Traditional Machismo, Caballerismo, and the Pre-exposure Prophylaxis (PrEP) Cascade among a Sample of Latino Sexual Minority Men

Abstract

From 2010 to 2017, HIV diagnoses increased 17% among Latino sexual minority men (SMM) while decreasing 19% among White SMM and stabilizing among African American SMM. Traditional machismo is characterized by aggressiveness/power; caballerismo consists of family values/chivalry. Latino SMM high in traditional machismo may avoid seeking Pre-Exposure Prophylaxis (PrEP) to avoid being stigmatized as effeminate. Latino SMM high in caballerismo may be more likely to use PrEP to remain healthy for their family and/or partners. The current study explores the association between traditional machismo and caballerismo with four steps of the PrEP cascade. Participants were 151 HIV-negative/unknown Latino SMM living in San Diego, California (M = 24.18 years old) who completed an online study. Traditional machismo was associated with low odds of PrEP awareness, willingness, and adherence, and high odds of PrEP use. Caballerismo was associated with greater odds of PrEP awareness, willingness, use, and adherence. High levels of traditional machismo among Latino SMM may be a barrier to PrEP. Caballerismo may be a facilitator of PrEP awareness, willingness, use, and adherence. Programs which serve to move Latino SMM through the PrEP cascade may benefit from discussing culturally-relevant masculinity given the potential for their differential association with PrEP variables.

Sexual minority men (SMM; e.g., gay, bisexual, and/or other men who have sex with men) are disproportionately affected by HIV, accounting for two-thirds of new HIV infections in 2017 (Centers for Disease Control and Prevention, 2018) despite comprising approximately 4% of the U.S. population (Purcell et al., 2012). Latino SMM bear disproportionate HIV burden in comparison to their White peers; despite comprising a smaller percentage of the sexual minority population in the U.S. (59% of SMM identify as non-Hispanic White while 23% identify as Latino; The Williams Institute, 2019), Latino SMM had more new HIV diagnoses (7,436) compared to White SMM (6,982) in 2016 (Centers for Disease Control and Prevention, 2017). In addition, the rate of new diagnoses among Latino SMM may be on the rise; while HIV incidence rates remained stable or decreased from 2010 to 2017 for African American and White SMM, Latino SMM had a 17% increase in new HIV diagnoses (Centers for Disease Control and Prevention, 2018). Given the elevated risk of HIV infection that Latino SMM bear, there is a strong need to address HIV prevention in effort to decrease rates of HIV infection among this population.

In 2012, Pre-Exposure Prophylaxis (PrEP) became an FDA-approved biomedical approach to reduce the risk of HIV infection for HIV-negative individuals (Grant et al., 2010; McCormack et al., 2016). When daily adherence is maintained, PrEP is up to 99% effective at preventing HIV infection (Anderson et al., 2012). Although daily PrEP use is associated with the greatest reduction in HIV risk, taking 4 doses of PrEP a week has been reported to reduce HIV risk by 96% and 2 doses per week is associated with a 76% reduction in risk (Anderson et al., 2012). Despite PrEP’s ability to reduce the risk of HIV transmission, Latino SMM reported low odds of PrEP use and high odds of perceived PrEP need when compared with White SMM (Pulsipher et al., 2016). To examine the potential causes for low PrEP use among this population a PrEP cascade model may be useful.

PrEP cascade models are derived from HIV continuum of care models and are used to examine barriers and facilitators associated with PrEP awareness, willingness, use, and adherence (Parsons et al., 2017; Blashill et al., 2019). Each step of a PrEP cascade model allows the possibility for an intervention to take place in effort to move individuals onto the next step (Nunn et al., 2017). Latino SMM have reported less knowledge of where and how to obtain PrEP and less PrEP use in comparison to White SMM (Pulsipher et al., 2016); they have also reported low PrEP adherence (Garcia & Harris, 2017). Due to Latino SMM low PrEP awareness, use, adherence and negative attitudes towards PrEP, more research is needed to better understand what factors play a role in moving Latino SMM through the PrEP cascade.

