Stigma and Conspiracy Beliefs Related to Pre-exposure Prophylaxis (PrEP) and Interest in Using PrEP Among Black and White Men and Transgender Women Who Have Sex with Men

Lisa A. Eaton,1 Seth C. Kalichman,2 Devon Price,2 Stephanie Finneran,2 Aerielle Allen,2 and Jessica Maksut1

Introduction

The current US HIV epidemic calls for urgent attention in addressing rates of HIV transmission among men and transgender women who have sex with men (MTW) [1]. Of great concern, are the race-related disparities in HIV transmission, in particular, the exceedingly high rates of HIV infection among Black/African–American MTW (BMTW) compared with White MTW (WMTW). For example, although HIV prevalence is elevated among MTW compared to the general population, rates of new HIV infections among BMTW are 6.0 times higher than rates among WMTW [2]. It is estimated that 61% of BMTW could be living with HIV by the time they reach age 40 [3].

Pre-exposure prophylaxis (PrEP), or the use of antiretrovirals such as Truvada®, to prevent HIV transmission among HIV negative persons at-risk for HIV is a highly effective option for HIV prevention [4, 5]. Although PrEP for HIV prevention was approved by the US FDA in 2012, uptake of PrEP among individuals in-need has been limited [6–8]. In order for PrEP to have a population-level impact on incident HIV infections, scale-up efforts must be prioritized and barriers to implementation need to be addressed.

Broader implementation of PrEP for MTW could potentially result in a substantial decrease in incident HIV infections [9]. Multiple factors, however, have impeded access to and interest in taking PrEP among MTW. Main barriers to use include a lack of wide-spread messaging to promote PrEP in communities of elevated HIV prevalence, costs associated concerns among individuals with no/limited insurance, lack of prescribing providers [10], concerns regarding side-effects and long-term use, and sociocultural barriers to use [11], such as experiences of stigma [12, 13] and other negative beliefs about its use [14].

There is increasing concern for the latter barrier, i.e., sociocultural barriers to PrEP interest and use. Popular press reports regarding PrEP have described individuals using PrEP as “Truvada Whores”—a disparaging term that associates promiscuity with use of PrEP [13, 15]. These commentaries have generated considerable discussion on social media [16], yet little empirical research has assessed what influence these sociocultural barriers have had on individuals’ interest in PrEP. These potential barriers to PrEP interest and use are not well-understood as this topic is a novel area of research focus. In implementation research, understanding how communities respond to prevention strategies, either by adopting or rejecting them, is critical, but we have very limited information on this topic with respect to PrEP.

Based on what is known from informal reports and empirical research on how PrEP has been embraced by communities, stigma related to PrEP uptake appears to be an important sociocultural barrier to PrEP interest [13]. Briefly, stigma is a social construction where social devaluation occurs through a process of labeling, stereotyping, separation, status loss, and discrimination [17]. This process serves as a way to maintain social power structures by subordinating those whose possess devalued characteristics and elevating those who do not. In the case of PrEP, the emergence of negative stereotyping—an important component of stigma—towards individuals who use PrEP deserves further attention and understanding [18].

It is known that the negative labeling of groups (in this case those who use PrEP) can dissuade interest in being part of such group. For example, simply using PrEP implies concern for risk of HIV transmission, which, in turn, may imply engagement in sexual risk taking behavior. Engagement in sexual risk taking has a long-standing history of violating perceived social mores. Further, stigma by association is also known to occur when an individual experiences stigma as a result of being connected to a stigmatized person or group [17]. Negative interpersonal associations have the potential to affect how individuals are perceived. In the case of PrEP, individuals may be concerned about using an antiretroviral for HIV prevention if they associate PrEP use with persons living with HIV—a highly stigmatized group. These societal processes have stymied HIV prevention and treatment efforts since the beginning of the epidemic [18, 19] and has the potential to inhibit PrEP implementation.

Along similar lines, conspiracy related beliefs about biomedical approaches to HIV prevention [20–22] are also likely to affect PrEP implementation, but research in this area has yet to be conducted. Conspiracy beliefs are typically thought to imply that organizations or individuals in power furtively manipulate events in a self-serving manner. Conspiracy beliefs in HIV treatment have been attributed to a historical legacy of mistreatment of race minority populations by medical establishments [23]. For example, it is well-documented that conspiracy beliefs about biomedical strategies—primarily antiretroviral use—for HIV treatment are prevalent and related to poor HIV-related health outcomes, particularly, among HIV positive, race-minority individuals [24]. Given the existence of these beliefs in HIV treatment efforts, it is probable that these beliefs would affect PrEP interest as well.