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HIV testing and pre-exposure prophylaxis (PrEP) use, familiarity, and attitudes among gay and bisexual men in the United States: A national probability sample of three birth cohorts
 
 
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Sept 7 2018
 
Our study is the first to examine HIV testing behavior, PrEP use, knowledge, and attitudes in a national probability sample of three distinct cohorts of HIV-negative gay and bisexual men. Despite recent public health efforts focused on educating gay, bisexual, and other men who have sex with men about HIV testing and promoting the availability of PrEP, our findings suggest that health educational efforts are not adequately reaching sizable and distinct groups of men at risk for HIV infection. In particular, our finding that 25% of young gay/bisexual men who are sexually active with a same-sex partner have never been tested for HIV is striking. It is, however, consistent with findings from a recent analysis that reported 29% of gay men aged 15-44 in the US have never been tested for HIV. The number of PrEP users in the sample was extremely low (4.1%) but within the range of recent findings from nonprobability samples[13, 23, 34, 35]. Visiting an LGBT clinic and searching for information online on LGBT sources were significantly associated with PrEP use. The small number of respondents who reported PrEP use reduced the precision of our estimates, possibly leading to type-2 error (not detecting as significant associations that are in fact true).
 
Awareness of PrEP was also low, with only about 50% of men in the younger and older cohorts reporting familiarity with PrEP, compared to nearly 80% in the middle cohort. ......Given that increased likelihood of PrEP familiarity was associated with connections to LGBT-affiliated clinics and websites and living in urban locations. more efforts are needed to create knowledge of PrEP outside of urban LGBT communities.
 
Among those already familiar with PrEP, the majority expressed positive attitudes toward it. However, sizeable minorities within each cohort-one half to one third-did not express a positive attitude. More research is needed to understand factors contributing to attitudes toward PrEP in the broader population of gay, bisexual, and other men who have sex with men. It is noteworthy that our sample did not include men who identify as heterosexual or "mostly straight" and have sex with men. Men in our study identified as sexual minorities. Given the recent discovery that many men who have sex with men identify as straight or mostly straight[36, 37], future research needs to examine members of this unique population of men who are at high risk for HIV.
 
There are several limitations to the current study. We used a broad category of men as eligible for PrEP, defined here as men who have had sex with men in a 5-year period. CDC recommendations are much narrower and call for risk assessments that we were unable to make, including history of anal sex without condoms[38]. Given that the present study did not measure sexual risk behavior, it is not possible to correctly estimate the population of men who met current recommendations for PrEP use. Because of that, our estimate of 4% use is biased, with the actual proportion of eligible men who do not use PrEP probably lower. Finally, the way in which we asked the question about support for PrEP ("are you for or against HIV-negative people taking Truvada as PrEP to prevent the transmission of HIV?") did not provide any information to respondents about PrEP effectiveness, adverse effects, or the meaning of "prevent." Respondents unaware of PrEP may have interpreted the question in various ways. Future studies should further consider ways to assess support for PrEP in survey instruments.
 
Public health implications
 
Our study is the first to examine HIV testing behavior, PrEP use, knowledge, and attitudes in a national probability sample of three distinct cohorts of HIV-negative gay and bisexual men. Our findings suggest the need to reinvigorate HIV prevention efforts to promote testing and awareness of PrEP, especially among younger gay and bisexual men and those who may not have access to LGBT communities and LGBT health providers. Although PrEP was approved over four years ago, there are many barriers to access to it, including affordability and lack of knowledge or access[15, 34, 35]. PrEP awareness may increase with access. In the meantime, public health efforts focused on promoting HIV testing and PrEP awareness need to be more inclusive of diverse populations of gay and bisexual men, especially those in rural areas who are less affiliated with the LGBT community, so that they and their health care providers can make informed decisions about PrEP use in managing risk for HIV.
 
This study examined HIV testing and use, familiarity, and attitudes toward pre-exposure prophylaxis (PrEP) among HIV-negative gay and bisexual men in the United States. A national probability sample (N = 470) of three age cohorts (18-25, 34-41, and 52-59 years) completed a survey between March, 2016 and March, 2017.
 
