Tag: PrEP

Current Climate of HIV Disparity in NC: Part 2

Impact of Disparity

Research has shown that the prevalence of HIV diagnoses and the rates of new HIV infections are highest in the southern US, including North Carolina.7 In the state of North Carolina:

  • Male-to-male sexual contact represents the mode of transmission for almost 70% of men living with HIV8
  • Almost 6% of transmissions for men living with HIV were the result of dual exposure through injection drug use and male-to-male sexual contact8
  • Almost three-fourths of total HIV transmission in the state are the result of male-to male sexual contact8
  • Among new diagnoses, these numbers only seem to be increasing, closer to 84%8
  • Black men in the state of North Carolina are also 6 times more likely to be living with HIV than white males8
  • The Durham-Chapel Hill, Winston-Salem, Greensboro-High Points metropolitan areas were also identified within the top 25 metropolitan areas for prevalence of HIV diagnoses and rates of new infections7

Causes of Disparity

Pre-exposure prophylaxis offers many opportunities to prevent the spread of HIV; however, stigma surrounded the drug itself may be preventing many gay and bisexual men from seeking out the drug and many medical providers from prescribing the drug to their gay and bisexual patients. This could partially be a result of general stigma about asking patients sexual health questions or questions about sexuality. Simply prescribing PrEP to all gay and bisexual men would result in overuse. Hence, discussions about sexual risk behaviors is important for assessing an individual’s need for the drug. However, medical provider stigma might represent a larger barrier to accessing PrEP, especially for black men who have sex with men. Further, the population of medical providers has been less of a focus for current public health interventions to increase the use of PrEP.



  1. Duran, D. Truvada Whores? Huffinton Post. 2012. https://www.huffingtonpost.com/david-duran/truvada-whores_b_2113588.html
  2. Addison, V. Larry Kramer, Truvada Whores and the Angry Divide Between Two Generations. HIVEqual. n.d. http://www.hivequal.org/homepage/larry-kramer-truvada-whores-and-the-angry-divide-between-two-generations
  3. Logo. Revisiting “Truvada Whore” Three Years Later. NewNowNext. 2016. http://www.newnownext.com/revisiting-truvada-whore-three-years-later/02/2016/
  4. Emory University Rollins School of Public Health. North Carolina. AIDSVu. n.d. https://aidsvu.org/state/north-carolina/
  5. Calabrese SK, Underhill K. How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize “Truvada Whores”. American journal of public health. 2015;105(10):1960-1964.
  6. Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS and behavior. 2014;18(2):226-240.
  7. Rosenberg ES, Grey JA, Sanchez TH, Sullivan PS. Rates of Prevalent HIV Infection, Prevalent Diagnoses, and New Diagnoses Among Men Who Have Sex With Men in US States, Metropolitan Statistical Areas, and Counties, 2012-2013. JMIR Public Health Surveill. 2016;2(1):e22.
  8. Britz JJ. To Know or not to Know: A Moral Reflection on Information Poverty. Journal of Information Science. 2004;30(3):192-204.

Exploring Dating Application Profile Fields Through Health Behavior Theories

Location-aware or geososocial mobile dating and sex-seeking applications are becoming more and more common for men who have sex with men (MSM). Of these apps, Grindr is likely the most popular with 3.5 million users opening the app each day (Kelly, 2018). This mobile app presents other users profile images in a 3-column grid, allowing a user to quickly scan through the profile images of other users to find potential partners. Goedel and Duncan (2015) suggest that MSM use multiple apps and spend considerable time on them, meaning that there are many different sites for interventions with MSM but also the sustained time on the apps might suggest that these would be fruitful locations.

Given the high use of these applications, I’m interested in the ways that public health researchers can work with(in) these applications or the ways that these applications can make themselves more socially responsible with respect to users’ sexual health. Using Grindr as a case study, we can look at the ways that the user profile works with the Health Belief Model (HBM) and Social Cognitive Theory (SCT) to possibly result in health behavior changes for HIV testing and pre-exposure prophylaxis (PrEP) usage (Glanz, Rimer, & Viswanath, 2008).

