The Role of PrEP Initiation on Depression Severity, HIV-Related Anxiety, HIV Stigma, and PrEP Stigma Among Sexual Minority Men in Singapore: Findings from a Prospective Cohort and Longitudinal Mixed-Methods Study.

This longitudinal concurrent mixed-methods study examined the impact of initiating HIV pre-exposure prophylaxis (PrEP) on depression severity and HIV- and PrEP-related stigma among gay, bisexual, and other men who have sex with men (GBMSM) in Singapore. A cohort of 53 HIV-negative, GBMSM was followed over 12 months, utilizing repeated quantitative assessments and in-depth qualitative interviews to explore psychosocial outcomes and lived experiences. Quantitative analyses revealed significant reductions in depressive symptoms (adjusted coefficient = -1.55; 95% CI: -2.81, -0.29), HIV-related stigma (-2.26; 95% CI: -4.20, -0.32), and PrEP-related stigma (-2.08; 95% CI: -3.35, -0.81), with the most pronounced improvements observed at the 12-month follow-up compared to baseline and 6-month assessments. Qualitative findings highlighted PrEP's role in alleviating HIV transmission anxiety, enhancing sexual confidence, and fostering a greater sense of agency in participants' health management. Although anxiety was not directly quantified, participants' narratives supported its relief as a psychological benefit of PrEP. Nevertheless, external stigma, particularly the perception of PrEP users as promiscuous persisted, representing a substantial barrier to uptake and adherence. While some participants expressed concerns about risk compensation behaviours, such as reduced condom use, these apprehensions were not corroborated by longitudinal behavioural data. Importantly, PrEP initiation contributed to destigmatization of individuals living with HIV, as participants reported a shift toward greater empathy and openness in their sexual and social relationships. These findings underscore PrEP's dual utility as both a biomedical intervention and a psychological support mechanism. To maximize its public health impact, targeted educational campaigns and culturally tailored stigma reduction strategies, such as, (1) public education to dispel myths about PrEP users, (2) integration of PrEP counselling into primary care and sexual health services, (3) training for healthcare providers on LGBTQ + affirming practices, and (4) financial subsidies to improve affordability. These efforts are critical for promoting PrEP uptake and adherence in Singapore and similar sociocultural settings. This study highlights the multifaceted benefits of PrEP, advocating for its prioritization within comprehensive HIV prevention strategies in the region.