Let Them Talk: Coping with PrEP-Related Stigma and Sustaining PrEP Persistence Among Men Who Have Sex with Men in...

Background: Pre-exposure prophylaxis (PrEP) offers over 99% protection against HIV when used consistently, but stigma continues to undermine persistence in care. While much research has described the external manifestations of PrEP-related stigma, less is known about how individuals cope with these stigmas and how such coping processes influence persistence. Guided by Social Cognitive Theory, this study examined the psychosocial strategies men who have sex with men (MSM) in Tanzania use to cope with PrEP-related stigma and sustain persistence in care. Methods: Thirty-two in-depth interviews were conducted with purposefully selected MSM aged 18-38 years at Ngamiani Health Centre in Tanga region. The sampling included both persistent and non-persistent PrEP users with variation in age and sexual position preferences. Participants were sampled for variation in persistence status (persistent and non-persistent), age, and sexual position preference to capture heterogeneity in stigma experiences and coping processes. Interviews were conducted in Kiswahili, audio-recorded, transcribed, translated, and analyzed using reflexive thematic analysis. Results: Participants described PrEP-related stigma as socially constructed through narratives that equated PrEP with HIV treatment, labeled it a "gay pill," associated it with promiscuity, or linked it to bodily harm or increased HIV risk. These stigmas impact persistence in care through discouraging clinic visits and daily pill taking. However, some participants remained persistent in care despite stigma by using protective mental strategies such as personal agency, mental time travel, and affirmation from supportive social connections, which buffered emotional impacts and sustained persistence. Conclusions: Persistence in PrEP care is shaped not only by stigma in the social environment but also by how individuals interpret and respond to it. Interventions should therefore combine structural stigma-reduction efforts with mental health-informed strategies that strengthen agency and supportive social relationships to sustain PrEP engagement among MSM.