On Grindr, there are currently options for sharing information about HIV status and last tested date (see image below). Users can select from various restricted vocabulary options to show to their fellow users. In this sense, seeing that other people are taking PrEP or have gotten tested recently might work within the SCT concepts of collective efficacy and observational learning. MSM on these apps can see other MSM are getting tested and taking PrEP, and these aspects might impact individual self-efficacy and perceived benefits within the Health Belief Model while also serving as a cue to action for the behavior change. As such, combining these aspects of SCT and the HBM, these two simple factors on the dating profile might increase the likelihood of users on these apps engaging in HIV testing or PrEP usage.

However, it was recently revealed that Grindr was sharing this health information with other companies (Kelly, 2018). It will be interesting to see how users make choices about using these fields in the future if they feel distrust towards the application. This news came quickly after Grindr proposed offering reminders and information about HIV testing to users based on the last tested dates provided on their profiles (McNeil, 2018).

Other dating applications for MSM, and for other populations, could employ similar strategies in their user profile descriptive schemas. Future research could also look empirically at the impact of these aspects of the profile on health behavior change. It may also be possible to expand sexual health information sharing to include information about other STIs to encourage testing and prevention beyond HIV.



Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education: theory, research, and practice. John Wiley & Sons.

Goedel, W. C., & Duncan, D. T. (2015). Geosocial-Networking App Usage Patterns of Gay, Bisexual, and Other Men Who Have Sex With Men: Survey Among Users of Grindr, A Mobile Dating App. Journal of Medical Internet Research, 17(5), 1-1. doi:10.2196/publichealth.4353

Kelly, H (2 April 2018). Grindr to stop sharing HIV status of users with outside companies. CNN Money. Retrieved 4 April 2018.

McNeil, D. G., Jr (26 March 2018). Grindr App to Offer H.I.V. Test Reminders. NY Times. Retrieved 4 April 2018.


The Continuing HIV Disparity for Black Men

Despite only making up 2% of the U.S. population, men who have sex with men (MSM) account for 52% of the U.S. population of individuals living with HIV, and these rates don’t seem to be decreasing.[1] In 2013, MSM accounted for 65% of new HIV diagnoses.[2] Among MSM, black men are disproportionately at risk of contracting HIV, accounting for 30% of MSM living with HIV and almost 40% of new HIV diagnoses in 2012 though black people only constitute about 13% of the U.S. population.[3] Of these black MSM newly diagnosed, 38% were between the ages of 13 and 24 in 2015.[4] Of black gay and bisexual men living with HIV, only 54% received continuous HIV care.[5]

These statistics illustrate the stark disparity in HIV treatment and prevention for queer black men, especially younger queer black men. According to a 2018 CDC report, black men are not receiving PrEP prescriptions or being provided PrEP at the rate that they should be.[6] Some health professionals will likely attempt to target black MSM, claiming that they are less likely to be aware of PrEP, are more likely to have sex with other black men and are thus more likely to contract HIV because of the higher prevalence rate in black communities, are more likely to participate in riskier sexual behaviors, are less willing to take medications, etc. Many of the reasons for lower PrEP usage among black MSM will likely be attributed to decisions made by black MSM themselves.

However, in 2014, Calebrese et al found, in a nationally representative sample of medical students, that students were less likely to prescribe PrEP to a black man than a white man.[7] A pervasive logic surrounding PrEP, exacerbated by the stereotype of the Truvada Whore, is that people who take PrEP will participate in riskier sex.[8] However, PrEP should be the answer to protecting individuals who are participating in riskier behavior.[9] Ultimately, this logic is backwards and slut-shaming, and it puts black MSM at greater risk because it keeps them from being prescribed PrEP.

We should be looking to medical schools to better prepare their students to provide necessary care to LGBTQ+ people more broadly, but also from this example more specifically to black MSM. We should also be targeting current providers to combat issues of implicit bias, homophobia, and heterosexism that are preventing LGBTQ+ individuals, especially black MSM, from accessing the best possible care.

[1] “MSM Population Profile.” AIDSVu, 9 Mar. 2018, aidsvu.org/aidsvu-in-use/msm-population-profile/. AIDSVu is maintained by faculty and staff at Emory University’s Rollins School of Public Health in partnership with Gilead Sciences, Inc. and the Center for AIDS Research at Emory University (CFAR) with assistance from members of other institutions. Some of the data and statistics presented on the AIDSVu website is provided from other medical and health surveillance institutions, such as the CDC.

