Introduction
Methods
Study Design and Participants
Procedures
PrEP-Related Stigma Measure
Domain | Original item | Included in adapted version for PrEP? | Adapted item |
---|---|---|---|
Personalised stigma | Have lost friends by telling them I have HIV | Y | I have lost friends by telling them that I take PrEP |
Hurt by how people reacted to learning I have HIV | Y | I have been hurt by how people reacted to learning that I take PrEP | |
People avoid touching me if they know I have HIV | N | ||
Stopped socializing with some due to their reactions | Y | I have stopped socialising with some people due to their reaction when learning that I take PrEP | |
People I care about stopped calling after learning | Y | People I care about stopped speaking to me after learning that I take PrEP | |
People seem afraid of me because I have HIV | N | ||
People have physically backed away from me | N | ||
Some people who know have grown more distant | N | ||
People who know tend to ignore my good points | N | ||
Don’t want me around their children once they know | N | ||
I feel set apart, isolated from the rest of the world | N | ||
I regret having told some people that I have HIV | Y | I regret having told some people that I take PrEP | |
Some fear they’ll be rejected because of my HIV | N | ||
Some people act as though it’s my fault I have HIV | N | ||
As a rule, telling others has been a mistake | N | ||
Some told me HIV is what I deserve for how I lived | N | ||
Most with HIV are rejected when others learn | N | ||
Knowing, they look for flaws in your character | N | ||
Disclosure concerns | I never feel I need to hide the fact I have HIV (R) | N | |
I worry people who know I have HIV will tell others | N | ||
I am very careful whom I tell that I have HIV | Y | I am very careful whom I tell that I take PrEP | |
I work hard to keep my HIV a secret | Y | I work hard to keep my PrEP use a secret | |
I told people close to me to keep my HIV a secret | N | ||
In many areas of my life, no one knows I have HIV | Y | In many areas of my life, no one knows I take PrEP | |
Telling someone I have HIV is risky | Y | Telling someone I take PrEP is risky | |
I worry that people may judge me when they learn | N | ||
Easier to avoid friendships than worry about telling | N | ||
I worry about people discriminating against me | Y | I worry about people discriminating against me because I take PrEP | |
Additional items included in “anticipated PrEP-related stigma” domaina | N/A | N/A | I worry that people will assume that because I take PrEP I have sex with lots of people |
N/A | N/A | I worry that people will assume that because I take PrEP I am HIV positive |
Data Analysis
Results
Participants
Psychometric Properties of PrEP-Related Stigma Measure
Subscale | Item | Rotated factor loading | Item-total correlation | Item-rest correlation | Cronbach’s alpha if item removed |
---|---|---|---|---|---|
Enacted PrEP-related stigma | People I care about stopped speaking to me after learning that I take PrEP | 0.759 | 0.784 | 0.654 | 0.815 |
I have lost friends by telling them that I take PrEP | 0.816 | 0.829 | 0.724 | 0.797 | |
I have been hurt by how people reacted to learning that I take PrEP | 0.701 | 0.803 | 0.632 | 0.832 | |
I regret having told some people that I take PrEP | 0.748 | 0.794 | 0.657 | 0.814 | |
I have stopped socialising with some people due to their reaction when learning that I take PrEP | 0.713 | 0.778 | 0.690 | 0.818 | |
Anticipated PrEP-related stigma | Telling someone I take PrEP is risky | 0.790 | 0.860 | 0.803 | 0.869 |
I work hard to keep my PrEP use a secret | 0.904 | 0.851 | 0.803 | 0.873 | |
I am very careful whom I tell that I take PrEP | 0.839 | 0.856 | 0.788 | 0.869 | |
In many areas of my life, no one knows I take PrEP | 0.826 | 0.812 | 0.722 | 0.878 | |
I worry about people discriminating against me because I take PrEP | 0.721 | 0.791 | 0.704 | 0.880 | |
I worry that people will assume that because I take PrEP I have sex with lots of people | 0.655 | 0.745 | 0.641 | 0.887 | |
I worry that people will assume that because I take PrEP I am HIV positive | 0.496 | 0.609 | 0.476 | 0.905 |
Associations Between PrEP-Related Stigma and Sociodemographic and Psychological Measures
Domain | Variable | Level | Enacted PrEP-related stigma (yes/no) | Anticipated PrEP-related stigma (score) | ||||||
---|---|---|---|---|---|---|---|---|---|---|
OR | 95% CI | z** | p | β | 95% CI | z* | p | |||
Sociodemographics | Age (years) | 1.05 | 0.97 to 1.13 | 1.12 | 0.262 | − 0.01 | − 0.11 to 0.09 | − 0.21 | 0.837 | |
Ethnicity | White British | Reference category | − 0.56 | 0.576 | Reference category | − 0.44 | 0.661 | |||
Not White British | 0.50 | 0.04 to 5.63 | − 0.69 | − 3.76 to 2.39 | ||||||
Used PrEP prior to study | No | Reference category | 0.84 | 0.401 | Reference category | − 0.80 | 0.424 | |||