Low PrEP awareness, use, and adherence among Latino SMM may be due, in part, to cultural conceptions of masculinity and how they relate to behavioral health outcomes. Machismo, a culturally specific conception of masculinity, is a multidimensional construct associated with healthy and unhealthy behaviors (Arciniega et al., 2008). Two separate components of machismo are traditional machismo and caballerismo. Traditional machismo is characterized by hypermasculinity, dominance, and aggression (Arciniega et al., 2008). High traditional machismo has been associated with low levels of HIV testing, high illicit drug use, and low medication adherence (e.g., antiretroviral therapy [ART]; Dillon et al., 2018; Estrada, Rigali-Oiler, Arciniega, & Tracy, 2011; Galvan et al., 2014). Latino men high in traditional machismo may have low medication adherence due to the wishful coping styles associated with traditional machismo in which these individuals may be in denial of their vulnerability of being HIV-positive (Galvan et al., 2014). Additionally, previous qualitative research has reported traditional machismo to be associated with low prostate cancer screening (Rivera-Ramos & Buki, 2011). Thus, given that PrEP must be prescribed by a healthcare provider, Latino SMM high in traditional machismo may be less likely to use PrEP due to low healthcare utilization.

Caballerismo is comprised of chivalry, familial ties, and is associated with emotional connectedness (Arciniega et al., 2008). Associations between caballerismo and behavioral health outcomes, however, have mainly produced mixed findings (Estrada et al., 2011; Gast, et al., 2017). Latino SMM high in traditional machismo may be reluctant to seek PrEP to avoid being stigmatized as gay, effeminate, or HIV-positive (Garcia & Harris, 2017). Conversely, among Latino men living with HIV, caballerismo was positively associated with ART adherence (Galvan et al., 2014). Because caballerismo is associated with strong family values, Latino SMM high in caballerismo may be more likely to use PrEP because of the positive impact that their health may have on their family, sexual partners, or both. Therefore, caballerismo among Latino SMM may be associated with high PrEP adherence.

No known published studies have examined the association between machismo and the PrEP cascade among Latino SMM – a population which has elevated risk for HIV infection. Thus, the current study analyzes the association between traditional machismo and caballerismo and the four steps of the PrEP cascade: PrEP awareness, willingness, use, and adherence among a sample of Latino SMM. It is hypothesized that individuals who score high in traditional machismo will possess lower odds of PrEP awareness, willingness, use, and adherence. In contrast, individuals who score high in caballerismo will possess higher odds of PrEP awareness, willingness, use, and adherence.

Method

Participants

A total of 207 individuals who self-identified as HIV-negative or unaware of their HIV status were recruited to take part in an online questionnaire study. Fifty-six participants were removed (N = 151) due to invalid responses (see validity check information, below). Participants were between 18 and 29 years old (M = 24.18, SD = 3.19), residing in the county of San Diego, California, and were primarily recruited via Grindr, a dating/hook-up site for gay, bisexual, queer, and transgender populations. Participants were also recruited using a research lab registry from participants who had previously indicated interest in participating in future studies. The inclusion criteria to participate in the present study were: (a) gay, bisexual, and/or sexually attracted to men, (b) HIV-negative or unaware of HIV status, (c) residing in the county of San Diego, California (d) male gender identity, (e) English or Spanish speaking, (f) of Latino/Hispanic ethnic identity, (g) between the ages of 18 through 29 years old.

Procedure

Participants recruited through Grindr clicked on an advertisement which directed them to a website where they entered their name and an email address in order to receive a secure link to an eligibility pre-screener. Previous lab registry participants were emailed a secure link which directed them to an eligibility pre-screener. Those found eligible for the study were directed to Qualtrics, an online survey platform, to complete the entire online questionnaire.

