Contextual barriers to PrEP uptake and continuation among young Black gay and bisexual men who have sex with men living in the South.

Young, Black Gay, and Bisexual men who have sex with men (YBGBM) are disproportionately impacted by HIV, especially in Southern United States. We conducted a cross-sectional survey (Feb19-Mar20). Eligibility criteria were self-reported age 16-29 years, HIV-negative, Black race, and cis-gender male. We assessed associations between demographics, religiosity, intersectional stigma, and pre-exposure prophylaxis (PrEP) use (never, previous or current) among YBGBM in Alabama. Univariate and multivariable multinomial logistic regression models were fit with factors selected a priori, guided by a conceptual framework including individual-, interpersonal- and structural-level barriers to PrEP. 305 participants completed surveys (median age 24, 75% employed, 32% lacked personal transportation, and 41% reported annual incomes < $15,000). Compared to never PrEP use (n = 219), factors associated with current PrEP use (n = 51) included: ≥ college degree [AOR (95% CI): 5.48 (2.05, 14.62)], friends' social support [AOR (95% CI): 1.33 (1.00, 1.52)], perceived HIV risk [AOR (95% CI): 1.27 (1.14, 1.42)], and PrEP knowledge [AOR (95% CI): 1.42 (1.23, 1.65)] AND factors associated with previous PrEP use (n = 35) included: depression [AOR (95% CI): 3.08 (1.34, 7.09)], condom use less than all the time [AOR (95% CI): 11.98 (1.52, 94.41)], intrinsic religiosity [AOR (95% CI): 0.77 (0.68, 0.88)], stable housing [AOR (95% CI): 0.30 (0.11, 0.81)], perceived sexual stigma [AOR (95% CI): 0.84 (0.75, 0.94)], and perceived HIV risk [AOR (95% CI): 1.18 (1.05, 1.33)]. YBGBM face distinct challenges with engagement in HIV prevention services and further investigation is needed to understand individual, interpersonal as well as structural-level factors that may mediate the ability to utilize PrEP services. Tailored multilevel strategies are urgently needed to improve PrEP uptake and persistence in YBGBM.