ABSTRACT
BACKGROUND: Scientific evidence indicates that HIV viral suppression to an undetectable level eliminates sexual transmission risk ("Undetectable=Untransmittable" or "U=U"). However, U=U messaging has been met with skepticism among sexual minority men (SMM) and others. In this survey-based experiment, we manipulated messaging about HIV risk and examined reactions and perceived message accuracy among US SMM. METHODS: SMM living with HIV (n = 106) and HIV-negative/status-unknown SMM (n = 351) participated in an online survey (2019-2020). Participants were randomly assigned to 1 of 3 messaging conditions, which varied by level of HIV sexual transmission risk associated with an undetectable viral load (No Risk [U=U]/Low Risk/Control). Participants reported reactions, message accuracy, and reasons for perceiving inaccuracy. We coded open-response data (reactions and reasons) into conceptual categories (eg, "Enthusiasm"). We compared reactions, accuracy ratings, and reasons by condition and serostatus. RESULTS: In the No Risk Condition, common reactions were Enthusiasm (40.0%), Skepticism/Disagreement (20.0%), and Agreement (19.4%), reactions common to comparison conditions. A higher percentage of HIV-negative/status-unknown participants (24.1%) expressed Skepticism/Disagreement in the No Risk Condition compared with other conditions (3.2%-9.7%). Participants living with HIV were more likely than HIV-negative/status-unknown participants to perceive the message as accurate in all conditions. In the No Risk Condition, common reasons for perceiving inaccuracy were Risk Misstated (46.1%), Oversimplified/Caveats Needed (17.1%), and Personal Unfamiliarity/Uncertainty (14.5%), reasons common to comparison conditions. Across conditions, 10.3% of participants attributed message inaccuracy to undetectable being misdefined. CONCLUSION: Most SMM reacted favorably to U=U messaging. However, many-especially HIV-negative/status-unknown SMM-expressed skepticism. Interventions are needed to enhance U=U understanding and acceptance.
Subject(s)
HIV Infections , Sexual and Gender Minorities , Viral Load , Humans , Male , HIV Infections/transmission , Adult , United States , Middle Aged , Young Adult , Surveys and Questionnaires , Sexual BehaviorABSTRACT
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.
Subject(s)
HIV Infections , Pre-Exposure Prophylaxis , Sexual and Gender Minorities , Male , Humans , Condoms , Homosexuality, Male , Sexual Partners , HIV Infections/prevention & control , Viral Load , Sexual BehaviorABSTRACT
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.
Subject(s)
HIV Infections , Sexual and Gender Minorities , Male , Humans , Adolescent , Young Adult , Adult , Middle Aged , Aged , Aged, 80 and over , Homosexuality, Male , Cross-Sectional Studies , Sexual Behavior , Social StigmaABSTRACT
BACKGROUND: The Undetectable=Untransmittable (U=U) message has been promoted since it was demonstrated that viral suppression through HIV treatment prevents sexual transmission between serodiscordant partners (HIV treatment as prevention). Our study assessed familiarity with, perceived accuracy of, and willingness to rely on U=U in a national sample of gay and bisexual men in Australia. METHODS: We conducted a national, online cross-sectional survey in April-June 2021. Eligible participants were gay, bisexual and queer men and non-binary people who lived in Australia. Logistic regression was used to identify factors associated with familiarity, perceived accuracy and willingness to rely on U=U (by having condomless sex with a partner with HIV who has an undetectable viral load). RESULTS: Of 1280 participants, most were familiar with U=U (1006/1280; 78.6%), the majority of whom believed U=U was accurate (677/1006; 67.3%). Both familiarity and perceived accuracy were higher among participants living with HIV, followed by pre-exposure prophylaxis (PrEP) users, HIV-negative participants not taking PrEP, and untested/unknown status participants. Knowing at least one person living with HIV, among other factors, was associated with familiarity and perceived accuracy of U=U; and familiarity was associated with perceived accuracy. Among participants familiar with U=U, less than half were willing to rely on U=U (473/1006; 47.0%). Familiarity with U=U and knowing at least one person living with HIV were associated with willingness to rely on U=U, among other factors. CONCLUSIONS: We found familiarity with U=U was associated with perceived accuracy and willingness to rely upon it. There is an ongoing need to educate gay and bisexual men (particularly HIV-negative men) about U=U and its benefits.
ABSTRACT
BACKGROUND: The Undetectable=Untransmittable (U=U) message has been promoted since it was demonstrated that viral suppression through HIV treatment prevents sexual transmission between serodiscordant partners (HIV treatment as prevention). Our study assessed familiarity with, perceived accuracy of, and willingness to rely on U=U in a national sample of gay and bisexual men in Australia. METHODS: We conducted a national, online cross-sectional survey in April-June 2021. Eligible participants were gay, bisexual and queer men and non-binary people who lived in Australia. Logistic regression was used to identify factors associated with familiarity, perceived accuracy and willingness to rely on U=U (by having condomless sex with a partner with HIV who has an undetectable viral load). RESULTS: Of 1280 participants, most were familiar with U=U (1006/1280; 78.6%), the majority of whom believed U=U was accurate (677/1006; 67.3%). Both familiarity and perceived accuracy were higher among participants living with HIV, followed by pre-exposure prophylaxis (PrEP) users, HIV-negative participants not taking PrEP, and untested/unknown status participants. Knowing at least one person living with HIV, among other factors, was associated with familiarity and perceived accuracy of U=U; and familiarity was associated with perceived accuracy. Among participants familiar with U=U, less than half were willing to rely on U=U (473/1006; 47.0%). Familiarity with U=U and knowing at least one person living with HIV were associated with willingness to rely on U=U, among other factors. CONCLUSIONS: We found familiarity with U=U was associated with perceived accuracy and willingness to rely upon it. There is an ongoing need to educate gay and bisexual men (particularly HIV-negative men) about U=U and its benefits.
Subject(s)
HIV Infections , Sexual and Gender Minorities , Male , Humans , Homosexuality, Male , Cross-Sectional Studies , HIV Infections/prevention & control , Australia , Sexual PartnersABSTRACT
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.
Subject(s)
HIV Infections , Pre-Exposure Prophylaxis , Sexual and Gender Minorities , Male , Humans , Homosexuality, Male , Stereotyping , Social Marketing , Pre-Exposure Prophylaxis/methodsABSTRACT
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.
Subject(s)
Advertising , HIV Infections , Pre-Exposure Prophylaxis , Sexual and Gender Minorities , Humans , Male , Black or African American , HIV Infections/prevention & control , HIV Infections/drug therapy , Homosexuality, Male , Pre-Exposure Prophylaxis/methodsABSTRACT
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.