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Learn More. Interviews were analyzed using a grounded theory approach. Participants had widely divergent levels of knowledge about these prevention methods. Gay men have long been faced with a complex set of sexual health options, including condom use, negotiated safety, partner selection, and abstinence.

However, today there are still more options, some carrying more complex biomedical implications. While recent studies suggest that some gay men are interested in using PrEP, 18 there are still issues that need to be addressed regarding awareness, education, access, and uptake of these biomedical HIV prevention tools. For instance, several exploratory studies of PrEP attitudes and acceptability among gay men have identified potential barriers, including lack of awareness, concerns about access, efficacy, cost, and side effects, fear of HIV-related stigma, and self-perceptions of not being a suitable candidate for PrEP.

By contrast, some felt that using PrEP could enhance the reputation of users. PrEP has also faced resistance among some gay men due to stigma and misinformation about the medication.

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Most notably, among all of these studies, concern around users being labeled as sexually deviant or too sexually adventurous seems to be a critical barrier to widespread acceptance of PrEP use. The insights gained from these exploratory studies highlighting stigma as a barrier are crucial to understand in more depth as biomedical interventions for HIV prevention become more widespread. In addition, we are aware of no research that has examined how communication with peers may affect YBMSM's willingness to adopt biomedical HIV prevention strategies.

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Research has shown that peer norms for safer sex are associated with lower levels of sexual risk behavior among YBMSM. Studies focused on African Americans have found that if peers were perceived to use condoms, then respondents were more likely to report condom use themselves. Similarly, if peer norms were perceived to be unsupportive of safer sex, YBMSM were more likely to engage in condomless intercourse.

However, sexual communication regarding perceived norms can also be harmful if it is perceived to be judgmental or stigma-based. Given the of complex issues related to HIV transmission prevention in this new era of combination prevention options, it is important to identify the kinds of information and support that could assist YBMSM in making the best sexual health decisions for their individual needs over time. In addition, it is important to ensure that people are using the right tool for them.

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Therefore, our purpose in this article is to explore their thoughts about PrEP use in the context of the larger toolbox for HIV prevention that will be increasingly available nationally and globally. Twenty-four pairs of friends were interviewed together in Los Angeles, CA, inwith each interview lasting approximately 2 h.

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The dyadic interview format provided opportunities to compare and contrast the two friends' perspectives, and to facilitate active discussions between friends about how they communicate. We also conducted individual interviews with the target participant lasting about 15 min in order to identify any issues he may not feel comfortable discussing with his friend in the dyad interview and to ask about his sexual communication with other friends.

The study protocol was approved by the institutional review boards California State University, Dominguez Hills and the University of Alabama; additional interviews were conducted in Birmingham, Alabama but these were not included in these analyses since PrEP and PEP were not asked about in those interviews, as very few participants had heard about these biomedical interventions in Birmingham, Alabama.

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A total of 48 individuals participated in the study in the Los Angeles arm, 24 target participants and 24 friends. To be eligible for inclusion, the target participant had to be a between 19 and 24 years of age, b self-identify as black or African American, c living in Los Angeles for at least 2 years, d in a friendship with someone between the ages of 19—29 with whom they discussed sexual health topics, and e out as gay to this friend for at least a year.

It was requested that the participant select his closest friend and that the friend was not a family member, boyfriend, or lover. The minimum age for all participants was 19 instead of 18 because 19 is the age of consent for the IRB at the University of Alabama.

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Purposive sampling methods are well-suited to exploratory research that seeks to identify particular types of cases, such as friendship dy, for in-depth investigations. Sampling s were predetermined based on the of interviews typically required to achieve theoretical saturation in qualitative research, 35 and our experience conducting research with this population.

Theoretical saturation on major themes was reached, confirming that the sampling s were adequate.

Demographic data for the sample are presented in Table 1. The dyad interviews focused on the content of participants' communication about sex and sexual health related to several salient topics, such as relationship issues, dating, and sexual activities; as well as on the topic we are focusing on for this analysis: their knowledge of and thoughts about PrEP, PEP, and other forms of prevention, such as condom use. We probed for how they communicated about topics found to be salient in our own preliminary research with young gay men and their friends, and other research with young men who have sex with men.

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The style of interviewing followed qualitative methods deed to provide opportunities to explore both anticipated and unanticipated themes, 39—41 and to limit the influence of social desirability bias. This process involved building rapport, assuring confidentiality, sequencing interview items to begin with less personal topics, and using neutral, open-ended questions followed by probes to elicit participants' descriptions of experiences with sexual communication. We also collected limited quantitative data in our eligibility screener and a brief survey administered before the interview.

