The PrEP Cascade in a National Cohort of Adolescent Men Who Have Sex With Men

Pre-exposure prophylaxis (PrEP) has been an available biomedical intervention for at-risk adolescents for over 2 years; however, progression from awareness to uptake and adherence has been slow. In response, we map adolescent men who have sex with men (AMSM) onto the PrEP Motivation Cascade to identify stages for intervention. We analyzed PrEP-related attitudinal and behavioral data from a US national cohort of 1398 AMSM. A majority of the sample (53.9%) were identified as appropriate PrEP candidates. Of those identified as appropriate candidates, 51.8% were precontemplative (stage 1; unwilling to take or believing they were inappropriate candidates for PrEP), and 48.2% reached contemplation (stage 2; willing and self-identified as appropriate candidates). Only 16.3% of candidates reached preparation (stage 3; seeing PrEP as accessible and planning to initiate PrEP), and 3.1% reached PrEP action (stage 4; prescribed PrEP). Although few of the AMSM identified as appropriate candidates were on PrEP, most users (87%) reported high adherence to 4+ doses per week (stage 5; PrEP maintenance). Factors associated with reaching later stages were being older, being out to parents, and engaging in previous HIV/sexually transmitted infection testing. AMSM PrEP use falls short of recommended levels. PrEP campaigns are needed to raise awareness by targeting key AMSM subgroups that underestimate the appropriateness of use. Equally important, parents and health providers of AMSM should serve educational roles to help facilitate potential PrEP uptake, by motivating adolescents and giving them the skills needed to request, fill, and adhere to a prescription.