‘Oh, I Don’t Really Want to Bother With That:’ Gay and Bisexual Young Men’s Perceptions of Barriers to PrEP Information and Uptake

Abstract

Pre-exposure prophylaxis (PrEP), a daily oral pill for HIV prevention demonstrated to be effective for adults, was recently approved by the US Food and Drug Administration for use with young people weighing at least 35 kilograms. Given that young people aged 13–19 years account for a disproportionate share of new US HIV infections, PrEP presents an important opportunity. There has been limited effort, however, to increase PrEP awareness and uptake among young people. While prior work has identified barriers young people face in getting PrEP, effective strategies for overcoming these barriers have not yet been identified. This paper presents results from interviews with 15–19 year old gay and bisexual young men about their knowledge and perceptions of PrEP, and the barriers they perceive. Results suggest that participants were aware of PrEP but confused by the details of insurance coverage and out-of-pocket costs. Participants also felt parents and providers would not be knowledgeable or supportive, and were reluctant to share their own use of PrEP on social media. Suggested next steps include online parent and provider education, systemic health care reform to streamline and simplify access to preventative care and awareness campaigns that meet youth where they are on popular platforms.

Introduction

Sexual transmission between men accounts for 79% of new HIV infections diagnosed among 13–19 year-olds in the USA (Centers for Disease Control and Prevention 2018b). HIV prevention efforts targeting gay and bisexual young men are crucial in reducing these numbers. One promising recent development is the US Food and Drug Administration’s (FDA) approval of daily oral pre-exposure prophylaxis (PrEP) for biomedical HIV prevention in young people weighing over 77 pounds (Centers for Disease Control and Prevention 2018a). When taken as prescribed, PrEP is over 90% effective at reducing sexual transmission of HIV among adults (Centers for Disease Control and Prevention 2019a). One study suggests that making PrEP available to gay and bisexual young men could prevent 27.8% of new HIV infections in this group (Goodreau et al. 2018).

Despite this need, there are few existing prevention programmes, interventions (Mustanski and Fisher 2016) or strategies for moving forward, although available resources are likely inadequate. Fewer than 10% of US students aged 13–21 in a 2017 survey reported receiving LGBTQ-inclusive sex education (GLSEN 2017), and evidence-based HIV prevention programmes have focused predominantly on adults and/or heterosexual youth (Centers for Disease Control and Prevention 2019b).

In this paper, we present data from interviews with young men in the USA, aiming to better understand barriers they face in accessing PrEP and how to overcome them. To first identify known barriers to PrEP awareness and uptake, we looked to literature from studies of both adults and young people. Three themes were used to frame our research questions and arguments. The first two themes were types of barriers to PrEP uptake: information and logistics, including PrEP awareness and accurate knowledge (Macapagal et al. 2020), health insurance confusion (Moskowitz et al. 2020), and willingness to take a daily pill (Hosek and Henry-Reid 2020); and social risks and discomfort, including outness and cultural context (Annequin et al. 2019), social stigma (Fields et al. 2021; Golub 2018), and uncomfortable interactions with parents and doctors (Moskowitz et al. 2020). The third theme included resources, campaigns and strategies for overcoming these barriers and directed our focus to young people’s desires for specific types of information about PrEP.

Information and Logistical Barriers

The first theme in the literature included information barriers and difficulties in obtaining and administering PrEP. Limited information about PrEP has been an important barrier to PrEP uptake among adults (Cohen et al. 2013; Krakower et al. 2012; Landovitz, Combs, and Currier 2009; Mehta et al. 2011; Dubov, Altice, and Fraenkel 2018). This can also include information about risk of HIV infection. Those who believe, accurately or not, that their risk of contracting HIV is low, may be less interested in PrEP (Khawcharoenporn, Kendrick, and Smith 2012; MacKellar et al. 2007; Mimiaga et al. 2007; Schechter et al. 2004). Cost or perceived cost is another key barrier, with 31.6% of participants in an anonymous HIV testing programme indicating they would have no means to pay for PrEP (Wilton et al. 2016). Ensuring that LGBTQ+ adults can access relevant PrEP information via their health care providers has also been a barrier. Devarajan and colleagues (2020) found that participants wanted more tailored health advice and access to explicitly LGBTQ-friendly PrEP providers.