Yes | 2.02 | 0.39 to 10.45 | − 1.18 | − 4.09 to 1.72 | ||||||
Sex and relationships | Relationship status | Single | Reference category | − 0.40 | 0.692 | Reference category | − 1.11 | 0.267 | ||
Not single | 0.71 | 0.14 to 3.76 | − 0.85 | − 2.35 to 0.65 | ||||||
Number of condomless sexual partners in previous week | Zero | Reference category | 4.18 | 0.124 | Reference category | 2.64 | 0.268 | |||
One | 0.72 | 0.19 to 2.66 | − 0.59 | − 1.43 to 0.25 | ||||||
More than one | 7.08 | 0.77 to 64.93 | 0.17 | − 0.78 to 1.12 | ||||||
Psychological measures | HIV risk without PrEP | No/small chance | Reference category | 0.97 | 0.330 | Reference category | 1.11 | 0.267 | ||
Moderate/high chance | 1.70 | 0.59 to 4.91 | 0.55 | − 0.42 to 1.53 | ||||||
HIV risk with PrEP | No/small chance | Reference category | − 1.72 | 0.086 | Reference category | − 0.35 | 0.723 | |||
Moderate/high chance | 0.27 | 0.06 to 1.21 | − 0.23 | − 1.47 to 1.02 | ||||||
People who are important to me approve of me taking PrEP as prescribed (injunctive norms) | Strongly agree | Reference category | 1.77 | 0.077 | Reference category | 2.68 | 0.007 | |||
Not strongly agree | 2.79 | 0.90 to 8.66 | 0.90 | 0.24 to 1.55 | ||||||
Taking PrEP as prescribed is up to me (perceived autonomy) | Strongly agree | Reference category | 2.18 | 0.029 | Reference category | 0.61 | 0.543 | |||
Not strongly agree | 3.53 | 1.14 to 10.94 | 0.29 | − 0.63 to 1.21 |
Qualitative Analysis Highlighting Areas for Scale Development
Furthermore, participants recounted experiences where their partner had questioned the purpose of their PrEP use.You have a couple of people that would say, “Oh I don’t agree with that” and it was often because … it’s a way of fuelling a deviant sexual life. But I would say nine out of ten of the responses were always positive, and of those one out of ten, there was never anything particularly against me personally, it was just around the subject in general. [PID 8, aged 20 to 30 years, discontinued PrEP]
At a structural level, participants described instances where a lack of awareness of understanding about PrEP in healthcare professionals who worked outside of sexual health led to assumptions that they were living with HIV, rather than taking antiretrovirals for prevention.He (Partner) said to me, “When are you Going to meet with Anybody?” So I said, “I don’t Really feel like it.” And then he said, “Well is there any Point in you Still Taking PrEP, Because you’re only ever with me?” It wasn’t a case of he doesn’t Support me. He was just sort of Saying, well, you don’t meet with Anybody Except me. I haven’t got Anything. [PID 4: aged 31+ years, continued PrEP]
While scores demonstrated better distributional properties for the anticipated stigma subscale, additional items regarding implied sexual orientation may had led to further improvement.A couple of weeks ago, I had a call off my nurse [non-sexual health specialist for healthcare need unrelated to PrEP] and I told her that I was on PrEP, and she turned round, and just said “Oh that’s okay then. I just didn’t realise”. And then I had this feeling that [she thought] I was already HIV. So I mentioned it and she said “Oh right, I’m so sorry”. [PID 11, aged 31+ years, continued PrEP]
This discretion extended from the interpersonal- to structural-level, with concerns raised about interacting with healthcare professionals and sharing details about PrEP use in one-to-one and more open environments.It [taking PrEP to prevent HIV] tells people [about] my sexual activity…. So again I think it’s … wanting to be discreet about … the kind of sexual activity I have. Fundamentally I’m gay but I’m not out… So I don’t want that to be common knowledge. [PID 31, aged 31+ years, continued PrEP]
Originally when I was prescribed it at the clinic I did ask for them not to even notify my doctor that I was taking it. Last week I had to have some antibiotics, and I had to tell them the GP that I was taking it [PrEP] because obviously I wasn’t sure whether the antibiotics contradicted the PrEP… His suggestion was to tell the pharmacy and I mean the quite difficult bit for me was having to say that I was taking PrEP to a pharmacist in the middle of the pharmacy. And then he says to me, I don’t know what you’re talking about, what PrEP are you talking about? So it was like how do I get around this in an open environment? … I live in an area where everything is quite communal. So you got to the chemist, okay you might not know the pharmacist himself, but it’s that you know the staff the other side of the desk or whatever, so, you know although there is a level of confidentiality it always gives you that doubt of actually what they’re sharing with friends and family or whatever. [PID 31, aged 31+ years, continued PrEP]