PrEP4Love: The Role of Messaging and Prevention Advocacy in PrEP Attitudes, Perceptions, and Uptake Among YMSM and Transgender Women

Abstract

Background:

Despite high efficacy, use of pre-exposure prophylaxis (PrEP) remains low among young men who have sex with men (MSM) and transgender women (TW), primarily due to barriers such as stigma and resource awareness. We evaluated a social marketing campaign known as PrEP4Love that works to eliminate PrEP stigma and awareness gaps via targeted advertising.

Setting:

Chicago, Illinois.

Methods:

Participants were enrolled within a cohort study of young MSM and TW (RADAR). Data were collected between June 2017 and April 2018 from HIV-negative individuals attending a follow-up visit. Surveys assessed demographics, PrEP attitudes and perceptions, and PrEP4Love campaign awareness. Associations between PrEP4Love awareness and PrEP perceptions, uptake, and behaviors were assessed using multiple logistic regression controlling for age, race/ethnicity, gender, sexual identity, and ever having used PrEP.

Results:

Of 700 participants, the majority (75.9%) indicated seeing PrEP4Love ads in Chicago. Those who had seen ads were more likely to be out to their providers (OR =1.95; 95% CI: 1.17, 3.23) than those who had not, and those who had conversations were significantly more likely to have initiated the conversation themselves. Individuals who had seen ads were more likely to have taken PrEP in the last six months (OR = 1.87; 95% CI: 1.15, 3.16), and more likely to believe their friends and the general public approved of and used PrEP.

Conclusion:

Social marketing campaigns are promising interventions that have the potential to alleviate barriers to HIV prevention, particularly among MSM and TW. Future research should evaluate the impact of these initiatives at multiple time points.

INTRODUCTION

In the United States (US), over 1.1 million individuals are currently living with HIV,¹ with certain demographics disproportionately impacted. Gay, bisexual, and other men who have sex with men (MSM) accounted for 70% of new HIV diagnoses overall in 2017, including 83% of new diagnoses among men.^2,3 This disparity is especially pronounced among Black MSM (BMSM),^2,4,5 Latinx MSM (LMSM),^3,6 and young MSM (YMSM).^2,7 Likewise, transgender women (TW) are disproportionately impacted; a staggering 56% of Black TW are estimated to be living with HIV.⁸

Pre-exposure prophylaxis (PrEP) is an effective prevention strategy for HIV-negative individuals. Taken as prescribed, PrEP can reduce risk of contracting HIV by 92–99%.^9–11 Since market approval of Truvada for PrEP in 2012, there has been an increase in PrEP awareness among MSM;¹² however, this has not resulted in a sufficient increase (defined by the Getting to Zero Illinois [GTZ-IL] initiative as a 20% increase in use of PrEP)¹³ in uptake, particularly among vulnerable populations.^14–19

Commonly cited barriers to PrEP use include cost, adherence regimen, and access to a prescription or insurance.²⁰ Social dynamics are also key: BMSM and LMSM in particular cite PrEP stigma as a barrier to uptake.²¹ For example, the belief that men who take PrEP are more promiscuous or likely to engage in risky sexual behavior may discourage PrEP use for some MSM.²² Furthermore, medical mistrust and conspiracy beliefs surrounding PrEP and the overall health system are more common among Black MSM and TW, and are unsurprisingly related to disinterest in PrEP.²³ One study of Black gay and bisexual men (GBM) indicated that medical mistrust, culturally insensitive health care for gay men, and concerns regarding side effects were most related to low uptake.²⁴ TW also experience unique barriers to PrEP use, such as lack of trans-inclusive marketing, prioritisation of hormone use, and medical mistrust due to transphobia.²⁵ Considering these concerns, there is an evident need for culturally responsive interventions to encourage PrEP uptake among populations most impacted by HIV.

Targeted messaging – the diffusion of information through content-specific communication for certain populations – represents a potentially impactful means of addressing barriers to PrEP uptake; mass media campaigns have previously demonstrated efficacy in health promotion.^26–29 Although existing campaigns have primarily focused on decreasing smoking or alcohol consumption, a recent review concluded that social media campaigns are a promising messaging tool for HIV prevention.³⁰ Moreover, one Chicago-based study of young MSM and TW found that increased PrEP knowledge was associated with lower stigma, indicating that knowledge-based messaging may help to remove barriers to PrEP uptake.³¹ However, there remains an ongoing debate regarding the efficacy of direct-to-consumer advertising of prescription medicines such as PrEP,^32–35 indicating a need to evaluate the potential impact these campaigns may have on beliefs and behaviors of PrEP-eligible individuals.

