Persistent Stigmatizing and Negative Perceptions of Pre-Exposure Prophylaxis (PrEP) Users: Implications for PrEP Adoption among Latino Men Who Have Sex with Men

Abstract

The Centers for Disease Control and Prevention (CDC) estimates the lifetime HIV risk is one in four for Latino men who have sex with men (MSM). Pre-Exposure Prophylaxis (PrEP) is an efficacious biomedical prevention strategy to help prevent acquisition of HIV. At present, there has been limited uptake of PrEP by Latino MSM. Unfortunately, the negative perceptions and social stigma surrounding PrEP and those who use it may deter uptake of this novel prevention strategy, particularly among high-risk Latino MSM. In this qualitative study, we explore the experiences of using PrEP among Latino MSM. Participants were recruited using gay-oriented social and sexual networking apps to complete an interviewer-administered, semi-structured qualitative interview. Thematic analysis was used to identify emerging themes relating to perceptions of PrEP users and PrEP as an HIV prevention strategy. Major themes included: feelings of protection and sexual freedom; negative and stigmatizing labels associated with PrEP use; assumptions about sexual behaviors and perceptions of sexual risk taking and irresponsibility; and attitudes related to PrEP use in relationships. A striking but not prevalent theme was the perception reported by participants that monolingual Spanish speaking Latino MSM are skeptical about the effectiveness of PrEP. These findings suggest that efforts are needed to address the stigmatizing and negative perceptions of PrEP that persist in the gay community that may deter adoption among Latino MSM.

Introduction

Latino men who have sex with men (MSM) are disproportionately impacted by the HIV/AIDS epidemic in the United States. In 2015, Latino MSM accounted for 83% of all HIV diagnoses among Latino males and 71% among Latinos in general (CDC, 2016a). The Centers for Disease Control and Prevention (CDC) estimates the lifetime HIV risk is one in four for Latino MSM (CDC, 2016b). In Los Angeles County (LAC), the site of the present study, Latino MSM are particularly burdened by HIV. In the most recent HIV surveillance data, Latino MSM comprised the largest percentage (47%) of all new HIV diagnoses among MSM of all racial or ethnic groups and 86% among Latinos in general (Division of HIV and STD Programs (DHSP), Los Angeles County Department of Public Health, 2014). Based on these epidemiological trends, greater efforts are needed to promote HIV prevention strategies among this highly impacted population.

Pre-Exposure Prophylaxis (PrEP) is a proven efficacious strategy that involves daily oral use of TRUVADA® (emtricitabine/tenofovir disoproxil fumarate) to prevent acquisition of HIV (Baeton et al., 2012; Choopanya et al., 2013; Grant et al., 2010; Thigpen et al., 2017). In 2012, the CDC issued clinical guidance for administering PrEP to high-risk individuals and estimates that 1.2 million Americans may benefit from using PrEP, including 1 in 4 MSM (CDC, 2014; Smith et al., 2015). PrEP has the potential to reduce HIV infections among Latino MSM, a population with higher perceived HIV risk and higher sexual risk behaviors than their white MSM counterparts (Bedoya et al., 2012; MacKeller et al., 2007; Rhodes, Yee, & Hergenrather, 2006). In prior research, Latino MSM reported high levels of interest in using PrEP, with percentages reaching levels between 62.6% and 72% ( Hoots, Finlayson, Nerlander, & Paz-Bailey, 2016; Mantell et al., 2014). Nonetheless, PrEP use in this population remains low, with uptake ranging between 2.6% to 11.7% in multiple studies (Holloway et al., 2017; Hoots et al., 2016; Kuhns, Hotton, Schneider, Garofalo, & Fujimoto, 2017; Strauss et al., 2017).

