Understanding the Association Between PrEP Stigma and PrEP Cascade Moderated by the Intensity of HIV Testing

Abstract

Abstract Background In the United States, men who have sex with men (MSM) account for the majority of new HIV infections. On the other hand, pre-exposure prophylaxis (PrEP) is an effective strategy to curb HIV transmission, but it is widely underutilized. It is unknown how stigma affects PrEP care in the context of other HIV prevention strategies (e.g., HIV testing).17 In the current study, we explored how PrEP and HIV-related stigma affect the PrEP care cascade (i.e., awareness, willingness, and uptake) and how the intensity of HIV testing services moderates the association. Methods We recruited a group of MSM from two cities in the U.S. With informed consent being collected, we included a total of 318 MSM in the current analysis. We employed bivariate and multivariable analyses to assess the association between PrEP stigma and PrEP cascade while controlling for potential confounders on each specific pathway. We further used a series of moderation analyses based upon the intensity of HIV testing within different timeframes to assess the association between PrEP stigma and PrEP cascade. In addition, we conducted the trend-analyses to assess the pattern of PrEP cascade across different time points of HIV testing. Results Compared with MSM who used PrEP, those who never used PrEP reported higher internalized (0.59 vs. 2.99) and vicarious PrEP stigma (3.66 vs. 5.56). Internalized PrEP stigma has significantly reduced the likelihood of PrEP willingness and PrEP uptake among this group. With the increased frequency of HIV testing, stigma became stronger to negatively impact the likelihood of PrEP willingness and PrEP uptake in MSM. The Jonckheere–Terpstra test with Monte Carlo permutations showed significant trend patterns across different frequencies of HIV testing. The same patterns have been identified under other timeframes (i.e., in the past 12m, 6m, and 3m). Conclusions Findings indicated that HIV prevention services might discourage MSM from PrEP use under the influence of stigma. A structural-level reform is urgently needed to turn the HIV service encounters into opportunities to facilitate and optimize the PrEP cascade among this group who may benefit from PrEP use.