Introduction
Stigma impairs access to health care by gay, bisexual, and other men who have sex
with men. Gay, bisexual, and other men who have sex with men who are open about their
sexuality, or out, are more resilient to stigma than those who are not out. Outness
may influence healthcare utilization and prescription of HIV pre-exposure prophylaxis
to HIV-negative gay, bisexual, and other men who have sex with men.
Methods
Analyzing the 2018 American Men's Internet Survey during 2019, the adjusted prevalence
ratios of healthcare stigmas and outness to healthcare providers were calculated.
The effect of outness on annual healthcare visits and stigma was measured. Pre-exposure
prophylaxis seeking and denial by providers was quantified and stratified by outness.
Results
Of 5,794 respondents, 3,402 (58.7%) were out to their provider. Out gay, bisexual,
and other men who have sex with men were less likely to experience anticipated stigma
(adjusted prevalence ratio=0.75, 95% CI=0.72, 0.80) but more likely to experience
enacted stigma or discrimination (adjusted prevalence ratio=1.23, 95% CI=1.18, 1.28).
In a subsample of out gay, bisexual, and other men who have sex with men, recently
experienced discrimination was associated with higher healthcare utilization (adjusted
prevalence ratio=1.51, 95% CI=1.14, 1.51). Conversely, recent experienced discrimination
was associated with lower healthcare utilization in not out gay, bisexual, and other
men who have sex with men (adjusted prevalence ratio=0.67, 95% CI=0.54, 0.82). Of
3,104 out gay, bisexual, and other men who have sex with men, 1,417 (45.7%) discussed
pre-exposure prophylaxis with their providers, compared with 120 of 1,711 (7.0%) gay,
bisexual, and other men who have sex with men who were not out (p<0.001). Pre-exposure prophylaxis denials were less common among out (116/793, 14.6%)
than not out (14/55, 25.5%) gay, bisexual, and other men who have sex with men (p=0.044).
Conclusions
Healthcare provider–related stigmas impair healthcare engagement among not out gay,
bisexual, and other men who have sex with men who were also more commonly denied pre-exposure
prophylaxis. Ending the HIV epidemic necessitates creating safe environments for disclosure
of sexual preferences and practices to facilitate access to HIV prevention.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Preventive MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- The prevalence of sexual behavior stigma affecting gay men and other men who have sex with men across Sub-Saharan Africa and in the United States.JMIR Public Health Surveill. 2016; 2: e35
- Measuring sexual behavior stigma to inform effective HIV prevention and treatment programs for key populations.JMIR Public Health Surveill. 2017; 3: e23
- Access to basic HIV-related services and PrEP acceptability among men who have sex with men worldwide: barriers, facilitators, and implications for combination prevention.J Sex Transm Dis. 2013; 2013953123
- Medical mistrust as a key mediator in the association between perceived discrimination and adherence to antiretroviral therapy among HIV-positive Latino men.J Behav Med. 2017; 40: 784-793
- Health care discrimination, sex behavior disclosure, and awareness of pre-exposure prophylaxis among black men who have sex with men.Stigma Health. 2018; 3: 330-337
- Hidden from health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey.AIDS. 2015; 29: 1239-1246
- Pathways from sexual stigma to incident HIV and sexually transmitted infections among Nigerian MSM.AIDS. 2017; 31: 2415-2420
- Experiences of stigma and health care engagement among black MSM newly diagnosed with HIV/STI.J Behav Med. 2018; 41: 458-466
- Stigma and outness about sexual behaviors among cisgender men who have sex with men and transgender women in Eswatini: a latent class analysis.BMC Infect Dis. 2019; 19: 211
- “Outness” as a moderator of the association between syndemic conditions and HIV risk-taking behavior among men who have sex with men in Tijuana, Mexico.AIDS Behav. 2016; 20: 431-438
- The longitudinal associations between outness and health outcomes among gay/lesbian versus bisexual emerging adults.Arch Sex Behav. 2019; 48: 1111-1126
- Identity formation, outness, and sexual risk among gay and bisexual men.Am J Mens Health. 2014; 8: 98-109
- Sexual identity disclosure and awareness of HIV prevention methods among black men who have sex with men.J Sex Res. 2018; 55: 975-983
CDC. HIV among Gay and Bisexual Men. CDC fact sheet.www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-msm-508.pdf. Published 2019. Accessed February 28, 2020.
U.S. Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States - 2017 update: a clinical practice guideline.www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf. Published2018. Accessed February 28, 2020.
