Intimate Partner Violence Perpetration and PrEP Use Among Sexual Minority Men: The Mediating Roles of Internalized Homonegativity and PrEP Stigma

Abstract

Cisgender sexual minority men (SMM) report intimate partner violence (IPV) at rates comparable to or higher than heterosexual cisgender women, often linked to increased HIV risk. This study explores the relationship between IPV perpetration and pre-exposure prophylaxis (PrEP), considering the potential mediating effects of sexual orientation related minority stress and PrEP stigma. Utilizing baseline data from the Empowering Relationships and Opportunities for Safety (EROS) cohort, this cross-sectional study examined survey data from partnered cisgender SMM in the U.S. Through online and community recruitment, participants were assessed for IPV perpetration using a validated measure, while internalized homonegativity and related stigma were evaluated through standardized scales. Current PrEP use was assessed through self-report and confirmed through dried blood spot assays. Of the 500 participants, 125 (25%) reported IPV perpetration, with perpetration of identity-related IPV (e.g., threatening to out a partner to family or coworkers; telling partner to act straight) significantly higher among non-PrEP users; mean number of identity-related IPV perpetration items endorsed was 0.21 (SD = 0.53) among non-PrEP users compared to 0.02 (SD = 0.14) among PrEP users. Perpetration of identity-related IPV was positively correlated with internalized homonegativity (r =.19, p <.001), experienced sexual orientation discrimination (r =.15, p <.01), and PrEP stigma (r =.14, p <.001). A logistic regression mediation analysis found that, separately, internalized homonegativity (OR = 0.97, 95% CI [0.94-0.99]) and PrEP stigma (OR = 0.48, 95% CI [0.40, 0.57]) had significant associations with PrEP use, and that each mediated the relationship between perpetration of identity-related IPV and PrEP use as demonstrated by their significant indirect effects (OR = 0.88, 95% CI [0.78, 0.98] and (OR = 0.77, 95% CI [0.60, 0.98], respectively). The study underscores internalized homonegativity and PrEP stigma as critical mediators of the relationship between perpetration of identity-related IPV and PrEP use among SMM. Findings call for interventions aimed at reducing internalized homonegativity, PrEP stigma and enhancing PrEP access while addressing IPV dynamics. Future research should further delineate these pathways to inform culturally sensitive interventions promoting health equity among SMM.

Keywords: HIV pre-exposure prophylaxes (PrEP); Internalized homonegativity; Intimate partner violence (IPV); PrEP stigma; Sexual minority men (SMM).