The Potential Role of Undetectable = Untransmittable (U = U) in Reducing HIV Stigma among Sexual Minority Men in the US.

The Undetectable = Untransmittable (U = U) message and its scientific underpinnings have been widely suggested to reduce HIV stigma. However, misunderstanding and skepticism about U = U may prevent this destigmatizing potential from being fully realized. This cross-sectional study examined associations between U = U belief (belief that someone with a sustained undetectable viral load has zero risk of sexually transmitting HIV) and HIV stigma among US sexual minority men. Differences by serostatus and effects of brief informational messaging were also explored. The survey was completed online by 106 men living with HIV and 351 HIV-negative/status-unknown men (2019-2020). Participants were 18-83 years old (M[SD] = 41[13.0]). Most were non-Hispanic White (70.0%) and gay (82.9%). Although nearly all participants (95.6%) were aware of U = U, only 41.1% believed U = U. A greater percentage of participants living with HIV (66.0%) believed U = U compared with HIV-negative/status-unknown participants (33.6%). Among participants living with HIV, U = U belief was not significantly associated with perceived, internalized, or experienced HIV stigma or with viral load prejudice (prejudice against people who have a detectable HIV viral load). Among HIV-negative/status-unknown participants, U = U belief was associated with less frequently enacted HIV discrimination, more positive feelings toward people with an undetectable viral load, and lower personal endorsement of stigmatizing beliefs. Brief informational messaging about U = U did not affect most stigma dimensions and did not favorably affect any. Interventions are needed to correct commonly held, outdated misconceptions about HIV transmission risk. Such initiatives must not only engage people living with HIV but also engage HIV-negative/status-unknown people to maximize the destigmatizing potential of U = U.

RESUMEN: Para reducir el estigma del VIH se ha recomendado difundir extensivamente el mensaje Indetectable = Intransmisible (U = U) y sus fundamentos científicos. Sin embargo, falta de comprensión y escepticismo acerca de U = U pueden impedir que se realice plenamente su potencial desestigmatizante. Este estudio transversal examinó las asociaciones entre la creencia U = U (creencia de que alguien con una carga viral indetectable sostenida tiene cero riesgo de transmitir sexualmente el VIH) y el estigma del VIH entre hombres de minorías sexuales estadounidenses. También se exploró si el efecto de los mensajes informativos breves dependía del estatus serológico. La encuesta fue completada en línea por 106 hombres que viven con el VIH y 351 hombres VIH negativos o de estatus desconocido (2019­2020). Los participantes tenían entre 18 y 83 años (M[DS] = 41[13,0]). La mayoría eran blancos no hispanos (70,0%) y gay (82,9%). Aunque casi todos los participantes (95,6%) sabían sobre U = U, sólo el 41,1% creían en U = U. Un mayor porcentaje de participantes con VIH (66,0%) creían que U = U en comparación con los participantes VIH negativos o de estatus desconocido (33,6%). Entre los participantes con VIH, la creencia U = U no se asoció significativamente con el estigma del VIH percibido, interiorizado o experimentado ni con el prejuicio sobre la carga viral (prejuicio contra las personas que tienen una carga viral de VIH detectable). Entre los participantes VIH negativos/con estatus desconocido, la creencia U = U se asoció con menor frecuencia de discriminación por VIH, sentimientos más positivos hacia las personas con una carga viral indetectable y menor respaldo personal a las creencias estigmatizantes. Los mensajes informativos breves sobre U = U no afectaron la mayoría de las dimensiones del estigma y no afectó favorablemente a ninguno. Se necesitan intervenciones para corregir conceptos frecuentes sobre el riesgo de transmisión del VIH que son erróneos y obsoletos. Para maximizar el potencial desestigmatizador de U = U, estas iniciativas no sólo deben involucrar a las personas que viven con el VIH, sino también a las personas VIH-negativas o de estatus desconocido.

The Implications of PrEP Use, Condom Use, and Partner Viral Load Status for Openness to Serodifferent Partnering Among US Sexual Minority Men (SMM).

