AIDS Behav (2016) 20:14351442

DOI 10.1007/s10461-016-1353-6

ORIGINAL PAPER

Correlates of Awareness of and Willingness to Use Pre-exposure

Prophylaxis (PrEP) in Gay, Bisexual, and Other Men Who Have
Sex with Men Who Use Geosocial-Networking Smartphone
Applications in New York City
William C. Goedel1,2,3 Perry N. Halkitis1,2,4,5,6 Richard E. Greene6,7

Dustin T. Duncan1,2,4,5,6,8

Published online: 10 March 2016

Springer Science+Business Media New York 2016

Abstract Geosocial-networking smartphone applica-
tions are commonly used by gay, bisexual, and other men
who have sex with men (MSM) to meet sexual partners.
The purpose of the current study was to evaluate aware-
ness of and willingness to use pre-exposure prophylaxis
(PrEP) among MSM who use geosocial-networking
smartphone applications residing in New York City.
Recruitment utilizing broadcast advertisements on a
popular smartphone application for MSM yielded a sam-
ple of 152 HIV-uninfected MSM. Multivariable models
were used to assess demographic and behavioral corre-
lates of awareness of and willingness to use PrEP. Most
participants (85.5 %) had heard about PrEP but few
& William C. Goedel
william.goedel@nyu.edu
1
Department of Population Health, School of Medicine,
New York University, 227 East 30th Street, New York,
NY 10016, USA
2
College of Global Public Health, New York University,
New York, NY, USA
3
Department of Sociology, College of Arts and Science,
New York University, New York, NY, USA
4
Center for Drug Use and HIV Research, College of Nursing,
New York University, New York, NY, USA
5
Population Center, College of Arts and Science, New York
University, New York, NY, USA
6
Center for Health, Identity, Behavior, and Prevention Studies,
College of Global Public Health, New York University,
New York, NY, USA
7
Department of Medicine, School of Medicine, New York
University, New York, NY, USA
8
Center for Data Science, New York University, New York,
NY, USA
(9.2 %) reported current use. Unwillingness to use PrEP
was associated with concerns about side effects
(PR = 0.303; 95 % CI 0.130, 0.708; p = 0.006). Given
that more than half (57.6 %) of participants were willing
to use PrEP, future research is needed to elucidate both
individual and structural barriers to PrEP use among
MSM.
Resumen El uso de los aplicaciones de telefonos inte-
ligentes es comun entre los homosexuales, bisexuales, y
otros hombres que tienen sexo con hombres (HSH) para
cumplir con las parejas sexuales. El objetivo del estudio
fue evaluar la conciencia y la voluntad de utilizar la
profilaxis pre-exposicion (PrEP) entre los HSH que usan
aplicaciones para telefonos inteligentes que residen en la
ciudad de Nueva York. El reclutamiento se utilizan
anuncios de difusion en una aplicacion para telefonos
inteligentes popular para los HSH dio una muestra de 152
HSH sin VIH. Modelos multivariables se utilizaron para
evaluar los correlatos demograficos y conductuales de la
conciencia y la voluntad de utilizar PrEP. La mayora de
los participantes (85.5 %) eran conscientes de PrEP, pero
u poco (9.2 %) reportado el uso actual. Renuencia a usar
PrEP se asocio con preocupaciones sobre los efectos
secundarios (PR = 0.303; 95 CI 0.130, 0.708;
p = 0.006). Dado que mas de la mitad (57.6 %) de los
participantes estaban dispuesto a utilizar PrEP, se nece-
sitan investigaciones futuras para dilucidar las barreras
individuales y estructurales del uso de PrEP entre los
HSH.
Keywords Gay mens health
Men who have sex with
men (MSM)
Pre-exposure prophylaxis (PrEP)

