From 2014 to 2018, new annual HIV diagnoses in the United States decreased from 40,836 to approximately 37,000, with almost all at-risk populations experiencing declines. However, young Black and Latinx sexual minority men (YBLSMM) continue to experience a disproportionate burden of new HIV infections. In 13–24 year old sexual minority men (SMM), Black/African American and Hispanic/Latinx accounted for the highest percentage of new HIV diagnoses (52% and 27%, respectively) [1]. Pre-exposure prophylaxis (PrEP) with oral tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) is highly effective at preventing new HIV infections [2]. However, data of SMM in the United States supports unequal PrEP access, uptake, and persistence across different ages, races, and ethnicities [3–9]. Of 78,360 PrEP users in 2016, only 11.2% were Black/African American and 13.1% were Hispanic [10]. Reasons identified for low PrEP uptake among YBLSMM include concerns about side effects, perceived high cost, limited access, and stigma [11–14].

Social determinants may also contribute to low PrEP uptake among YBLSMM. The uptake of biomedical prevention tools and health services in general has been shown to be impacted by unmet social determinants of health (SDOH) needs [15]. These include basic needs (e.g., food, shelter, water), health/social service needs (e.g., healthcare), and economic needs (e.g., money for savings). Socioeconomic factors identified to affect PrEP uptake in the general population included lack of insurance, difficult access to transportation, and inflexible work situations [16, 17]. Individuals with more unmet SDOH needs may have other priorities that divert their focus from obtaining preventative health services [18].

Young SMM have substantial financial hardship and SDOH needs, which may impact their health service utilization [15]. However there is a paucity of information about SDOH needs among HIV-negative YBLSMM. Additionally, there is little known about associations of SDOH needs with PrEP uptake in YBLSMM. Our research investigated associations of SDOH needs with both intention to use and current use of PrEP in a sample of YBLSMM. We hypothesized that more unmet SDOH needs would be associated with lower proportions of both intention to use and current use of PrEP.

In one of the first studies exploring the relation of PrEP adoption with SDOH needs among mostly YBLSMM, we found that almost all participants had some unmet needs. We further found that among those not currently using PrEP, intention to use PrEP was associated with greater unmet basic and economic SDOH needs. Surprisingly, we did not observe any associations between PrEP use and SDOH needs.

Individuals with greater unmet SDOH needs are vulnerable to adverse health related outcomes due in part to chronic stressors in daily living [20]. Associations have been seen between chronically stress-inducing life experiences (e.g., socioeconomic disadvantages) and sexually transmitted infection acquisition [21, 22]. Our results suggest that YBLSMM with unmet SDOH needs believe that they would benefit from using PrEP, likely due to concomitant unmet sexual healthcare needs. However, the higher rates of unmet SDOH needs may leave this population without resources to move from intention to action. Research has shown that individuals often forego PrEP due to pressing requirements of daily life, such as employment demands, housing insecurity, or other social hardships [23–25]. The findings from this study underscore the importance of previous recommendations to assess SDOH needs in at risk populations for optimized health intervention benefit. For example, prior research demonstrates that improving housing and neighborhood quality can reduce HIV risk [26]. Additionally, more holistic support may improve PrEP use, as implementation of client centered care addressing social and material needs was associated with high PrEP uptake (79%) in Black men who have sex with men [27, 28]. Such targeted interventions however have not been evaluated in YBLSMM. Examining the impact of SDOH interventions paired with PrEP outreach in YBLSMM may provide valuable insight to addressing discrepancies between intent and use. Nevertheless, our findings help fill a critical void in the literature regarding the impact of SDOH on PrEP adoption in YBLSMM.

Unexpectedly, there were no significant differences in mean SDOH needs scores between current PrEP use and not currently taking PrEP. This may have likely been due to the low PrEP use (n = 29) and relative homogeneity of unmet SDOH needs in this sample, suggesting that people with unmet SDOH needs may need to prioritize other concerns over PrEP. New York City contains a large and robust network of social and medical services, including outreach programs for young SMM and numerous LGBTQ-competent/affirming, Medicaid-accepting or low cost/free medical providers [29]. Among participants in this study, health and social service needs were more likely than other needs to be met all of the time, suggesting that YBLSMM in New York City may be able to access healthcare despite other unmet needs [30]. However, despite access to healthcare, PrEP uptake remained low in our sample, signifying that additional strategies are needed to overcome barriers to PrEP use.

Our findings should be interpreted in the context of this study’s limitations. Given the cross-sectional design, causality cannot be inferred; longitudinal studies would be helpful to understand potential downstream impacts of unmet SDOH needs on PrEP uptake. Participants in this study were all in a similar age range, recruited online, and based in New York City, potentially limiting generalizability to other settings. Given the low PrEP use in this sample, studies with larger YBLSMM samples may help to further elucidate associations between PrEP use and SDOH needs. We conducted this survey in English, and thus findings may not be generalizable to YBLSMM who are not fluent in English, and who may have more unmet SDOH needs.

Overall, YBLSMM in this study had high unmet SDOH needs and low PrEP uptake. Intention to use PrEP among YBLSMM is a likely marker of unmet SDOH needs, as YBLSMM with unmet needs may have limited resources to move from intention to action. Recognizing this association is crucial for effective care delivery in this population. Future research should evaluate programs engaging YBLSMM intending to use PrEP with interventions to screen for and address SDOH.

We thank all the participants and Nataly Rios for their contributions to this study.