The initial question of the pre-screener asked participants to indicate either English or Spanish as their preferred language in which consent forms, measures, and surveys were presented. All measures provided in Spanish were either translated and validated by their original author or by an English and Spanish speaking bilingual researcher and research assistant. A community-based validation process was conducted to verify translations by two Latino SMM who met the inclusion criteria for the present study.

Facebook credentials were also obtained to verify participants’ residency in the county of San Diego; therefore, only participants who had a Facebook account participated in this study. Participant IP addresses were also obtained for the purpose of this study to prevent individuals from completing the questionnaire more than once. All identifiable information was deleted after completion of the questionnaire. Participants received a $10 gift card to an online retailer as compensation. This study was approved by the San Diego State University Institutional Review Board.

Measures

Demographics.

Participant demographic information was collected as part of the survey. Participants were asked their age, race, ethnicity, sexual orientation, sexual attraction, citizenship, relationship status, country of origin, zip code, education level, employment status, number of condomless anal sex (CAS) partners, and annual income.

Traditional Machismo and Caballerismo.

The 20-item Traditional Machismo and Caballerismo scale (Arciniega et al., 2008) was used to assess traditional machismo and caballerismo in Latino/Hispanic culture. The measure asks participants to indicate how likely they agree with each statement presented using a 7-point Likert scale ranging from 1 (Very Strongly Disagree) to 7 (Very Strongly Agree). The measure consists of two subscales, the traditional machismo subscale and the caballerismo subscale. Both subscales are composed of 10-items. The Traditional Machismo and Caballerismo scale is available in both and English and Spanish. A two-factor model factor has been previously employed and indicated this measure to appropriately measure traditional machismo and caballerismo among Latino SMM (Estrada et al., 2011). Internal consistency of this measure for the current sample was α = .86 for the traditional machismo subscale and α = .84 for the caballerismo subscale.

PrEP Awareness.

PrEP awareness was assessed using the question “Before this study, have you ever heard about PrEP?” in which participants responded “yes”, “no”, or “not sure” (Blashill et al., 2019). Those who responded “yes”, were categorized as PrEP aware.

PrEP Willingness.

PrEP willingness was assessed using the question: “How likely would you be to use PrEP?” in which participants indicated their PrEP willingness using a 5-point Likert scale ranging from 1 (Extremely Unlikely) to 5 (Extremely Likely). Participants who responded with a score of four or greater were categorized as PrEP willing (Blashill et al., 2019).

PrEP Use.

PrEP use was assessed using the question: “Have you ever taken PrEP?” in which participants responded “yes” or “no” (Blashill et al., 2019). Participants who responded “yes”, were categorized as PrEP users.

PrEP Adherence.

Participants who indicated PrEP use within the last 30 days, were asked about their PrEP adherence using the question: “Thinking about the past 30 days, what percent of the time did you take all of your PrEP medications as your doctor prescribed?” (Blashill et al., 2019). Participants responded using a scale of 0–100%. Participants who responded with 60% or greater adherence, were categorized as high adherence, since a minimum of 57% PrEP adherence has been previously reported to significantly reduce the risk of HIV infection (Anderson et al., 2012).

Validity Check.

Three questions (e.g., “For this question, please select ‘Slightly Disagree’”) were embedded throughout the online survey to assess for participant effort in completing the survey (Aust et al., 2013). Participants who answered at least two of the three questions incorrectly were removed due to low participant effort. A total of fifty-six participants were removed.