Geosocial-networking smartphone applications

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1436
Introduction
As the number of new HIV infections continues to rise in
the United States [especially among gay, bisexual, and
other men who have sex with men (MSM)], many
researchers have begun to develop new bio-behavioral
interventions to prevent HIV transmission. In November
2010, the iPrEx trials demonstrated that oral pre-exposure
prophylaxis (PrEP) with a once-daily tablet containing
tenofovir disoproxil fumarate and emtricitabine (TDF/
FTC) reduced the risk of HIV infection among at-risk
MSM by 44 % relative to a placebo [1]. In the experi-
mental arm, the relative risk of HIV infection was reduced
by 92 % in subjects with detectable levels of the drug
compared to those without detectable levels of the drug [1].
Later in 2012, the drug received approval from the Food
and Drug Administration (FDA) for use as PrEP for pre-
venting HIV infection [2]. Most recently, referrals for and
initiation of PrEP have increased dramatically in a larger
clinical practice setting in San Francisco, California since
2012, and despite high rates of sexually transmitted
infections in this sample of 657 PrEP users, there were no
new HIV infections in this population, showing PrEP to be
highly effective in clinical practice [3].
Despite demonstrated cost effectiveness on a population
level [46], PrEP uptake in clinical practice appears to be
low [7] amidst growing concerns portrayed in mainstream
media sources [811] that PrEP use would result in reduced
condom use and HIV testing. In one study of MSM in New
York City, 70 % reported a willingness to use PrEP, and
only 35 % of willing individuals reported that they would
be likely to decrease condom use while on PrEP [12]. A
more recent study of MSM in New York City found that
awareness of PrEP increased over time following the
release of the results of the iPrEx trials in 2011 [1], FDA
approval in 2012, and social media campaigns both for and
against PrEP in 2013 [13], but willingness to use PrEP and
the perceived impact of PrEP on condom use did not
change [14]. In the iPrEx trials, believing one was
receiving the drug was not associated with an increase in
condomless receptive anal intercourse from baseline
through follow-up [15].
Similar to condom use, PrEP use is affected by aware-
ness, affordability, and adherence [16]. Awareness has
increased with time. In 20062007, only 36.0 % of a
sample of MSM recruited at two New York City bath-
houses were aware of non-occupational post-exposure
prophylaxis (nPEP) or PrEP [17], but this survey did not
differentiate between these two prophylactic approaches. In
another study of MSM in New York City, the percentage of
those having heard of PrEP increased from 53.0 % in 2011
to 72.4 % in 2013 [14]. However, the percentage of those
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AIDS Behav (2016) 20:14351442
willing to use PrEP remained relatively stable, with a
moderate increase from 45.5 % in 2011 to 48.3 % in 2013
[14]. With regard to affordability, in a study of MSM
presenting for HIV testing in San Diego, California who
were offered PrEP and education about potential efficacy,
the most common reason for declining was feeling that the
drug was too expensive [18].
Given potential difficulties in adhering to the daily
medication regimen, many researchers have begun to
investigate the efficacy and acceptability of alternative
methods of delivering the medication. For example, among
a sample of 197 young MSM in New York City, 79.2 %
favored a long-acting injectable form of PrEP every 3
months over a daily pill [19]. In a large sample of MSM in
North America, having had planned sexual encounters in
the last 3 months was associated with a preference for
event-based PrEP, while having frequent or unplanned
condomless anal intercourse was associated with a prefer-
ence for daily or time-driven PrEP regimens [20]. Recent
clinical trials in the United Kingdom [21] and France [22]
have noted that both daily and intermittent dosing of the
medication are effective in reducing the incidence of HIV
among at-risk MSM compared to placebo groups.
Recently, geosocial-networking smartphone applica-
tions (apps) have increased in use among MSM to meet
sexual partners [2326]. For example, a study among MSM
in Washington, DC found that 63.6 % reported having used
an app to meet a sexual partner in the past year [27]. These
apps utilize global positioning system (GPS) technology to
form connections between users based on their current
locations [28]. These new technologies have generated
quicker and easier ways for MSM to meet potential part-
ners, and may facilitate a users ability to have multiple
concurrent partners, thereby increasing their risk for
acquiring HIV [26, 29, 30]. Importantly, in September/
October 2014, the New York City Department of Health
and Mental Hygiene began using broadcast advertisements
on two apps commonly used by MSM to advertise PrEP as
a new strategy for preventing HIV transmission [31].
Additionally, 45.5 % of MSM sampled from one of these
apps encountered a partner who had disclosed PrEP use on
the app [32].
There is a documented increased risk for testing positive
for sexually transmitted infections (STIs) such as gonor-
rhea and chlamydia in MSM who meet partners via
smartphone applications compared to those who met part-
ners using other methods (e.g. Internet, in-person) [28]. As
such, they may represent a subset of MSM at increased risk
for acquiring HIV. Given that PrEP is recommended for
MSM with multiple partners and previous diagnoses with
STIs, MSM who use smartphone applications may repre-
sent a group where PrEP may be highly suitable. To our
AIDS Behav (2016) 20:14351442
knowledge, no prior studies have examined PrEP aware-
ness, use, and willingness to use PrEP in MSM who use
smartphone applications in New York City. Therefore, the
purpose of the current study was to assess demographic and
behavioral correlates of PrEP awareness, use, and will-
ingness to use PrEP among MSM who use geosocial-net-
working smartphone applications residing in New York
City.
Methods
Sample Recruitment
Recruitment procedures have been described previously
[33, 34]. Broadcast advertisements on a popular geosocial-
networking smartphone application among MSM were
used to recruit users. In brief, an advertisement with text
encouraging the user to click through the advertisement
and complete a web-based survey was shown. In this time,
380 users clicked through the advertisement and 298 users
(78.4 %) provided informed consent and began the survey,
where 175 users completed the survey, representing an
overall response rate of 46.1 %. All protocols were
approved by institutional review board prior to data col-
lection. All respondents reported being at least 18 years old
at the time of survey administration.
Measures
Sexually Transmitted Infections and Sexual Behaviors
Participants indicated the total number of partners with
whom they had receptive anal intercourse (RAI) and with
whom they had insertive anal intercourse (IAI) in the
preceding 3 months. For both behaviors, participants were
then asked with how many of these partners they did not
use a condom in the preceding 3 months, hereby referred to
as condomless RAI (CRAI) and condomless IAI (CIAI).
All sexual behavior variables were then dichotomized as 0
partners and 1 or more partners. HIV status was assessed
based on self-report as positive, negative, or unknown/
never tested. History of STIs was assessed through self-
report, where participants reported whether or not they had
been treated for or diagnosed with chlamydia, gonorrhea,
or syphilis in their lifetimes.
