It has been 5 years since the FDA approved Truvada (Emtricitabine and Tenofovir Disoproxil Fumarate) for HIV preexposure prophylaxis (PrEP), a daily oral pill designed to prevent infection.1 Preexposure prophylaxis uptake has been slow,2,3 but continues to increase, as does its widespread acceptance as a prevention strategy.4,5 One factor often mentioned as a barrier to PrEP implementation is PrEP stigma, ie, negative attitudes toward the medication and the individuals who use it.6–8 Preexposure prophylaxis stigma was first recognized after attacks of PrEP users on social media and among several prominent HIV activists and providers.9,10 Since then, data indicate significant and persistent stigma against PrEP users.8 The primary manifestation of PrEP stigma is the belief that PrEP users are promiscuous and/or unwilling to engage in “responsible” sexual behavior.7,11,12 But many individuals also describe a form of PrEP stigma that results directly from HIV-related stigma; given that the specific medication used for PrEP is also used to treat HIV among people who are HIV positive, some individuals have reported concerns that people who see them taking PrEP will assume that they are actually HIV positive.13,14
Available prescription data indicate disparities in PrEP uptake by race/ethnicity, with fewer men of color receiving PrEP prescriptions, which is especially concerning when considering the disproportionate burden of new infections among this population.15,16 There is evidence that intersectional stigma, ie, erroneous stereotypes about greater sexual risk–taking among men of color,17,18 may contribute to lower provider willingness to prescribe PrEP to black patients.19 Little research has been performed on the impact of racism on PrEP-related stigma at the community level, ie, whether people of color experience greater PrEP-related stigma than their white counterparts.7
Preexposure prophylaxis stigma has been demonstrated to have significant negative impacts on PrEP uptake, adherence, and persistence. Endorsing negative stereotypes about PrEP is associated with decreased PrEP interest among potential users,7,20 stigmatizing beliefs are associated with reduced willingness to prescribe PrEP on the part of providers,21–23 and experiences of PrEP stigma are cited as barriers to adherence and persistence among participants in PrEP trials and demonstration projects.24–26 A recent metaanalysis of studies conducted with men who have sex with men identified PrEP stigma as one of the most significant barriers to PrEP acceptability worldwide.27
At the same time, there are increasing numbers of social media campaigns designed to combat PrEP stigma, and researchers, policy makers, and advocates have argued for reconceptualizing PrEP in a manner that reduces and discourages stigma.6 And, as uptake has grown, PrEP users have become more open about their PrEP adoption. One of the indications of this openness is the advertising of PrEP status in profiles on geospacial social networking applications, ie, “hookup apps” such as Scruff or Grindr.28 These apps have made it easier for people to post this type of information on their profiles, and some have even added specific fields that allow users to search and filter for PrEP use or other prevention strategies.29,30 Given concerns about the impact of PrEP-related stigma on uptake and use, it is important to understand the extent to which disclosing PrEP use may influence the experience of individuals on these sites or any potential discrimination they may encounter. In 1 study, app users reported stereotype-confirming behavior from PrEP users, indicating that individuals who disclose PrEP use on their profile are more likely to request condomless sex and refuse a hookup unless it was condomless.28 However, it is possible that increased visibility of PrEP use on these applications may also work to decrease stigma among users and normalize uptake, which calls for further investigation. Although PrEP stigma is directly related to enduring HIV stigma, anecdotal evidence and preliminary data from PrEP demonstration projects suggest that PrEP uptake may actually reduce HIV stigma among users. Individuals report that PrEP allows them to consider both HIV-positive and HIV-negative sexual and romantic partners, whereas in the pre-PrEP era, they disqualified HIV-positive individuals from consideration.31 Media reports suggest an increased openness to mixed serostatus dating and sexual encounters more broadly.32 It is important to understand the ways in which HIV stigma may be impacted by increasing uptake of PrEP, especially within the gay community.
