Study Design and Participants
The sampling and recruiting strategies have been documented in detail elsewhere.18 Briefly, starting from 2019 May, we conducted a cross-sectional study in two cities (Nashville, Tennessee, and Buffalo, New York) in the United States. We employed a multi-pronged recruiting strategy including peer referral, flyer distribution, social media posts, and venue-based and event-based recruitment. The study protocol was reviewed and approved by the Institutional Review Boards at the University of Rochester and Buffalo. With informed consent being collected, a total of 318 MSM were included in the current analysis.
Data collection and Measures
Participants were asked to complete a self-administered survey via the Research Electronic Data Capture (REDCap) to report data regarding demographics, sexual behaviors, history of substance use, HIV testing experience, mental health status, PrEP/HIV related stigma, and PrEP cascade (i.e., awareness, willingness, and uptake).
Demographics include their age (in years), race (Black vs. White), education level, housing status (stable vs. unstable), insurance coverage, marital status. Risk behaviors were measured by their sexual practice (e.g., condomless insertive or receptive sex, sex with HIV-positive partners, substance use during sex, and sex position). A series of indicators measured mental health status. Anxiety was assessed using the 7-item Generalized Anxiety Disorder Assessment (GAD-7) Scale (e.g., “Have you been feeling nervous, anxious, or on edge in the past four weeks?”; Cronbach’s α =0.93).19 Depression was measured using the 9-item Patient Health Questionnaire (e.g., “In the past four weeks, how often did you feel little interest or pleasure in doing things?”; Cronbach’s α =0.94).20,21 Loneliness was measured using the University of California at Los Angeles (UCLA) Loneliness Scale (e.g., “I feel left out”; Cronbach’s α =0.80).22 Perceived stress was assessed using the 10-item Perceived Stress Scale (PSS) that measures stress in the past four weeks (e.g., “how often have you been upset because of something that happened unexpectedly?”; Cronbach’s α =0.89).23 Suicide was measured using a four-question scale adapted from validated studies (e.g., “have you ever thought about or attempted to kill yourself?”; Cronbach’s α =0.83).18,24 Internalized homophobia was measured by a four-item Internalized Homophobia Scale that measures the extent to which gay and bisexual individuals do not accept their sexual orientation or sexual identity (e.g., “Sometimes I dislike myself for being gay or bisexual”; Cronbach’s α =0.91).25 Resilience was measured by the 10-item Conner-Davidson Resilience Scale (CD-RISC-10) (e.g., “I am able to adapt to change”, Cronbach’s α =0.88). The Condom use Self-Efficacy Scale measured confidence of condom use to assess one’s confidence with using a condom or asking sexual partners to use condoms (e.g., “I would feel comfortable discussing condom use with a potential partner before we engaged in sex.”; Cronbach’s α =0.88). A 12-item scale measured HIV testing self-efficacy (e.g., “Knowing where you can go for an HIV test”, “Getting tested for HIV at least every 3-6 months”; Cronbach’s α =0.91) to ask them how confident they were they about enacting behaviors concerning HIV testing.30 HIV testing was measured by asking participants whether they had (yes vs. no) tested for HIV in the past 3, 6, or 12 months. PrEP and HIV related stigma was measured by internalized PrEP stigma (e.g., “I should avoid taking PrEP because it is only for slutty people”; Cronbach’s α =0.93), vicarious PrEP stigma (e.g., “I’ve seen/heard people not wanting to hang out with folks who are taking PrEP”; Cronbach’s α =0.93) and perceived HIV stigma toward MSM (e.g., “People I care about would stop being in touch with me after if I had HIV”; Cronbach’s α =0.94) that adopted from a recent study.31 PrEP cascade was assessed using PrEP awareness, willingness to PrEP use in general and at specific scenarios (e.g., “If PrEP may cause mild side effects, such as nausea, headaches, and rashes in a small number of people, would still you take PrEP EVERY DAY so you can lower your HIV risk by 90%?”, “If you need to see a clinician every 3-6 months for a new prescription, would you still consider taking PrEP everyday to lower your HIV risk by 90%?”), and PrEP uptake (i.e., ever used and currently using). This study used indicators along the PrEP cascade (i.e., PrEP awareness, willingness, and uptake) as dependent variables.
Statistical Analysis: Descriptive statistics were displayed for both continuous and categorical variables. We used Chi-square and Independent t-test to examine if demographics, risk behaviors, and mental health status varied by different stages of the PrEP cascade. We employed bivariate and multivariable analyses to assess the association between PrEP stigma and PrEP cascade while controlling for potential confounders on each specific pathway. Furthermore, a series of moderation analyses were conducted using Hayes’ PROCESS macro32 with 2,000 times bootstrapping samples to assess the effect of frequency of HIV testing under different timeframes (e.g., in the past 3, 6, 12, and 24month) on the association between PrEP/HIV stigma and PrEP cascade. Adjusted odds ratios and corresponding 95% confidence intervals were reported. In addition, trend analyses using the Jonckheere–Terpstra test with Monte Carlo permutations were used to assess the trend of PrEP cascade across different time points of HIV testing. We conducted all statistical analyses using Stata 16.0TM (StataCorp LP, College Station, Texas, USA).