[2] Ibid.

[3] Ibid.

[4] Ibid.

[5] “HIV among African American Gay and Bisexual Men.” Centers for Disease Control and Prevention, 14 Feb. 2018, www.cdc.gov/hiv/group/msm/bmsm.html.

[6] “HIV prevention pill not reaching most Americans who could benefit – especially people of color.” Centers for Disease Control and Prevention, 6 Mar. 2018, www.cdc.gov/nchhstp/newsroom/2018/croi-2018-PrEP-press-release.html.

[7] Calabrese, S. K., Earnshaw, V. A., Underhill, K., Hansen, N. B., & Dovidio, J. F. (2014). The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS Behav, 18(2), 226-240. doi:10.1007/s10461-013-0675-x

[8] Calabrese, S. K., & Underhill, K. (2015). How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize “Truvada Whores”. Am J Public Health, 105(10), 1960-1964. doi:10.2105/ajph.2015.302816

[9] Calabrese, S. K., Magnus, M., Mayer, K. H., Krakower, D. S., Eldahan, A. I., Hawkins, L. A. G., . . . Dovidio, J. F. (2017). “Support Your Client at the Space That They’re in”: HIV Pre-Exposure Prophylaxis (PrEP) Prescribers’ Perspectives on PrEP-Related Risk Compensation. AIDS Patient Care STDS, 31(4), 196-204. doi:10.1089/apc.2017.0002

Changes to HIV Criminalization Laws in NC

According to a report updated in August 2017, 34 states in the US had HIV criminalization laws still on the books, written at least twenty years ago at the height of the AIDS epidemic [1]. According to the Human Rights Campaign, 25 states in the US have “laws that criminalize behaviors that carry a low or negligible risk of HIV transmission” [2]. Most of these laws require disclosure of HIV status for those living with HIV, and in some states, failure to disclose or follow other laws could result in a felony.

There are various examples of these laws being put to work, including a man living with HIV being convicted of a felony and sentenced for 35 years for spitting on a police officer because his saliva was considered a deadly weapon though HIV transmission doesn’t occur through saliva [3].

In North Carolina, HIV criminalization laws are contained in the health code, and the North Carolina Commission for Public Health recently voted to update the laws in order to better reflect our current understanding of HIV and the current methods available for HIV treatment and prevention [4].

According to the previous law, any individual living with HIV was required to disclose their HIV status to any sexual partners and to use a condom during sex, and anyone living with HIV was unable to donate organs. With the changes to the law, an HIV positive individual who is virally suppressed for at least 6 months does not have to disclose their HIV status to sexual partners or use a condom during sex, and even if they aren’t virally suppressed, if their partner is taking PrEP, they don’t have to use a condom. Also, an individual living with HIV doesn’t have to use a condom when having sex with another individual living with HIV, and individuals living with HIV can donate organs to other individuals living with HIV [5]

This is an exciting step forward for North Carolina that will hopefully make changes for HIV stigma while also representing current options for HIV treatment and prevention. These changes also recognize that HIV is an ongoing issue, especially with high rates of new diagnoses of HIV in the South.

Nonetheless, some activists are still worried that this is only a step forward for those who are already at an advantage. Many individuals are still unable to access healthcare and the medical system for various reasons, limiting their access to PrEP for HIV treatment to attain viral suppression. Only 50% of individuals living with HIV stay in care. Further, Black and Latinx individuals still receive worse care and have less access to care. This results in a continued disparity. Though the changes to these laws are a step forward in creating evidence-based laws and hopefully decreasing stigma and unjust prosecution, there are still significant barriers for individuals seeking HIV treatment and prevention care [6].

“Chart: State-by-State Criminal Laws Used to Prosecute People with HIV, Center for HIV Law and Policy (2017).” The Center for HIV Law and Policy, 1 Aug. 2017, www.hivlawandpolicy.org/resources/chart-state-state-criminal-laws-used-prosecute-people-hiv-center-hiv-law-and-policy-2012

Jackson, Hope. “A Look At HIV Criminalization Bills Across The Country.” Human Rights Campaign, 26 Feb. 2018, www.hrc.org/blog/a-look-at-hiv-criminalization-bills-across-the-country.