Among gay and bisexual young people, recent studies suggest that many have become aware of PrEP from social media and adult-oriented dating apps rather than targeted information initiatives (Fields et al. 2021; Goedel et al. 2016; Holloway et al. 2017; Macapagal et al. 2020). Despite such awareness, however, many feel they have not had enough information about HIV, how PrEP works, and how to get it (Matson et al. 2021).

A key logistical challenge has been the inconvenience of a daily pill (Hosek and Henry-Reid 2020). These authors argue that this delivery mechanism may be particularly challenging for gay and bisexual adolescents living with their parents. Parents may be an access barrier regardless of delivery mechanism, however, because of their gatekeeping role in access to health care (Macapagal et al. 2020). Given these barriers, educating and informing young people and their parents requires a deeper understanding of the information needed. Our first research question (RQ1) therefore was: what barriers and information gaps do participants perceive in getting access to PrEP?

Social Risks and Discomfort

The second theme included perceived risks of social stigma, negative reactions from others and uncomfortable conversations. Among adults, a prevalent stereotype is that PrEP’s effectiveness encourage promiscuous or risky behaviour (Milam et al. 2019). PrEP users are sometimes perceived as ‘hypersexual’ (Calabrese and Underhill 2015), so some may hesitate to disclose PrEP usage. This, in turn, reduces awareness of the prevalence of PrEP use in the community and may be associated with reduced uptake (Eaton et al. 2017).

Results from an analysis of testimonial blog posts by PrEP users show that many sought and shared strategies for coping with stigma (Hedrick and Carpentier 2020). This may be true among gay and bisexual young people as well, with a recent survey suggesting participants aged 15–18 in that study would be reluctant to disclose their own use of PrEP (Birnholtz et al. 2020). Participants in that study did say however that they would perceive others who disclosed PrEP usage positively.

Moreover, Moskowitz and colleagues (2020) found that a majority of gay and bisexual youth participants felt their parents would not support their taking PrEP and might punish them for doing so. Fears of parental reactions also contributed to participants feeling that PrEP was not right for them. Parents can be an important barrier given that they typically control or monitor youth access to health care (Newcomb et al. 2018; Thoma and Huebner 2018).

To overcome these social barriers, we need a deeper and more nuanced understanding of how gay and bisexual young people aged 13–19 think about and navigate these issues. As RQ2, we therefore asked: what role do participants’ perceptions of PrEP and how they feel others perceive PrEP play in their thinking about adopting or seeking information about PrEP?

Toward Strategies to Increase PrEP Knowledge and Uptake

Our third theme augments the first two by helping us understand how others have sought to overcome barriers to PrEP, and how we might better reach gay and bisexual young adults. While work cited above suggests that many young adults are already aware of PrEP, many remain unaware and very few actually use PrEP. Evidence from adult populations suggests that PrEP awareness campaigns can positively affect uptake and attitudes toward PrEP and its use within the community (Keen et al. 2020; Kudrati, Hayashi and Taggart 2021).

Given that many gay and bisexual young adults meet each other and get valuable social support and information from interaction on social media platforms (Birnholtz and Macapagal 2021; Fox and Ralston 2016), this is likely an important avenue for reaching this population. One possibility would be to encourage young adults to share information about their own use of PrEP or more general information about PrEP on online platforms. Birnholtz et al.’s (2020) survey of gay and bisexual young adults, however, found that most participants were generally unlikely to share information about their own PrEP use, with some exceptions for platforms that afford ephemeral content and where family members were unlikely to be in the expected audience. One motivation for the present study was to understand this more deeply, exploring how gay and bisexual young adults think about the information they share, and how they wish to receive information about PrEP. We therefore asked (RQ3), how would participants like to get information about PrEP? How would they feel about campaigns that asked them to participate by sharing information?

