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Shahin Davoudpour, PhD, MA, discusses the Keeping It LITE study and the use of sex-positive campaigns to disentangle PrEP use from promiscuity.

“PrEP [pre-exposure prophylaxis] is a life-saving intervention against HIV, yet stigma remains a major barrier to its optimal use,” Shahin Davoudpour, PhD, MA, tells Physician’s Weekly (PW). “While existing research often treats stigma in broad terms, attention to the different facets and types of stigma and the specific actors involved has been limited. By focusing on the perception of stigma, particularly among current PrEP users—an often-underrepresented group—this study provides a more nuanced understanding of the stigma associated with PrEP and its use, which is crucial for developing targeted strategies to increase its uptake.”

In what Dr. Davoudpour and his colleagues report is the first scholarly work to explore factors associated with perceptions of stigma toward PrEP use, they analyzed data from the Keeping It LITE Study of 3,330 sexual minority men, transgender men and women, and nonbinary individuals in the US. Participants ranged in age from 13 to 34, and 87% were assigned male at birth. Overall, 53.9% identified as White, 19.8% as Latinx, 10.7% as Black or African American, and smaller proportions as other races or ethnicities.

The results, which were published in Sexes, “underscore the complexity of PrEP stigma, with implications for healthcare providers and public health strategies,” he adds.

PW spoke with Dr. Davoudpour to learn more.

PW: Did the results surprise you?

Shahin Davoudpour, PhD, MA: Two of the study’s outcomes were particularly surprising. First, the finding that prior social contact did not reduce stigma challenged the theoretical expectations informed by contact theory, which posited that interaction with other PrEP users would alleviate stigma. The lack of statistical significance in this area calls into question the assumption that disclosing PrEP use inherently destigmatizes it.

Second, the internalized stigma among current PrEP users was unexpected. It is typically assumed that individuals using PrEP, especially those in high-risk groups, would not hold stigmatizing attitudes toward it. We believe that PrEP’s initial marketing to individuals at highest risk for HIV, particularly those with multiple sexual partners, associated its use with promiscuity.

Are any strengths or limitations of the study especially noteworthy?

Strengths of this study included its robust sample size, which allowed for a more comprehensive analysis, and the diversity of questions included, which provided valuable insights into the perceptions of stigma around PrEP use.

However, some limitations need to be considered. The sample encompassed a broad age range from 13 to 34, which includes individuals at different life course milestones—teenagers and recent postgraduates, for example, may have very different experiences and perspectives. Additionally, the sample was predominantly White, which may limit the generalizability of the findings to more diverse populations. The reliance on self-reported data and the cross-sectional design also restrict the ability to make causal inferences. A key limitation is the lack of relationship and network data—specifically, we don’t know who other PrEP users are or the nature of the relationships involved. This is particularly important, given that knowing other PrEP users and the quality of those relationships (for example, negative vs positive relationships), may explain why prior social contact did not reduce stigma in this data.

How can clinicians allay perceptions of stigma about PrEP?

Clinicians can play a crucial role in reducing their patients’ perceptions of PrEP stigma by creating a supportive, nonjudgmental environment where patients feel safe to discuss their concerns openly. This begins with using nonstigmatizing language, framing PrEP as a responsible choice for HIV prevention, and emphasizing its use among all vulnerable populations, not just those engaging in high-risk sexual behaviors.

By emphasizing that PrEP is a tool for anyone at risk of HIV, clinicians can help patients see it as part of a broader public health strategy rather than something only associated with certain risks or sexual behavior.

What resources are available that encourage PrEP use?

Local and federal public health agencies are likely the most powerful actors in this dynamic, as they have the authority to frame and reframe HIV prevention strategies, set formal prevention recommendations, and influence healthcare and insurance policies. Given their broad reach, these agencies can drive the narrative around PrEP, emphasizing its benefits for all individuals at risk for HIV and shifting public perception from associating it solely with high-risk sexual behaviors to viewing it as a responsible and accessible tool for HIV prevention.

While several PrEP awareness campaigns exist, PrEP’s multifaceted nature makes it challenging to identify a one-size-fits-all approach. Attitudes toward PrEP and the stigma surrounding it are highly contextualized and can vary significantly depending on geographical region, demographics, and social norms. Public health campaigns need to be adaptable to local communities, and what works in one setting may not work in another.

For this reason, I highly encourage clinicians and public health practitioners to stay connected with their local HIV communities, such as their local Centers for AIDS Research (CFAR), to remain informed about regional HIV landscapes and the specific barriers and attitudes surrounding PrEP in their area. These local resources are invaluable for understanding the unique challenges and opportunities related to PrEP in different regions and communities. Public health agencies, through localized campaigns and collaborations with community organizations, can provide the guidance and tools necessary to address stigma, promote informed decision-making, and ultimately encourage greater uptake and adherence to PrEP.

How does PrEP stigma influence Ending the HIV Epidemic goals?

Achieving the Ending the HIV Epidemic (EHE) goals is entirely within reach, but it can only be realized if we overcome the crucial barrier of stigma attached to HIV and its prevention methods. Scientists have already provided us with PrEP, a powerful tool, and with recent policy changes expanding PrEP’s accessibility, policymakers have done their part. Now, it is up to us as a society to move beyond the arbitrary stigmas associated with PrEP and HIV. While stigma remains a challenge, fully understanding and addressing it will be essential to reaching the 2030 EHE targets.

What questions remain unanswered for you?

Future research could benefit from employing multiple measures of PrEP stigma or creating a composite scale to more comprehensively capture stigmatizing attitudes and behavioral intent toward PrEP. I am also interested in exploring the role of moral responsibility in PrEP use, especially in light of our finding that individuals who view PrEP users as responsible in their sexual behavior are more likely to stigmatize PrEP users as promiscuous. This raises the question of whether framing PrEP as the responsible choice could increase its uptake and consistent use or further stigmatize it.

I strongly encourage clinicians to be mindful of the ongoing challenges faced by current PrEP users, particularly the stigma that can persist even after they begin taking the medication. It’s crucial not to assume that the conversation around PrEP ends once the first prescription is filled. As this study shows, even individuals actively using PrEP may still struggle with internalized stigma and other concerns, which can impact their long-term engagement with the medication.

Clinicians should continue to offer support and recognize the complexity of stigma in the context of PrEP use. Moreover, I hope clinicians stay informed about the evolving HIV landscape in their communities, understanding that perceptions of HIV prevention and the associated stigma are constantly changing. Engaging in respectful, open conversations with patients is essential to creating a patient-centered approach where individuals feel empowered to make informed decisions about their health. For example, clinicians can proactively use nonstigmatizing language and foster an environment of trust. Trust can lead to more informed decisions, encourage greater engagement with HIV prevention, and help individuals overcome perceptions of stigma and other barriers to PrEP.