One of the challenges to studying stigma and stigmatizing attitudes is social desirability bias, ie, participants often know that researchers are studying stigma and change their self-reported attitudes to make themselves seem less biased.33 By contrast, the use of implicit measures of stigma, ie, presenting stimuli that might activate stigmatized attitudes without participants being aware of it, can provide important insights into individuals' true beliefs and behaviors.34 This study was designed to examine implicit stigma toward PrEP users who disclose their PrEP use on geospatial social networking applications. Our goal was to have participants' view sample app profiles that were identical in all aspects (eg, profile picture, level of attractiveness, and height/weight specifications), except that some included potentially stigmatizing information (eg, PrEP use and HIV-positive status). Participants would merely rate the attractiveness and desirability of the different app profiles, without knowing that this aspect of the profile (ie, the potential stigmatizing information) was the focus of the study. This strategy was designed to examine implicit bias toward specific profile characteristics. For example, if profiles that disclosed PrEP use were rated more negatively (eg, less attractive or desirable) compared with identical profiles of those who reported an HIV-negative status but did not report being on PrEP; this discrepancy would indicate a degree of negative bias toward individuals who included PrEP information in their profiles.
Study Overview and Hypotheses
As part of our examination of implicit stigma, we were interested in testing 4 hypotheses. First, we hypothesized that profiles that disclosed PrEP use would be rated more negatively than profiles that reported an HIV-negative serostatus without PrEP use (ie, implicit stigma against PrEP users). Second, to evaluate the magnitude of PrEP stigma, we included 2 other characteristics with known stigmatized associations: (1) HIV-positive serostatus and (2) active substance use. The presence of HIV-related stigma has been discussed above; evidence also supports prevalent stigmatized attitudes toward substance users.35,36 We hypothesized that profiles that disclosed PrEP use would be rated comparably to profiles who disclosed HIV-positive serostatus (ie, implicit PrEP stigma would be comparable to implicit HIV stigma) but would be rated more positively than active substance users (ie, implicit stigma against substance users would be stronger than implicit PrEP stigma).
Third, we hypothesized that racism would exacerbate PrEP stigma and result in an interaction between PrEP use and race in profile ratings, such that implicit PrEP stigma would be greater when participants rated profiles of black individuals compared with white individuals. Finally, we hypothesized that implicit PrEP stigma would be reduced or eliminated among PrEP-experienced individuals, (ie, those with a history of PrEP use), such that their ratings of PrEP users would not differ from ratings of HIV-negative profiles that did not disclose PrEP use.
To test these hypotheses, this study was conducted using a 2 (race of profile: black of white) by 4 (characteristic: HIV negative, HIV positive, on PrEP, or substance user) mixed factorial design. Participants were presented with simulated profiles, designed to look like those used on a popular geosocial networking application (Fig. 1). Other than the mention of the potentially stigmatizing characteristic, profiles had been pretested for comparability in attractiveness (see profile construction, below). Each participant was randomized to see either 4 profiles of black men or 4 profiles of white men (between-subject factor), and each participant rated 1 profile paired with each of the 4 potentially stigmatized characteristics (within-subject factor). Participants were asked to rate each profile on 5 dependent measures: attractiveness, desirability, trustworthiness, how likely they would be to use a condom with that person, and how risky it would be to have sex with that person. Comparing ratings across profiles with different characteristics would allow us to test for the presence of implicit stigma associated with each characteristic.
Profile Construction and Testing
As the experimental stimuli for this study were simulated geospatial networking application profiles, the first step was to ensure that profiles were matched in attractiveness before pairing with the experimental characteristics. We selected 16 stock images (8 black and 8 white) for testing. To reduce the potential recognition of images and to reduce variability in individuals' attraction to particular type of facial features, we used images of men's torsos, rather than their faces. A small, but significant number of profiles on these types of applications use torso pictures in their profile, so this was not considered outside the norm for participants viewing the profiles. Selected pictures were then embedded in a simulated profile, which included height, weight, and race identifiers (Fig. 1). Height and weight specifications for the profiles were selected based on average ranges for men in the United States. All photo editing was performed using the program GIMP 2.
Simulated profiles were pretested by 217 respondents, recruited through the listservs of 2 collaborating New York City event promoters. Pretest participants viewed either the black or white profile pictures and asked to rate each for attractiveness using a 10-point Likert-type scale. Attractiveness scores ranged from 3.18 to 7.84. To ensure adequate variability in the experimental study, we selected the 4 middle-rated profiles within each group (ie, the 6 most and 6 least attractive profiles were discarded). This preselection process yielded 8 profiles that were used in the final study.