Methods

Participants

We sought a diverse sample of English-speaking 15–19 year-olds in the USA who had been assigned male at birth and who identified as sexually attracted to other men at least some of the time. There were 23 participants (see Table 1) in total (age, M=17.04, SD=0.98). Most participants had completed an earlier survey by the authors on social media and PrEP use and had volunteered for a follow up interview. They had been recruited for the earlier study in 2019 via paid advertisements on Facebook and Instagram. Participants who were aged 15 were emailed after having been recruited using similar methods and deemed ineligible (due to age or sexual inexperience) for an earlier study. Everybody who responded to our email query had the opportunity to schedule an interview; those who did so were enrolled as participants.

Table 1.

Study participants

Participant Pseudonym	Age	Race	Self-Reported Sexuality	US State	Density
Eric	16	White/Black	Gay	Ohio	Urban
Lee	18	White	Gay	Connecticut	Rural
Brennan	17	Did not share	Gay	Maryland	Suburb
Tyler	17	White	Demisexual/Gay	Ohio	Suburb
Cory	18	Asian	Gay	New Jersey	Suburb
Zach	19	White	Queer/Gay	Washington	Suburb
Wyatt	17	White	Gay	N. Dakota	Rural
Sam	18	Asian/Native Hawaiian/Pacific Islander	Gay	Connecticut	Suburb
James	16	Black	Bisexual	Florida	Urban
Kai	17	White/Asian	Gay	N. Carolina	Rural
Jesse	18	White	Bisexual	Florida	Rural
Marc	17	White/Black	Gay	Michigan	Rural
Andrew	19	White	Gay	Pennsylvania	Rural
George	17	Did not share	Gay	New Mexico	Urban
Riley	16	White	Pansexual	Texas	Urban
Austin	17	White	Gay	Wisconsin	Rural
Colin	17	White	Gay	Utah	Suburb
Jamie	17	White	Bisexual	Oregon	Urban
Stephen	17	Black	Gay	Missouri	Urban
Ethan	19	White	Bisexual	Massachusetts	Rural
Theo	15	White	Asexual or Bisexual	Pennsylvania	Not available
Charlie	16	White	Bisexual	Utah	Suburb
Danny	16	White	Panromantic or Pansexual	Virginia	Suburb

Procedure

Semi-structured interviews were conducted by two of the authors (JB, AK) from January to mid-March 2020. All but one were completed prior to the COVID-19 shutdown. Interviews used audio conference or telephone call, in line with the participant’s preference. This research was approved by Northwestern University’s Institutional Review Board (IRB). As gay and bisexual young people may be unwilling to seek parental permission for research participation (Macapagal et al. 2017), we requested and obtained a waiver of the IRB’s parental permission requirement. Consent (for those ≥ 18) or assent (for those < 18) was obtained via a short online questionnaire and comprehension quiz. Participants were asked to complete the form prior to the interview, read a reminder before the interview, and given an opportunity to ask questions.

Interviews lasted between 54–157 minutes (M=78.00, SD=26.13) and participants received a US $25 gift card for participating. The same protocol was used for all interviews. Questions covered participants’ use of social media and LGBTQ+-focused apps, their coming out experience, how they sought information about sex and STIs, who they discussed sensitive issues with, and their knowledge of and attitudes toward PrEP. All interviews were recorded and transcribed by a professional transcription service.

Analysis

Using techniques described by Huberman and Miles (1994), four of the authors (JB, AK, LT, SS) coded the transcripts using Dedoose software. Coding was largely inductive in that we aimed to code the transcripts exhaustively and the coding scheme was developed through iterative reading and discussion, however our reading was also informed by the research questions and literature cited above. Every transcript was coded at least twice, with some transcripts coded being a gain to reflect coding scheme changes.