Despite its effectiveness, the roll out of PrEP has prompted negative views toward this newest HIV prevention strategy. Stigmatizing attributes have been reported by participants in PrEP demonstration projects and other studies with MSM non-PrEP users and were recognized as potential barriers to uptake (Eaton et al., 2017; Liu et al., 2014; Mitchell et al., 2016). The negative perceptions and social stigma attached to PrEP and those who use it may deter both adoption and persistent use among high-risk populations, including Latino MSM. However, most of the prior research documenting attitudes and beliefs about PrEP come from the perspectives of non-PrEP users (Brooks et al., 2011; Eaton et al., 2017; Golub, Gamarel, & Surace, 2017; Mitchell et al., 2016; Thomann, Grosso, Zapata, & Chiasson, 2017). In this study, we qualitatively explored both the positive and negative perceptions of PrEP and PrEP users directly from the experiences of Latino MSM who are using PrEP. The study was conducted in Los Angeles County, the second largest HIV/AIDS epicentre in the United States, where the local public health department is implementing a robust, multimodal PrEP program (LAC Commission on HIV and DHSP, 2016). It will be important for PrEP implementation programs to address the negative labels, assumptions, and perceptions associated with PrEP in order to promote uptake among those who would most benefit from its adoption.

Methods

Participants

Between January 2017 and October 2017, a purposive sample of Latino MSM PrEP users was recruited through gay-oriented sexual and social networking apps (i.e. Grindr and Growlr), community events, and community agency referrals to complete an in-person, semi-structured interview. Individuals met inclusion criteria if they were 18 years of age or older, Hispanic/Latino, have had sex with a male partner in the previous six months, were currently prescribed and using Truvada® for PrEP, and resided in Los Angeles County. Individuals were excluded if they did not have a current PrEP prescription bottle at the time of the study interview. The Institutional Review Board of the University of California, Los Angeles approved all study materials. Participants provided informed consent and received a $50 gift card for their participation. A total of 53 individuals were screened for the study. Of those, 39 individuals were eligible and 29 completed the study interview. We terminated recruitment at 29 participants because we had reached data saturation with the completed study interviews (i.e. interviews were no longer providing new information).

Data Collection

A semi-structured interview guide was developed to explore experiences of using PrEP among Latino MSM. As part of the study, participants were asked: “What was your main reason for starting PrEP?,” “What are some of the positive/negative comments you have either heard or read about PrEP in the gay community?,” and “Are you familiar with any of the labels commonly associated with PrEP users (e.g., ‘Truvada whore,’ promiscuous)?.” Interviews were conducted in English, in a private room at a University-affiliated research clinic, by a trained interviewer. The interviewer’s characteristics (i.e. gender, race/ethnicity, sexual orientation, PrEP use) reflect those of the target population. Participants were assigned a unique identification code to maintain confidentiality. Interviews were digitally recorded and lasted 30-60 minutes. After the interview, participants completed an Audio Computer-Assisted Self-Interview (ACASI) survey to provide information on sociodemographic characteristics, PrEP adherence and disclosure, and sexual and substance use behaviors. Research staff transcribed verbatim and checked for accuracy all interview audio files. ATLAS.ti (version 8.0.42) was used for the management and analysis of qualitative data.

Data Analysis

Interview transcripts were iteratively coded, sorted and analyzed using a thematic analysis process (Braun & Clarke, 2006). Initial codes were developed from the interview guide, field notes, and multiple readings of the transcripts. The research team reviewed and discussed the codes, their definitions, refined and deleted codes, and identified exemplar text associated with each code before reaching consensus on the final codes. A subset of codes was selected for a test of inter-coder reliability. Two research staff members independently coded a randomly selected interview transcript. An inter-coder reliability score was computed for the codes (Cohen’s kappa coefficient, k = 0.92). Final codes were entered into ATLAS.ti. and attached to their associated quotations for all transcripts. Codes were sorted into potential themes and coded data extracts were reviewed by the study team to refine each theme. Themes were selected based on prevalence across the data set and importance in assessing perceptions of PrEP and PrEP users.

Results

Participant demographics, PrEP use characteristics, and sexual and substance use behaviors are summarized in Table 1. The mean age of participants was 29.8 years (SD = 6.5). Most participants reported completing at least some college (89.7%), working full or part-time (79.3%), and having an annual household income of $40,000 or less (79.2%). The mean number of male sex partners in the past 6 months was 25 (SD = 36; median = 11; range = 1-178). About two-thirds of participants did not use a condom during their last receptive anal (66.7%) or insertive anal (69.2%) sex encounter. The most commonly reported substances used in the past 6 months included alcohol (89.7%), marijuana (62.1%), and poppers (58.6).