The interviews were transcribed by a professional transcription service, and reviewed by staff for accuracy. All personal identifying information was removed, and pseudonyms chosen by the participants were used in place of their actual names. Pairs of friends were asked to select pseudonyms with matching first letters e. This approach allowed us to identify themes based on participants' own views of their sexual communication, HIV prevention strategies, and their friends' influence on their behaviors.

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Using this method, the research team first reviewed a subsample of transcripts and developed a working codebook that included both emerging themes and themes relevant to existing theoretical frameworks and our own preliminary work. Transcripts were entered into a qualitative data analysis software program Dedoose for coding.

This strategy of investigator triangulation 4344 facilitates analytical cooperation and exchange.

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The process entailed the active involvement of multiple team members, with diverse backgrounds. We prioritized team consensus over individual interpretations of the data, reaching unanimous agreement on all major themes.

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As subthemes were identified, they were coded and then compared with other subthemes for similarities and differences for categorization using a constant comparison method. Emerging were subjected to a process of member validation in which community stakeholders offered feedback to assess credibility. The first and second author discussed any discrepancies between coders, reconciling differences by consensus. Analyses were complete once we reached theoretical saturation.

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The sample consisted of 48 participants. All male friends identified as either gay or bisexual. See Table 1 for more details. Participants differed widely in the extent of their knowledge about biomedical prevention methods. Among those who had heard of them, most had limited knowledge, but a few possessed a fairly thorough familiarity with them and even an awareness of current debates in the popular and scientific press.

Participants learned about PrEP and PEP from various sources, including prevention education programs, youth groups, health care providers, friends, or the Internet. Many obtained information from multiple sources and then integrated this information.

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Some also described how they would share what they learned with friends, since they considered biomedical prevention an important topic to discuss with peers. For example, Chenet learned about PrEP at a youth group and shared this information with his best friend Ciara.

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Chenet felt that this repetition helped reinforce the new information about PrEP:. When we talk about [PrEP] in the group and then [Ciara and I] revisit it, it makes me better understand what's going on, so I can go and share the information with my other friends who don't go to the group, or who are not inside the conversation. Chenet, male, age 21, target. Often, if a participant was unsure about something related to PrEP, he would turn to a friend for clarification, often appearing to prefer friends to other possible sources of information about sexual health.

For example, in the following conversation, Noho was able to learn more about PrEP from his friend Nial, who had gotten information from a hospital youth group. NOHO male, age 22, target : I knew about like, the morning after and like you have to take it before you have the sex—or—I forgot. NIAL male, age 22, friend : No, you have to get to it before three days is over.

So you go to the hospital saying I had bareback sex and I think I may….

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These types of detailed discussions were mostly reported by dy that contained two males rather than dy that had one male and one female. Female participants were generally less likely to have heard about PrEP, and if they had, prior discussions about the topic between the friends were minimal. Participants expressed a variety of concerns about potential problems with biomedical prevention, particularly uncertainties about efficacy. I kind of question that. Is it really effective?

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A variety of other concerns were mentioned less frequently. One participant, Ulysses male, age 23, targetattributed his ificant liver damage to use of PrEP and PEP along with alcohol consumption. A few participants also thought that PrEP might be connected to conspiracies within the medical establishment.

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One believed that PrEP was opposed by a local medical clinic because biomedical prevention could lead to fewer HIV infections and thus less income for the clinic. A more common assumption was that pharmaceutical companies were encouraging the use of PrEP while withholding a cure for HIV in order to generate income from medication sales.

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Because biomedical strategies were mainly seen as suited to sexually promiscuous or risk-prone individuals, some participants felt that using these methods would lead to being stigmatized. For example, Judith expressed a concern that to disclose use of PrEP would mean risking a judgmental response from others, who might assume that one was more sexually risky because they were on PrEP. Are you always having unprotected sex? Many participants were concerned that PrEP might be used to intentionally engage in more frequent condomless intercourse.

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Although almost no participants said they would do this themselves, they felt that others might. For example, Edmund described a youth group in which he participated, and his sense that some of his peers were overly optimistic about PrEP as an opportunity to engage in safer sex without the need for condoms.

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Yet, like nearly all of the others we interviewed, Edmund himself felt it would be unwise to forgo condom use:. I don't think it's the greatest idea.

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Edmund, male, age 24, friend. God is on my side. He's supplying me with these special pills.

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In contrast to the majority, a few participants felt that if someone was using PrEP, they would not be stigmatized, but instead respected because they would be caring for their own health and that of others. His friend Quincy expanded on this theme:.

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I feel like if they're [on PrEP], they're not only protecting themselves. It's also for the well-being of other people that they're having sex with.

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I don't think there's anything bad. I think it's all positive.

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