Coding began with an initial phase in which common phenomena were identified through independent reading and weekly team discussions to develop a preliminary coding scheme. This was used to code a subset of transcripts and identify data elements that did not clearly fit, reflected discordant interpretation by the coders or otherwise warranted discussion. Each transcript was then coded by one coder, with frequent peer check-ins to ensure reliability and refine the coding scheme throughout the process. Coding was also spot-checked for reliability reviewing all of the data elements marked with particular codes to verify that codes were being consistently applied.

Once transcripts had been initially coded, we examined the data for each initial code, discussed relationships between these, and used these relationships to derive and apply a second set of higher-order codes reflecting our research questions. This secondary coding resulted in the themes we draw on in presenting our results below.

In our coding and analysis processes, we were cognisant of the diversity of the sample and the systemic barriers some people face in accessing health care. We were also attentive to possible differences along demographic or other relevant categorical distinctions between participants (e.g. outness, supportive parents), however we could not reliably identify any systematic differences along these lines in our analysis as described above or in a subsequent check when transcript excerpts in relevant coding categories were compared.

Findings

Perceived Barriers

Information Barriers

Consistent with prior research, most participants were aware of and had basic knowledge about PrEP. Some also had ideas about how they might access it. They were far less confident about how to pay for it. For these details, Colin² (17, White, Gay) said he would go directly to his health insurance provider, though admitted that he was not sure how to do that:

… I’m not a person that goes to the doctor very frequently. So I’m not someone that’s super educated about that topic. So I would, assuming that I know how to contact my health insurance company, I would probably contact them as well if necessary.

Another participant, Lee (18, White, Gay), had tried searching for information on his health insurance provider’s web site, but found this unhelpful. Asked to elaborate, he said:

Definitely how confusing the pricing and what other programmes are available to supplement insurance, because you can price PrEP on my insurance website, and it comes out so expensive. And then the PrEP assistance programme, all of it is so confusing and vague, I’m not sure how much I will actually end up paying for it.

Lee’s experience illustrates how difficult it can be for young people to independently seek information in a complicated context they do not fully understand. The lack of clarity and consistency in available information made the prospect of obtaining PrEP even more daunting.

Logistical Barriers

Logistical barriers included the inconvenience or difficulty of taking a daily pill and the need for periodic blood tests, and whether these hassles were worth the effort required to get PrEP. These challenges were amplified for participants who felt they had to conceal PrEP use for fear of stigma or uncomfortable conversations with parents.

Other logistical challenges participants mentioned included lack of transport and access to a car, frequently moving back and forth between home and college, and the difficulty of seeing a doctor without their parents’ awareness. Marc (17, White/Black, Gay), for example, said he would not want to tell his parents he was going to the doctor to get PrEP, so ‘I would have to find a reason to go to the doctor other than to go get that medication.’

Many felt their level of risk from sexual activity was not high enough to warrant the struggle. Sam (18, Asian/Native Hawaiian/Pacific Islander, Gay) said:

My doctor asked me if I wanted to, but then I was like, ‘oh, I don’t really want to bother with that.’ Just because I don’t really want to take the pill every day and have to go deal with the blood tests. Plus I’m also dealing with other mental and physical health stuff already and …I wasn’t really actively looking to hook up with people at the time. …I was like, ‘I don’t think this is necessary given all the stuff you have to do.’

Social Issues and Risk Perception

Parents’ Attitudes

Given the gatekeeping role that parents play in access to health care, participants perceived their parents’ possible reactions or attitudes as a barrier to comfortably accessing PrEP. Most participants were out to their parents about their sexuality and reported having had at least one conversation about their sexual orientation and activity. This was rarely a comfortable topic, however, so participants were not eager to start conversations about PrEP.