PrEP4Love, a PrEP messaging and prevention-advocacy campaign led by the AIDS Foundation of Chicago and the Illinois PrEP Working Group (IPWG), represents an opportunity to test this impact. Launched in February 2016, PrEP4Love promotes PrEP in a variety of paid and unpaid Chicago advertising locations (e.g., event spaces, transit, health service providers) and via social media (e.g., Instagram and Facebook accounts) using sex-positive messaging designed to prioritize intimacy, pleasure, and peace of mind in sexual encounters.

PrEP4Love re-appropriated the epidemiological language of disease transmission and applied it to sex-positive messages (e.g., “spread tingle” or “transmit love”). PrEP4Love also uses depictions of real local couples with a variety of racial identities, gender identities, and sexual orientations to promote engagement with diverse audiences. Promotional materials linked to online resources supporting PrEP initiation and uptake, such as hotlines and service provider webs that noted geographic location and information of various Illinois PrEP providers, including services for Spanish-speaking patients. Live events organized and facilitated by community members and partners acted as a means of fostering community conversations and mobilizing people around PrEP uptake in various settings.

To assess the successes and limitations of the PrEP4Love campaign, this study leveraged an existing Chicago-based cohort of diverse YMSM and TW, exploring associations between an independent variable of exposure to PrEP4Love messaging and dependendent variables of perceptions and beliefs surrounding PrEP use and stigma, PrEP uptake-related behaviors, and current/past PrEP use.

METHODS

Data were collected within RADAR, a Chicago-based longitudinal cohort study focused on understanding individual, dyadic, network, social, and biologic factors associated with HIV infection among youth assigned male at birth. Study participants complete an initial in-person, interviewer-administered assessment that includes a network survey, an individual-level psychosocial survey, and collection of biological samples for HIV/STI testing. Follow-up visits occur every six months for the duration of the study. Participants are compensated for all study visits. RADAR was reviewed by the Northwestern University Institutional Review Board and given full ethical approval. Data for this manuscript came from participants who attended a visit between June 6, 2017 and April 27, 2018, were HIV-negative, and were administered the PrEP4Love items, resulting in an analytic sample of 700. For participants who completed the survey at multiple visits, only their first survey was included.

PrEP4Love Development

PrEP4Love was developed by a social marketing committee within the Chicago PrEP Working Group (now IPWG) made up of individuals representing a variety of demographics, perspectives, expertise, and organizational affiliations. Pro bono support was secured through four connected advertising agencies who supported efforts related to creative vision, design, copy, strategy, placement and metric. The team – inclusive of IPWG members and 60 advertising professionals – worked iteratively to develop a campaign prioritizing intimacy and connection. Towards the end of the development process, four focus groups were held with members of target populations. IWPG used input from the focus groups to further refine PrEP4Love and its proposed implementation.

Participants

In order to be enrolled in the RADAR cohort, participants had to meet the following criteria: between 16–29 years of age, assigned male sex at birth, English-speaking, and reported a sexual encounter with a man in the previous year or identified as gay or bisexual. Participants were recruited in three ways: 1) involvement in a cohort of YMSM and/or sexual and gender minority youth (Project Q2,³⁶ Crew 450,³⁷ and a new 2015 cohort) all of which enrolled individuals when they were between 16 and 20 years old; 2) through being a serious partner of an existing RADAR cohort member (i.e., being in a current serious relationship with a RADAR cohort member); or 3) through peer recruitment by an existing RADAR cohort member. Details about the previous cohorts can be found elsewhere;^36,37 the new 2015 cohort was recruited using venue-based, peer-referral, and online recruitment methods. All serious partners were eligible for a one-time visit, but were required to meet the above criteria for enrollment in the cohort. Peer recruits needed to meet the same criteria, and needed to be between 16 and 20 years of age. Age was restricted for peer recruits to match the recruitment design of the previous cohorts (i.e., Project Q2 and Crew 450), which at the time of the current study also had older participants (i.e., ages 20–29). The overall RADAR sample needed to represent a full range of ages to achieve the multiple cohort, accelerated longitudinal design.³⁸

Measures

Demographics

At baseline, participants were asked to report their racial identity, and whether they identified as Hispanic or Latino. Following the 2007 United States Department of Education guidelines for combining ethnicity and race data, anyone who identified as Hispanic/Latino regardless of race was classified as Hispanic/Latino.³⁹ All non-Hispanic/Latino individuals who identify as a single race were classified as that race; anyone who identified as two or more races was classified as multiracial. For sample size purposes, Asian, American Indian or Alaska Native, Multi-Racial, and Native Hawaiian or Other Pacific Islander individuals were recoded as “Other.” Other demographic information collected includes age, gender identity, and sexual orientation. The age variable was recoded based on quartiles: 16 to 20, 21 to 22, 23 to 24, and 25 to 31 years.

