State-level structural sexual stigma and HIV prevention in a national online sample of HIV-uninfected MSM in the United States.
BACKGROUND
Stigmatizing social environments (of which 'structural stigma' is one component) negatively affect health-related outcomes. However, few studies have examined structural stigma related to sexual minority status as a risk factor for HIV outcomes among MSM.


METHODS
In August 2013, members of a large MSM social and sexual networking site in the United States completed a survey about HIV-prevention practices. A previously validated composite index provided values for state-level structural stigma, including density of same-sex couples, proportion of public high schools with Gay-Straight Alliances, state laws protecting sexual minorities, and public opinion toward homosexuality. Multivariable logistic generalized estimating equations assessed the relationship between structural stigma and condomless anal intercourse, use and awareness of antiretroviral-based HIV-prevention strategies (i.e. pre and postexposure prophylaxis, or PEP and PrEP), and comfort discussing male-male sex with primary care providers.


RESULTS
Among the 4098 HIV-uninfected MSM, lower state-level structural stigma was associated with decreased odds of condomless anal intercourse [adjusted odds ratio (aOR) 0.97 per one unit increase in structural stigma score, 95% confidence interval (CI) 0.94-0.99], increased odds of awareness of PEP (aOR 1.06, 95% CI 1.02-1.09), and PrEP (aOR 1.06, 95% CI 1.02-1.10), having taken PEP (aOR 1.15, 95% CI 1.05-1.26) and PrEP (aOR 1.21, 95% CI 1.01-1.44), and comfort discussing male-male sex with providers (aOR 1.08, 95% CI 1.05-1.11), after adjusting for social and state-level confounders.


CONCLUSIONS
MSM living in more stigmatizing environments had decreased use of antiretroviral-based HIV-prevention strategies compared to those in less stigmatizing environments. Legal reforms protecting sexual minorities should be evaluated as structural interventions that could reduce HIV risk among MSM.
aDepartment of Epidemiology, Harvard School of Public Health, Boston, Massachusetts bDepartment of Sociomedical Sciences, Columbia Mailman School of Public Health, New York, USA cDivision of Infectious Diseases, Department of Internal Medicine, Beth Israel Deaconess Medical Center dOLB Research Institute, Online Buddies, Inc., Cambridge eThe Fenway Institute, Fenway Community Health fDepartment of Psychiatry, Harvard Medical School/Massachusetts General Hospital gDepartment of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA.
Catherine E
CE
Oldenburg
Amaya G
AG
Perez-Brumer
Mark L
ML
Hatzenbuehler
Douglas
D
Krakower
David S
DS
Novak
Matthew J
MJ
Mimiaga
Kenneth H
KH
Mayer
D000328:Adult; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D015658:HIV Infections / Q000517:prevention & control*; D018451:Homosexuality, Male / Q000523:psychology*; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D056990:Post-Exposure Prophylaxis; D057545:Social Stigma; D011795:Surveys and Questionnaires; D014481:United States