Statistical Analyses

Unadjusted and adjusted models were employed using SPSS (v26). A correlation matrix was created to examine bivariate associations between study variables (see Table 2). Four binary logistic regressions were conducted with traditional machismo and caballerismo entered as the independent variables and the PrEP awareness, willingness, use, and adherence binary variables entered as criterion variables. The adjusted model controlled for sexual orientation, relationship status, country of origin, CAS status, and age; however, country of origin was not included as a covariate for PrEP use and adherence, as there was no variability for those two outcome variables as a result of all PrEP users being from the United States. Model fit (Nagelkerke R²), Wald statistics, point-biserial correlation coefficients (r), and odds ratios (OR) along with their 95% confidence intervals (CI) for each binary logistic regression are reported. Refer to Table 3 for unadjusted and adjusted model Wald statistics, point-biserial correlational coefficients, and OR.

Table 2.

Bivariate Correlations of Study Variables

Variable	1	2	3	4	5	6	7	8	9	10	11
1. Age	—
2. Sexual Orientationa	.04	—
3. Relationship Statusb	−.26**	.15	—
4. Country of Originc	−.14	−.002	.10	—
5. CAS Statusd	−.04	.05	−.003	−.12	—
6. Traditional Machismo	.31**	−.12	−.13	.19	−.30**	—
7. Caballerismo	−.13	.15	.09	−.10	.14	−.39**	—
8. PrEP Awarenessg	−.04	.38**	.20*	−.14	.16	−.37**	.49**	—
9. PrEP Willingnessg	.04	.05	.11	−.09	.25**	−.23**	.33**	.40**	—
10. PrEP Useg	.16*	.21**	.10	.15	.11	.08	.19*	.37**	.31**	—
11. PrEP Adherenceg	.35	.10	.25	—f	.06	−.32	.45	.28	.58**	—e	—

Note.

^a1 = Gay, 0 = Other

^b1 = Single, 0 = Non-single

^c1= U.S., 0 = Other

^dCondomless anal sex (CAS) status defined as 1 = 1 or more CAS partners in the past 3 months, 0 = 0 CAS partners in the past 3 months

^eNot computed as the PrEP adherence item is a subset question of the PrEP use item

^fNot computed as all PrEP users were from the U.S.

^gBinary variables

^*p < .05.

^**p < .01.

Table 3.

Logistic Regression Analyses

Unadjusted Model Binary Logistic Regressions

Variable	Wald x2	OR	95% CI	r	P
PrEP Awareness
Traditional Machismo	6.60	0.62	0.43, 0.82	−.13	.010*
Caballerismo	20.35	2.75	1.77, 4.26	.27	< .001**
PrEP Willingness
Traditional Machismo	1.93	0.80	0.58, 1.10	−.06	.165
Caballerismo	9.69	1.81	1.25, 2.63	.16	.002*
PrEP Use
Traditional Machismo	4.05	1.53	1.01, 2.32	.12	.044*
Caballerismo	8.15	1.91	1.23, 2.98	.18	.004*
PrEP Adherence
Traditional Machismo	3.21	0.04	0.001, 1.35	−.66	.073
Caballerismo	4.74	4.13	1.15, 14.84	.36	.030*