Table 1.

Demographics, PrEP Use Characteristics, and Sexual and Substance Use Behaviors among Latino MSM PrEP Users (N=29)

Characteristic	N (%) or M, SD
Demographics
Age (in years)	M= 29.83, SD=6.53
Sexual orientation
Gay/homosexual/queer/same gender loving	25 (86.2)
Bisexual	4 (13.8)
Highest level of education completed
High school graduate or received GED	3 (10.3)
Some college, AA degree, trade/technical school	13 (44.8)
Bachelor’s degree (BA, BS)	7 (24.1)
Some graduate school	2 (6.9)
Master’s degree	4 (13.8)
Employment status
Working full-time	17 (58.6)
Working part-time	6 (20.7)
On permanent disability	1 (3.4)
Unemployed	5 (17.2)
Annual income
$0-9,999	7 (24.1)
$10,000-19,999	7 (24.1)
$20,000-39,999	9 (31.0)
$40,000-59,999	3 (10.3)
$60,000-99,999	3 (10.3)
Health insurance
Does not have health insurance	1 (3.4)
Private medical insurance or employer-provided insurance	13 (44.8)
Medicare	6 (20.7)
Medi-Cal/Medicaid	5 (17.2)
Insurance through parent	2 (6.9)
Other insurance	1 (3.4)
Relationship status
Single and not dating anyone special	15 (51.7)
Dating someone in an open relationship (have sex with other people)	8 (27.6)
Dating someone in a closed relationship (don’t have sex with other people)	1 (3.4)
Partnered or married in an open relationship (have sex with other people)	3 (10.3)
Partnered or married in a closed relationship (don’t have sex with other people)	1 (3.4)
Other	1 (3.4)
HIV-positive partner (N=13)a
Yes	5 (38.5)
No	8 (61.5)
PrEP Use Characteristics
Length of time using PrEP (in months) (N=28)b	M=16.54, SD=16.23
Number of people told about PrEP use
No one	2 (6.9)
A few people	10 (34.5)
A lot of people	17 (58.6)
Disclosed PrEP use to (N=27)c
My main partner or spoused	12 (44.4)
One or more other sex partners	23 (85.2)
One or more family members	18 (66.7)
One or more friends	25 (92.6)
Health care providers	21 (77.8)
Othere	2 (7.4)
Adherence to PrEP medication past monthf
Very poor	0 (0)
Poor	0 (0)
Fair	2 (6.9)
Good	5 (17.2)
Very good	8 (27.6)
Excellent	14 (48.3)
Sexual and Substance Use Behaviors
Number of male sex partners past 6 mos. (N=28)g	M=25, SD=36
Number of times receptive anal (RA) sex past 6 mos. (N=27)h	M=19, SD=19
Condoms used during RA sex past 6 mos.
All of the time	3 (11.1)
Most of the time (three out of four times)	7 (25.9)
Occasionally (about half the time)	4 (14.8)
Rarely (about one in four times or less)	8 (29.6)
Never	5 (18.5)
Last RA sex encounter condoms used
Yes	9 (33.3)
No	18 (66.7)
Number of times insertive anal (IA) sex past 6 mos. (N=26)i	M=21, SD=23
Condoms used for IA sex past 6 mos.
All of the time	3 (11.5)
Most of the time (about three out of four times)	5 (19.2)
Occasionally (about half the time)	6 (23.2)
Rarely (about one in four times or less)	7 (26.9)
Never	5 (19.2)
Last IA sex encounter condoms used
Yes	8 (30.8)
No	18 (69.2)
Substances used in past 6 mos.
Alcohol	26 (89.7)
Marijuana	18 (62.1)
Poppers, nitrates or other inhalants like glue or paint	17 (58.6)
Tobacco, (e-)cigarettes, hookah	12 (41.4)
Powder cocaine also known as snow or blow	7 (24.1)
Methamphetamine also known as crystal, “Tina,” speed	5 (17.2)
Molly, MDMA, Ecstasy (XTC)	5 (17.2)

^aIncludes only participants who indicated they were in a relationship.

