CME
Physicians: maximum of 1.00 AMA PRA Category 1 Credit
Released: June 09, 2025
Expiration: June 08, 2026
Introduction
In this didactic module, Iskandar Azwa, MD, discusses how to address HIV pre-exposure prophylaxis (PrEP)–related stigma and explores strategies for reducing barriers to PrEP uptake with a focus on the Asia Pacific region. Key points in this module are illustrated with thumbnails from the accompanying downloadable PowerPoint slideset, which can be found here or downloaded by clicking any of the slide thumbnails in the module alongside the expert commentary.
Case: Addressing PrEP Stigma
I would like to start off with a case study on addressing PrEP stigma.
In this example, Dr Wong is a primary care provider committed to offering and scaling up PrEP as a key HIV prevention option in his practice. Yet he encounters a number of stigma-related challenges, especially when discussing other HIV prevention strategies like condom use alongside PrEP.
Some patients expressed concerns that using PrEP without condoms will be perceived by healthcare professionals (HCPs) as sexually irresponsible.
In addition, some colleagues are hesitant to discuss condomless sex with PrEP users or potential PrEP users. They may insist that condoms and PrEP must be used together for HIV prevention, thereby reinforcing the stigma around patient choices.
In this module, we will explore reasons behind this PrEP-related stigma and explore strategies for open-minded, impartial discussions about PrEP.
Understanding Stigma
So, what is stigma? Stigma is defined as possessing personal characteristics or attributes that confer a negative judgment or value and are considered socially discrediting.
Stigma can take various forms. Relevant to this module is sexual stigma, which is the result of negative attitudes toward individuals based on attributes around sex such as sexual behavior, orientation, or gender identity.1,2
There is also intersectional stigma, which refers to the overlapping forms of stigma that individuals experience because of possession of multiple marginalized identities or social positions, such as race, gender, sexual orientation, HIV status, or socioeconomic status. Intersectional stigma is based on a concept introduced by legal scholar Kimberlé Crenshaw, which highlights how various forms of social inequality exist separately but have interwoven effects.1-3
An example of intersectional stigma in the setting of HIV care and prevention may be a gay man living with HIV who faces increased HIV-related stigma because he is a sexual minority.1,2
PrEP stigma is linked to HIV stigma because PrEP is designed to prevent HIV infection. PrEP is also linked to sexual stigma because it is associated with the idea of enabling sexual pleasure and expression with less risk. As a result, PrEP users are often unfairly stereotyped as being sexually irresponsible and promiscuous.1,2
The discussion around PrEP and condoms has historically served as the basis of classifying sex as either “safe” or “unprotected.” Despite being a more effective form of HIV prevention than condoms, PrEP is sometimes considered an inferior HIV prevention choice to condoms because it is perceived as the less responsible choice.1,2
PrEP users are sometimes seen as wanting to engage in condomless sex, which serves as a stand-in for other risky behaviors. This is known as “risk compensation.” This includes changes in sexual activity resulting from a decrease in HIV susceptibility such as reduced condom use or increased number of sexual partners, and is often regarded unfavorably.1,2
PrEP Stigma Remains at an All-Time High
Unfortunately, PrEP stigma is still very prevalent in the Asia Pacific region. I observed this personally when the Malaysian Ministry of Health (MOH) decided to scale up PrEP in the public sector after many years of effort on the part of HIV HCPs to convince the MOH to do so.
Unfortunately, this decision hit religious fault lines, triggering a huge backlash, particularly by religious scholars, academics, and doctors who were not in line with PrEP. The debate about the public health perspective of preventing HIV vs the moralistic perspective of preventing promiscuity continued for a long time.4
However, this is not the first time a public-health initiative has encountered backlash because of stigma. For example, Malaysia has a successful harm-reduction program that expanded opioid substitution therapy use and implemented a needle syringe program. This program initially faced similar backlash from religious scholars and the MOH, but eventually attained great success.4
Ultimately we can learn lessons from these other public-health initiatives and apply those lessons to PrEP.
Stigma as a Barrier to PrEP Uptake
How does stigma act as a barrier to PrEP uptake?
Fear of judgmentdiscourages PrEP uptake and persistence. The fear of judgment is largely tied to the stereotype of PrEP users being perceived as sexually irresponsible, promiscuous, or immoral.2
Risk-based PrEP implementation strategies that focus on risk behaviors of key populations can also perpetuate stigma.
