Background: PrEP implementation raises questions about potential impacts on stigma, attitudes, and norms in MSM communities. Media reports on “Truvada whores” suggest some negative attitudes about PrEP among MSM, and a popular view that PrEP users are irresponsible or promiscuous. We interviewed MSM and male sex workers to explore attitudes toward PrEP, awareness of PrEP stigma within the MSM community, and expectations of how PrEP may change community norms and HIV-related stigma.
Methods: We conducted in-depth interviews with 31 MSM and 25 male sex workers in Providence, RI, in 2013-14, building on results of 8 prior focus groups (n=38). Participants were HIV-negative or of unknown status and reported recent unprotected anal sex with an HIV-positive or unknown-status partner. Interviewers provided information about PrEP and explored PrEP knowledge, acceptability, predicted social stigmas or benefits associated with PrEP, and predicted changes in community norms. Interviews were audiorecorded and analyzed in NVivo.
Results: Knowledge of PrEP was low, but some participants had heard of stigma associated with PrEP use. When informed of PrEP, some MSM expressed stigma-related concerns about using PrEP, including fears of seeming promiscuous, HIV-positive, or ill. Several MSM in primary partnerships, including sex workers with female partners, noted that PrEP use would imply infidelity; for these men, the need for covert use made daily PrEP less acceptable. But most participants reported low predicted stigma, or noted that stigma would not impede their own use. Some described PrEP as a potential catalyst for reducing HIV stigma among MSM, and even suggested that PrEP would promote community inclusion of HIV-positive individuals and increase MSM community empowerment. Several sex workers also viewed PrEP as a lever for personal change, suggesting that PrEP use is proof of increased self-worth and can provide a foundation for other health behaviors.
Conclusions: Strategies are needed to help PrEP users educate partners, family, and peers to reduce potential misconceptions driving PrEP stigma. But both MSM and male sex workers express positive expectations of PrEP as an agent of community and individual empowerment. PrEP outreach efforts and messaging should leverage these expectations to maximize PrEP acceptability.