^bOne participant was not asked about length of time on PrEP, as assessed by self-report.

^cIncludes only participants who disclosed their PrEP use.

^dIncludes only the 13 participants that indicated they were dating or in a relationship.

^eOther included: Strangers, friends of friends

^fPrEP adherence was measured via self-report using a validated Likert scale from very poor to excellent (Feldman et al., 2012)

^gOne participant missing.

^hIncludes only participants who indicated having receptive anal sex.

ⁱIncludes only participants who indicated having insertive anal sex.

The primary reasons for initiating PrEP included a self-assessment of high risk sexual behaviors (e.g., preferring and engaging in condomless sex, having multiple sex partners, a previous sexually transmitted infection or an incident with a potential exposure to HIV), being in a HIV serodiscordant relationship or having HIV-positive sex partners. The mean length of time using PrEP was 16.5 months (SD = 16.2; median = 11.0; range = 0.50-68.0) and the majority (75.9%) reported adherence to their medication as “very good” or “excellent.”

Perceptions of PrEP and PrEP Users

Five themes emerged from the interviews with Latino MSM PrEP Users:

• (1)Feelings of protection and sexual freedom;
• (2)Persistent negative and stigmatizing labels associated with PrEP use;
• (3)Assumptions about sexual behaviors and perceptions of sexual risk taking and irresponsibility;
• (4)Attitudes related to PrEP use in relationships; and
• (5)PrEP conspiracy and skepticism.

Common sources of PrEP-related perceptions included friends and peers, social media (e.g., Facebook), and gay-oriented sexual and social networking apps, such as Grindr, Scruff, and Jack’d.

Feelings of Protection and Sexual Freedom

Several participants reported hearing or reading that PrEP has reduced the anxiety of contracting HIV, resulting in less worry or greater peace of mind during sex (Table 2, Quotes 1-2). One participant specifically mentioned how PrEP has “changed the landscape” within the gay community by eliminating fear of people who are HIV-positive and allowing for the potential for engaging in open relationships without fear of contracting HIV (Quote 3). Others in the community described PrEP as ground-breaking, referring to it as a “magic pill” and “a miracle drug” for HIV prevention (Quotes 4-6).

Table 2.

Statements Regarding Feelings of Protection and Sexual Freedom

Reduced anxiety about HIV during sex

1. So basically, you have sex, whether it be condom or condomless, and you don’t have to worry about HIV like you did before, because that was a big thing. (age 39, 37 months on PrEP)

2. Peace of mind, finally feeling at ease with…being sexually active and their sexuality. (age 44, 27 months on PrEP)

3. I’ve seen like, “This is revolutionary.” I’ve seen that this is changing the landscape. It’s opened up the possibilities to different types of relationships and not fearing people that are HIV-positive. (age 32, 42 months on PrEP)

PrEP as an innovative prevention strategy

4. Well, I think the positive things were just like, this is like a magic pill that kills the danger of HIV and getting HIV. So I think it’s just like that positive protection. (age 24, 4 months on PrEP)

5. But what have I heard? That it’s lifesaving. That it’s a miracle drug…. That it’s one of the new tools that’ll help usher in a new era. (age 25, 68 months on PrEP)

6. Some of the most common is it’s a great strategic tool if you’re popular – I don’t want to say “high risk” – and you really want to have fun and you have a way to protect yourself if you don’t like using condoms. (age 22, 12 months on PrEP)

Persistent Negative and Stigmatizing Labels Associated with PrEP Use

The majority of participants indicated that PrEP users continue to experience stigma in the form of negative labels and perceptions. While participants were familiar with the term “Truvada whore” (Table 3, Quote 1), the most common labels they heard or read attached to PrEP users were “promiscuous,” “slut,” and “whore” (Quotes 2-5). However, a few participants described a current movement within the gay community toward reclaiming “Truvada whore” as a term of empowerment (Quotes 6-7). Participants also discussed the labeling of PrEP as a “party drug,” relating it to a users’ perceived high-risk behaviors and promiscuity (Quotes 8-9).