Concerns about sexual risk compensation can make HCPs less willing to prescribe PrEP.2
This PrEP stigma has the potential to undermine policy, funding, and infrastructure that support PrEP implementation and enable PrEP access for potential beneficiaries. PrEP stigma also can lead to misconceptions about who “deserves” PrEP, thereby preventing key populations such as sexual minorities or people who inject drugs from accessing it.2
Using an HIV Status–Neutral Approach Can Shift Paradigms of HIV Treatment and Prevention
One way of reducing PrEP stigma, which has been proposed across a number of settings, is an HIV status–neutral approach.5
This approach shifts the messaging and programming paradigms of HIV treatment and prevention. It all begins with an HIV test, followed by active engagement in care regardless of a person’s HIV status. Those who test positive for HIV are engaged in treatment and antiretroviral therapy right away, whereas those who test negative for HIV are immediately engaged in HIV prevention, be it PrEP or postexposure prophylaxis.5
Ultimately, a status-neutral approach leads people both with and without HIV to a final common stage of being continuously engaged in clinical care with negligible risk of either transmitting or acquiring HIV.5
Strategies for Prescribers to Address PrEP Stigma
But what can we as HCPs do to ensure stigma-free communications around PrEP?
It all starts with being comfortable taking a sexual history. We need to ask sensitive questions about sex, and many HCPs do not feel at ease doing that. It is critical that HCPs feel comfortable having open, unbiased conversations with patients about sexual health. Sexual health is healthcare, and treating it as such will help relieve stigma.1,6
Of more importance, HCPs should normalize discussions about PrEP as an HIV prevention option for all sexually active patients as part of routine care. This means moving that conversation away from a risk-based assessment. Taking risk out of the equation will help dismiss the notion that PrEP is reserved only for people engaging in high-risk behaviors.1,6
HCPs should also talk about sexual pleasure and satisfaction as an integral part of sexual health, rather than relegating it to a discussion about the absence or presence of sexually transmitted infections. Integrating sexual pleasure into sexual health is a major part of addressing sexual stigma.7
On a more basic level, providing nonjudgmental, culturally sensitive care is also key to addressing stigma. HCPs should use inclusive language and shared decision-making to empower patients and build confidence in the healthcare system.
By inclusive language, I mean words that respect and acknowledge all people, regardless of their gender, sexual orientation, race, and ethnicity. For example, inclusive language is using the word “partner” rather than “boyfriend” or “girlfriend.” This gender-neutral word implies acceptance with whomever the person has an intimate relationship.1,8
Finally, HCPs should use positive “gain-framing” messaging about PrEP, focusing on empowerment and health promotion in a sex-positive way, framing discussions as gains and benefits. Focusing on the benefits that PrEP can afford patients, such as increased intimacy and reduced HIV anxiety, is important for dispelling PrEP stigma and bringing patients forward to seek PrEP.9
In all, concerns about risk compensation and changes in sexual behavior do not medically justify withholding information or access to PrEP.
Ensuring Stigma-Free Communications Around PrEP
As we have rolled out PrEP, we have found that it is important to get the messaging about “safer sex” right.
The messaging about safe sex while on PrEP needs to evolve so that patients are not stigmatized by HCPs for not using condoms. I believe that HCPs should encourage the use of condoms as an option to prevent other sexually transmitted infections but should be clear that this is not necessary to prevent sexual transmission of HIV while on PrEP.1,6,7
Creating safe spaces in clinic and promoting representation and visibility of key populations can also promote stigma-free communication about PrEP. Creating an environment where all patients feel comfortable will help facilitate open discussion.1,6
I also think it is important to provide HCPs antistigma training and sensitization to reduce biases and improve cultural competence. Getting the community and community leaders involved can also promote positive messaging.1,6,8,9
Framing PrEP as a Positive Health Choice
How do we best frame PrEP as a positive health choice? How should HCPs respond when patients express fear of judgment for taking PrEP?
First, HCPs can emphasize that taking PrEP is about empowerment and self-care, not risk. PrEP can empower people to take charge of their sexual health, rather than relying on partners to use condoms.10-12
HCPs should not dismiss the fear of judgment but should acknowledge that there is stigma associated with PrEP. However, the conversation should be focused on reinforcing the benefits of PrEP, including feeling safer during sex, less anxiety, and developing stronger relationships.10-12
Similar to normalizing conversations about PrEP and sexual health, presenting PrEP as a routine prevention option for all sexually active persons—similar to contraception and HPV vaccines—will help reduce stigma.10-12
Finally, acknowledging that real-world data show that PrEP users do not always increase their overall risk-taking behaviors can help to show that PrEP is a net positive for public health.10-12
Normalizing Condomless Sex in PrEP Discussions
In conclusion, HCPs should work to normalize condomless sex in PrEP discussions. We should reframe the discussion to focus on patient autonomy and shared decision-making, emphasize that PrEP is highly effective in preventing HIV with or without condoms, and use neutral language that does not imply moral judgment about condom use.1,2,13
In terms of patient autonomy, it is important to acknowledge that many people use PrEP because they may not be completely satisfied with condoms to prevent HIV.
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