Introduction

Human immunodeficiency virus (HIV) disproportionately impacts Black and Latino/a populations in the United States (U.S.), who in 2019 respectively comprised 40.3% and 24.7% of the new HIV diagnoses despite accounting for 13.4% and 18.5% of the population [1]. While extant HIV research in the U.S. context has largely focused on men who have sex with men (MSM) and people who inject drugs (PWID), the magnitude of racial and ethnic disparities in HIV diagnosis remains more pronounced among heterosexual individuals than in MSM and PWID [2]. These disparities were particularly apparent among Black heterosexual men, who were 29 times more likely to be diagnosed with HIV than their white counterparts in 2015 [2]. In New York City (NYC), over half of diagnosed HIV cases were linked to heterosexual contact in 2021, indicating notable risk of HIV transmission among both heterosexual men and women [3].

Black and Latino heterosexual men may be at heightened risk for HIV transmission related to HIV risk behaviors, and limited understanding of PrEP. Stressors such as mass incarceration and fewer opportunities for socioeconomic advancement in historically-disenfranchised, urban neighborhoods have been associated with increased HIV transmission rates among Black heterosexual men [4]. Low levels of sexual health literacy among Black and Latino immigrants stemming from stigma around discussing sex and limited access to multilingual resources may also contribute to increases in HIV-risk behaviors [5]. Additionally, ideologies around hegemonic masculinity and gendered power relations in Black and Latino communities contribute to HIV risk behaviors such as inconsistent condom use and multiple sexual partners among heterosexual men [6]. Hegemonic masculinity posits that there exists a set of societal norms, often established by men in power to organize gendered dynamics in unequal ways, that reinforces men’s domination over women as well as the power of some men over other men [7]. As such, HIV risk behaviors driven by normative expectations around the subordination of women are especially salient in relational contexts and may contribute to increased HIV transmission rates, and gender inequity at both the personal and societal level.

Low uptake of oral pre-exposure prophylaxis (PrEP), a highly effective medication taken daily to prevent HIV acquisition among HIV-negative individuals, may also contribute to higher risk of HIV transmission among Black and Latino/a populations [8]. In 2015, the World Health Organization and Centers for Disease Control and Prevention (CDC) updated their guidelines to include heterosexually active adults as a population that could greatly benefit from PrEP usage [9,10]. In the same year, the CDC recommended the administration of PrEP to 624,000 heterosexual individuals in the U.S. with indications for PrEP [10]. However, 2019 data from the CDC National HIV Behavioral Surveillance found that 32.3% of heterosexually active adults were aware of PrEP, but less than 1% of heterosexually active adults in high-prevalence cities utilized PrEP—a finding that was particularly pronounced among Hispanic or Latino men and limited English proficient (LEP) individuals [11]. Uptake among heterosexual men remains especially low, a finding reflected in various community studies across urban settings in the U.S. [12].

Despite the documented risk factors for HIV transmission and lower PrEP uptake among Black and Latino heterosexual men, few studies have examined factors influencing HIV risk behaviors and PrEP uptake concurrently, in spite of the shared characteristics such as low sexual health literacy that may be associated with both. To this extent, there remains an even more substantial gap in literature on PrEP-related adherence along the HIV prevention continuum, which involves pathways flowing from linkages to prevention services, retention in these services, and adherence support [13]. Our study seeks to address this gap in literature by understanding the multi-level factors influencing HIV risk behaviors and oral PrEP use among Black and Latino men who have heterosexual contact in NYC. The study elicits voices from both English speakers and LEP Spanish-speaking men. Given the U.S. States federal government’s commitment to reducing new HIV infections by 90% by 2030, as well as the continued roll-out of newer long-acting injectable PrEP, it is imperative that HIV prevention efforts equitably understand factors impacting HIV prevention efforts among at-risk, and underserved populations [14,15].

Methods

Results

General characteristics of study participants

Sixteen individuals were interviewed. Participant characteristics are presented in Table 1. The median age of participants was 38.5 years old, with a range from 29 to 59 years of age. A majority of participants identified as Latino (n = 11, 68.75%). Five interviews with Latino participants were conducted in Spanish, while the rest were conducted in English. The results are organized into the following themes relating to multilevel factors on oral PrEP and HIV risk behaviors: 1) conceptualization of HIV risk behaviors; 2) attitudes towards PrEP among participants and their social network; 3) hegemonic masculinity and mixed, diverse sexual networks; and 4) social and contextual factors. Fig 1 depicts these main themes, which were not mutually exclusive and instead informed one another. This figure demonstrates how factors influencing both HIV risk behaviors and oral PrEP use share characteristics, such as a participants’ beliefs around their own susceptibility to HIV.

