Pre-exposure prophylaxis (PrEP) is a daily medication that prevents HIV in HIV-negative persons. When taken appropriately, it can reduce the transmission of HIV during sex by more than 90% (CDC, 2020). PrEP is an effective biomedical approach to the HIV epidemic which has disproportionately burdened queer identities. In Fresno County specifically, 78% of all of the new HIV infections for 2017 were of men who have sex with men (MSM), with an additional 5% from MSM who inject drugs (Fresno County Department of Public Health, 2017). Transgender women (TGW), have also been disproportionally impacted by the HIV epidemic, it is estimated that 14% percent of U.S. transgender women are living with HIV (Becasen et al., 2019). In regards to gender non-binary individuals (GNBI), there is still no readily available national HIV data regarding this population. Considering these statistics, PrEP, in combination with other behavioral and structural interventions, can be utilized in HIV prevention among these identities.
The awareness and uptake of PrEP are increasing among men who have sex with men (MSM), yet relatively low among TGW and GNBI. Between 2014 and 2017, awareness of PrEP among MSM increased from 60% to 90% (Finlayson et al., 2019). There was also an increase in the uptake of PrEP from 6% to 35% among MSM PrEP candidates (Finlayson et al., 2019). According to Sevelius et al., (2020), 35% of U.S. TGW were familiar with PrEP, but only 2% of them were on it. In one study examining the awareness and uptake of PrEP among a sample of gender non-binary youth, 54% of them have heard of PrEP before, yet none of the participants were on it (Horvath et al., 2019). Both TGW and GNBI are underrepresented in HIV research and prevention while facing additional barriers compared to cisgender gay and bisexual men, such as survival sex work, conflation with MSM, and non-inclusivity (Klein & Golub, 2019). The purpose of the present study was to examine the awareness, uptake, and accessibility of PrEP among a sample of MSM, TGW, and GNBI who reside in Fresno County.
Respondents were recruited through social media sites, namely Instagram, and on one electronic mailing list. Participants were entered into a drawing for a $50 Amazon gift card, upon completion of the online survey. A total of 71 responses were collected, within a one-week time frame. However, only 59 of those responses met the project criteria and were used for the present study. Three participants were removed due to incomplete responses for the gender identity and/or the city of residence item, seven were removed due to them not residing within Fresno County, and two were removed due to being repeated. The mean age of the participants was 27.95 years (SD = 10.81). Other participant characteristics are displayed in Table 1.
The survey utilized an inductive approach and relied on a branch logic design where respondents moved on to the next section contingent upon their previous answer. A branch logic design allowed for the examination of reasons for the non-uptake of PrEP. The design filtered out respondents who had not heard of PrEP before and those who were currently on it. The survey consisted of multiple-choice, check all that apply, and open-ended items on awareness, knowledge, uptake, and reasons for the non-uptake of PrEP. The survey did not require all items to be answered, which resulted in some missing data.
The item measuring awareness of the existence of PrEP, 83% of the 59 participants indicated that they have heard of PrEP before. Further gender breakdown demonstrates that 11 (69%), 36 (88%), and 2 (100%) of GNB, MSM, and TGW have heard of PrEP before, respectively. The most common source from which respondents heard of PrEP was on social media, with other sources displayed in Figure 1. Of those 49 participants who were aware of PrEP, 80% of them indicated that they were not on it. Further gender breakdown indicates that 10 (91%), 29 (81%), and 2 (100%) of GNB, MSM, TGW were not on PrEP, respectively. The most common individual reason as to why individuals were not on PrEP was not considering their behaviors as posing a risk for them in acquiring HIV, with 26 responses. The most common structural reason as to why individuals were not on PrEP was the financial cost of the medication, with 14 responses. Additional individual and sociocultural and/or structural reasons are listed in Figures 2 and 3, respectively. On the item identifying the respondent’s knowledge of PrEP, 47 participants responded. Many of them demonstrated a basic understanding of the purpose of PrEP, which is to prevent HIV infection. The item identifying other reasons for the non-uptake of PrEP had two common themes, general lack of consumer awareness and discontinued use. General lack of consumer awareness inhibited participants from uptaking PrEP. A few participants indicated that they were on PrEP, but discontinued use due to the novel coronavirus. Examples of the knowledge responses and other reasons for the non-uptake of PrEP are illustrated in Table 2.