Between late April and early May 2015, participants were recruited through pop-up advertisements on the mobile site of a geospacial networking application. Eligible individuals were born male (regardless of current gender identity), aged 18 years or older, and were users of the geospacial networking application (a recruitment agreement, during which our study aims were made transparent, was established between researchers and representatives of the application before any research activity commenced). On clicking the ad, participants were invited to complete a 10-minute Qualtrics-based online survey. Participants then read an informed consent page regarding the contents of the survey, the voluntary nature of the survey, and data confidentiality; those who agreed to participate clicked on the survey to indicate consent. Pop-up ads were geolocated to 4 US metropolitan areas (New York, Atlanta, Miami, and Washington DC/Baltimore) and were advertised over the course of 2 days.
Experimental Design and Procedures
Participants were first randomized to the race of the profiles to be rated (black or white). Profile race was defined as a between-subject factor because we were worried that seeing profiles of different races might cause participants to think that the study was about racial bias, potentially impact responding across profiles, and confounding within-subject differences in the stigma characteristics. Participants were then presented with the 4 profiles selected in pretesting, each paired with one of the 4 stigma characteristics (Fig. 1). For the HIV-negative characteristic, the profile said “HIV negative, month/year,” with the month/year being approximately 2 months before the study, ie, a recent negative test. For the HIV-positive characteristic, the profile said “Poz, undetectable.” For the on PrEP characteristic, the profile said “On PrEP.” For the substance use characteristic, the profile said: “ParTy,” a commonly used phrase indicating an interest in using drugs to enhance sexual experience. For each participant, the specific profile/characteristic combination (ie, which profile picture was paired with which characteristic) was randomized, and the order of characteristic presentation (ie, whether participants rated the HIV-positive profile first, second, etc.) was counterbalanced using a Latin Square design. Participants were asked to rate each profile on 5 Likert-type scale items (see dependent measures, below). Participants then responded to a brief set of survey items. On completion of the survey, participants were given the option to enter a raffle for $100 by entering their email address in a separate survey, to maintain the confidentiality of their data. All procedures were reviewed and approved by the Human Research Protections Program at the City University of New York.
After viewing each profile, participants rated the profile by answering the following 5 questions on a 10-point Likert-type scale, with higher numbers indicating higher ratings: (1) How attractive is this person?; (2) How much do you want to meet/hook up with this person?; (3) How much do you trust this person?; (4) How likely would you be to use a condom if you had sex with this person?; and (5) How risky would it be to have sex with this person? These variables were selected to represent the types of judgments that individuals are most likely to make on these types of apps when they are evaluating potential partners. These judgments were used as a proxy for stigma, ie, differences in profile ratings would indicate more negative attitudes based solely on the presence of a given stigmatized characteristic.
Demographics and PrEP Status
Participants reported their race/ethnicity, age, education, income, sexual identity, relationship status, and city of residence. Participants were also asked whether or not they had ever taken PrEP (yes/no).
A total of 1195 individuals clicked on the survey link. Data were screened for completeness, duplicate IP addresses, and suspicious responding (eg, completing the survey too quickly or responding identically to every question). Of those who clicked on the survey, 265 (22%) did not complete the profile ratings and an additional 149 (12%) did not complete the demographics and PrEP questions. Of the remaining sample (n = 781), 89 additional participants were excluded from this analysis because of the following: (1) living outside the United States (n = 7), (2) self-reporting that they were HIV-positive (n = 80);, or (3) providing inconsistent/suspicious data (n = 2), for example, responding with the same value to every single question. As such, our final analytic sample included 692 participants.
Descriptive statistics were obtained for all dependent variables of interest, including tests for normality. We began by testing our initial hypotheses, using a 2 (between subjects: race) by 4 (within subjects: characteristic) repeated-measures factorial analysis of variance. We then conducted analyses examining the impact of PrEP history using participant's PrEP use (yes/no) as the between-subject factor in a repeated-measured analysis of variance. Final results are presented and adjusted for demographic factors significantly associated with PrEP use. Analyses were conducted in using SPSS software 23 (IBM SPSS Statistics, IBM Corporation, Chicago, IL).37
Demographic characteristics of the sample are presented in Table 1. Nearly a fourth of the sample identified as Latino (22%), and an additional 23% identified as nonwhite (including 10% black and 11% multiracial). The sample ranged in age from 18 to 70 (M = 33, SD = 10.7), with almost half the sample (47%) being under 30. Almost two-thirds of the sample (67%) held at least a bachelor's degree and half the sample reported earning more than $50,000 per year. Most participants resided in New York City (45%), followed by the Washington DC area (30%), Miami (15%) and Atlanta (10%).