Adjusted Model Binary Logistic Regressions

Variable	Wald x2	OR	95% CI	r	P
PrEP Awareness
Traditional Machismo	5.46	0.58	0.37, 0.92	−.15	.019*
Caballerismo	17.53	2.72	1.70, 4.35	.27	< .001**
Country of Origina	1.19	0.41	0.08, 2.04	−.24	.276
Sexual Orientationb	12.77	6.28	2.29, 17.18	.45	< .001**
Relationship Statusc	3.78	2.48	0.99, 6.21	.24	.052
Age	1.22	1.08	0.94, 1.25	.02	.269
CAS Statusd	0.36	1.35	0.51, 3.60	.08	.548
PrEP Willingness
Traditional Machismo	1.10	0.82	0.56, 1.19	−.06	.294
Caballerismo	9.61	1.85	1.26, 2.74	.17	.002*
Country of Origina	0.09	0.81	0.21, 3.15	−.06	.765
Sexual Orientationb	0.18	0.85	0.39, 1.84	−.04	.673
Relationship Statusc	1.94	1.72	0.80, 3.70	.15	.164
Age	2.66	1.11	0.98, 1.26	.03	.103
CAS Statusd	5.57	2.65	1.18, 5.96	.26	.018*
PrEP Use
Traditional Machismo	4.40	1.68	1.04, 2.74	.14	.036*
Caballerismo	6.30	1.83	1.14, 2.93	.16	.012*
Sexual Orientationb	4.09	3.87	1.04, 14.40	.35	.043*
Relationship Statusc	2.15	2.11	0.77, 5.75	.20	.143
Age	3.48	1.17	0.99, 1.37	.04	.062
CAS Statusd	2.61	2.35	0.83, 6.65	.23	.106
PrEP Adherence
Traditional Machismo	1.10	0.10	0.001, 7.45	−.54	.295
Caballerismo	2.28	4.12	0.66, 25.83	.36	.131
Sexual Orientationb	0.005	0.82	0.003, 205.28	−.05	.945
Relationship Statusc	0.83	6.41	0.12, 351.79	.46	.364
Age	1.02	1.44	0.71, 2.92	.10	.314
CAS Statusd	0.20	2.12	0.08, 55.44	.20	.652

Note.

^a1 = U.S., 0 = Other

^b1 = Gay, 0 Other

^c1 = Single, 0 = Non-single

^dCondomless anal sex (CAS) status defined as 1 = 1 or more CAS partners in the past 3 months, 0 = 0 CAS partners in the past 3 months

^*p < .05.

^**p < .001.

Results

Descriptive Statistics

Sample (N = 151) descriptive statistics are displayed in Table 1. Seventy-one participants (47%) reported PrEP awareness. Ninety-seven participants (64.2%) indicated having had sex in the past three months. Of those participants, forty-four (29.1%) reported an instance of CAS in the past three months. Seventy participants (46.4%) reported they were willing to use PrEP. Twenty-eight participants (18.8 %) reported previous or current PrEP use. Of those twenty-eight who used PrEP, twenty-two (78.5 %) adhered to PrEP at 60% or greater in the last thirty days. The average traditional machismo score among participants was 3.35 (SD = 1.13) and the average caballerismo score was 4.55 (SD = 1.03).

Table 1.

Descriptive Statistics (N= 151)

Age Range	Mean (SD)
18–29	24.18 (3.19)
	N (%)
Race
White	83 (55)
Black or African American	40 (26.5)
Native American or American Indian	6 (4)
Asian or Pacific Islander	4 (2.6)
Other	17 (11.3)
Declined to answer	1 (0.7)
Sexual Identity
Gay	104 (68.9)
Bisexual	46 (30.5)
Pansexual	1 (0.7)
Sexual Attractiona
Only attracted to males	91 (60.3)
Mostly attracted to males	19 (12.6)
Equally attracted to males and females	37 (24.5)
Mostly attracted to females	4 (2.6)
Relationship Statusa
Single	93 (61.6)
Legally married	33 (21.9)
Civil unionized	3 (2)
In a monogamous relationship	14 (9.3)
Sexually active with more than one person	16 (10.6)
Other	1 (0.7)
Country of Origin
United States	138 (91.4)
Mexico	11 (7.3)
Other	2 (1.3)
Employment Statusa
Employed full-time (30+ hours per week)	98 (64.9)
Employed part-time (<30 hours per week)	38 (25.2)
Unemployed	10 (6.6)
Student	22 (14.6)
Disabled	1 (0.7)
Highest Education Attained
Less than high school	6 (4)
High school or GED	29 (19.2)
Some college	72 (47.7)
Some graduate work (no degree to date)	31 (20.5)
Graduate/Professional Degree	11 (7.3)
Annual Individual Income (before taxes)
Less than $6,000	19 (12.6)
$6,000 to $11,999	16 (10.6)
$12,000 to $17,999	11 (7.3)
$18,000 to $23,999	31 (20.5)
$24,000 to $29,999	50 (33.1)
$30,000 to $59,999	21 (13.9)
$60,000 or more	3 (2)
Previous PrEP awareness
Yes	71 (47)
No	78 (51.7)
Not Sure	2 (1.3)
Willingness to Use PrEP
Extremely unlikely	6 (4)
Unlikely	35 (23.2)
Undecided	40 (26.5)
Likely	48 (31.8)
Extremely likely	22 (14.6)
Previous PrEP Use
Yes	28 (18.5)
No	123 (81.5)
PrEP Adherence in the past 30 daysb
20% of the time	1 (3.6)
30% of the time	1 (3.6)
40% of the time	1 (3.6)
50% of the time	3 (10.7)
60% of the time	3 (10.7)
80% of the time	2 (7.1)
90% of the time	11 (39.3)
100% of the time	6 (21.4)