Kovach, Gretel C. “Prison for Man With H.I.V. Who Spit on a Police Officer.” The New York Times, The New York Times, 16 May 2008, www.nytimes.com/2008/05/16/us/16spit.html.

Adeleke, Christina. “Choose Science over Fear.” QNotes, 24 Feb. 2018, goqnotes.com/58326/choose-science-over-fear/.

“HIV Criminalization Laws Change in North Carolina.” WNCAP, 20 Feb. 2018, wncap.org/2018/02/20/hiv-criminalization-laws-change-north-carolina/

Salzman, Sony. “Updated HIV Laws May Only Protect the Privileged.” Tonic, 20 Mar. 2018, tonic.vice.com/en_us/article/wj7e9z/updated-hiv-laws-may-only-protect-privileged.

Implicit Bias in Prescription of PrEP

African American men who have sex with men (MSM) are disproportionately affected by HIV; however, recent research suggests that medical providers are less likely to prescribe Pre-Exposure Prophylaxis (PrEP), a preventative treatment for HIV, to black MSM (Calebrese et al, 2014). This is a direct result of implicit racial bias, prejudice, and a lack of institutional knowledge on the part of medical providers. Current stereotypes about gay men exist among many medical practitioners, specifically with regard to “Truvada Whores.” It is assumed that MSM who take PrEP will participate in more risky behaviors and thus be at greater risk of HIV, though PrEP is an important measure for reducing risk of HIV. This is further exacerbated by implicit racial bias which corroborates beliefs by providers that black MSM are even more likely than white MSM to partake in risky sexual behaviors if they are prescribed PrEP. As such, medical providers are less likely to prescribe PrEP to black MSM, barring them from access to an important and potentially life-saving measure to prevent HIV, a disease that they are disproportionately affected by.

This research suggests that public health interventions that focus on black MSM might be misplacing their efforts by focusing on changing the behaviors of the individuals or encouraging use of PrEP if they don’t have the necessary support from their doctors. Perhaps, public health interventions should focus on developing additional institutional knowledge to prepare medical providers for caring for black MSM and providing adequate sexual health care.

Calabrese, S. K., Earnshaw, V. A., Underhill, K., Hansen, N. B., & Dovidio, J. F. (2014). The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS Behav, 18(2), 226-240. doi:10.1007/s10461-013-0675-x

PrEP for Life

Reflecting on the models of health discussed previously (part 1 & part 2), a queer man without human immunodeficiency virus (HIV; disregarding other illnesses) would be healthy, whereas a queer man with HIV would be unhealthy within the medical model of health. In the sociocultural model of health, both a queer man with HIV and without HIV would likely be considered healthy. Given current treatments, there would likely be no affect on an individual’s ability to perform the five activities of daily living. Finally, in the psychological model, we have no easy way to estimate beforehand.

However, within the “drugs for life” model, since queer men are identified within the public health discourse as high risk for HIV, they are immediately seen as bodies-at-risk. Within this model, being queer men can become a predisease for HIV. Much like pre-hypertension for hypertension, the predisease becomes an illness to be treated in itself. Here, we treat the predisease with public health interventions, but the predisease is the behavior of men having sex with men. However, with the best intentions, public health interventions and health communications campaigns can exacerbate the stigma within the queer community with regards to HIV and pre-exposure prophylaxis (PrEP).

Within this model, PrEP becomes another “drug for life.” There’s no point at which individuals can stop taking PrEP to prevent HIV. It has to be consistently taken in the same way that one would consistently take drugs after contracting HIV. Hence, the treatment for the disease and the treatment to prevent the disease have the same consequences. Presumably, patients would only stop taking PrEP after finding a long-term partner with whom they are monogamous (also presumably both partners would be HIV negative). However, this assumes compulsory monogamy and perhaps even compulsory matrimony. For queer men who don’t want to become monogomous or get married or who are worried about their partner’s (or partners’) infidelity might still be taking PrEP. This combination of high NNT (especially high NNT when we consider the effectiveness of condoms, which should still be used while taking PrEP, since it isn’t 100% effective) with the endless length of the prescription results in considerable profits for drug companies and a significant economic injustice for queer men.