Table 3.

Statements Regarding Negative and Stigmatizing Labels Associated with PrEP Use

Slut shaming (e.g., promiscuous, slut, whore) and labeling “Truvada whore”

1. But AHF [AIDS Healthcare Foundation], their CEO and president comes out and saying, “I don’t trust gay men using PrEP – they’re Truvada Whores! What, you’re just going to take a pill and it’s magically all going to go away?” (age 25, 68 months on PrEP)

2. I think there’s a perception that if you’re using PrEP you’re more sexually active, so you’re thought of as promiscuous and maybe a little irresponsible in your sexual activities, and, therefore, you’re using PrEP to kind of cover that up instead of it being the opposite that you’re actually being more responsible by using PrEP. (age 24, 4 months on PrEP)

3. And then the stigma of people kind of pinning you as this sexual deviant because you are on PrEP. (age 26, 16 months on PrEP)

4. The stigma…like, “Oh, you’re on PrEP? That means you’re going around fucking everyone.” (age 30, 10 months on PrEP)

5. But then again, there are some people who don’t really necessarily believe in it. The reason being is because mainly what I’ve heard is that those who are on PrEP are sluts and whores. (age 22, 12 months on PrEP)

Reclaiming labels

6. Well, the only label that I know that a certain someone said was a “Truvada whore,” which now became a term that kind of got taken back. Kind of like the word queer [was] repurposed. Like, “I’m a Truvada whore and what?” (age 27, 18 months on PrEP)

7. I know people have used “Truvada whore,” but it’s been used by people who use PrEP as like an empowering term. (age 24, 8 months on PrEP)

PrEP as a “party drug”

8. Oh, that it’s a party drug. I’ve heard that it’s for people who can’t control their sexual appetite. (age 37, 23 months on PrEP)

9. Some people would describe it as a “party drug” or some people would say that people are using it as an excuse just to have bareback sex. (age 30, 24 months on PrEP)

Assumptions about Sexual Behaviors and Perceptions of Sexual Risk Taking and Irresponsibility

Nearly all participants described an assumption being made that PrEP users are more promiscuous and more likely to engage in condomless sex than non-PrEP users (Table 4, Quotes 1-3). When discussing the perceived sexual roles of PrEP users, one participant highlighted the misperception that users are “bottoms” or the receptive partner in anal sex (Quote 4). In addition, PrEP users were viewed by others within the gay community as lacking concern regarding contracting other STIs (Quote 5) or were blamed for the increase in STIs among gay men (Quote 6).

Table 4.

Statements Regarding Assumptions of Sexual Behavior and Perceptions of Sexual Risk Taking and Irresponsibility

Association between PrEP and condomless/bareback sex

1. If you tell somebody you’re on PrEP, it’s almost code for like, “Hey, I’ll let you bareback me.” So that’s kind of like the whole thing, like people who are on PrEP are probably more promiscuous or let you bareback them. (age 34, 7 months on PrEP)

2. Some guys have told me, “Oh, why are you on it? Are you trying to bareback all the time or something?” (age 25, 1 month on PrEP)

3. I think everybody understands that if somebody says they are on PrEP on Grindr, it means that I will most likely let you cum in me. (age 21, NA)1

4. But everybody just assumes that you’re out there taking loads or you’re just bottoming and stuff…. And so people’s assumptions of what your sexual roles are. (age 26, 16 months on PrEP)

False sense of security and less concern about other STIs

5. Sometimes I’ve actually seen it like in dating apps, where people kind of say they use PrEP, but they kind of make it seem like that’s the end all be all, and there’s no more risk for other STIs. (age 30, 12 months on PrEP)

6. Sometimes you’ll see people on apps like Grindr or Jack’d say that it’s just causing a rise in STD rates or something like that. (age 24, 26.5 months on PrEP)

¹Participant was not asked about length of time on PrEP.