Given that participants felt PrEP was intended for people who were particularly sexually active, many feared that mentioning PrEP to their parents might imply a level of sexual activity that was inconsistent with their parents’ expectations. They also felt these conversations would give their parents unnecessary insights into their private lives. Kai (17, White/Asian, Gay), for example, worried that his parents might subsequently try to restrict his opportunities for sex, rather than help him get PrEP.

They would form a mental image of what I’m doing that would require PrEP that definitely wouldn’t be accurate. It probably wouldn’t be the most positive. I mean of course they would think it’s preferable for me to use it rather than not if I’m going to be doing those things, but at that point they would do what they would need to do to prevent me from doing those things in the first place.

For participants without supportive parents, talking about PrEP could be even more challenging. Cory (18, Asian, Gay) said his parents would be willing to engage in a conversation about PrEP so long as it was framed around STI and HIV prevention and not his sexuality:

I think my parents would be more open to it if it was just like STD, HIV prevention, and not associating it with the gay. Then I feel that although it would still be a really awkward conversation and they probably wouldn’t want to talk about it, they would be more open to listening and hearing about that than about gay sex.

Doctors/Medical Professionals

A second theme related to our second research question was that most participants did not see their doctors or health care providers as knowledgeable allies who could help them get access to PrEP. Most participants said they had not talked with their primary doctor about their sexual orientation or sexual behaviour. When we asked why these conversations had not taken place, participants said they felt the doctor would not be interested or would not be knowledgeable about their situation. Others worried their providers might be unsupportive or reluctant to prescribe medication. Marc (17, White/Black, Gay) said:

There was one time that it wasn’t my primary care doctor. It was a different doctor. …and she spoke heavily religiously and was telling me, because she thought I had depression, she was saying going to church would help that. And I felt in my mind if she believes this as a doctor and is recommending this to me, I probably should not tell her about being gay.

For participants who did try to start a conversation about PrEP, their fears were often borne out. For example, Cory (18, Asian, Gay) said:

Yes. I have talked to my doctor about it [PrEP]… and that did not go so well. I had come out to him only as a matter of I needed STD testing, and I grew up with the same [primary care doctor] from when I was a baby, so I don’t really know what I was expecting, but it really was not a good experience. He wasn’t aware of a lot of the things that I was inquiring about. I actually had asked him about PrEP at the time. He did not have any idea of that. It just became really, really awkward and uncomfortable, and none of us knew how to go about the conversation.

While doctors were not seen as a valuable resource, several participants said they have helpful conversations with mental health professionals about their sexual orientation. Theo (15, White, Asexual or Bisexual) felt he would want to talk first to his therapist about PrEP:

I feel like I’d probably want to talk to my therapist first about it. Because that’s one of those things where it’s like basically … You’re afraid to even ask your parents, it’s like basically saying, ‘Oh, I want to have gay sex.’ And so it’s something that I try and find a way to discreetly do without my parents knowing if possible. And if it’s not possible, it’s probably something I’d just not do.

Overall, participants struggled to negotiate the tension between knowing they would likely need to talk with their doctor or another health care provider to access PrEP, but not being confident that these individuals would actually be helpful or supportive.

Looking toward campaigns/social media

Information Resources

The first theme in our results related to our third research question was that participants felt certain facts about PrEP might motivate them and others to seek out more information about PrEP. Participants felt that attention-getting facts, such as in a social media story shared by an LGBTQ+ organisation they follow, might help attract them to other PrEP information they were interested in. Charlie (16, White, Bisexual), for example, was especially taken by PrEP’s efficacy:

… yeah this thing can reduce chances of getting HIV by 99% or something like that, because that just astonishes me. It’s a very cool thing… [one] that I didn’t think could exist in the first place, you know?

