2).

Table 2.

Results from the logistic regression analyses showing the moderation effect of age on the relationship between healthcare-related discrimination and PrEP awareness.

Model Estimate SE p CI (lower) CI (upper)
Model 1
Intercept −.87 .25 .001 −1.37 −.38
 Age → PrEP Awareness −.07 .03 .018 −.13 −.01
 Healthcare Discrimination → PrEP −2.84 1.44 .048 −5.66 −.02
Awareness −.32 .17 .049 −.64 −.01
 Healthcare Discrimination × Age → PrEP
 χ2 (df)
Model 2
Intercept −.73 .19 .001 −1.10 −.36
 Age → PrEP Awareness −.05 .02 .009 −.09 −.01
 Disclosure → PrEP Awareness .82 .40 .031 .04 1.60
 Disclosure × Age → PrEP Awareness .06 .04 .396 −.03 .14
χ2 (df)
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Note. For each of the two models, the 95% CIs were obtained by bias-corrected bootstrapping with 10,000 resamples. In Model 1, perceived healthcare-related discrimination (Healthcare Discrimination is the independent variable (X1), age (Age) is the moderator variable (M), and awareness of PrEP (PrEP Awareness) is the outcome variable (Y). In Model 2, disclosure of same-sex sex behavior (Disclosure) is the independent variable (X2), age (Age) is the moderator variable (M), and awareness of PrEP (PrEP Awareness) is the outcome variable (Y). CI (lower) = lower bound of a 95% confidence interval; CI (upper) = upper bound of a 95% confidence interval.

Interaction Effects in the Logistic Regression Models

As shown in Figure 1, age significantly moderated the relationship between perceived healthcare-related discrimination and PrEP awareness (β = −.32, SE = −.17, p = .05, CI: −.64, −.01). The estimate indicated that the significant, negative relationship of perceived healthcare-related discrimination to PrEP awareness became stronger by 0.32 for each one-year increase in age. Contrary to our hypothesis that age moderated the relationship between disclosure of same-sex sex behavior and PrEP awareness, there was no evidence for age moderating the relationship between same-sex sex behavior disclosure and PrEP awareness in Model 2 (β = .06, SE = .04, ns).

Figure 1.

Figure 1

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The interaction between the mean centered variables perceived healthcare-related discrimination and age.

In order to understand how the relationship between perceived healthcare-related discrimination and PrEP awareness varies at different age values, simple (conditional) slopes were estimated for the association between perceived healthcare-related discrimination and PrEP awareness at different levels of age (sample range = 18–59). The values of age of 20.3 years, 30.6 years, and 40.9 years, which represent the mean age –1 SD, the mean age of the sample, and the mean age +1 SD, were chosen. The simple slopes were estimated, and they were found to be statistically significant at 30.6 years and at 40.9 years, but not at 20.3 years. The simple slope value at 40.9 years (−1.02, p < .05) was more negative than the value at 30.6 years (−.47, p < .05), meaning that the simple slope became more negative as age increased. Otherwise stated, higher perceived healthcare-related discrimination was significantly, negatively associated with PrEP awareness at 30.6 and 40.9 years, but not at 20.3 years, and that this relationship became stronger as age increased. The J-N procedure was used to find the range of ages for which the conditional slopes between the independent variable (i.e., perceived healthcare-related discrimination) and the dependent variable (i.e., PrEP awareness) is statistically significant. It was found that the relationship between perceived healthcare-related discrimination and PrEP awareness became statistically significant at, and remained significant for all ages above, 30.2 years.

Discussion

Perceived healthcare-related discrimination was significantly, negatively associated with PrEP awareness, and same-sex sex behavior disclosure to healthcare providers was significantly, positively related to PrEP awareness among the BMSM in the present sample. These findings are important because little is known about the role that psychosocial factors play in MSM’s, especially BMSM’s, PrEP awareness (Reisner et al., 2010). Further, healthcare providers are an obvious but untapped resource for PrEP information for BMSM (Bauermeister, Meanley, Pingel, Soler, & Harper, 2013). Healthcare providers must be aware of the psychosocial, discrimination-related concerns of their patients and that these issues work to impact BMSM’s access to information about their HIV prevention options, including PrEP, by hindering conversations that would signal to healthcare providers that they may be eligible for PrEP.

The analyses also showed that age plays a particularly important role in understanding PrEP awareness among BMSM. Specifically, the results of the present study revealed that older BMSM were significantly less aware of PrEP as an HIV prevention strategy than were their younger counterparts. Further, age moderated the relationship between perceived healthcare-related discrimination and PrEP awareness, such that perceived healthcare-related discrimination was significantly, negatively associated with PrEP awareness beginning at age 30.2 years. This finding is important, especially given the Centers for Disease Control and Prevention’s (CDC) emphasis on implementing HIV prevention strategies specifically for young BMSM (e.g., BMSM 18–29 years of age), and evidence that gay communities may be youth-oriented and that young MSM, in general, may be better able than their older counterparts to access support and information from these communities (Lyons, Croy, Barrett, & Whyte, 2015). Older MSM, including older BMSM, who are not actively involved in these communities may rely more heavily on healthcare providers for information to guide them in making sexual health decisions. However, there is evidence that older Black men report medical mistrust and perceived race-based discrimination from healthcare providers at higher rates than their younger counterparts (Hammond, 2011). It is also possible that older BMSM, relative to younger BMSM, experience these constructs at higher rates due to a longer history of interacting with the medical system. Therefore, healthcare providers must make concerted efforts to recognize and address their older BMSM patients’ discrimination-related concerns, and failure to do so will likely have a substantial effect on uptake of PrEP for this community.