PrEP Use

Participants were asked if they had ever taken PrEP, whether they had taken PrEP in the last six months, and whether they were currently using PrEP. Follow-up questions varied based on these responses.

PrEP4Love Awareness

Awareness of the PrEP4Love campaign was assessed by asking “Have you seen or heard any advertisement(s) about PrEP (such as the PrEP4Love campaign) in Chicago?” All participants who responded “Yes” were asked “Where did you see or hear the PrEP4Love campaign?”

PrEP Attitudes and Perceptions of Usage

Perceived PrEP prevalence was assessed through two questions: “Of all the gay and bisexual men in the United States, how many do you think are on PrEP?” and “Now, thinking about all of your gay and bisexual male friends, how many do you think are on PrEP?” Response options ranged from 1 (Almost None) to 5 (Almost All). Similarly, attitudes about PrEP use were assessed through two questions: “Thinking about all the gay and bisexual men in the United States, how do you think most feel about PrEP?” and “Now, thinking of your gay and bisexual male friends, how do you think most feel about PrEP?” Response options ranged from 1 (Strongly Disapprove) to 5 (Strongly Approve). (Note: participant perceptions of PrEP use among TW or individuals of other genders was not assessed).

PrEP Disclosure

Participants who indicated they had never taken PrEP, but had heard of it were asked the question: “Would you feel comfortable telling anyone that you are taking PrEP if you ever began taking it?” Regardless of PrEP status, all participants were asked “Do you know anyone on PrEP?” Those who responded “Yes” were asked to specify who they knew who was on PrEP.

Provider Conversations and Healthcare

As outness to provider can result in provider-prompted conversations about PrEP,⁴⁰ all participants were asked “Are you out to your provider as an LGBTQ person?” All participants were also asked “Has a medical provider, such as a doctor or nurse, ever talked to you about PrEP?” All participants who answered “Yes” were asked “Who initiated this conversation about PrEP?” with the options “I did” or “My medical provider did.”

Statistical Analysis

All data cleaning and statistical analyses were performed in R Version 3.5.1. Univariate statistics were used to describe participant demographics as well as proportions of individuals who had seen PrEP4Love ads. Regarding PrEP4Love, three domains were of interest: awareness of the campaign, perceptions of PrEP, and interactions with medical providers. First, simple logistic regression was used to determine outcomes of interest. Subsequently, multiple logistic regression models were constructed, controlling for age, race, gender, and sexual orientation. Models relating to PrEP exposure, attitudes, and beahviors also controlled for ever having been on PrEP.

RESULTS

Demographics and Awareness

Similar proportions of the 700-person sample identified as Latinx (31.7%), White (30.3%), and Black (27.0%) (Table 1). Participants were a mean of 22.3 years of age (standard deviation = 2.9; range: 16.4 – 30.7). Gay was the most frequently reported sexual orientation (69.6%), followed by bisexual (17.7%) and queer (7.0%). Participants predominantly identified as cisgender men (91.6%), with a smaller group identifying as transgender women (4.3%) or another gender (4.1%). Nearly one-quarter of participants (24.9%) had ever used PrEP, and approximately one-fifth of participants indicated using PrEP in the prior 6 months (18.9%). Of those, 89 (67.4%) reported current PrEP use.

Table 1.

Demographics and PrEP Characteristics of RADAR Participants (N = 700).