Pre-exposure Prophylaxis Awareness
Current awareness of PrEP as an HIV prevention strategy
was assessed in two items. Firstly, participants were given
the following information: There is a new prescription
medication that people who are HIV-negative can take
1437
every day to lower their risk of acquiring HIV, and then
asked Have you ever heard of this medication? with
response options categorized as yes or no. Participants
reporting ever hearing about PrEP were asked where they
heard about this medication, with response options
including a friend, in the media, from a medical provider,
from a sexual partner, or online.
Current Pre-exposure Prophylaxis Use
Participants were then asked if they had ever taken PrEP.
Participants reporting current non-use were asked to select
their reasons for non-use from a list of three options, with
response options categorized as selected or unselected for
each reason. These reasons included concern about the
potential side effects, not knowing where to access the
medication, and believing one could not afford them.
Willingness to Use Pre-exposure Prophylaxis
Individuals were asked how willing they were to use PrEP
in the future if they reported no current use of the medi-
cation. There were seven response options including very
willing, willing, somewhat willing, undecided, somewhat
unwilling, unwilling, and very unwilling. Responses were
grouped as willing, undecided, and unwilling for analytical
purposes.
Demographic Characteristics
Age was measured continuously and then categorized as
1825, 2630, 3140, 4150, and 5160 years. Race/eth-
nicity was categorized as White, Black/African American,
Hispanic/Latino, Asian/Pacific Islander, and multiracial/
other. Sexual orientation was categorized as gay, bisexual,
straight, or other. Educational attainment was categorized
as completing less than 12th grade, high school, some
college, a Bachelors degree, or a Masters degree or
higher. Individual income was categorized as less than
$25,000; $25,000 to $49,999; $50,000 to $74,999; and
$75,000 or higher.
Statistical Analyses
Recruitment utilizing broadcast advertisements yielded an
overall sample size of 175 participants. Given that PrEP is
used as a strategy to prevent new cases of HIV infection, 23
participants who reported being HIV-positive were exclu-
ded from these analyses, thus restricting the analytic
sample to 152 HIV-uninfected MSM. All analyses were
performed in IBM SPSS Version 21.0 in JulyNovember
2015. First, descriptive statistics were calculated. Bivari-
able associations between PrEP-related variables and
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1438
demographic variables and sexual behaviors were assessed
using Chi square tests of independence.
While the most common method of modeling binomial
and multinomial outcomes respectively are binary logistic
regression and multinomial logistic regression, the odds
ratios derived from these models may overestimate the
prevalence ratios when working with frequent outcomes
[35, 36]. Given that our outcomes of interestPrEP
awareness and willingness to use PrEPwere common
among the sample (85.5 and 57.6 %), we fit a log-binomial
model for PrEP awareness and a log-multinomial model for
willingness to use PrEP with coefficients exponentiated to
prevalence ratios (PRs). Continuous variables were trans-
formed into categorical variables as described above to be
used as predictors in multivariable models as continuous
variable are a potential cause for model misbehavior (e.g.,
non-convergence) when using log-binomial and log-
multinomial regressions [37]. Significance was determined
by 95 % confidence intervals (CIs) and p \ 0.05.
Results
Sample Demographics
Demographic characteristics of the sample are reported in
Table 1. The average age in the sample was 29.59
(SD = 8.99), where 42.8 % were between 18 and 25 years
old. A majority of participants (83.6 %) identified as gay.
Most participants were non-White (56.6 %), where 11.2 %
identified as Black or African American and 26.3 %
identified as Hispanic or Latino. Almost all (98.6 %)
completed at least high school or some equivalent, where
56.4 % complete a Bachelors degree or higher. A majority
(69.1 %) reported earning less than $50,000 per year.
Sexually Transmitted Infections and Sexual
Behaviors
Most participants self-reported their HIV serostatus as
negative (89.5 %); 10.5 % reported their HIV status as
unknown or having never been tested. Respondents
engaged in RAI with a median of 1.00 partner
(IQR = 3.00) in the preceding 3 months. In addition,
respondents engaged in CRAI with a median of 0.00
partners (IQR = 1.00) in the preceding 3 months, where
37.5 % of respondents engaged in CRAI with at least one
partner. Respondents engaged in IAI with with a median of
1.00 partner (IQR = 2.00) in the preceding 3 months.
Additionally, respondents engaged in CIAI with a median
of 1.00 partner (IQR = 3.00) in the preceding 3 months,
where 43.4 % of respondents engaged in CIAI with at least
one partner.
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AIDS Behav (2016) 20:14351442
Pre-exposure Prophylaxis Awareness
Most participants (85.5 %) had previously heard about
PrEP. At the bivariable level, educational attainment was
associated with PrEP awareness. Three-fourths (75.4 %) of
those who completed high school or less were aware of
PrEP, compared to 95.0 % of those who completed a
Bachelors degree and 100.0 % of those who completed a
graduate degree or higher, v2(3) = 15.759, p = 0.001.
However, this association did not persist in multivariable
models when controlling for age, race/ethnicity, income,
engagement in condomless anal intercourse behaviors, and
having ever been tested for HIV (results not shown). Those
who had heard about PrEP (n = 130) most commonly
heard about it in the media (29.2 %) or online (25.4 %);
16.9 % heard about it from a friend, 13.8 % heard about it
from a medical provider, 7.7 % heard about it from a
current or recent sexual partner, and 6.9 % heard about it
from some other source.
Current Pre-exposure Prophylaxis Use
Despite the fact that most participants reported hearing
about PrEP, only a small portion (9.2 %) reported ever
taking it. Most of current PrEP users (85.7 %) engaged in
CRAI with one or more partners in the preceding 3 months,
compared to only one-third (32.1 %) of current non-users,
v2(7) = 37.15, p \ 0.001. Similarly, about two-thirds
(64.3 %) of current PrEP users engaged in CIAI with one
or more partners in the preceding 3 months, compared to
40.0 % of current non-users, v2(8) = 15.76, p = 0.046.
Among those who had heard of the medication and were
not currently taking PrEP (n = 116), 41.4 % reported non-
use because of concerns about side effects. About one-third
(31.0 %) reported non-use because they did not know
where to get it from if they wanted it. Similarly, about one-
third (30.2 %) reported non-use because of concerns about
being able to afford it. Reporting this reason for non-use
was associated with individual income in the past year,
where 38.5 % of those making less than $50,000 reported
this reason for non-use compared to only 13.2 % of those
making more than $50,000, v2(3) = 9.09, p = 0.028.
Willingness to Use Pre-exposure Prophylaxis
Among those not currently taking the medication
(n = 137), most participants (57.6 %) reported being very
willing, willing, or somewhat willing to take PrEP; 18.9 %
reported being very unwilling, unwilling, or somewhat
unwilling to take PrEP and 23.4 % were undecided. In the
multivariable models (Table 2), among those not currently
taking the medication, being unwilling to take PrEP in the
future was associated with being 2630 years old (3.472;
AIDS Behav (2016) 20:14351442 1439