^aParticipants marked all that applied

^bAmong PrEP Users

Primary Analyses

The unadjusted model revealed a significant fit for PrEP awareness (χ² = 47.09, p < .001, Nagelkerke R² = .36), willingness (χ² = 18.52, p < .001, Nagelkerke R² = .15), use (χ² = 9.59, p = .008, Nagelkerke R² = .10), and adherence (χ² = 11.85 p = .003, Nagelkerke R² = .53). Results indicated high traditional machismo was associated with statistically significant lower odds of PrEP awareness and greater odds of PrEP use. Although not reaching statistical significance, high traditional machismo was also associated with lower odds of PrEP willingness and adherence. High caballerismo was associated with statistically significant greater odds of PrEP awareness, willingness, use, and adherence. Statistical notations for the unadjusted model are reported in Table 3.

Results from the adjusted model indicated a significant fit for PrEP awareness (χ² = 70.36, p < .001, Nagelkerke R² = .50), willingness (χ² = 24.44, p < .001, Nagelkerke R² = .17), use (χ² = 24.07, p = .001, Nagelkerke R² = .24), and adherence (χ² = 14.14, p = .028, Nagelkerke R² = .61). High traditional machismo was associated with statistically significant lower odds of PrEP awareness and greater odds of PrEP use. Despite not reaching statistical significance, high traditional machismo was also associated with lower odds of PrEP willingness and adherence. High caballerismo was associated with statistically significant greater odds of PrEP awareness, willingness, and use. Although not reaching statistical significance, high caballerismo was also associated with greater odds of PrEP adherence. Statistical notations for the adjusted model are reported in Table 3.

In accordance with new standards of examining effect size (Funder & Ozer, 2019), results from the adjusted model indicated traditional machismo to have a small-to-medium effect on PrEP awareness and use, a very small-to-small effect on PrEP willingness, and a very large effect on PrEP adherence. Results indicated caballerismo to have a medium-to-large effect on PrEP awareness, a large-to-very large effect on adherence, and a small-to-medium effect for PrEP willingness and use. Despite not all results attaining statistically significant p-values, interpretation of effect sizes may be of clinical importance.

Discussion

The current study examined the association between two components of masculinity, traditional machismo and caballerismo, and four steps of the PrEP cascade: PrEP awareness, willingness, use, and adherence. Between 2010 and 2017, HIV diagnoses increased 17% for Latino SMM while diagnoses decreased or stabilized for other racial/ethnic groups (Centers for Disease Control and Prevention, 2018). Moreover, Latino SMM have reported low PrEP use in comparison to White SMM despite the ability for PrEP to reduce to risk of HIV transmission by up to 99% when daily adherence is maintained (Shover et al., 2018; Anderson et al., 2012). This study adds to the literature by examining how traditional machismo and caballerismo are associated with steps of the PrEP cascade.

