Explicit Relationship Agreements and HIV Pre-exposure Prophylaxis Use by Gay and Bisexual Men in Relationships

Abstract

Relationship agreements are important for HIV prevention among gay and bisexual men (GBM) in relationships, with research earlier in the HIV epidemic often finding that agreements specified monogamy or condom use with casual partners. There is evidence that HIV pre-exposure prophylaxis (PrEP) has shifted sexual practices among some men in relationships, such as allowing condomless sex with casual partners, but there has been little attention paid to relationship agreements among GBM who use PrEP. In this paper, we analyzed national, Australian, cross-sectional data from an online survey completed by non-HIV-positive GBM in 2021 (N = 1,185). Using logistic regression, we identified demographic characteristics, sexual practices and the types of relationship agreement that were associated with PrEP use among GBM in relationships. Using Pearson’s chi-squared tests, we explored whether PrEP users in relationships reported similar sexual practices to PrEP users not in relationships. PrEP use among GBM in relationships was independently associated with older age, identifying as gay, being in a non-monogamous relationship, having a spoken (explicit) relationship agreement, having a primary HIV-negative partner taking PrEP or a primary partner living with HIV, reporting recent condomless casual sex, reporting an STI diagnosis in the past year, and knowing at least one other PrEP user. We found that PrEP users in relationships had similar sexual practices to PrEP users not in relationships. GBM in relationships who have casual sex and who meet PrEP suitability criteria may be good candidates for PrEP. Our findings suggest that explicit relationship agreements remain important for HIV prevention, and they support PrEP use among GBM in relationships.

Factors Associated With Willingness to Use Daily Antibiotics as Sexually Transmitted Infection Prophylaxis Among HIV Preexposure Prophylaxis–Experienced Gay and Bisexual Men in Australia

“…Our analysis of HIV-PrEP–experienced GBM in Australia found that more than half of the participants (54.4%) were willing to use daily STI-PrEP. Our results are comparable to previously published, similar studies conducted in Australia and internationally 12–14 . Willingness to use daily STI-PrEP in our analysis was higher in those participants who believed they were at higher risk of acquiring STIs.…”

“…Although two-thirds of men in our sample reported a desire to avoid STIs, most (90.2%) had also engaged in condomless sex in the past 6 months, which confers a significantly higher risk of STI transmission than condom-protected sex 21 . The high prevalence of condomless sex in our sample is similar to other estimates for HIV-PrEP–experienced GBM 13,22 . Given that the desire to avoid STIs does not seem to be strong enough to motivate consistent condom use, there is a need for other prevention strategies, such as STI-PrEP (if proven safe and effective) that can be used instead of, or in addition to, condom use.…”

“…These participants may be willing to use nondaily STI-PrEP options, such as event-driven STI-PrEP or STI-PEP. Other studies have consistently found willingness to use STI-PEP (i.e., a single dose after sex) to be higher than STI-PrEP 12–14 . The proportion of participants using event-driven HIV-PrEP increased over the span of the PrEP in NSW Transition Study, a trend that has been reflected in other studies of Australian GBM 13,23 .…”

“…Other studies have consistently found willingness to use STI-PEP (i.e., a single dose after sex) to be higher than STI-PrEP 12–14 . The proportion of participants using event-driven HIV-PrEP increased over the span of the PrEP in NSW Transition Study, a trend that has been reflected in other studies of Australian GBM 13,23 . The increase in event-driven HIV-PrEP use may be due to endorsement of event-driven dosing in the 2019 update of the Australian HIV-PrEP guidelines 24 .…”

“…The 2011 study also found that of the 2095 GBM surveyed, 52.7% would be willing to use daily STI-PrEP if it decreased their chances of syphilis infection. A more recent Australian study found that of 1280 GBM surveyed in 2021, 49.5% were willing to regularly take low-dose antibiotics (STI-PrEP), and 70.0% were willing to take an antibiotic pill after sex (STI-PEP) to prevent STIs 13 . Although these studies recruited GBM generally, a Canadian study specifically examined willingness to use STI-PrEP and STI-PEP among 424 HIV-PrEP–experienced GBM, and found that 44.1% and 60.1% were in favor of these dosing modalities, respectively 14 …”