PrEP-Related Medical, Structural and Institutional Mistrust among a Socioeconomically Diverse Sample of Black, Latine, Asian, and White Young Sexual Minority Men: Lived Experiences of Intersectional Inequity.

Abstract

Mistrust among marginalized populations has been shown to negatively impact health behaviors and outcomes. Young sexual minority men (YSMM) experience many health inequities, including those related to HIV. Understanding how YSMM think about and experience medical, structural, and institutional mistrust is critical to effectively promoting engagement in preventive services like pre-exposure prophylaxis (PrEP). The study recruited 43 YSMM (ages 25-27) from diverse racial, ethnic, and socioeconomic backgrounds in New York City. Semi-structured interviews were conducted from July- November 2018 and focused on sexual health, HIV-related beliefs, PrEP, and experiences with healthcare systems and providers. Three main themes were identified: (1) concerns regarding PrEP as a medication, including its perceived novelty, potential side effects, and the perceived lack of a compelling reason to take preventive medication; (2) ethical and philosophical apprehensions around perceived U.S. government-pharmaceutical collusion, and (3) PrEP and healthcare providers are not necessarily perceived as nefarious; mistrust can coexist with support for PrEP. Although most participants expressed some level of government-pharmaceutical mistrust, such mistrust did not necessarily dissuade them from supporting or even taking PrEP. While most participants did not consider healthcare providers as actors in government-pharmaceutical collusion, clinicians can play an essential role in addressing patients' concerns and building trust. Clinicians should endeavor to make space for open, non-judgmental conversations not only about sexual behavior, but also patients' experiences of discrimination and socioeconomic exclusion. Finally, structural interventions must seek to address societal and institutional inequities to undo harm and earn trust.