Results mainly aligned with stated hypotheses, that greater traditional machismo would be uniformly associated with poor PrEP cascade outcomes, with the exception of PrEP use. The small-to-medium effect of PrEP use may be consequential as it likely to accumulate across time (Funder & Ozer, 2019). In comparison with previous research, the effect size of traditional machismo in relation to PrEP adherence was of much greater magnitude than the effect previously reported by researchers examining the association between traditional machismo and ART adherence among Latino men who predominantly identified as a sexual minority (Galvan et al., 2014). The very large effect revealed in the current study is likely attributed to the wide range of confidence intervals resulting from a relatively small sample size of Latino SMM who used PrEP in the current study. Thus, the size of the effect is likely to decrease if such association is examined with a larger sample (Funder & Ozer, 2019). The direction of the association between traditional machismo and PrEP adherence may have aligned with that of Galvan (2014) and colleagues due to similarities between ART and PrEP, since both are administered daily in the form of a pill and relate to sexual health. Given the sequence of the PrEP cascade, an individual must be aware of PrEP in order to proceed to willingness, use, and adherence; therefore, the small-to-medium effect for traditional machismo and PrEP awareness may be the most consequential in the long-term in the prevention of HIV among Latino SMM as a result of its additive affect (Funder & Ozer, 2019). Thus, if confirmed by additional prospective research, high traditional machismo may be a factor associated with low PrEP awareness, willingness, and adherence. It is important to note that HIV sexual risk behavior (i.e., CAS) was relatively low in the recruited sample. However, programs seeking to decrease the HIV epidemic have progressively shifted towards providing PrEP without recent HIV sexual risk behavior in an effort to decrease the HIV epidemic, such as the Ready, Set, PrEP program by the U.S. Department of Health and Human Services (“Ending the HIV Epidemic: Ready, Set, PrEP”, n.d.).

As hypothesized, high caballerismo was associated with greater odds of PrEP awareness, willingness, use, and adherence. The positive association found between caballerismo and PrEP adherence aligns with previous research reporting that greater caballerismo was associated with greater ART adherence (Galvan et al., 2014). However, the effect size of caballerismo on PrEP adherence was twice as large as that reported by Galvan (2014) and colleagues. As previously mentioned, such discrepancy is likely a result of a relatively small sample of Latino SMM who used PrEP in the current study. Gast (2017) noted a non-significant, but positive association between caballerismo and protective health behavior, such as eating healthily, complying with medical instructions, and precautionary health screenings. Our results also find caballerismo to be correlated with positive health behavior, such as PrEP use; however, comparing results from the current study to other studies in the area, it is important to note that most have reported non-significant or mixed findings (Estrada et al., 2011; Gast et al., 2017). Thus, more research is needed to further comprehend how caballerismo influences health behavior among this vulnerable population. The small-to-medium effect of caballerismo on PrEP willingness and use are likely to accumulate in the long-term and therefore should not be disregarded (Funder & Ozer, 2019). The medium-to-large effect size of caballerismo on PrEP awareness and adherence indicate that caballerismo may be a protective factor for PrEP awareness and adherence. Thus, if confirmed with prospective data, caballerismo may be a factor that may enable PrEP awareness, willingness, use, and adherence.

Given the distinct characteristics that encompass traditional machismo (e.g., hypermasculinity and aggressiveness) and caballerismo (e.g., chivalry and strong family values), both of these masculinity constructs may have differential associations with the PrEP cascade. It is possible that Latino SMM who endorse high levels of traditional machismo may be less aware of PrEP due to a lack of PrEP exposure from their primary health providers as men with more hypermasculine traits may be less likely to disclose their sexual orientation to their health care providers (Levison et al., 2017). Latino SMM who avoid disclosing their sexual orientation with their health care providers may be less likely to discuss PrEP and therefore be less PrEP willing or less likely to adhere to PrEP properly. Traditional machismo was negatively associated with PrEP awareness, willingness, and adherence, but positively associated with PrEP use, a pattern that appears contradictory. Given that PrEP use typically is preceded by awareness and willingness, the fact that traditional machismo was positively associated with PrEP use suggests an alternative PrEP pathway. Individuals high in traditional machismo may be more likely to avoid appearing weak and therefore, traditional masculine perceptions may prevent Latino SMM to seek PrEP from a healthcare provider. High caballerismo may be associated with greater PrEP awareness, willingness, use, and adherence due to strong family values associated with caballerismo. In accordance with these family values, Latino SMM may be less concerned about appearing weak and rather concerned about remaining healthy resulting in greater odds of PrEP willingness, use, and adherence. The current study provides additional support that masculinity is a multidimensional construct and should continue to be assessed as such given the differential effects that traditional machismo and caballerismo had on the four PrEP cascade outcome variables.