Seventy-eight participants (11%) reported having taken PrEP. Table 1 also compares PrEP naive and PrEP-experienced participants on demographic characteristics. Preexposure prophylaxis–experienced participants reported higher education and income, compared with PrEP naive participants. Preexposure prophylaxis–experienced participants were also more likely to live in New York City and Washington, D.C., compared with Atlanta and Miami.
Average profile ratings by stigma characteristic, adjusted for profile race, are presented in Table 2. For each dependent variable, there was a significant effect of stigma characteristic (all Ps < 0.001) but no significant race by stigma interaction effect (P values range from 0.30 to 0.66). HIV-negative profiles were rated as more attractive than HIV-positive profiles, which were rated as more attractive than substance user profiles. However, attractiveness ratings of PrEP profiles did not differ from HIV-negative profiles. In terms of desirability, HIV-negative and PrEP profiles were rated as significantly more desirable than HIV-positive or substance user profiles. By contrast, HIV-positive profiles were rated as the most trustworthy, followed by PrEP profiles, HIV-negative profiles, and substance user profiles. Participants were most likely to say that they would use a condom during sex with HIV-positive and substance user profiles, and least likely to use a condom with those on PrEP. However, it is important to note that all condom use ratings were above 8.8 on a 10-point scale, indicating high condom use intentions across profiles. Finally, participants rated sex with substance user profiles as the most risky, followed by sex with the HIV-positive profile. Rating of risk from sex with the HIV-negative and PrEP user profiles did not differ significantly.
To examine differences in stigma by participants' PrEP history, we constructed general linear models with PrEP use (PrEP experienced/PrEP naive) as the between-subject factor, and with demographic factors associated with PrEP experience (ie, education and income), included as covariates. The PrEP use by stigma interaction was significant for 4 of the 5 dependent variables (desirability, trust, condom use, and sex risk), indicating that PrEP-experienced participants rated the 4 profiles differently than PrEP naive participants, all Ps < 0.001. The PrEP use by stigma interaction for attractiveness scores was only marginally significant (P = 0.06), but the quadratic contrast was highly significant (P = 0.002), suggesting the presence of significant paired differences between profiles.
To better understand the significant PrEP use by stigma interactions (ie, which profiles were rated differently by PrEP naive compared with PrEP-experienced participants), we conducted post hoc comparisons of stigma characteristic ratings stratified by history of PrEP use. Ratings of PrEP user profiles and substance user profiles did not differ between PrEP naive and PrEP-experienced participants, ie, they followed the same pattern as the overall scores in Table 2 (data not shown). However, there were significant differences in the way in which PrEP naive and PrEP-experienced participants rated HIV-positive profiles. As demonstrated in Table 3, PrEP naive participants rated HIV-positive profiles as significantly less attractive and less desirable, compared with HIV-negative profiles. They also indicated that they would be more likely to use a condom with HIV-positive partners and that sex with HIV-positive partners was riskier. By contrast, PrEP-experienced participants did not demonstrate differences in ratings of HIV-positive and HIV-negative profiles. The only significant difference in ratings between HIV-positive and HIV-negative profiles among PrEP-experienced participants was that HIV-positive profiles were rated as significantly more trustworthy than HIV-negative profiles.
We did not find evidence of significant implicit PrEP stigma in this sample of gay and bisexual men using geospacial social networking applications. Participants did not rate profiles of PrEP users more negatively compared with profiles that indicated an HIV-negative status but did not disclose PrEP use. In the full sample, we did find evidence of implicit HIV-related stigma; HIV-positive profiles were rated as significantly less attractive and desirable than HIV-negative or PrEP profiles. However, when the sample was split by history of PrEP use, HIV-related stigma remained significant only among participants who had never taken PrEP. Participants with any history of PrEP use demonstrated no difference in their ratings of HIV-negative and HIV-positive profiles, with the exception of deeming HIV-positive profiles more trustworthy.
These data provide the first empirical evidence of the ways in which PrEP can work to reduce HIV-related stigma in the gay community. Qualitative and anecdotal evidence has suggested that individuals on PrEP are more open to HIV-positive partners, both for sexual encounters or romantic relationships. Individuals have noted that being on PrEP changes their perception of HIV-positive individuals for the better. These data suggest that such attitude changes may translate into reductions in implicit stigma, ie, individuals on PrEP may no longer “see” HIV-positive individuals in the same negative light as their counterparts who have not taken PrEP.