HIV continues to be a major public health concern, in particular for gay, bisexual, and other men who have sex with men in the United States, who account for 70% of new HIV infections annually[1]. Of these new infections, African American men account for the highest number (38%), followed by Latino (28%) and White (28%) men[2]. Over 60% of those who are undiagnosed are gay, bisexual, and other men who have sex with men[3], which is why the Centers for Disease Control and Prevention (CDC) recommends annual screening for this population. HIV testing is the entry point for accessing prevention and treatment.
 
Once considered a lethal diagnosis, HIV infection came to be seen as a chronic, manageable condition with the discovery of antiretroviral therapies in the mid-1990s[6]. This shift was accompanied by complacency about prior prevention methods such as condom use[7, 8] and called for new prevention approaches to reduce HIV transmission.
 
The emergence of pre-exposure prophylaxis (PrEP) using Truvada as a highly effective tool in preventing transmission of HIV[9] signals a potential turning point in the public health and sexual culture of gay, bisexual, and other men who have sex with men.
 
The prevalence of PrEP use appears to be considerably lower than the CDC's estimated 24.7% of men who have sex with men ages 18 to 59 who have indications for PrEP[14], though no research has examined PrEP use in a national probability sample to our knowledge.
 
RESULTS of study -
 
Most men did not meet CDC recommendations for HIV testing, and 25.2% of men in the younger cohort had never tested.
 
Only 4.1% used PrEP across cohorts
 
Overall, only 21 men, or 4.1% (SE = 1.1) of the total sample of HIV-negative sexually active gay and bisexual men reported taking Truvada as PrEP, which did not significantly vary by age cohort (design-based F = 0.48, p = 0.6). Bivariate logistic regressions revealed that bisexual men were less likely than gay men to use PrEP (OR = 0.1, 95% CI = 0.01, 0.9). Visiting an LGBT clinic and searching for information online on LGBT sources were associated with PrEP use (OR = 9.2, 95% CI = 2.7, 30.8; OR = 3.6, 95% CI = 1.1, 11.2, respectively).
 
- Visiting an LGBT clinic and searching for LGBT resources online were associated with PrEP use.
 
- Men in the middle cohort were more familiar with PrEP (79%) than men in the younger (52%) and older (57%) cohorts.
- Bisexual and non-urban men were less familiar with PrEP.
- Attitudes were positive among most men (68.4%) familiar with PrEP.
- Findings suggest that most men potentially at risk for HIV do not meet CDC guidelines for testing, and PrEP use continues to be minimal.
- Efforts to educate gay and bisexual men about HIV risk and prevention need to be reinvigorated and expanded to include non-gay-identified and non-urban men.
 
HIV testing
 
Of men in the young cohort, 25.2% (SE = 3.8) had never been tested for HIV, significantly more than men from the middle (7.7%, SE = 3.0) and older (7.8%, SE = 2.2) cohorts. Although this finding indicates that most men in all cohorts have tested for HIV at some time, in fact many men had not met CDC recommendation for HIV testing: only 45.3% (SE = 4.2) of the men in the young cohort, 58.5% (SE = 5.3) of men in the middle cohort, and 36.0% (SE = 4.2) of men in the older cohort had tested for HIV at least annually. Table 2 shows results of multiple logistic regression predicting HIV testing behavior that meets CDC recommendations (adjusted full model ORs are reported). Men in the young cohort (AOR = 2.1, 95% CI = 1.1, 4.1) and middle cohort (AOR = 2.1, 95% CI = 1.1, 4.2) were more likely than men in the older cohort to meet CDC recommendation for HIV testing. Black respondents were more likely than White respondents to meet recommendations for HIV testing (AOR = 4.4, 95% CI = 1.6, 12.4), but White and Latino respondents did not differ. Also, as Table 2 indicates, gay, bisexual, and men who use other identity terms (e.g., queer) did not differ in testing behavior.
 