The significant interaction between perceived healthcare-related discrimination and age indicates that, at low levels of healthcare-related discrimination, younger and older BMSM have approximately the same odds of knowing about PrEP. However, as perceived healthcare-related discrimination increases, disparities between younger and older BMSM’s PrEP awareness grows. It is possible that perceived healthcare-related discrimination negatively impacts BMSM’s willingness to disclose their sexual orientations or behaviors, or initiate conversations regarding the HIV prevention options that are available to them (Nyblade, Stangl, Weiss, & Ashburn, 2009). If the burden to initiate conversations around PrEP is placed on patients, particularly older patients for whom providers may assume are not sexually active or otherwise not at risk (Lindau, Schumm, Laumann, Levinson, O’Muircheartaigh, & Waite, 2007), those who perceive high levels of healthcare-related discrimination may be less likely to be aware of PrEP. Our results indicate that this is a reality for BMSM who are approximately 30 years of age and older, but not for younger BMSM. This finding may be due to the fact that healthcare providers may not think that it is an option that would interest or be appropriate for older patients. For example, Arnold et al. (2012) argue that it is important for healthcare providers to have clear and standardized guidelines for PrEP recommendations, and to implement these standards in their clinical practice. Our results, paired with previous literature on the effects of racism and ageism in the healthcare context, support this more streamlined, less subjective approach to discussing PrEP with BMSM patients.

For younger BMSM, the results of the current study suggest that, even in light of the experience of healthcare-related discrimination, they are more likely to be aware of PrEP than older BMSM. Efforts to educate MSM on the effectiveness of PrEP have mostly focused on younger populations, particularly those age 18–29 years of age (Bauermeister, Meanley, Pingel, Soler, & Harper, 2013; Hosek et al., 2013; Smith, Toledo, Smith, Adams, & Rothenberg, 2012). It is possible that younger BMSM are accessing information about PrEP from sources (e.g., individuals, groups, or institutions) that older BMSM are not interacting with as often, or interact with in different ways (e.g., friend groups, promotional strategies that target young MSM, healthcare providers).

It is also possible that healthcare providers include PrEP in discussions of sexual health more readily with younger BMSM patients. The opportunity to disclose same-sex sex behavior with a healthcare provider significantly increased BMSM’s likelihood of reporting PrEP awareness. Current research does suggest the need for caution with these findings as more often than not, as when sexual health and HIV are discussed, the conversation is initiated by the patient rather than the provider (Bernstein et al., 2008). In order to better serve the needs of BMSM, providers must initiate sexual health- and PrEP-oriented conversations regardless of the age, revealed sexual orientation or behavior, or partner HIV status of the patient.

Limitations

The findings of the current study should be interpreted in light of their limitations. The current sample is isolated to one region of the country; therefore, these findings may not generalize to the larger population of BMSM in other areas of the U.S. Further, the sample size is relatively small, and data for this study are cross-sectional were collected using self-report measures, which are prone to social desirability bias. Additionally, measures of PrEP awareness and disclosure of same-sex sexual behavior to providers were limited in that they each only included a single, dichotomous item. Further, the present study’s findings are limited by potential issues around lack of context about the temporal window for same-sex sexual behavior disclosure, as well as the personal relevance of the healthcare provider to whom participants may have disclosed. More comprehensive measures of these constructs are needed for future analyses. Finally, the analyses lacked inclusion of relevant psychological mechanisms that may affect the relationships between perceived healthcare-related discrimination, same-sex sexual behavior disclosure, age, and PrEP awareness.

Conclusion

The implementation of PrEP has focused mainly on clinical trials demonstrating efficacy (Marcus et al., 2016). More recently, however, the focus of prevention efforts has been redirected towards long-term maintenance and improved efforts to reach the highest risk populations (Mayer & Krakower, 2015). BMSM are among the most at risk for HIV transmission, yet they are the least likely to seek PrEP treatment (Marcus et al., 2016). The findings of the current study provide important contextual information on factors relating to PrEP awareness within the BMSM community, and highlight the need to better understand the relationship between healthcare providers, patients, and PrEP awareness and uptake. Healthcare providers must be open to initiating non-judgmental sexual health conversations consistently without discriminating against certain groups. An important future area of study is how income impacts BMSM’s perceptions of the healthcare system. Further, future intervention efforts should focus on training and educating healthcare providers to recognize discriminatory behaviors, strategies to minimize these behaviors, and methods to introduce and navigate sensitive discussions, such as those about sex behaviors, HIV risk, and PrEP. Additional, innovative strategies to promote PrEP to BMSM outside of the healthcare setting, including passive and active strategies for PrEP promotion, are needed. Finally, compiling a list of MSM-friendly healthcare sites and making it accessible to BMSM is a relatively easy strategy that may improve the quality of care and likelihood that BMSM who are at risk for HIV will be able to access PrEP and other HIV prevention information from providers.

Acknowledgments

This research was supported by awards from the National Institute of Mental Health (#R01 MH094230 and #R01 MH109409), as well as an award from the National Institute of Drug Abuse (#R01 DA043068).

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