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Table 1. Sociodemographic characteristics among Black and Latino Men with heterosexual contact in New York City, NY (n = 16).

https://doi.org/10.1371/journal.pone.0327677.t001

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Fig 1. Multilevel factors impacting HIV risk behaviors and oral PrEP use.

https://doi.org/10.1371/journal.pone.0327677.g001

Discussion

This study sought to qualitatively explore multi-level factors influencing oral PrEP uptake, adherence, and HIV risk behaviors among cisgender Black and Latino men who engage in heterosexual contact and receive care at an urban safety net hospital in New York City. In addition to broadly exploring barriers and facilitators to oral PrEP uptake and adherence, interviews revealed men’s interactions with their mixed and diverse sexual networks, which were informed by hegemonic masculinity [21–23]. HIV risk behaviors were also contextualized through participants’ experiences with social and structural factors such as substance use, trauma, and language barriers across their lives, indicating a need to better frame HIV risk through a trauma-informed, life course lens [24,25].

Partner- and gender-related factors were among the most prominent themes and sub-themes and impacted participants’ HIV risk behaviors and romantic and/or sexual networks. Women were often regarded as either inherently untrustworthy or riskier sexual partners, which thus influenced participants’ willingness to utilize protection or engage in sexual intercourse with women. HIV risk behaviors were deeply embedded in hegemonic masculine norms, ones which position women as subordinate with little power in matters involving sexual intercourse and relational decision making [23]. Relational power is a significant predictor of condom usage among women, with women with high levels of relationship power reporting higher levels of consistent condom use than those with low levels of relationship power [26]. Interventions should consider incorporating discussions of sexual health and decision at the interpersonal level between men and their partner, which in turn may contribute to broader societal efforts to address gender equity [7]. As both gendered norms and men’s perception of trustworthiness were critical factors for decisions around sexual intercourse and condom usage, providers may benefit from further educating men on their individual factors that increase HIV and STI transmission risk. For example, all men in the study were indicated for PrEP by their primary care providers, but most men did not explicitly make connections between their past STI histories and increased transmission risk.

Additionally, a closer inspection around the processes of hegemonic masculinity among US men may produce narratives that enhance conversations on how men resist and/or conform to gendered norms influencing HIV risk behaviors [27,28]. In particular, themes around hegemonic masculinity were juxtaposed with participants’ willingness to engage in and disclose information about concurrent sexual and romantic relationships with gay men, bisexual men, transgender individuals, and sex workers. Participant’s mixed sexual networks demonstrate that men with heterosexual contact may critically challenge societal assumptions that reinforce norms around sexual dominance over women. To this extent, participants were comfortable disclosing the mixed nature of their sexual and romantic networks, a notion to the idea that men are open to discussing sexual health behaviors antithetical to the pressures put forth by hegemonic masculinity [29]. Despite engaging in these diverse and mixed sexual networks, participants perpetuated stigmatizing attitudes towards the LGBTQ+ community, utilizing inconsistent terminology when referring to transgender populations and exhibiting compensatory behaviors to resist notions that they are gay. The study calls for more research in regards to these mixed sexual networks, as a lack of understanding around HIV risk behaviors among men with heterosexual contact in the U.S. may grossly underestimate the true transmission risk of STIs and HIV for this population. At the patient-provider level, providers are encouraged to directly ask patients about the nature of patients’ relationships, with an emphasis on avoiding gendered stereotypes of men who engage in heterosexual contact.

At the individual level, participants expressed limited health literacy around HIV. Men underscored their belief that they were not as at risk as sexual minority men and implicated HIV as a “gay disease.” The association of HIV with certain subpopulations is a historically-consistent paradigm, one that continues to stigmatize LGBTQ+ (Lesbian, gay, bisexual, transgender, queer, and other) populations, immigrant communities, and communities of color [30,31]. This paradigm was further reinforced through targeted advertisements of PrEP on social media and television, which participants noted were only directed towards men who have sex with men. Such stigmatizing beliefs are not only damaging to individuals with sexual minority identities but also inaccurate: numerous participants reported both heterosexual and non-heterosexual contact embedded in mixed sexual networks, which likely increased their risk of contracting HIV [32,33]. The dichotomization of men with heterosexual contact vs. sexual minority men fails to reflect the realities of sexual behavior among individuals with mixed sexual networks, and future research may benefit from interrogating whether current characterizations of these subpopulations are accurate.