It is important to note that our data are correlational, so an alternative interpretation of these data would be that individuals who chose to take PrEP are less likely to stigmatize HIV-positive individuals in the first place and that this effect is not caused by their PrEP use. There is certainly some truth to this interpretation, especially as it is likely that the PrEP users in our sample were “early adopters,” who might have the least stigmatizing attitudes. More research is needed examining HIV-related stigma before and after PrEP uptake and among a larger and more diverse sample of PrEP users. Our data belie much of the current discourse on PrEP stigma and suggest that perhaps negative stereotypes about PrEP users do not extend to negative implicit judgments about them on social networking sites. These data are encouraging and may reflect the success of national efforts to promote PrEP in a way that helps individuals understand its true potential and dispel misconceptions about its negative implications. This ancillary benefit of PrEP use can be of essential consequence in reducing HIV-related stigma, with potentially profound positive impact on treatment outcomes, romantic relationships, and mental health for individuals living with HIV. More research is warranted to explore this unexpected benefit of PrEP use among gay and bisexual men. Our sample was comprised gay and bisexual men in 4 East Coast cities (New York, Washington D.C., Atlanta, and Miami), but it is important to note that the dynamics of the HIV epidemic and access to prevention/treatment in each of these cities is quite different, lending credence to the potential generalizability of these findings. It is possible that much of the current focus on PrEP-related stigma stems from or is reinforced by health care providers and/or programs that emphasize risk assessment and risk compensation,22,23 rather than from gay men themselves. At a community level, this biomedical strategy to protect against HIV may indeed achieve a dual and powerful impact by having the potential to lift decades-long stigmatization away from HIV-infected individuals.
HIV-positive profiles were rated as the most trustworthy, and this effect was present regardless of participants' history of PrEP use. We hypothesize that participants rated HIV-positive individuals as more trustworthy because they were being honest about their HIV status. Ironically, in the context of HIV-related stigma, participants may understand that people may be reluctant to disclose their HIV status on networking apps. It will be important to track and better understand HIV-status disclosure in the emerging context of the undetectable equals uninfectious campaigns.38
On another positive note, we did not find evidence of stigma by race interactions, suggesting that neither PrEP stigma nor HIV-related stigma was exacerbated for individuals of color. However, at the polar opposite end of the spectrum were ratings of profiles of substance users, who received significantly lower ratings than the rest of the profiles across all 5 outcomes. Thus, substance use stigma remains pervasive, which is also likely to play a role in increasing sexual risk and poor mental health outcomes among substance-using individuals. It is important to note that we saw more negative ratings for substance users although the profile indicated recreational use, rather that a substance use disorder. Stigma related to individuals with substance use disorders is likely to be even more significant and pervasive. Efforts to integrate hybrid substance use harm reduction strategies and HIV-related interventions should therefore remain a priority.
Our data are subject to several limitations. These data were collected in 2015, and different attitudes may exist today, given the steady speed at which PrEP implementation has occurred. However, one would expect PrEP stigma to continue to decrease (rather than increase) in the time since these data were collected because awareness of and understanding of PrEP efficacy are rapidly canvasing more and more cities in the United States. Another limitation is the fact that participants knew they were rating fictitious profiles, which may have impacted their ratings. This potential shortcoming is counteracted, we believe, by the robust experimental design and pretesting of images/profiles. This study was specifically focused on gay and bisexual men, and there has been limited research on PrEP stigma among other populations. These data would not be generalizable to other groups, and more data are needed on PrEP-stigma dynamics among heterosexuals, cisgender women, and transgender individuals. It seems likely that PrEP-related stigma would remain high among these populations, and it is critical to better understand the impact of such stigma on uptake among other groups. Last, the sample was 55% white; our own and other research suggests that PrEP- and HIV-related stigma may differ by race/ethnicity. Future investigations should examine more diverse samples to better understand implicit PrEP- and HIV-related stigma.
Despite these limitations, these data provide compelling evidence for the positive impact of PrEP use on HIV stigma. The potential of PrEP to revolutionize the ways in which we conceptualize risk and perceive stigma seems to be profound. It is important that its existence as a preventive option, its efficacy, and access further permeate communities of sexual minorities, but also of the general public, whose own understandings of sexual health and the HIV epidemic remain in need of change and expansion.
The authors gratefully acknowledge the efforts of members of the Hunter HIV/AIDS Research Team (HART), 2 anonymous reviewers who made valuable suggestions for manuscript revision, and the participants who gave their time and energy to this project.
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