PrEP stigma still high among men who have sex with men

Many male couples in the U.S. seem to be underestimating the effectiveness of HIV pre-exposure prophylaxis (PrEP) for HIV prevention, and educating partners together could improve the number of male couples who decide to adopt PrEP. These conclusions come from a study reported in the July/August issue of The Journal of the Association of Nurses in AIDS Care (JANAC), the official journal of the Association of Nurses in AIDS Care.

PrEP—medicine taken to prevent HIV infection—reduces the risk of getting HIV from sex by about 99%, according to the U.S. Centers for Disease Control and Prevention. Yet among men who have sex with men, PrEP use is suboptimal, and new HIV diagnoses have decreased by only 5%. One-third to two-thirds of new HIV infections in this group come from the man’s primary partner.

Rob Stephenson, Ph.D., a professor at the University of Michigan School of Nursing, and colleagues studied how PrEP-related stigma (shame) and views of PrEP effectiveness affect decisions of male couples about whether to use it. “[A]lthough risk perceptions may help reduce stigma by framing PrEP as a potential protector against… perceived risks, there is evidence that partnered men may also be undervaluing the efficacy of PrEP,” they say.

The team conducted an online survey of 375 U.S. cisgender male couples in which one or both partners was HIV-negative. All couples had been together for at least 3 months. Partners took the survey individually and each reported his own views of PrEP effectiveness. Each also rated his agreement (scale of 1–5) with these statements:

• I would feel dirty if a doctor recommended PrEP to me
• Someone who takes PrEP is probably promiscuous
• Most people I know think that taking PrEP is a sign of a weak character
• If you’re on PrEP you probably have a sexually-transmitted infection
• Taking PrEP means you have poor morals

A majority of participants (62.6%) rated PrEP as very effective, while 29.8% rated it somewhat effective and 7.6% rated it minimally effective. But of 25 possible points on the stigma scale, the average score was 21, indicating a high level of PrEP-related stigma. Other key results were:

• High-risk behaviors such as binge drinking and having sex partners outside the relationship were linked to reduced PrEP stigma. This suggests partnered men with HIV-related risks are practical about the need for HIV prevention. However, those risk factors were often associated with reduced trust in PrEP effectiveness.
• A man’s level of PrEP-related stigma and his rating of PrEP effectiveness was likely to be influenced by his partner’s behavior and experiences. For instance, among men whose partners reported behaviors associated with high risk of HIV, ratings of PrEP-related stigma were reduced—but so were ratings of PrEP effectiveness.
• “Serodiscordant” couples—those in which only one man was HIV-negative—reported higher levels of PrEP-related stigma than couples in which both partners were HIV-negative. The explanation might be that serodiscordant couples encounter more judgment and disapproval from family, friends, and healthcare providers.

HIV prevention efforts (e.g., pretest education, HIV testing, and post-test education) commonly involve both members of a couple, the authors note. They suggest adapting that approach when educating patients about PrEP. “Providing this information to couples provides an opportunity for them to learn together and talk through their concerns about PrEP and their potential to use it.”