	N	%
Race/Ethnicity
White	212	30.30
Black or African American	189	27.00
Hispanic/Latinx	222	31.70
Other	77	11.00
Age, years
16 to 20	217	31.00
21 to 22	218	31.10
23 to 24	101	14.40
25 to 31	164	23.40
Sexual Identity
Gay	487	69.60
Bisexual	124	17.70
Queer	49	7.00
Straight/Heterosexual	19	2.70
Unsure/Questioning	8	1.10
Other	13	1.90
Gender Identity
Cisgender Male	641	91.60
Transgender Female	30	4.30
Other	29	4.10
Used PrEP
Ever	174	24.90
Last 6 Months	132	18.90
Currently Using	89	12.71
Heard/seen any ads about PrEP (PrEP4Love) in Chicago	531	75.90
Location:
Internet	307	57.80
At pride events	269	50.70
At local bars/clubs	148	27.80
From friends	186	35.00
From family	27	5.10
From healthcare provider	170	32.00
Chicago Transit Authority (CTA)	136	25.60
Somewhere else	39	7.30

The majority of participants indicated that they had seen a PrEP4Love ad in Chicago (75.9%) (Table 1). Most participants indicated seeing ads on the internet (57.8%). Approximately half reported seeing ads at pride events (50.7%). Fewer participants reported seeing or hearing about ads for PrEP from friends (35.0%), from healthcare providers (32.0%), at local bars or clubs (27.8%), or on Chicago public transportation (CTA; 25.6%). Having ever taken PrEP was associated with seeing PrEP4Love ads (odds ratio [OR] = 2.13; 95% confidence interval [CI]: 1.34, 3.36); subsequent analyses relating to seeing ads controlled for having ever been on PrEP.

PrEP4Love Impact on Health Beliefs and Behaviors

After controlling for ever having been on PrEP, individuals who had seen ads were significantly more likely to be out to their medical provider (OR = 1.67; 95% CI: 1.00, 2.82) and to have had a conversation about PrEP with a medical provider (OR = 2.52; 95% CI: 1.69, 3.75) than those who had not seen ads (Table 2). Of these individuals, those who had seen PrEP4Love ads were significantly more likely to have initiated the conversation (OR = 2.07; 95% CI: 1.12, 3.82). Further, individuals who had seen ads were also more likely to have taken PrEP in the past 6 months (OR = 1.99; 95% CI: 1.20, 3.30; ever PrEP users, but not in last 6 months, were excluded [n = 41]). Of those who had never taken PrEP, individuals who had seen ads were more likely to indicate that they would feel comfortable disclosing PrEP use if they ever began taking it (OR = 1.89; 95% CI: 1.08, 3.28). After controlling for age, race/ethnicity, sexual identity, and gender identity, adjusted ORs (AORs) for the above associations only differed slightly from unadjusted ORs, with no changes in significance.

Table 2.

PrEP Attitudes and Uptake Behaviors Associated with Seeing PrEP4Love Ads

	Seen Ad for PrEP4Love (N = 700)
	N (%)	OR	95% CI	AOR	95% CI
Among GBM in the US, how many do you think are on PrEP?
1 - Almost None	30 (4.3)	1.00	(−)	1.00	(−)
2	242 (34.6)	1.36	(0.61, 3.06)	1.44	(0.62, 3.33)
3	337 (48.1)	1.91	(0.85, 4.26)	1.84	(0.80, 4.21)
4	64 (9.1)	1.79	(0.68, 4.68)	1.56	(0.58, 4.23)
5 - Almost All	27 (3.9)	0.85	(0.29, 2.53)	0.66	(0.21, 2.05)
Among all of your GBM friends, how many do you think are on PrEP?
1 - Almost None	281 (40.1)	1.00	(−)	1.00	(−)
2	166 (23.7)	3.54	(2.18, 5.97)	3.54	(2.15, 6.01)
3	156 (22.3)	2.30	(1.46, 3.69)	2.20	(1.37, 3.59)
4	63 (9.0)	3.92	(1.89, 9.19)	4.96	(1.93, 9.63)
5 - Almost All	34 (4.9)	3.31	(1.35, 9.95)	3.40	(1.34, 10.52)
Among GBM in the US, how do you think most feel about PrEP?
1 - Strongly Disapprove	9 (1.3)	1.00	(−)	1.00	(−)
2	31 (4.4)	2.63	(0.58, 12.76)	3.57	(0.71, 20.02)
3	249 (35.6)	3.26	(0.84, 13.51)	4.49	(1.03, 21.86)
4	223 (31.9)	4.33	(1.11, 18.05)	6.32	(1.44, 31.11)
5 - Strongly Approve	188 (26.9)	5.46	(1.38, 23.08)	7.41	(1.67, 36.68)
Among all of your GBM friends, how do you think most feel about PrEP?
1 - Strongly Disapprove	15 (2.1)	1.00	(−)	1.00	(−)
2	41 (5.9)	4.25	(1.16, 16.19)	4.15	(1.10, 16.27)
3	200 (28.6)	2.31	(0.78, 6.73)	2.35	(0.77, 7.10)
4	174 (24.9)	2.59	(0.86, 7.61)	2.82	(0.90, 8.64)
5 - Strongly Approve	270 (38.6)	3.34	(1.13, 9.71)	3.52	(1.15, 10.58)
Are you out to your provider as an LGBTQ person? (N = 378)
No	108 (28.6)	1.00	(−)	1.00	(−)
Has a medical provider, like a doctor or nurse, ever talked to you about PrEP?
No	332 (47.4)	1.00	(−)	1.00	(−)
Yes	368 (52.6)	2.77	(1.93, 4.00)	2.76	(1.91, 4.01)
Who initiated this conversation about PrEP? (N = 368)
My Provider Did	170 (46.2)	1.00	(−)	1.00	(−)
I Did	198 (53.8)	2.07	(1.15, 3.85)	2.24	(1.23, 4.25)
Have you taken PrEP in the past 6 months?
No	567 (81.0)	1.00	(−)	1.00	(−)
Yes	133 (19.0)	1.87	(1.15, 3.16)	1.86	(1.13, 3.18)
If you began taking PrEP would you feel comfortable telling someone? (N = 566)
No	64 (11.3)	1.00	(−)	1.00	(−)
Yes	502 (88.7)	1.98	(1.14, 3.38)	2.02	(1.14, 3.52)
Do you know anyone on PrEP?
No	259 (37.0)	1.00	(−)	1.00	(−)
Yes	441 (63.0)	2.87	(2.02, 4.11)	3.02	(2.07, 4.44)