Attitudes related to PrEP use in relationships

For MSM in HIV serodiscordant relationships, PrEP was seen as necessary and “understandable” (Table 5, Quote 1). Conversely, PrEP use in HIV-negative concordant relationships was deemed unnecessary (Quote 2-3), raised issues of trust (Quote 4-5), and led to an assumption that one’s partner is HIV-positive (Quote 6). Despite the belief that PrEP is not required in HIV-negative concordant committed relationships, participants voiced a desire to continue using PrEP while in a relationship to remain protected in the event of partner infidelity (Quote 5).

Table 5.

Statements Regarding Attitudes Related to PrEP Use in Relationships

PrEP deemed acceptable in serodiscordant relationships

1. I think it’s divided. I think there are people who see it as a tool to use if, let’s say, you have a partner that’s HIV-positive. I think they see it as, “Okay, that’s understandable.” And then you have a lot of people who think that you just want to be dirty, you just want to have sex with whoever you want, and you’re eliminating a risk. (age 30, 9 months on PrEP)

Negative perceptions of PrEP in relationships

2. I’ve heard that…you don’t really need to take PrEP if you’re in a committed relationship with someone who’s HIV-negative. (age 37, 23 months on PrEP)

3. My friend told me that it’s kind of difficult if you’re like in a committed relationship…to get PrEP because you’re not as promiscuous…. There’s a certain criteria that follows that you’re allowed to get PrEP. (age 29, 12 months on PrEP)

4. Everybody else tells me the opposite. He’s like, “Well, if you get in a committed relationship, would you just stop using PrEP?” And I was like, “Well, a lot of people do, do that. And I’ve known a lot of people that have.” And I told them, I was like, “But in my experiences, we’re all human. We all fuck up. There’s always that opportunity.” (age 26, 16 months on PrEP)

5. And then another guy…he was also in an open relationship, I told him about it. Him and his partner had a conversation with me and my partner, like, “Why do you take it? Don’t you guys trust each other?” And I’m like, “It’s not about that. You’re not always there together, and the shit I’ve seen him do in front me, I can only imagine what he’s doing when I’m not in front of him.” And their reaction was also not as supportive initially. (age 39, 37 months on PrEP)

6. I think there’s a stigma still with it…. People are always going to talk like, “Oh, you’re on PrEP. That means you’re going around fucking everyone” or “that means the person he is probably dating is HIV-positive.” (age 30, 10 months on PrEP)

PrEP Conspiracy and Skepticism

A minority of participants highlighted conspiracies surrounding PrEP, specifically that pharmaceutical companies were exaggerating its effectiveness to increase profits (Table 6, Quote 1) and that funding for promotion of PrEP would be withdrawn just as campaigns finally begin targeting communities of color (Quote 2). Participants also identified the difficulty monolingual Spanish speaking Latino MSM have in trusting PrEP’s effectiveness (Quotes 3-4).

Table 6.

Statements Regarding PrEP Conspiracy and Skepticism

PrEP conspiracy

1. I think he had heard a little bit about PrEP, but it was more like he said they were over-hyping its effectiveness on purpose to get money. (age 37, 23 months on PrEP)

2. I know they’re trying to start this campaign to bring PrEP into communities of color, but I already have a feeling that once that starts happening there will suddenly be no more funding. (age 30, 9 months on PrEP)

PrEP skepticism

3. So I think the people that I tell about PrEP, there’s some people that they don’t believe it. So this is coming specifically from people that I work with and I think these are more monolingual Spanish speakers. And so for them, they’re not sure how effective it is…. Then they’ve heard about the three failures or the people that got it [HIV]. Then it’s like, “Oh, it doesn’t really work.” (age 32, 42 months on PrEP)

4. I also remember talking to one guy who was an immigrant from Mexico, still learning English, and I remember him telling me that he’s not sure if he can trust a drug like that, that it could maybe fail. (age 24, 26.5 months on PrEP)

Discussion

We sought to describe community perceptions of PrEP users as experienced by Latino MSM who are using PrEP. Our sample included Latino MSM PrEP users who reported high risk sexual behaviors, indicating they remain appropriate candidates for PrEP. In addition, the substances reported by participants, such as alcohol, poppers, cocaine and methamphetamine, have been associated with HIV sexual risk behaviors among MSM in prior research (Colfax, et al., 2005; Forrest et al., 2010; Heath, Lanoye, & Maisto, 2012) and may be contributing to the risk behaviors reported by our study participants. On average, participants reported using PrEP for more than a year, thus providing them with a unique position to report on how the gay community views gay and bisexual men who are using PrEP for HIV prevention.

