The Impact of Sexual Orientation on PrEP Motivating Factors Among Young Adults Experiencing Homeless

Background: Young adults experiencing homelessness (YAEH) are up to 12 times more likely to contract HIV than their housed peers. One possible explanation is that many YAEH identify as members of the lesbian, gay, or bisexual (LGB) community, which has been disproportionately impacted by HIV. For example, although men who have sex with men (MSM) make up only about 1.4% of the US population, they account for 70% of new HIV infections.

One important HIV prevention tool is pre-exposure prophylaxis (PrEP), a daily medication that reduces sexual transmission of HIV by 99% and injection drug transmission by at least 74%. Despite its effectiveness, few studies examine PrEP use among YAEH, particularly among those who identify as LGB. The present study adds to this emerging literature by exploring knowledge about and interest in using PrEP, as well as motivating factors for PrEP use among YAEH in the Mountain West region. Further, the study conducts exploratory analyses to identify which facilitators and barriers may be particularly salient to LGB YAEH.

Methods: In partnership with a non-profit organization in the Mountain West, 160 YAEH aged 18 through 24 were recruited from July 2017 to March 2018. Participants were administered a survey that included questions on sexual risk behaviors, knowledge about and interest in using PrEP, facilitators and barriers to PrEP use, and general demographic information. A total of 135 YAEH fully completed the survey. Chi-Squared tests assessed if participants varied on knowledge about PrEP, interest in using PrEP, and motivational factors for PrEP use based on sexual orientation identity.

Results: The majority of the sample identified as White (41%) cisgender men (61%), with a mean age of 20.7. Fifty (37%) identified as LGB and 85 (63%) as straight. Straight participants were significantly more likely to have never heard of PrEP (p=.009) or have no interest in using PrEP (p=.042) than their LGB peers. YAEH who identified as LGB were significantly more likely to report access to free sexual healthcare and monitoring (p=.032) and access to counseling about sex life (p=.020) as being very or extremely important than their straight peers. In terms of reported barriers to prep use, LGB participants were significantly more likely to report concerns that if they became HIV+ PrEP would interfere with certain medications (p=.027), and less likely to report concern that PrEP wouldn’t provide complete protection against HIV (p=.024).

Conclusions and Implications: As LGB YAEH represent one of the most vulnerable populations in terms of HIV risk, understanding facilitators and barriers to PrEP use will help develop and implement HIV prevention programs. For example, as LGB YAEH were more likely to report free sexual healthcare and counseling as important facilitators to PrEP use, it may be productive to include these services as a core component of PrEP distribution programs targeting LGB YAEH. Similarly, the higher proportion of straight YAEH who reported concerns about PrEP ineffectiveness as a key barrier suggests that attempts to educate YAEH about the effectiveness of PrEP may be particularly important in non-LGB specific spaces.