Individuals who had seen PrEP4Love ads more commonly believed that GBM in their social circles and in general approved of and were taking PrEP. People who had seen ads were significantly more likely to perceive their GBM friends as strongly approving of PrEP, as compared to strongly disapproving, than those who had not seen ads (AOR = 3.85; 95% CI: 1.28, 11.6). Similarly, they were also more likely to believe that all GBM in the country strongly approved of PrEP, as compared to strongly disapproving, than those who had not seen ads (AOR = 8.02; 95% CI: 1.78, 36.1). Finally, people who had seen ads were more likely to perceive that almost all of their GBM friends were on PrEP, as compared to perceiving that none of their friends were on PrEP, than those who had not seen ads (AOR = 3.59; 95% CI: 1.18, 10.9). People who reported seeing ads for PrEP were more likely to know someone on PrEP (AOR = 2.85, 95% CI: 1.95, 4.17). All analyses controlled for having ever taken PrEP.

DISCUSSION

PrEP4Love’s mission is to increase awareness and uptake of PrEP and to break uptake-inhibiting stigmas related to PrEP. Although our data prohibits causal inference, there is evidence to suggest that PrEP4Love may have been successful. Individuals who had seen ads were more likely to be on PrEP and more likely to believe that people perceived PrEP to be widely used by GBM. Accordingly, participants who reported not seeing ads were significantly more likely to believe that almost no GBM in the US were on PrEP. Conversely, individuals who had seen ads tended to believe that GBM in general had a more positive view of PrEP than those who had not. This may indicate that individuals viewing PrEP4Love messaging perceive less stigma associated with PrEP use within the GBM community, which increases the likelihood of future PrEP usage.

We also found that participants who had seen PrEP4Love ads were more likely to know someone on PrEP. This could be potentially interpreted as evidence that seeing PrEP advertisements leads individuals to seek out more information about PrEP from social connections. However, caution should be exercised as it is entirely possible that perceptual bias plays a role in these results, especially considering the positive association between having ever used PrEP and seeing PrEP4Love ads. Subsequent analyses controlled for having ever been on PrEP, improving the rigor of the associations, but other factors could also potentially drive perceptual bias. Individuals who know someone on PrEP may be more familiar with the medication, and therefore more likely to notice PrEP ads. Similarly, those who hold prior beliefs that many GBM are on PrEP, or perceive PrEP positively, may be more likely to notice ads. Given that paid PrEP4Love campaign advertising on transit had concluded several months in advance of our assessment, it is possible that PrEP4Love exposure may have led to increased PrEP information seeking. To alleviate the temporal uncertainty of these analyses, rigorous longitudinal evaluation of PrEP promotional campaigns is needed.