Table 1 Sample demographics City [31, 40]. Despite high levels of awareness in this
% (n)
sample, use was low (9.2 %). Comparatively, 77.4 % of a
sample of 84 HIV-negative MSM using geosocial-net-
Age working smartphone applications in Atlanta surveyed in
1825 years 42.8 (65) January 2015 were aware of PrEP and 11.9 % reported
2630 years 19.7 (30) current use [41]. Given the low rates of PrEP uptake, future
3140 years 24.3 (37) research should focus on a wide range of motivational and
4150 years 9.2 (14) structural barriers to use.
5160 years 3.3 (5) Low PrEP uptake is potentially due to perceived cost
Sexual orientation and concerns regarding perceived potential side effects. In
Homosexual or gay 83.6 (127) this sample, about one-third (30.2 %) reported non-use due
Bisexual 10.5 (16) to concerns about being able to afford PrEP. While PrEP is
Queer/other 5.3 (8) currently covered under most private insurance options as
Race/ethnicity well as Medicaid and the manufacturers patient assistance
White/Caucasian 43.4 (66) program, the necessary testing and monitoring and sup-
Black/African American 11.2 (17) porting services are often not covered [42]. Recently,
Hispanic/Latino 26.3 (40) Governor Andrew M. Cuomo announced a new PrEP
Asian/Pacific Islander 9.9 (15) assistance program in New York State as part of the
Multiracial/other 8.6 (13) recently implemented blueprint to end the HIV/AIDS
Educational attainment epidemic in New York State by the end of 2020 [43]. As
Less than 12th grade 0.7 (1) part of this program, eligible providers would be reim-
High school or equivalent 42.1 (64) bursed for the package of care and support services (i.e.
Four-year degree 40.1 (61) HIV testing, adherence counseling) required for eligible
Masters degree or higher 16.4 (25)
high-risk individuals receiving PrEP [42]. The medication
Yearly individual income
itself will be provided to uninsured and underinsured
Less than $25,000 42.8 (65)
individuals through the manufacturers patient assistance
program [42], so the uptake of PrEP in New York City may
$25,000$49,999 26.3 (40)
soon begin to increase.
$50,000$74,999 13.8 (21)
Concerns regarding side effects were common, where
$75,000 or higher 17.1 (26)
41.4 % of those not currently taking the medication
reporting not doing so because of potential side effects. In
95 % CI 1.130, 10.638; p = 0.030) and reporting current multivariable models, these concerns were significantly
non-use due to concerns about side effects (3.300; 95 % CI associated with being unwilling to use the medication in
1.412; 7.692; p = 0.006). the future. In a sample of 184 MSM and transgender
women in New York City, perceived potential side effects
were identified as important barriers to PrEP utilization
Discussion [44]. Results from the iPrEx trial were encouraging in
terms of the time-limited nature of mild side effects [1] and
Awareness of PrEP has increased with time. In a commu- a systematic review suggests that TDF may be associated
nity-based sample of at-risk MSM in New York City, the with significant, though modest, renal function problems
percentage of those having heard of PrEP increased from [45] and that these findings seem supported by low rates of
53.0 % in 2011 to 72.4 % in 2013 [14]. We found that renal problems among participants across PrEP studies.
awareness at the time of data collection (March 2015) was Cost and concerns about side effects represent only two of
higher than these recent estimates at 85.5 %. It is believed many potential reasons for non-use, so future research is
awareness may increase with time, and it is possible that necessary to investigate other potential reasons for non-use
this high level of awareness is due to the high levels of (e.g. perceived susceptibility, current relationship status,
education attained by most of the sample [38, 39]. Addi- engaging in condomless intercourse and being perceived as
tionally, this awareness may have been increased by recent promiscuous). Additionally, individuals may not want to
campaigns for PrEP by the New York City Department of take a daily pill but may wish to take the medication based
Health and Mental Hygiene utilizing broadcast advertise- on periods of perceived or actual risk rather than continu-
ments on two geosocial-networking smartphone applica- ously. Further work is needed to better understand both
tions used by MSM in late 2014 and by the efforts on the patient and provider concerns about the medication, and
part of many non-government organizations in New York develop potential solutions to alleviate them.