- Estimates of adults with indications for HIV pre-exposure prophylaxis by jurisdiction, transmission risk group, and race/ethnicity, United States, 2015.Ann Epidemiol. 2018; 28: 850-857.e9
- Trends in the use of oral emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis against HIV infection, United States, 2012–2017.Ann Epidemiol. 2018; 28: 833-840
- Knowledge is power! Increased provider knowledge scores regarding pre-exposure prophylaxis (PrEP) are associated with higher rates of PrEP prescription and future intent to prescribe PrEP.AIDS Behav. 2015; 19: 802-810
- Are we prepped for preexposure prophylaxis (PrEP)? Provider opinions on the real-world use of PrEP in the United States and Canada.Clin Infect Dis. 2014; 58: 704-712
- Preexposure prophylaxis for HIV infection: healthcare providers’ knowledge, perception, and willingness to adopt future implementation in the southern U.S.South Med J. 2012; 105: 199-206
- A cross-sectional online survey of HIV pre-exposure prophylaxis adoption among primary care physicians.J Gen Intern Med. 2017; 32: 62-70
- The impact of patient race on clinical decisions related to prescribing HIV pre-exposure prophylaxis (PrEP): assumptions about sexual risk compensation and implications for access.AIDS Behav. 2014; 18: 226-240
- Association of HIV preexposure prophylaxis with incidence of sexually transmitted infections among individuals at high risk of HIV infection.JAMA. 2019; 321: 1380-1390
- A closer look at racism and heterosexism in medical students’ clinical decision-making related to HIV pre-exposure prophylaxis (PrEP): implications for PrEP education.AIDS Behav. 2018; 22: 1122-1138
- Sexual orientation disclosure in primary care settings by gay, bisexual, and other men who have sex with men in a Canadian city.LGBT Health. 2017; 4: 42-54
- Culturally competent sexual healthcare as a prerequisite for obtaining preexposure prophylaxis: findings from a qualitative study.LGBT Health. 2017; 4: 310-314
- A qualitative study examining young adults’ experiences of disclosure and nondisclosure of LGBTQ identity to health care providers.J Homosex. 2017; 64: 1390-1410
- The Annual American Men's Internet Survey of behaviors of men who have sex with men in the United States: protocol and key indicators report 2013.JMIR Public Health Surveill. 2015; 1: e3
- National trends in sexual behavior, substance use and HIV testing among United States men who have sex with men recruited online, 2013 through 2017.AIDS Behav. 2018; 22: 2413-2425
- 2013 NCHS Urban-rural classification scheme for counties.Vital Health Stat 2. 2014; 166: 1-73
Augustinavicius JL, Baral SD, Murray SM, et al. Characterizing cross-culturally relevant metrics of stigma among men who have sex with men across eight Sub-Saharan African countries and the United States. Am J Epidemiol. In Press. Online January 13, 2020. https://doi.org/10.1093/aje/kwz270.
Food and Drug Administration. Supplemental approval for Truvada use in adolescents.www.accessdata.fda.gov/drugsatfda_docs/appletter/2018/021752Orig1s055ltr.pdf. Published2018. Accessed February 28, 2020.
- Stigma and racial/ethnic HIV disparities: moving toward resilience.Ann Psychol. 2013; 68: 225-236
- Reflecting resiliency: openness about sexual orientation and/or gender identity and its relationship to well-being and educational outcomes for LGBT students.Am J Commun Psychol. 2015; 55: 167-178
- The role of stigma and medical mistrust in the routine health care engagement of black men who have sex with men.Am J Public Health. 2015; 105: e75-e82
- “The fear of being black plus the fear of being gay”: the effects of intersectional stigma on PrEP use among young black gay, bisexual, and other men who have sex with men.Soc Sci Med. 2019; 232: 86-93
- Homonegativity, religiosity, and the intersecting identities of young black men who have sex with men.AIDS Behav. 2016; 20: 51-64
- Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review.BMC Med. 2019; 17: 6
- Stigma in health facilities: why it matters and how we can change it.BMC Med. 2019; 17: 25
- Office-based care for lesbian, gay, bisexual, transgender, and questioning youth.Pediatrics. 2013; 132: 198-203
- Do you PrEP? A review of primary care provider knowledge of PrEP and attitudes on prescribing PrEP.J Assoc Nurs AIDS Care. 2018; 29: 83-92
- Knowledge, practices, and barriers to HIV preexposure prophylaxis prescribing among Washington state medical providers.Sex Transm Dis. 2018; 45: 452-458
- Persistence on HIV preexposure prophylaxis medication over a 2-year period among a national sample of 7148 PrEP users, United States, 2015 to 2017.J Int AIDS Soc. 2019; 22: e25252
- Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three U.S. cities.J Int AIDS Soc. 2016; 19: 20903
- Sexual risk compensation in a pre-exposure prophylaxis demonstration study among individuals at risk of HIV.J Acquir Immune Defic Syndr. 2019; 80: e9-e13
- Sexual stereotypes ascribed to black men who have sex with men: an intersectional analysis.Arch Sex Behav. 2018; 47: 143-156
- Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors.AIDS. 2007; 21: 2083-2091
- Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis.Lancet. 2012; 380: 341-348
Article Info
Publication History
Published online: May 03, 2020
Identification
Copyright
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine.