Psychosocial predictors of meeting CDC recommendations for HIV testing included one's assessment that he is at risk for HIV infection (AOR = 1.9, 95% CI = 1.3, 2.9), having visited an LGBT-specific clinic (AOR = 2.8, 95% CI = 1.4, 5.9), and being out to health care providers (AOR = 3.2, 95% CI = 1.3, 8.1).
 
Familiarity with PrEP: Just above half the men in the younger and older cohorts (52.0%, SE = 4.3, and 57.0%, SE = 4.4, respectively) said they were familiar with the use of Truvada as PrEP, which is significantly fewer than men in the middle cohort, with 79.0% (SE = 4.6). Table 2 shows that demographic predictors of familiarity with PrEP include having more than high school education (AOR = 2.9, 95% CI = 1.4, 6.1), while having a bisexual identity (versus gay or other identities) and residing in a non-urban area were associated with reduced familiarity with PrEP (AOR = 0.2, 95% CI = 0.1, 0.5; AOR = 0.3, 95% CI = 0.1, 0.6, respectively). Psychosocial predictors of familiarity with PrEP include having tested for HIV (AOR = 4.2, 95% CI = 1.8, 9.9).
 
Attitudes toward PrEP: Among men who were familiar with PrEP, most had a positive attitude toward it, which did not vary by age group with 68.4% (SE = 3.2) of the total sample reporting they were "for HIV-negative people taking Truvada as PrEP to prevent the transmission of HIV." (However, in the fully controlled model, Table 2, more younger men had a favorable attitude toward PrEP than older men, AOR = 3.0, 95% CI = 1.2, 7.6). Fewer men with other than gay or bisexual identity (e.g., "queer") compared with gay men had a favorable attitude toward PrEP (AOR = 0.3, CI = 0.1, 0.98). Also, Latino men (compared with White men) were less likely to have a positive attitude towards PrEP (AOR = 0.3, 95% CI = 0.1, 0.7). Of the psychosocial variables, having a connection to the LGBT community was associated with positive attitudes toward PrEP (AOR = 2.3, 95% CI = 1.2, 4.2).
 
Existing research on PrEP use has relied upon community samples of gay and bisexual men and has only minimally addressed the role that birth cohort may play in HIV testing or PrEP use, familiarity, or attitudes[18]. Because gay and bisexual men of distinct birth cohorts likely experienced the AIDS epidemic and sex education associated with it in unique ways[6], it is important to examine differences and similarities across birth cohort. For example, men over 50 experienced formidable trauma and loss with the AIDS epidemic, as they lost partners and entire social networks[5]. By contrast men in their 30s and 40s today were largely too young to have experienced these personal losses, but they experienced childhood and adolescence at the height of the epidemic and thus likely associated sex with other men with disease and death[6]. Men in this cohort also were socialized for strict condom use in a way that the prior generation had not. Men currently in early adulthood developed at a time when the meaning of HIV had transformed from a lethal illness to a chronic, manageable condition, and thus they likely view sex and sexual health through a different lens than both prior generations[6]. Studies with nonprobability samples of gay and bisexual men suggest that there is not an age difference for HIV testing[19]; however, younger men appear more willing to take PrEP than older men[20, 21]. No research to our knowledge has examined differences in use, familiarity, and attitudes across distinct birth cohorts.
 