Results from the current study should be considered within the context of its limitations. First, a cross-sectional design was employed, which does not allow the ability to assess for causality or temporal ordering. Second, Grindr, the primary method of recruitment utilized, is not representative of all Latino SMM, which may impact the external validity. Third, the sample of men who used PrEP was small (n = 28), affecting the ability to generalize results from the current sample to the larger population of Latino SMM who use PrEP. Fourth, statistical power to examine an interaction term was low; however, future studies are encouraged explore the interaction between traditional machismo, caballerismo, and the PrEP cascade among a larger sample of Latino SMM, as these two constructs are not mutually exclusively of one another. That is, individuals may score high or low on both traditional machismo and caballerismo. Additionally, the current study was only inclusive of Latino SMM residing in the county of San Diego, California; therefore, study results cannot be generalized to Latino SMM residing in other regions. Future studies should examine these associations with larger, representative samples of Latino SMM using a longitudinal study design.

Results from the current study may have some implications for applied work. Clinicians should be cognizant of the characteristics that comprise traditional machismo and caballerismo to identify patients that may be more likely to be engaged or disengaged across steps of the PrEP cascade. Latino SMM with higher traditional machismo may be at a greater risk of being unaware of PrEP as a potential treatment option and could benefit from supplementary discussion of PrEP. Programs designed to move Latino SMM through each step of the PrEP cascade should explore addressing traditional machismo and caballerismo given the associations revealed in the current study between these constructs and engagement across the PrEP cascade. HIV prevention programs may benefit from discussing the multiple components of Latino masculinity, including potential restructuring of masculinity schemas to focus on caballerismo. Previous gender transformative intervention research, interventions which seek to transform traditional gender role conceptualizations to equitable gender role conceptualizations (Dworkin et al., 2013), have reported a brief 3 session intervention to increase gender role equity associated with decision making among men 9-months post intervention; however, the effect was non-significant at 18-months (Fleming et al., 2018). Additionally, culturally sensitive intervention work addressing conceptualizations of masculinity, among other factors, among Latino immigrant men have shown to reduce HIV sexual risk behavior (Rhodes et al., 2011). However, changes in masculinity were not assessed. Thus, more research is needed develop and test a program addressing cultural conceptualizations of masculinity among Latino SMM. Restructuring such masculinity schemas may be beneficial given the positive associations revealed between caballerismo and PrEP awareness, willingness, use, and adherence; the emphasis on caballerismo keeps the discussion of masculinity culturally salient.

Latino SMM who endorse high levels of caballerismo may be more likely to be aware of PrEP, willing to use PrEP, current PrEP users, and adherent to PrEP. Latino SMM who endorse high levels of traditional machismo may be less aware of PrEP, less willing to use PrEP, more likely to use PrEP, and less likely to adhere to PrEP sufficiently to reduce the risk of HIV infection. As a result of these findings, future longitudinal studies could examine caballerismo as a factor that could enable engagement across steps of the PrEP cascade and traditional machismo as a risk factor for PrEP awareness, willingness, and adherence. More research is needed to develop and test an HIV prevention program to determine the effectiveness of discussing cultural masculinity constructs, such as traditional machismo and caballerismo, in Latino SMM as part of the program.