Beyond the Pre-Exposure Prophylaxis (PrEP) "Cascade": Addressing Social, Community, and Structural Challenges in Biomedical HIV Prevention for Gay, Bisexual and Other Men Who Have Sex with Men

Background and Purpose: Based on the weight of evidence from >12 clinical trials and demonstration projects, the U.S. FDA approved PrEP for HIV prevention in 2012, followed by Health Canada in 2016. Nevertheless, PrEP uptake has been slow among gay, bisexual, and other men who have sex with men (GBM) at high risk for HIV acquisition, with challenges in PrEP adherence and retention in care. The model of a “PrEP cascade” has increasingly been applied to identify “attrition” and gaps in care, and “failures” at each stage. Our objectives were: 1) to explore the experiences of GBM in considering, accessing, and using (or not using) PrEP; and, 2) to understand emerging sexual health, social, and community issues among GBM in the PrEP era.

Methods: From October 2015 to March 2016, we conducted an exploratory qualitative study. We purposively sampled and recruited PrEP-naïve and PrEP-experienced GBM in Toronto, Canada using flyers posted in community clinics and organizations serving GBM, and by word-of-mouth. An in-depth semi-structured interview guide with scripted probes explored PrEP perspectives and decision-making, PrEP access, initiation, use over time, psychosocial considerations, and impact on sexual health. Interviews (45-90-minutes) were audio-recorded, transcribed verbatim, and analyzed independently by three investigators using thematic content analysis, and then contrasted with the PrEP cascade. Differences in coding were resolved by consensus. We used memo-ing, peer debriefing, negative case analysis, and created an audit trail to increase methodological rigor. Participants completed a brief self-administered demographic questionnaire. We used Fisher’s exact tests to assess demographic differences between PrEP users and non-users.

Results: Participants (n=29) mean age was 36.7 years-old (SD=8.2). Most identified as gay (n=25; 86.2%), cisgender male (89.7%), and white (79.3%). The majority had some college education (n=24; 82.8%) and were employed full-time (n=18; 62.1%). Half (n=15, 51.7%) had insurance that covered PrEP. By design, participants were equally divided between PrEP users (n=15; 51.7%) and non-users (n=14; 48.3%). PrEP users were significantly more likely to identify as gay versus bisexual/queer and to have insurance that covers PrEP. Overall, themes illustrated barriers and opportunities broadly corresponding to stages of the PrEP cascade; however, they also revealed its limitations: the binary construction of users/non-users; the assumption that HIV risk perception corresponds with greater willingness to use PrEP; a model of linear stages; universal endpoint of long-term retention in care; pervasive and multi-faceted PrEP stigma; and impacts of PrEP on GBM sexual cultures and sexual expectations. Findings suggest an emerging PrEP-user/Non-user divide within GBM communities.

Conclusions and Implications: Findings suggest reconceptualizing the PrEP cascade: incorporating alternate trajectories (i.e., intermittent and short-term use), integrating psychosocial challenges (i.e., pervasive PrEP stigma) with clinical challenges, and acknowledging limitations in modeling PrEP use for HIV prevention on antiretroviral use for treatment of people living with HIV. Social workers can contribute to HIV risk assessments, identifying insurance coverage, empowering GBM to make informed decisions about uptake (or not), and advance interventions to support adherence, and mitigate PrEP and sexual stigma, thereby promoting sexual and psychosocial health in addition to the physical health of GBM.