Discussion
 
Despite recent public health efforts focused on educating gay, bisexual, and other men who have sex with men about HIV testing and promoting the availability of PrEP, our findings suggest that health educational efforts are not adequately reaching sizable and distinct groups of men at risk for HIV infection. In particular, our finding that 25% of young gay/bisexual men who are sexually active with a same-sex partner have never been tested for HIV is striking. It is, however, consistent with findings from a recent analysis that reported 29% of gay men aged 15-44 in the US have never been tested for HIV[32]. While men in the middle and older cohorts had higher levels of testing than the young cohort-which may be attributable to their older age and first-hand knowledge of the impact of HIV[6]-all of the cohorts had low levels of testing when considering CDC recommendations for HIV testing[33]. One exception is that Black respondents were more likely than White respondents to meet recommendations for HIV testing, which may be due to recent efforts to target Black men for testing, such as the CDC's Testing Makes Us Stronger campaign. However, the overall low levels of testing suggest that there continue to be significant barriers to HIV testing among gay and bisexual men. Fear of knowing one's status, low risk perception, anticipated stigma and discrimination, and conspiracy beliefs comprise individual barriers to testing uptake[16, 17]. These issues may be particularly salient for young men.
 
The number of PrEP users in the sample was extremely low (4.1%) but within the range of recent findings from nonprobability samples[13, 23, 34, 35]. Visiting an LGBT clinic and searching for information online on LGBT sources were significantly associated with PrEP use. The small number of respondents who reported PrEP use reduced the precision of our estimates, possibly leading to type-2 error (not detecting as significant associations that are in fact true).
 
Awareness of PrEP was also low, with only about 50% of men in the younger and older cohorts reporting familiarity with PrEP, compared to nearly 80% in the middle cohort. Heightened awareness in the middle cohort may be related to the unique role of HIV/AIDS in the course of these men's lives, as they were saturated with information about AIDS during their childhood and adolescence in the 1980s and 1990s[6]. Given that increased likelihood of PrEP familiarity was associated with connections to LGBT-affiliated clinics and websites and living in urban locations, more efforts are needed to create knowledge of PrEP outside of urban LGBT communities.
 
Among those already familiar with PrEP, the majority expressed positive attitudes toward it. However, sizeable minorities within each cohort-one half to one third-did not express a positive attitude. More research is needed to understand factors contributing to attitudes toward PrEP in the broader population of gay, bisexual, and other men who have sex with men. It is noteworthy that our sample did not include men who identify as heterosexual or "mostly straight" and have sex with men. Men in our study identified as sexual minorities. Given the recent discovery that many men who have sex with men identify as straight or mostly straight[36, 37], future research needs to examine members of this unique population of men who are at high risk for HIV.
 
There are several limitations to the current study. We used a broad category of men as eligible for PrEP, defined here as men who have had sex with men in a 5-year period. CDC recommendations are much narrower and call for risk assessments that we were unable to make, including history of anal sex without condoms[38]. Given that the present study did not measure sexual risk behavior, it is not possible to correctly estimate the population of men who met current recommendations for PrEP use. Because of that, our estimate of 4% use is biased, with the actual proportion of eligible men who do not use PrEP probably lower. Finally, the way in which we asked the question about support for PrEP ("are you for or against HIV-negative people taking Truvada as PrEP to prevent the transmission of HIV?") did not provide any information to respondents about PrEP effectiveness, adverse effects, or the meaning of "prevent." Respondents unaware of PrEP may have interpreted the question in various ways. Future studies should further consider ways to assess support for PrEP in survey instruments.
 
Public health implications
 
Our study is the first to examine HIV testing behavior, PrEP use, knowledge, and attitudes in a national probability sample of three distinct cohorts of HIV-negative gay and bisexual men. Our findings suggest the need to reinvigorate HIV prevention efforts to promote testing and awareness of PrEP, especially among younger gay and bisexual men and those who may not have access to LGBT communities and LGBT health providers. Although PrEP was approved over four years ago, there are many barriers to access to it, including affordability and lack of knowledge or access[15, 34, 35]. PrEP awareness may increase with access. In the meantime, public health efforts focused on promoting HIV testing and PrEP awareness need to be more inclusive of diverse populations of gay and bisexual men, especially those in rural areas who are less affiliated with the LGBT community, so that they and their health care providers can make informed decisions about PrEP use in managing risk for HIV.
 
Published: September 7, 2018 -
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202806 - Phillip L. Hammack1*, Ilan H. Meyer2, Evan A. Krueger2, Marguerita Lightfoot3,

 
 
 
 
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