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Table 2 Correlates of
Prevalence ratio 95 % Confidence interval p value
willingness to use PrEP
Age
1825 years Ref.
2630 years 0.288 0.094, 0.885 0.030
3140 years 0.592 0.197, 1.777 0.350
4150 years 0.357 0.074, 1.717 0.199
5160 years 0.220 0.028, 1.707 0.284
Sexual orientation
Gay/homosexual Ref.
Bisexual 1.008 0.270, 3.764 0.990
Queer/other 0.802 0.121, 5.334 0.820
Race/ethnicity
White/Caucasian Ref.
Black/African American 3.925 0.943, 16.338 0.060
Hispanic/Latino 0.881 0.360, 2.158 0.782
Asian/Pacific Islander 5.618 1.112, 28.392 0.037
Multiracial/other 0.607 0.147, 2.515 0.491
Past year income
Less than $25,000 Ref.
$25,000$49,999 1.356 0.434, 4.236 0.600
$50,000$74,999 0.843 0.232, 3.066 0.795
$75,000 or higher 0.469 0.135, 1.634 0.235
Engaged in any CRAI 1.590 0.629, 4.019 0.327
Engaged in any CIAI 2.167 0.886, 5.303 0.090
Ever tested for HIV 0.434 0.075, 2.533 0.353
Reasons for PrEP non-use
Concerned about side effects 0.303 0.130, 0.708 0.006
Concerned about cost 2.467 0.931, 6.539 0.069
Not sure where to access medication 1.203 0.474, 3.053 0.697
Ever diagnosed with STI 2.353 0.932, 5.937 0.070