Participants also exhibited limited understanding of PrEP use, with few describing the importance of consistent ingestion of oral PrEP and dual usage of PrEP and condoms. The dual usage of PrEP and condoms serves to provide the most comprehensive protection against HIV and STIs together and should be repeatedly emphasized as best practice to prevent transmission [34,35]. Of note, several participants demonstrated an understanding of on-demand PrEP, where participants would take oral PrEP before, immediately prior, and after sexual intercourse to reduce HIV transmission [36]. On-demand PrEP, if taken correctly, is in line with harm reduction principles, which aim to reduce the negative consequences of sexual intercourse [37,38]. As such, providers should continue to educate their participants on the consistent ingestion of oral PrEP and usage of condoms, while providing information on the potential utility of on-demand PrEP if taken as directed. for situations when participants may be unable to take oral PrEP daily.

In comparison to their limited understanding of PrEP participants overwhelmingly expressed positive attitudes towards PrEP. This finding may be unusual, as these positive attitudes deviate from behavioral health theories and understandings of hegemonic masculinity, which would suggest high levels of stigma and negative perceptions of PrEP as a medication “traditionally” designed for gay men who have sex with men. In this regard, future research may explore how hegemonic masculinity impacts oral PrEP use and related HIV risk behaviors among heterosexual men in the US context, as much of the extant literature has focused on countries such as South Africa with historically high rates of heterosexual HIV transmission [27]. While the study did not explicitly explore patient-provider factors impacting PrEP attitudes, positive PrEP attitudes may be driven by a welcoming, non-stigmatizing environment bolstered by positive patient-provider interactions in the clinic where this study was situated. Regardless of PrEP adherence, participants continued to return to this clinic and noted the role of the primary care providers in delivering patient-affirming care.

Finally, while this study focused on factors influencing oral PrEP uptake, adherence, and HIV risk, men openly disclosed their experience with sexual trauma when probed on their upbringings. Participants directly linked their sexual trauma and attitudes towards relationships, with one participant noting that they found solidarity with romantic and sexual partners who shared similar pasts. Disclosure of sexual trauma among men is a narrative that contradicts current understandings of the impact of trauma on men, as most literature has focused on the cycle of abuse: men experience physical abuse during their childhood and later perpetrate physical abuse themselves [39]. The ability to openly discuss sexual trauma provides opportunities to investigate the impact of sexual trauma throughout men’s lives and reject gendered norms suggesting men’s inability to talk about sexual victimization [40–42]. Additionally, this disclosure of men’s trauma may inform HIV risk behaviors, as extant literature underscores the strong association between traumatic experiences and the use of substances as a coping mechanism [43]. In turn, substance use may increase the likelihood of engagement in HIV risk behaviors [44]. Care may be improved if providers considered the impact of sexual trauma on men such as by embracing the best practices of trauma-informed care [45], as the life course impacts of such violence may influence HIV risk behaviors and interpersonal relationships. In this process, providers may benefit from receiving guidance around the best practices of trauma-informed care focused on providing patient-centered care and minimizing the potential of harmful interactions in health-care settings in the process of trauma disclosure [45].

This study has several limitations. While authors were able to observe differences across English and Spanish-speaking participants, language of interview is a proxy for immigration status and acculturation. Rather, future studies may benefit from utilizing a socioecological framework to better capture the various dimensions of individuals (e.g., religious, linguistic, cultural, political) and environmental factors across subgroups [46,47]. Our study could have also benefited from the application of an explicit intersectional framework to inform the development of the interview guide, as the inclusion of Spanish-speaking participants lends itself to an analysis of how multiple marginalization produces compounding outcomes for individuals—especially for those who may be immigrants with limited English proficiency and low socioeconomic status. Further, our study population is one that is already engaged in care and may miss or underreport important vulnerabilities experienced by populations who have challenges in accessing and engaging in care.

In spite of these limitations, our study has several strengths. While previous studies on oral PrEP have primarily focused on men who have sex with men, transgender women of color, or individuals who inject substances, our study elicits the voices of cisgender Black and Latino men with heterosexual contact, which includes immigrants and limited English proficient Spanish speakers. Our analysis highlights how hegemonic masculinity and experiences across the life course shape the role of communal and societal norms in influencing men’s HIV risk behaviors and oral PrEP usage. Our results may facilitate HIV prevention by providing insights that increase effective use of oral PrEP and that reinforce the importance of multilevel interventions at the patient-provider, interpersonal, and communal level towards e fairer gender norms, greater self-sufficiency for sexual health decisions, and improved health literacy. Overall, this study fills an important gap in literature on oral PrEP use among men with heterosexual contact in the U.S., and future PrEP research and interventions should continue to include this population so as to reach the U.S.’s collective goal of ending the HIV epidemic by 2030 [15].

Supporting information