Behavior Disclosure, Access to Healthcare, and HIV/STI Testing Among Male Sex Workers and Other MSM in the US: Findings from a Qualitative Study on PrEP Acceptability

Background: As evidence builds for biomedical HIV prevention, including pre-exposure prophylaxis (PrEP), at-risk communities depend on clinicians as gatekeepers.  Men who have sex with men (MSM), especially those who sell sex, are a priority.  But PrEP uptake may be limited if individuals lack access to care, opportunities to disclose risk, and HIV/STI testing.  We investigated experiences of male sex workers (MSWs) and MSM regarding access to healthcare, testing, behavior disclosure to clinicians, and PrEP acceptability.

Methods: Qualitative interviews enrolled approximately 28 MSWs and 25 other MSM in Providence, RI.  Participants were males of uninfected/unknown HIV status reporting recent unprotected anal sex with a male of infected/unknown status.  Interviews explored access to healthcare, disclosure of risks to clinicians, HIV/STI testing, and PrEP acceptability.

Results: MSM were more likely than MSWs to have health insurance (80% vs. 32%) and a physician to whom they had disclosed MSM behavior (33% vs. 11%).  Disclosure barriers included mistrust; confidentiality concerns; shame; past/anticipated discrimination due to sexual identity, drug use, or homelessness; reluctance to seek preventive care; and believing that sexual behavior is irrelevant.  Approximately 50% across groups had recently tested for HIV.  STI testing was rare among MSWs; barriers included cost, inconvenience, and lack of concern and/or perceived risk.  PrEP knowledge was low, but acceptability was high across groups after interviewers provided PrEP information.  To obtain PrEP, participants reported willingness to disclose selective risks to providers working in primary care, HIV care, HIV testing, substance use treatment, and mental health services.

Conclusions: MSM and MSWs may accept PrEP in various clinical settings.  But nondisclosure of behavioral risks limits opportunities for provider-initiated discussion about PrEP.  Behavioral interventions are needed to educate MSM/MSWs about PrEP, to empower disclosure, to promote STI testing, and to help clinical providers and staff create receptive environments for MSM self-disclosure and discussion.