The United States has a dark history of medical mistreatment of African Americans including medical experimentation among African slaves, involuntary sterilization, the Tuskegee Syphilis Study, and continued unequal access to quality medical care, which may lead some individuals to be skeptical of accessing medical care 21. Mistrust of medical institutions, health care providers, and the health care system is comparatively high among African Americans and LGBT persons 20, 21 and may pose a significant barrier to accessing biomedical HIV prevention 22, 23. There is some evidence that medical mistrust, conceptualized as mistrust of doctors, health care providers, or drug companies, is associated with decreased willingness to take PrEP among young Black MSM 19. Some research has started to examine why there has been low PrEP utilization among at-risk Black individuals 13– 15, yet questions remain. PrEP use is particularly low among Black adolescents 11 and individuals under the age of 25 6, which is concerning given that youth aged 13–24 accounted for 21% of new HIV diagnoses in 2016 12. Furthermore, modeling studies indicate that with the current PrEP continuum of care, HIV incidence among White MSM could be halved in the next ten years, but only reduced by 23% among Black MSM 10. Yet, estimates of PrEP coverages indicate PrEP use is lowest among Black Americans 9, 10. There is also evidence of racial disparities in PrEP use of the 1.1 million persons estimated to be indicated for PrEP, 45% are Black 9. Most recent estimates suggest that less than 10% of individuals who could benefit are receiving PrEP 6. If disparities in PrEP use remain unaddressed, PrEP may become an HIV prevention mechanism accessible and utilized primarily by older, privately insured White MSM of higher socioeconomic status, further exacerbating HIV disparities 7, 8. Despite its success, uptake of PrEP outside of clinical trials has been relatively low 3– 5, particularly among younger and racial and ethnic minority populations 6. HIV pre-exposure prophylaxis (PrEP) is a promising component of HIV prevention, particularly for gay, bisexual, and other men who have sex with men (MSM), demonstrating high efficacy among adherent users 1, 2. Efforts to increase PrEP uptake and must address negative and discriminatory interactions with providers and the healthcare system. Focus group discussions revealed how previous and anticipated negative interactions with physicians and skepticism about the healthcare system have alienated young Black MSM from the health care system and created significant barriers to PrEP. Results from this study help to characterize what contributes to mistrust of the healthcare system and healthcare providers to negatively affect PrEP use among young Black MSM. We used a team-based approach to thematic content analysis to understand how racism and homonegativity affected healthcare access and experiences. Focus group transcripts were transcribed verbatim and coded using MAXQDA qualitative analysis software.
Focus group topics included participants’ knowledge and perceptions of PrEP, perceptions and stereotypes about PrEP users, and general healthcare utilization patterns and behaviors. In late 2017 and early 2018, we conducted six focus groups with 44 Black MSM ages 16–25 in Milwaukee. This study aimed to uncover how young Black MSM’s perceptions of, and experiences with, health care contribute to low engagement in the healthcare system and low PrEP utilization. These disparities may be due, in part, to medical mistrust and mistreatment within the healthcare system.
Young, Black, gay bisexual or other MSM are significantly less likely to use PrEP than their White counterparts.