Date of Degree

9-2020

Document Type

Dissertation

Degree Name

Ph.D.

Program

Psychology

Advisor

H. Jonathon Rendina

Committee Members

Sarit A. Golub

Christian Grov

Ian Holloway

Tyrel J. Starks

Subject Categories

Health Psychology

Keywords

pre-exposure prophylaxis, LGBTQ, HIV prevention, sexual health

Abstract

Pre-exposure prophylaxis (PrEP) was approved for all individuals 13 years of age and older in May 2018. However, research pertaining to uptake has mostly focused on adult sexual minority men (SMM), leaving out many barriers and facilitators that may exist for those under 18 years of age. Two of the most important precursors leading to PrEP uptake identified in prior research are the perception of self as a PrEP candidate and having intentions to begin PrEP. Developmental and dual processing theories suggest that individuals who are younger make behavioral decisions differently from those who are older. Developmental theories suggest that, compared to those who are older, those who are younger make decisions by placing more weight on social approval, as opposed to individual benefits. Dual processing theories suggest that, as individuals age, they utilize more ‘cold’ cognitive processing and conscious thought in their decision making; thus, those who are younger utilize more ‘hot’ affective processing. Taken together, theories of development and dual processing suggest that those who are younger may make decisions about PrEP use differently from those who are older. Current interventions aiming to increase PrEP uptake among adults may need to be altered to include the specific differences among decisions making in younger populations. As such, the aims of this dissertation were to: (1) examine PrEP use experience among both young sexual minority men (YSMM; ages 13-24) and SMM (25 years of age and up); (2a) investigate the role of age as a moderator between affective and cognitive dimensions of HIV risk perception as associated with self-perception of PrEP candidacy and PrEP intentions among YSMM who are at-risk for HIV seroconversion; and (2b) investigate the role of age as a moderator between perceived benefits of PrEP use and PrEP stigma as associated with PrEP intentions among YSMM.

To achieve these aims, data were analyzed from a larger study of SMM living across the United States. As part of this project, participants first completed an online survey and then once enrolled, completed a baseline assessment. Utilizing data collected from the screener survey, in Study 1, I tested a series of hypotheses examining differences in PrEP use within an age-stratified sample of YSMM and adult SMM. In bivariate analyses, I found that PrEP utilization was lowest among those 13-24 years of age. In regression analyses, stratified by age group and predicting PrEP use (i.e., former, and current), compared to never having used PrEP, I found that the odds of being a current PrEP user increased by 31% for each year of age for YSMM. Additionally, I found that while controlling for age, YSMM who were on their parent or guardian’s medical insurance had decreased odds of PrEP use compared to those on their own health insurance. There were also various demographic and behavioral differences that distinguished PrEP use history within the two age groups. These differences included sexual orientation, race, ethnicity, relationship status, region, medical insurance, and recent behavioral and sexual risk. Taken together, the findings from the first aim suggest there are many variables that need to be further investigated before PrEP uptake among YSMM is likely to increase.

Data for the second aim of this dissertation came from baseline data collected as part of the parent project, UNITE, a longitudinal cohort study examining the psychosocial and biological predictors of HIV seroconversion among SMM (UG3-AI133674). Utilizing these data, in Study 2, I investigated a series of theoretically grounded hypotheses predicting the associations between cognitive and affective dimensions of HIV risk and the two primary precursors to PrEP uptake (i.e., perceived PrEP candidacy, and PrEP intentions) among only YSMM (16-24 years of age, M = 21.2). I found that affective dimensions of HIV risk were significantly positively associated with PrEP candidacy and that this association was stronger among olderYSMM. Additionally, I found that cognitive dimensions of perceived HIV risk were significantly negatively associated with PrEP candidacy, and this association was weaker among older YSMM. Next, I tested affective and cognitive dimensions of HIV risk on PrEP intentions, mediated by perceived PrEP candidacy. I found support for perceived PrEP candidacy significantly mediating the associations between both affective and cognitive dimensions of perceived HIV risk and PrEP intentions. Lastly, I tested a model assessing whether age moderated the effects of perceived benefits of PrEP use and PrEP stigma on PrEP intentions. I found that perceived benefits of PrEP use were positively associated with PrEP intentions, and this association was stronger among older YSMM. In contrast, I found PrEP stigma was negatively associated with PrEP intentions, and this association was weaker among older YSMM. Findings from this dissertation highlight differences in factors that are known to change with increased age that significantly affects YSMM and may impede PrEP uptake.

There are many potential places for interventions to be made at different levels, including clinical, medical, and public health and policy. In order for the HIV epidemic to end in the United States, changes at all levels may be necessary, including interventions that focus on both young SMM and their caregivers. These intervention adaptations and future research ideas are discussed in the conclusions, as well as the limitations to this research.

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