PrEP has been reported to facilitate openness to serodifferent sexual partnerships among sexual minority men (SMM). However, other aspects of a sexual scenario likely come into play, including whether or not condoms are used and whether or not the partner living with HIV has an undetectable viral load. This online survey study evaluated the association between PrEP status and openness to serodifferent partnering, as well as the effects of various sexual scenario variables (condom use and partner's viral load) among 268 HIV-negative SMM in the US. Each participant reported their PrEP status and rated their openness to serodifferent partnering in four sexual scenarios, which varied by condom use (with/without) and partner viral load status (detectable/undetectable). Analyses of covariance (ANCOVAs) were conducted to assess differences in openness to serodifferent partnering by PrEP status in each scenario, adjusting for background characteristics. A two-way repeated measures ANCOVA and a three-way mixed factorial ANCOVA, including PrEP status as a between-subjects variable, were also performed to assess the effects of condom use and partner viral load status on openness. Across all scenarios, current PrEP users expressed significantly greater openness to serodifferent partnering compared to participants who had never used PrEP. Current PrEP users were also more likely than former PrEP users to consider partnering with someone with an undetectable viral load without using condoms. Both PrEP users and PrEP-inexperienced individuals had greater openness to serodifferent partnering with a partner having an undetectable (vs. detectable) viral load, which was magnified by condom use among the latter.

RESUMEN: Se ha reportado que hombres de minorías sexuales (HMS) están más dispuestos a tener parejas sexuales serodiferentes cuando usan PrEP. Sin embargo, es probable que existan otros aspectos del contexto sexual, como el uso o no de condones y si la pareja que vive con el VIH tiene o no una carga viral indetectable. Este estudio utilizó una encuesta virtual para evaluar la asociación entre el uso de PrEP y el estar abierto a parejas serodiferentes, así como los efectos de diversas variables del contexto sexual (uso de condón y carga viral de la pareja) entre 268 SMM VIH negativos en los EE. UU. Cada participante reportó su uso de PrEP y estimó su apertura a parejas serodiferentes en cuatro contextos sexuales, que variaron según el uso de condón (con o sin) y el estado de carga viral de la pareja (detectable/indetectable). Para examinar si la apertura a tener parejas sexuales serodiferentes estaba asociada con el uso de PrEP en cada contexto sexual, se realizaron análisis de covarianza (ANCOVA), controlando por características demográficas. También se utilizó ANCOVA de medidas repetidas de dos vías y una ANCOVA de diseño factorial mixto de tres vías, incluyendo el estado de PrEP como una variable entre sujetos, para evaluar los efectos del uso de condón y el estado de carga viral de la pareja en la apertura a tener parejas sexuales serodiferentes. En todos los contextos, las personas usando PrEP en ese momento expresaron una apertura significativamente mayor a las parejas serodiferentes comparados con los participantes que nunca habían usado PrEP. Las personas usando PrEP en ese momento también eran más propensas a considerar asociarse con alguien con una carga viral indetectable sin usar condones que los que habían descontinuado PrEP. Tanto los usuarios de PrEP como las personas sin experiencia en PrEP tuvieron una mayor apertura a tener relaciones serodiferentes con una pareja que tuviera una carga viral indetectable (versus detectable), que se magnificó por el uso de condones entre los sin inexperiencia.

'There are people like me who will see that, and it will just wash over them': Black sexual minority men's perspectives on messaging in PrEP visual advertisements.

The high incidence of HIV among US Black sexual minority men is a public health crisis that pre-exposure prophylaxis (PrEP) for HIV can help address. Public health campaigns, which often include pictures of Black sexual minority men alongside PrEP-related messaging, have been developed to encourage PrEP awareness and uptake. However, the acceptability of the messaging within these campaigns among Black sexual minority men is unclear. We conducted four focus groups with 18 HIV-negative Black sexual minority men in Washington, DC to explore their perspectives regarding promotional messaging (textual elements) in PrEP visual advertisements, including their reactions to three large-scale public health campaigns. Primary themes included: (1) the need for additional information about PrEP, (2) preference for slogan simplicity, (3) the desire to normalise PrEP use, and (4) mixed views on the inclusion of condoms. Results indicated that the messaging in current PrEP visual advertisements may not sufficiently address Black sexual minority men's questions about PrEP. Providing basic PrEP information and methods to access more information; using simple, unambiguous language; presenting PrEP use in a destigmatising, normalising fashion; and conveying the relevance of condoms if included in the advertisement could help increase the acceptability of future PrEP advertising among Black sexual minority men.

An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers' PrEP-Related Clinical Judgments.

Social biases may influence providers' judgments related to pre-exposure prophylaxis (PrEP) and patients' consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.