Individuals who had seen PrEP4Love materials were more likely to indicate comfort with disclosing PrEP status if they ever began using it. This has important implications for uptake, as PrEP stigma is a significant known barrier.^41,42 Prior analyses within the RADAR cohort have identified the importance of PrEP disclosure to social support, which can be key to effective PrEP adherence.⁴⁰ Furthermore, findings demonstrate that seeing ads is associated with key steps towards PrEP uptake. Individuals who had seen ads were more likely to be out to their providers, to have had a conversation about PrEP with their provider, and to have initiated aforementioned conversation. This suggests that PrEP publicity campaigns could play a role in facilitating service connectivity and patient-provider interactions that lead to PrEP prescription. Again, however, the non-longitudinal nature of the data available prohibits causal inferences, although the time between conclusion of paid out-of-home advertising and this assessment (transit ads ended more than 6 months before the survey, which asked about PrEP use in the prior 6 months) lends some credence to the interpretation that PrEP4Love helped to facilitate service connectivity. There is additional evidence in favor of a temporal relationship, as participants in our study who had seen ads for PrEP were more likely to have taken PrEP in the last six months. These encouraging findings emphasize the need for longitudinal research in future PrEP messaging implementation resaerch.

We also observed that Black and Latinx individuals were more likely than White participants to learn about campaign materials from their friends. Understanding the influence of social networks and how information is diffused into specific communities may be especially salient in developing methods to target populations with the lowest PrEP uptake and adherence.^43–46 For example, the network-based Popular Opinion Leader (POL) intervention has shown potential in improving numerous health outcomes, including increasing HIV preventive knowledge and behaviors, and reducing HIV stigma, among others,^47–49 and may be an effective means to support PrEP uptake in underserved populations.⁵⁰ Results from similar future analyses of campaign implementation could help to better specify existing effective interventions based on a detailed understanding of demographic-specific social contexts.

Findings related to gender identity added additional nuance. TWwere more likely than cisgender men to receive information about the PrEP4Love campaign from healthcare providers. There are several possible explanations for the result. First, TW are at elevated average risk for contracting HIV, which could potentially lead to more conversations related to PrEP when clinicians are aware of both this disparity and their patient’s gender identity. Second, TW often have multiple healthcare providers,⁵¹ which could increase the likelihood that at least one provider might initiate a conversation about PrEP. Relatedly, TW – particularly TW seeking gender-affirming medical care – may be more likely to be “out” to their care providers (depending on the health services sought) which, as we observed, increases the likelihood of physicians initiating a conversation about PrEP. Regardless of precise cause, this finding points to the importance of the care provider in PrEP uptake among TW specifically, and future PrEP campaigns may benefit from targeting messaging towards healthcare providers as well. Moreover, future research should consider potentially unique experiences of PrEP, PrEP providers, and PrEP advertising at the various intersections of racial, ethnic, gender, and sexual identities; qualitative inquiry may prove useful in disentangling these complex associations.

Limitations

The primary limitation is that data were cross-sectional. Therefore, we cannot specify directionality in associations between PrEP4Love exposure and outcomes. However, this limitation is not sufficient to eliminate PrEP4Love advertising as a potential causal factor in PrEP awareness and uptake. Future studies should longitudinally assess the impact of PrEP campaigns in order to eliminate this uncertainty. Crucially, if future research reveals that perceptual bias is driving these associations, rather than messaging impact, PrEP messaging campaigns should take this information into account when planning how best to reach their target populations. Further, because there was no picture identification of the PrEP4Love campaign for participants, it is possible that other PrEP campaigns were captured in our outcomes. Future studies could consider including visual prompts to ensure recall specificity. Moreover, while our sample of MSM and TW was large and diverse, it was entirely Chicago-based, which prevents generalization to TW and MSM at large. Our sample also had few transgender participants, and questions on PrEP attitudes and perceptions were geared exclusively towards GBM. Studies which include TW alongside MSM must be intentional in their development to ensure appropriate sample size and question design for analyses with transgender participants.

Conclusions

This study presents promising results surrounding the potential impact of targeted messaging and prevention advocacy campaigns on PrEP attitudes, perceptions and behaviors. Campaigns such as PrEP4Love could play an important role in HIV prevention, targeting barriers to care that health service provision interventions may have difficulty alleviating such as stigma and negative attitudes. This study’s specific strengths and limitations also serve to identify critical considerations for evaluation of messaging interventions. Continued implementation research in messaging and prevention advocacy is integral to establishing evidence-based approaches for this promising form of intervention.