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Combatting PrEP-related Stigma: Opportunities for Canada

Darrell H. S. Tan, MD, FRCPC, PhD

Associate Professor
Division of Infectious Diseases
University of Toronto
Division of Infectious Diseases
St. Michael's Hospital
Toronto, Canada

Darrell H. S. Tan, MD, FRCPC, PhD, has disclosed that he has received funds for research support from AbbVie, Gilead Sciences, and GlaxoSmithKline.

View ClinicalThoughts from this Author

Released: November 19, 2021

The 18th European AIDS Conference (EACS 2021) featured a range of presentations related to the real-world implementation of HIV pre-exposure prophylaxis (PrEP) among populations at increased HIV risk in Europe, as well as globally. My research team presented a study that may be of particular interest to healthcare professionals (HCPs) in Canada. It described aspects of PrEP-related stigma and PrEP status among gay, bisexual, and other men who have sex with men and transgender women in Ontario and British Columbia, Canada.

The data come from a multicomponent PrEP Implementation Project (PRIMP), which aims to increase the use of oral PrEP among gay, bisexual, and other men who have sex with men (gbMSM) and transgender women who met evidence-based guideline criteria for PrEP in 2 of Canada’s largest provinces: Ontario and British Columbia. The PRIMP study includes a community-based survey with the overall goals of understanding awareness, acceptability, and uptake of PrEP among urban gbMSM.

In the analysis presented at EACS 2021, the presenter, Dr. Pico-Espinosa, explored the complex construct of PrEP-related stigma by using survey responses measuring whether participants thought PrEP users were “promiscuous” or “responsible,” as well as whether they thought “other people think people who take PrEP are promiscuous.” Participants were then classified as harboring low, intermediate, or high degrees of PrEP-related stigma based on these responses, and then associations were examined between this variable and participants’ status as a current, former, or never PrEP user.

The key finding was that, compared with those harboring low levels of PrEP-related stigma, those with high PrEP-related stigma were more than twice as likely to be former PrEP users compared with being current PrEP users. No such relationship was found when comparing those never having used PrEP to those currently using PrEP.

PrEP Persistence
These findings are important because of what they tell us about barriers to “PrEP persistence,” the long-term continuation of PrEP among those who start it. As in other studies, our PRIMP study uses the concept of the PrEP cascade to document how well the healthcare systems in Ontario and British Columbia succeed at delivering PrEP to those who meet high-risk criteria.

Persistence is the last step in our PrEP cascade. In some ways, persistence represents the lowest-hanging fruit, as the denominator for this metric consists entirely of gbMSM who have already overcome the many personal, social, and structural barriers to PrEP initiation. Although some patients may appropriately choose to stop PrEP because of a true reduction in their HIV risk (for instance, upon entering a monogamous relationship with a partner who does not have transmissible HIV), the literature and our own clinical experience are rife with examples of HIV seroconversions after PrEP discontinuation.

It is disheartening, but not surprising, to know that PrEP-related stigma is a potential driver of gbMSM choosing to stop using this safe and efficacious intervention. These findings are a reminder of the importance of combatting PrEP-related stigma in all its forms. Furthermore, it is important to recognize that PrEP-related stigma is closely intertwined with other pervasive forms of stigma related to HIV and sexuality, as well as intersectional forms of discrimination. As HCPs, we all can play a role in countering PrEP-related stigma by loudly and publicly promoting PrEP use as a healthy choice for all those at risk for HIV, and by working collaboratively with our patients and the communities we serve to support positive decision-making regarding sexual health.

Your Thoughts?
How often do you encounter PrEP-related stigma in your practice? Join the discussion by posting a comment. For more details on this and other key HIV issues from EACS 2021, review more CCO Conference Coverage, including Capsule Summary slidesets, video recaps with expert faculty, and other ClinicalThought commentaries highlighting US and global perspectives.

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