Merely being motivated to seek information was not enough. Needed information had to be readily available. As a result, PrEP ad campaigns in recent years which suggest starting a conversation with a health care provider to learn more were seen as not helpful. As noted above, talking to a doctor or parent about PrEP can be hard for youth. As Colin (17, White, Gay) put it

As kids, we don’t know a whole lot about that. We don’t have control over our health insurance. When it says contact your health provider, talk about this, that’s usually the brick wall for most people, because… we can’t, or don’t have access to that. So, making sure that you have access to up to date information for every state so we don’t have to, first of all, go out of our way to try and navigate the horrible mess that is legislature on sexual health. It’s absolutely impossible to find information on that.

Ultimately, participants wanted enough information to feel they could find ways to get PrEP independently, without necessarily starting with a doctor who they often felt might be difficult to access and would not be helpful.

Sharing Information and Experiences Related to PrEP

A second theme related to RQ3 concerned participants’ perceptions of the appropriateness of sharing information about their own PrEP use on social media. Most felt that the use of PrEP was sensitive information that would be socially inappropriate to share. Lee (18, White, Gay) said, ‘I guess just because it’s medical stuff. I wouldn’t think to post a blood test on my story or something like that.’ When asked where they might expect to see posts about PrEP, most said they could be from celebrities or organisations. Marc (17, White/Black, Gay) said, ‘it probably wouldn’t be on any of my friends’ accounts. It’d probably be on one of the equality accounts or something like that. I’d expect [to find] it there.’

Participants said they had seen some of the social media influencers they followed mentioning PrEP, but also that very few influencers of their own age had disclosed that they themselves used PrEP. As Austin (17, White, Gay) said, ‘A lot of the guys do Q&As, or whatever, and one of the questions they always ask is, “Are you on PrEP?” and then they often say no. I’ve seen very few young people on it.’

Some participants, such as Charlie (16, White, Bisexual), said that they would be willing to share information about PrEP, but not about their own use of it.

I don’t think I would post about how I’m using it. I don’t know… It’s not the type of thing that I would post about myself using, but …I have posted about how easy access to condoms and stuff has affected teen pregnancy rates and stuff.

Others said they would be hesitant to discuss PrEP on social media because they tried to avoid sharing their opinions or spreading information/advocacy. One also said he tried to avoid sharing too much because his younger siblings followed him, and posts about sex might be inappropriate or hard to explain to them. When participants did say they might share information about PrEP, they generally felt that an ephemeral ‘story’-style post, which disappeared within 24 hours, would be a more appropriate venue than a more permanent post, which they would not want associated with their permanent profile.

Importantly, however, most participants did not worry about being judged by their peers for using PrEP or for being sexually active. Friends were felt to be generally supportive since PrEP was a strategy to stay safe. What caused participants to say they would not discuss or share information about PrEP was a sense that it would be inappropriate to share sexual and medical details in what they saw as a public place.

Discussion

We began this study with questions about barriers gay and bisexual young men faced in learning about and obtaining PrEP. Our results have several important implications.

Information Barriers

One empirical contribution of our work was the finding that participants did not feel they had the information they needed in order to get PrEP, were confused by available information, and were not fully confident that parents and doctors could help them.

Our findings suggest that medical and mental health providers may benefit from training in LGBTQ+-affirming youth healthcare (e.g., Hadland, Yehia, and Makadon 2016; Hosek et al. 2016). Healthcare providers would also benefit from the creation of developmentally-appropriate PrEP resources for young patients and guardians, as such resources are sorely lacking in the USA. Moreover, it is incumbent on providers to initiate conversations about sexual health, including PrEP, with young LGBTQ+ patients rather than expecting patients to do so. Together, such strategies could help realize Hosek and Henry-Reid’s (2020) vision of health care providers playing a more central role in reducing HIV and STI transmission among gay and bisexual youth.