These findings highlight the important positive, but mostly negative perceptions of PrEP users found in the gay community that may influence PrEP uptake and persistence. Positive views suggest that PrEP users are taking responsibility for protecting themselves from HIV acquisition and that PrEP reduces the fear associated with engaging in an intimate relationship with someone who is HIV-positive. This perception may help reduce the stigma attached to HIV in the gay community. In contrast, the more prevalent negative views suggest that PrEP users are using this strategy as a way to circumvent having to use condoms and giving them latitude to engage in high risk sexual behaviors without regard for consequences. In addition, the negative and stigmatizing labels attached to PrEP users such as “promiscuous,” “slut,” and “whore” have the potential to damage one’s personal reputation or diminish trust in a committed relationship. Furthermore, the assumption that PrEP users desires condomless sex may make it difficult for PrEP users who wish to use condoms to effectively negotiate condom use with sex partners. The social identity as a PrEP user is often associated with these negative perceptions (i.e. promiscuous, desires condomless sex) which may be in conflict with one’s personal identification (i.e. using condoms and PrEP, not promiscuous). Given the present low uptake of PrEP among Latino MSM, a population that would benefit from adoption, it is imperative that PrEP programs, health care providers, and local health departments understand how PrEP users are perceived within the community and how these perceptions may deter adoption and have personal consequences for the individual PrEP user. This study highlights the existing perceptions of PrEP and Latino MSM PrEP users and suggests the need to mediate negative views to facilitate uptake among Latino MSM.

Our findings indicate that PrEP is viewed as providing users a sense of protection not previously afforded gay men, thus allowing them to feel more at ease when having sex in general or with men who are HIV-positive. There was clear acknowledgement from participants that the reduced worry surrounding sex and intimacy with other men was crucial to users’ personal sexual identification and exploration. These findings support previous studies that have demonstrated the potential for PrEP use to positively impact the mental, emotional, and sexual health of MSM, as well as PrEP’s role in transforming sexual norms and behaviors (Collins, McMahan, & Stekler, 2017; Hojilla et al., 2016; Koester et al., 2014).

The persistence of negative and stigmatizing labels associated with PrEP use emerged as a prominent theme in the present study. Community groups and leaders who are anti-PrEP, such as the AIDS Healthcare Foundation, play an important role in perpetuating negative stereotypes and beliefs (Barro, 2014; Crary, 2014; The Associated Press, 2014). The CDC clinical guidelines for determining appropriate candidates for PrEP also contribute to PrEP-related stigma by inadvertently labeling a PrEP user as someone who engages in high-risk behaviors. For MSM, being labeled promiscuous or a whore as a result of using PrEP could impact their personal reputation (i.e. no longer viewed as a suitable partner for a relationship). Prior research with MSM non-PrEP users demonstrated a lack of interest in starting PrEP because of its association with promiscuity (Eaton et al., 2017). As such, the potential negative personal costs associated with PrEP use must be considered when promoting PrEP to Latino MSM.

Participants also reported the false assumptions being made about PrEP users’ sexual behaviors (e.g., desires condomless sex, receptive partner in anal sex), which may present unique challenges for MSM. It is possible that PrEP users may experience rejection from potential sex partners who assume that the PrEP user is open to more risky sexual acts and is seeking condomless sex (Mimiaga, Closson, Kothary, & Mitty, 2014). One study with MSM non-PrEP users found that participants had reservations about disclosing PrEP use to casual sex partners because it might unintentionally suggest they want to have condomless sex (Mimiaga et al., 2014). These misperceptions in the gay community may contribute to the belief that PrEP users are the cause for an increase in sexual risk taking and STIs among gay men.