RESUMEN: Los sesgos sociales pueden influir sobre los juicios de proveedores de salud con respecto a la profilaxis pre-exposición (PrEP) y el consecuente acceso de los pacientes a PrEP. Proveedores de cuidados primarios y de VIH en los Estados Unidos (n = 370) respondieron una encuesta experimental. Cada proveedor leyó una historia médica de un paciente ficticio interesado en obtener PrEP. Las historias médicas variaron la raza (Negro o Blanco) y conducta de riesgo (hombre que tiene sexo con hombres [HSH], hombre que tiene sexo con mujeres [HSM], u hombre  usuario de drogas inyectables [HDI]) del paciente. Los proveedores reportaron juicios clínicos y completaron medidas sobre prejuicio. La evidencia sobre sesgos raciales en los juicios clínicos fue mínima. Los proveedores que expresaron prejuicio sexual bajo a moderado, juzgaron que el paciente HSH tendría mayor adherencia a PrEP que el paciente HSM, lo cual se asoció con mayor intención de prescribir PrEP; el prejuicio sexual se asoció negativamente con la adherencia anticipada en HSH. El paciente HDI fue percibido como en mayor riesgo, con menor adherencia, menos preocupado por la seguridad, y menos responsable que los HSH y HSM; los juicios sobre baja adherencia y responsabilidad estuvieron asociados con menor intención de prescribir PrEP.

"Let's Be a Person to Person and Have a Genuine Conversation": Comparing Perspectives on PrEP and Sexual Health Communication Between Black Sexual Minority Men and Healthcare Providers.

Patient-provider communication is a key factor affecting HIV pre-exposure prophylaxis (PrEP) awareness and access among Black sexual minority men (SMM). Optimizing patient-provider communication requires a deeper understanding of communication dynamics. In this study, we investigated the perspectives of both HIV-negative/status-unknown Black SMM and practicing community healthcare providers regarding patient-provider communication about PrEP and sexual health. We conducted eleven semi-structured qualitative focus groups (six with Black SMM; five with providers) in the Northeastern USA and thematically analyzed transcripts. A total of 36 Black SMM and 27 providers participated in the focus groups. Our analysis revealed points of alignment and divergence in the two groups' perspectives related to patient-provider communication. Points of alignment included: (1) the importance ascribed to maximizing patients' comfort and (2) belief in patients' right to non-discriminatory healthcare. Points of divergence included: (1) Black SMM's preference for sexual privacy versus providers' preference that patients share sexual information, (2) Black SMM's perception that providers have an ethical responsibility to initiate conversations about PrEP with patients versus providers' perception of such conversations as being optional, and (3) Black SMM's preference for personalized sexual health conversations versus providers' preference for standardized conversations. Findings underscore a need for providers to offer more patient-centered sexual healthcare to Black SMM, which should entail routinely presenting all prevention options available-including PrEP-and inviting open dialogue about sex, while also respecting patients' preferences for privacy about their sexuality. This approach could increase PrEP access and improve equity in the US healthcare system.

Electronic Dissemination of a Web-Based Video Promotes PrEP Contemplation and Conversation Among US Women Engaged in Care at Planned Parenthood.

We evaluated the acceptability and impact of a web-based PrEP educational video among women (n = 126) by comparing two Planned Parenthood centers: one assigned to a Web Video Condition and one to a Standard Condition. Most women reported the video helped them better understand what PrEP is (92%), how PrEP works (93%), and how to take PrEP (92%). One month post-intervention, more women in the Web Video Condition reported a high level of comfort discussing PrEP with a provider (82% vs. 48%) and commonly thinking about PrEP (36% vs. 4%). No women with linked medical records initiated PrEP during 1-year follow-up.

Racial and ethnic differences in women's HIV risk and attitudes towards pre-exposure prophylaxis (PrEP) in the context of the substance use, violence, and depression syndemic.

Women with syndemic conditions, i.e., two or more co-occurring epidemics, are at elevated risk for HIV acquisition and are therefore prime candidates for pre-exposure prophylaxis (PrEP). However, PrEP uptake remains low among women, especially among Black and Hispanic women. This study examined associations of syndemic conditions with PrEP attitudes and HIV risk among women, and the moderating effect of race and ethnicity. In 2017, 271 non-Hispanic Black, non-Hispanic White, and Hispanic, PrEP-eligible women engaged in care at Planned Parenthood in the northeastern region of the U.S. completed an online survey. Participants reported syndemic conditions (i.e., intimate partner violence, depression, substance use), PrEP attitudes (e.g., PrEP interest), HIV sexual risk (e.g., multiple male sexual partners), and sociodemographics. Structural equation modeling was used to examine the effects of syndemic conditions on PrEP attitudes and HIV risk, and the moderating effect of race and ethnicity. Women with more syndemic conditions had a higher odds of reporting multiple male sexual partners. Syndemic conditions were positively associated with PrEP attitudes for Hispanic women than non-Hispanic Black and White women. Women with syndemic conditions, particularly Hispanic women, may be receptive to interventions promoting PrEP.

