Demographic, psychosocial, and behavioral predictors of pre-exposure prophylaxis (PrEP) persistence among men who have sex with men (MSM) in the southern United States Open Access

Das, Sagarika (Spring 2021)

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Objective: Examine the relationship of urbanicity, self-efficacy, HIV knowledge, and sexual behavior stigma with PrEP discontinuation among PrEP-using MSM in the southern United States

Introduction: Men who have sex with men (MSM) in the southern United States bear a disproportionate burden of new HIV diagnoses, including in rural areas. PrEP is an effective once-daily pill that can reduce the risk of contracting HIV from sex. However, southern MSM face barriers to PrEP uptake, adherence, and persistence. Factors such as lack of HIV knowledge, low self-efficacy, and sexual behavior stigma may influence PrEP discontinuation. These barriers might be exacerbated for MSM in rural areas due to increased stigma and reduced access to culturally competent care.

Methods: We analyzed data from the Emory PrEP study (October 2019 to July 2020), an observational longitudinal pilot study of an online cohort of PrEP-using MSM in the southern U.S. Our exposures of interest included urbanicity, HIV knowledge, self-efficacy, and sexual behavior stigma, and our outcome was self-reported PrEP discontinuation. We calculated descriptive statistics for all demographic variables, stratified by PrEP persistence. We estimated crude and adjusted prevalence ratios and confidence intervals for PrEP discontinuation using logistic regression with the predicted margins approach.

Results: Of 72 participants, 10 (13.9%) MSM discontinued PrEP. Unadjusted analyses showed that MSM who avoided healthcare had a moderate positive association with PrEP discontinuation (cPR=2.66, 95% CI= [0.80, 8.87]). After adjustment, they had a strong positive association with PrEP discontinuation, compared to their counterparts who did not avoid healthcare (aPR=3.31, 95% CI= [1.12, 9.76]). MSM who experienced gossip from healthcare workers had a moderate positive association with PrEP discontinuation (cPR=2.06, 95% CI= [0.32, 13.27]). After adjustment, they had a slightly stronger association with PrEP discontinuation (aPR=3.59, 95% CI= [1.02, 12.60]), compared to non-stigmatized MSM.

Discussion: PrEP-stable MSM experiencing sexual behavior stigma of healthcare avoidance and gossip from healthcare workers are more likely to discontinue PrEP compared to MSM who do not experience these stigmas. Stigma may play a role in PrEP discontinuation, and future work should address longitudinal fluctuations in HIV risk and reasons for PrEP discontinuation.

Table of Contents

Introduction, page 1

Methods, page 4

Results, page 8

Discussion, page 10

Conclusion, page 14

Tables, page 15

References, page 19

Appendix A. Directed Acyclic Graph, page 25

Appendix B. Sexual Behavior Stigma Questions, page 26

Appendix C. HIV Knowledge Questions, page 27

Appendix D. Self-Efficacy Questions, page 27

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