Our findings suggest that PrEP continues to be viewed as an important and acceptable HIV prevention strategy for MSM in HIV serodiscordant relationships, supporting findings from previous studies (Brooks et al., 2011; Mimiaga et al., 2014; Mitchell et al., 2016). However, MSM who use PrEP in HIV-negative concordant relationships are met with resistance from peers and partners who view their PrEP use as a sign of infidelity or an excuse to have condomless sex. Regardless of this negative perception, participants indicated a desire to continue using PrEP even in an HIV concordant committed relationship to protect themselves from HIV infection in the event of partner infidelity. Participants also discussed a fear of others falsely labelling their partner as HIV-positive when disclosing their own PrEP use, suggesting that HIV-related stigma continues to play a part in informing the experiences of PrEP users (Golub et al., 2017). These misperceptions may make it difficult for Latino MSM in monogamous or open relationships to justify and negotiate PrEP use with their partner. Latino MSM may also face difficulty in accessing PrEP from a medical provider who may dismiss their need for PrEP if focusing solely on their relationship status (i.e. in an HIV-negative concordant relationship) without exploring activities the partners may engage in outside of the relationship. PrEP also serves to protect those who are currently in open relationships and engage in condomless sex, but who want to remain protected from HIV (Mimiaga et al., 2014; Mitchell et al., 2016). Of the 13 participants who were in a relationship, 11 (85%) reported being in an open relationship. To support the reduction of PrEP stigma and maximize the availability of PrEP to persons in committed or open relationships, PrEP providers need to consider the variability of relationships found among gay men when assessing the appropriateness of PrEP for potential candidates.

For PrEP to achieve its full public health impact in reducing HIV infections among high-risk Latino MSM, efforts are needed to address the stigmatizing perceptions of PrEP present in the gay community that may deter adoption or persistent use. One potential strategy is through the use of personal testimonials by other Latino MSM PrEP adopters or scripted storytelling to help normalize the experience of using PrEP and demystify the negative misperceptions (Brooks et al., 2011). In the present study, social media platforms emerged as a common source for the varied perceptions of PrEP; as such, they may be an important venue for disseminating personal testimonials that help normalize PrEP use among Latino MSM. Of particular concern in the findings was the skepticism among monolingual Spanish speakers of PrEP’s effectiveness, negatively influencing their desire to ever adopt PrEP. In prior research, immigrant and monolingual Spanish speaking Latino MSM have reported mistrust of the medical care services and doctors, which may explain this population’s lack of trust in the effectiveness of PrEP (Calo et al, 2015; Dolwick Grieb, Desir, Flores-Miller, & Page, 2015; Sewell, 2015). For these reasons, a concerted effort should be made to work with Latino MSM and community stakeholders in developing language-specific and culturally sensitive messaging that builds trust in PrEP’s effectiveness.

These results should be interpreted within the context of the study limitations. Our study population was drawn from the Latino MSM population of Los Angeles and may not be generalizable to Latino MSM populations in other settings. The study population consists exclusively of English-speaking Latino MSM and may not reflect the experiences of monolingual Spanish-speaking Latino MSM. Additional research is needed with Spanish-speaking Latino MSM PrEP users given the differences that often exists between English and Spanish-speaking Latino MSM. In addition, a potential bias in our sample is that the study population included men who had been on PrEP for more than a year and these men may have adapted to the negative perceptions attached to PrEP users. Future research should seek to examine the experiences of Latino MSM PrEP users during the early period of initiating PrEP to see if negative perceptions impact adherence or continued use of PrEP.

Conclusion

The introduction of PrEP transformed how gay men view their HIV prevention options. In particular, PrEP has expanded the parameters of what constitutes “protected sex” to include the option of not using condoms but still being protected. As a result, gay men choosing to use PrEP are often viewed as sexually irresponsible and devalued for using PrEP. These negative views may curtail uptake of PrEP. Much work is needed to mitigate the negative perceptions of PrEP users in order to maximize its use among those most vulnerable to HIV infection, such as Latino MSM.