Figure 1. Source of PrEP
Figure 2. Individual Reasons for the Non-uptake of PrEP
Figure 3. Sociocultural and Structural Reasons for the Non-uptake of PrEP
Table 2. Knowledge and Other Reasons for the Non-uptake of PrEP
Significance and Moving Forward
There were three main objectives for the present study: to identify how many individuals were aware of PrEP, currently on PrEP, and if not on PrEP, reasons as to why they were not on it. A majority of the respondents were aware of PrEP’s existence, and also possessed a basic understanding of the purpose of PrEP, which is to reduce HIV transmission. The most common individual reason as to why individuals were not on PrEP was not considering themselves at risk of contracting HIV. The overwhelming response to this reason brings up the concern of whether individuals are truly cognizant of what behaviors constitute as posing a risk for HIV. Future prevention methods should incorporate sexual health education where educating participants on what behaviors pose a risk of acquiring HIV is emphasized.
The most common structural reason as to why individuals were not on PrEP was the financial cost of the medication. Future prevention methods should educate on and enroll participants in the programs that the state of California offers to access PrEP. These programs, such as PrEP-AP, can subsidize most if not all of the cost of PrEP and related medical services (California Department of Public Health, 2018). The present study was limited by the small sample size (n=59), due to resource and time constraints. Thus it will be difficult to draw comprehensive conclusions, especially regarding specific gender identities.
A potential outreach project in response to these results is a program facilitated by individuals from these queer identities. The program will include discussion groups, workshops, and client advocacy where the focus is on harm-reduction, sexual health promotion, and healing-centered engagement. Discussion groups will focus on sexual health education and collective healing, which can reduce sexually transmitted infections and/or maladaptive sexual behaviors and as well as address the collective trauma that queer people experience (Kirby et al., 2007; Ginwright, 2019). Workshops can include guest speakers, preferably those who identify as queer/LGBTQ+, doing work out in the community, such as a PrEP provider who can provide further information regarding PrEP. Through these workshops, participants can be provided with further knowledge of PrEP from the mechanism of actions to potential side effects. Lastly, client advocacy through referrals out in the community, such as PrEP providers or case managers that can assist with enrollment in Medi-Cal or PrEP-AP, is imperative in reducing the burden of accessing PrEP. These initiatives address both the individual’s needs and as well as the needs of the community.
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California Department of Public Health. (2018). PrEP-AP [Infographic].
Center for Disease Control and Prevention. (2020, June 10). Daily Pill Can Prevent HIV.
Retrieved July 17, 2020, from https://www.cdc.gov/hiv/default.html
Finlayson, T., Cha, S., Xia, M., Trujillo, L., Denson, D., Prejean, J., Kanny, D., & Wejnert, C.
(2019, March 7). Changes in HIV PrEP Awareness and Use Among Men Who Have Sex
with Men, 2014 vs. 2017 [Conference Session]. Conference on Retroviruses and
Opportunistic Infections (CROI), Seattle, WA, United States.
Ginwright, S. (2019, March 28). The future of healing: Shifting from trauma informed care to
healing centered engagement. https://medium.com/@ginwright/the-future-of-healing-
Horvath, K. J., Todd, K., Arayasirikul, S., Cotta, N. W., & Stephenson, R. (2019).
Underutilization of pre-exposure prophylaxis services among transgender and
nonbinary youth: Findings from Project Moxie and TechStep. Transgender Health,4(1),
Kirby, D. B., Laris, B., & Rolleri, L. A. (2007). Sex and HIV Education Programs: Their Impact
on Sexual Behaviors of Young People Throughout the World. Journal of Adolescent
Health,40(3), 206-217. doi:10.1016/j.jadohealth.2006.11.143
Klein, A., & Golub, S. A. (2019). Increasing access to pre-exposure prophylaxis among
transgender women and transfeminine nonbinary individuals. AIDS Patient Care and
STDs,33(6), 262-269. doi:10.1089/apc.2019.0049
Sevelius, J. M., Poteat, T., Luhur, W. E., Reisner, S. L., & Meyer, I. H. (2020). HIV testing and
PrEP use in a national probability sample of sexually active transgender people in the
United States. JAIDS Journal of Acquired Immune Deficiency Syndromes,84(5), 437-442.