Among PrEP users, condomless sexual behaviors were
substantially more common, as numbers of partners for
condomless receptive anal intercourse were four times
higher compared to non-users. According to risk compen-
sation theories, individuals adjust their behavior in
response to changes in risk perception [46, 47]. Risk
compensation has been linked to increases in sexual risk
behaviors coinciding with the introduction of antiretroviral
therapy, referred to as treatment optimism. [48] So-
called PrEP optimism may result in increased risk
behavior that could potentially reduce its effectiveness [5,
49]. Concerns about risk compensation among PrEP users
are common in social media campaigns against the medi-
cation [13], despite no evidence supporting these concerns
in clinical trials [15]. However, without information
regarding the sexual behaviors of the individuals in this
sample taking PrEP prior to beginning their use, it is dif-
ficult to contextualize this finding, but a similar pattern in
numbers of sexual partners across current PrEP use has
been observed a sample of MSM using geosocial-net-
working smartphone applications in Atlanta [41].
This study is subject to limitations. Firstly, our sample is
a relatively small sample of 152 MSM in New York City
recruited exclusively from a single geosocial-networking
smartphone application. A substantial percentage of indi-
viduals (53.9 %) who saw the advertisement and clicked on
it did not complete the survey, so the sample is likely to be
biased by some degree of self-selection. However, response
rates in other studies assessing sexual risk among MSM
who use apps has ranged from 15.2 % [26] to 31.9 % [50].
Given that individuals are more active on these apps at
different time periods [26], it is possible that our findings
are not generalizable to individuals active on the smart-
phone application outside of the two 13-h time periods
used for recruitment. However, this is the first study, to our
knowledge, to evaluate willingness to use PrEP in a pre-
dominantly non-White sample of smartphone application
users in New York City, a high-risk population in a high

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HIV prevalence location. Second, the sexual behaviors in
this study were assessed with self-report measures. Addi-
tionally, given that the recall period for STI diagnosis was
in ones lifetime, the findings are limited in that we did not
collect information about how recent the diagnosis was.
While there can be some misclassification in self-report,
the survey was conducted anonymously, so answers may
be more likely to be accurate.
Conclusion
This the first study, to our knowledge, assessing PrEP
awareness and use and willingness to use among MSM
who use geosocial-networking smartphone applications in
New York City. Despite high levels of awareness, uptake
of the medication is low, possibly due to concerns
regarding potential side effects. Given the high prevalence
of condomless sexual behaviors, continued targeted
advertising campaigns on these apps may not only increase
awareness of the medication but also increase its use in this
high-risk population of MSM who use geosocial-network-
ing smartphone applications.
Acknowledgments The authors thank two anonymous reviewers
and Mr. Joseph Gambino for commenting on earlier versions of this
manuscript. This work was funded by an individual research grant
from the New York University College of Arts and Science Deans
Undergraduate Research Fund (Principal Investigator: William C.
Goedel). Dr. Dustin T. Duncan was supported by his New York
University School of Medicine Start-Up Fund to work on this project.
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