HIV prevention medication users fear being stigmatized as ‘promiscuous’

The Centers for Disease Control and Prevention (CDC) aims to reduce new HIV infections in the United States by 90% by 2030. A key part of this initiative is encouraging the use of Pre-exposure Prophylaxis (PrEP), a medication that can reduce HIV risk by up to 99%.

However, public health messaging that drives stigma around PrEP appears to be discouraging uptake of the medication. While the potential mismarketing of the drug is well understood and has been studied extensively, few studies have examined factors associated with the perception of stigma among PrEP users.

A new study conducted by Northwestern scientists found that among PrEP users, many fear using PrEP puts them at risk of discrimination, even when they know other people who use the medication.

The study, published Aug. 16 in the journal Sexes, speculates about causes for self-stigma and recommends mitigation strategies to the CDC.

Examining stigma from the perspective of the stigmatized

"We are among the first to explore the perception of stigma attached to PrEP use among current PrEP users," said quantitative researcher Shahin Davoudpour, the study's first and corresponding author. "Typically, stigma-focused studies pay attention to stigmatizers rather than the stigmatized. Our findings are also novel as they show higher stigma perception among PrEP users - the group who we would expect to express the least stigmatizing behavior."

Davoudpour is a research assistant professor of medical social sciences at Northwestern Feinberg School of Medicine with a portfolio of research grounded in social stigma and HIV/AIDS.

Perceived stigma - the anticipation or fear of being discriminated against - is a powerful social motivator. It can be driven by several factors, often stemming from broader societal biases and misinformation about sexual practices and HIV risk. By looking at the stigmatized rather than stigmatizers, the scientists hoped to gain better insight into why uptake of PrEP has been slower than anticipated, as well as why the medication's users tend to be inconsistent in taking it.

The process

Davoudpour's team examined two common measures of perceived stigma in PrEP use: the assumption that PrEP users are seen as promiscuous and the perception that people who use PrEP are HIV-positive.

The study used data from the baseline survey of an online study (which enrolled participants between 2017 and 2019) of a racially diverse population of over 3,000 sexual minority men, trans men and women, and non-binary individuals in the U.S. The "Keeping it LITE Study" collected data about PrEP use, persistence and attitudes, which the team ran through models to assess several stigma factors.

What they found

Davoudpour called the findings "significant and counter-intuitive," including the conclusions that perception of stigma associated with PrEP remains high among PrEP users, and that that perceived stigma is not significantly reduced by knowing others who use PrEP.

"Current PrEP users are more likely to believe that PrEP users are promiscuous - a stigma marker - than those who have never used the medication," Davoudpour said.

Shifting how PrEP is promoted

"PrEP was initially promoted for individuals most vulnerable to HIV - especially those with multiple sex partners and inconsistent condom use - thus its use has been inexorably tied to promiscuity," said study co-author Gregory Phillips II, an associate professor of medical social sciences and preventative medicine at Feinberg. "However, PrEP can benefit a variety of people, including those in monogamous serodiscordant relationships (one partner is HIV-positive and the other is HIV-negative), but current messaging doesn't reflect the broader array of potential PrEP users."

Current marketing campaigns involving HIV preventatives tend to repeatedly highlight benefits of PrEP. Instead, the authors argue, "public health messaging can shift its focus to decreasing the perception of PrEP stigma among those vulnerable to HIV" via sex-positive messaging that disconnects PrEP from promiscuity and emphasizes its use among vulnerable populations.

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