Targeted social marketing of PrEP and the stigmatization of black sexual minority men.

Disparities in HIV incidence and PrEP uptake suggest a need to prioritize Black sexual minority men (SMM) in PrEP social marketing initiatives. However, images linking Black SMM to HIV and PrEP may inadvertently reinforce stigma. We examined HIV-negative/status-unknown Black SMM's responses to targeted PrEP advertisements using mixed methods, including an experiment embedded in a longitudinal online survey (Time 1: n = 96; Time 2 [eight weeks]: n = 73) and four focus groups (n = 18). The full factorial experiment included between-groups and within-subjects comparisons. For between-groups comparisons, each participant was randomly assigned to view one of 12 advertisements, which varied by couple composition (Black SMM couple/Black heterosexual couple/multiple diverse couples/no couples) and campaign (PrEPare for the Possibilities/PlaySure/PrEP4Love). We examined couple composition, campaign, and interaction effects on: advertisement judgments (Time 1), PrEP stigma (Time 1), PrEP motivation (Times 1 and 2), and PrEP behavior (Time 2). For within-subjects comparisons, each participant viewed all 12 advertisements, and we examined couple composition, campaign, and interaction effects on advertisement judgments (Time 2). Focus group participants discussed advertising preferences and responded to the same set of advertisements. For between-groups and within-subjects comparisons, we found significant couple composition effects but no or limited campaign and interaction effects on advertisement judgments. Advertisements featuring Black SMM exclusively were judged as more stigmatizing than advertisements without couples. Advertisements with diverse (vs. no) couples were considered more eye-catching and motivating. There were minimal effects of couple composition and campaign on PrEP stigma, motivation, and behavior. Focus group participants corroborated concerns about the potential for PrEP advertisements to be stigmatizing, suggesting advertisements featuring Black SMM exclusively could be alienating and fuel conspiracy theories. Focus group participants generally favored diverse and less sexualized advertisements, particularly for public spaces. Findings collectively highlight the potential for targeted PrEP advertisements to stigmatize Black SMM and support diverse representation.

Global scoping review of HIV prevention research with transgender people: Transcending from trans-subsumed to trans-centred research.

INTRODUCTION: Globally, transgender populations are disproportionally impacted by HIV and effective HIV prevention interventions targeting these populations are critically needed. Such interventions require research focused on the specific needs and experiences of transgender people. This methodological review aims to determine the extent to which HIV prevention research has included transgender participants by subsuming them into non-transgender populations, or by centring them either in comparison with other groups or as the sole focus of research. METHODS: We searched five electronic databases (e.g. SCOPUS) for empirical studies that focused on HIV prevention and included transgender participants, published through 31 December 2020. For each study, we extracted information on: (a) types of inclusion of transgender participants; (b) total sample size and number/percentage of transgender participants; (c) country(ies) where study was conducted; (d) HIV research topics; (e) methods (i.e. quantitative, qualitative or mixed-methods research) and (f) gender identity of transgender participants. RESULTS AND DISCUSSION: Of 667 HIV prevention studies included in the review, 38.5% subsumed transgender participants into cisgender populations (most frequently combining transgender women with cisgender men who have sex with men), 20.4% compared transgender and cisgender participants and 41.1% focused exclusively on transgender populations. Our global scoping review also revealed that these three types of transgender inclusion in HIV prevention research vary greatly over time, place and thematic areas. Transgender women are the focus of the majority of reviewed studies, whereas transgender men and gender expansive people are rarely included as participants. CONCLUSIONS: Inclusion of transgender persons as participants in HIV prevention research has significantly increased, particularly in the last decade. Further research centred on transgender participants and their experiences are needed to develop effective HIV prevention interventions for transgender populations. We advocate for HIV prevention research to move from subsuming transgender people, to trans-centred research that asks questions that focus on their specific needs and experiences. We provide recommendations to move from trans-subsumed to trans-centred HIV prevention research.