Much of the confusion we saw, moreover, is rooted in the complexities of the US health care system. In the USA, young people’s ability to seek healthcare independently of their parents/guardians depends on the specific type of care they are seeking, the laws of the state they live in, and health insurance policies regarding parental notification. This regulatory patchwork complicates seeking HIV preventative care like PrEP. Our results reinforce the importance of universal insurance coverage for preventative medications like PrEP and streamlining state-level restrictions on minors seeking care without parental notification (Huebner and Mustanski 2020; Hosek et al. 2016).

At a minimum, additional information about these issues should be available and accessible to both providers and young people. Providing this information would benefit from a subculture-centric approach that uses social media to minimise barriers between members of a subculture and care institutions (e.g. Ems and Gonzales 2016). This might involve reaching out directly to young people on social media, such as via Instagram direct message, and developing informative social media content that draws on the interests and norms of hard to reach populations.

Social Issues and Perceptions

Many participants hesitated to start conversations about PrEP with their parents to avoid implying that they were more, or differently, sexually active than they actually were. Participants also worried that their parents or providers might not see PrEP’s benefits relative to other preventative techniques.

This suggests that parent education will be an important element of campaigns building on Thoma and Huebner’s (2018) focus on youth-parent communication. A similar challenge has been faced by health care providers promoting human papillomavirus (HPV) vaccine uptake among sexually active teenagers (Hildebrandt, Bode and Ng 2019). Researchers have suggested that increasing the prevalence of positive vaccine stories on social and traditional media (Margolis et al. 2019) and facilitating parents’ receipt of vaccine advice from social contacts (Fu et al. 2019) may help increase uptake. Similar approaches that use media to provide parents of LGBTQ+ young people with information about HIV risk alongside stories about PrEP effectiveness and prevalence may be helpful, alongside opportunities for parents to engage with, and provide advice to, each other via social media channels. Parents could also be encouraged to discuss PrEP in the conversations about harm reduction that many of our participants described.

Finally, our results extend Birnholtz and colleagues’ (2020) results by suggesting that young people hesitate to share information about PrEP because they feel health and sex are not appropriate topics. As such, social media campaigns should focus less on individual sharing. Specific strategies might include content from gay or bisexual content creators or open discussion channels on platforms where young people seek information or community, such as TikTok, Reddit and Discord (Greensmith and King 2020; Simpson and Semaan 2020).

Limitations and Future Work

As with any study, this one has limitations. We chose to use qualitative methods in order to explore participants’ experiences in detail. There may, however, be additional barriers to PrEP knowledge and use beyond those reported by the young men participating in this study.

While we did our best to recruit a diverse sample and reduce barriers to participation, there are likely perspectives that are not represented here. Though we did not find evidence of systematic differences between different demographic groups and participants who were out or not, more focused research is needed to explore potential effects of these factors. We also did not enquire into the unique experiences of transgender and other sexual minority populations who also face risks from HIV infection. Using these initial results as a foundation, it will be important to explore these.

Beyond this, there is value in researchers and practitioners developing and testing new materials and ways to promote PrEP awareness and access for gay and bisexual young men.

Conclusion

This paper describes an interview study of gay and bisexual young men’s knowledge of PrEP, perceived barriers to using PrEP, and suggestions for future information campaigns and other efforts. Findings suggest that existing traditional and social media resources and campaigns for PrEP may be inadequate in several key respects. First, providers and parents are critical gateways to PrEP access, but often lack the information they need to initiate or participate in conversations with young people and answer questions about whether PrEP is appropriate and how to access it. Second, much information currently available via social channels focuses on awareness of PrEP and how it works, but not on the i complexities of insurance coverage and state-level differences in young people’s ability to independently access care. Third, some social media awareness campaign strategies depend on individual willingness to share sensitive health information that our participants were not comfortable sharing. In the long term, systemic reform that streamlines health care access and broadens awareness of the disparities faced by sexual minorities can help address these issues. More immediately, providing consistent information to caregivers and parents via both institutional and social channels can improve their capacity to act as effective gatekeepers. Moreover, providing information using channels and strategies appropriate to relevant subcultures may further improve uptake.