Public health morality, sex, and COVID-19: sexual minority men’s HIV pre-exposure prophylaxis (PrEP) decision-making during Ontario’s first COVID-19 lockdown

Abstract

Experts have warned that COVID-19 control measures may amplify health inequities among gay, bisexual, queer, and other men who have sex with men (GBM). For HIV-negative GBM, concerns have been raised as to how COVID-19 will disrupt access to HIV pre-exposure prophylaxis (PrEP). Our study offers empirical findings on these issues, drawing on in-depth interviews conducted with 25 HIV-negative GBM living in Ontario, Canada during the first wave of the COVID-19 pandemic. Our thematic analysis draws from the sociology of risk to elucidate how a public health moralitya contested ethical framework determining how to be a 'responsible' sexual citizen during the COVID-19 pandemic -informs GBM's sexual and PrEP decision-making. This public health morality was shaped by several factors, including: self-concern versus risks posed to others; anxiety, economic precarity, and becoming COVID-19 weary; shaming public health non-compliance; and comparisons with HIV and shaming (queer) sex. The participants significantly altered their sexual practices, with some stopping, restarting, and others stockpiling their PrEP. While some men's sexual practices ran counter to public health messaging to avoid 'nonessential' contact with those outside of their households, their risk reduction strategies, including avoiding new sexual partnerships and evaluating people's 'common-sense', mirrored the negotiated safety strategies earlier developed to mitigate HIV risk. Public health advice must account for the nuanced ways in which GBM are mitigating COVID-19 risks and are responding to a complex public health morality, in order to avoid stigmatization and potentially increasing COVID-19 transmission by neglecting practical risk reduction measures.

“What other choices might I have made?”: Sexual Minority Men, the PrEP Cascade and the Shifting Subjective Dimensions of HIV Risk

“…Participants were asked about their specific sexual practices and PrEP experiences, and any changes they were observing within the GBQM community because of PrEP. We also discussed the impact of COVID-19 lockdown procedures on sexual practices and PrEP use, which are reported on elsewhere ( Gaspar et al 2022 ). A web site and poster were used to recruit PrEP users and non-PrEP users.…”

“…Sexual risk-taking is rarely static and a GBQM’s need for PrEP is likely to change over time. For example, based on data collected as part of the current study, we previously reported on how many GBQM in Ontario stopped and restarted their PrEP use in response to shifting COVID-19 control measures that affected their ability to have sex with casual or new partners ( Gaspar et al, 2022 ). Newman et al’s (2018) analysis is influenced by research on HIV and GBQM which acknowledges that people do not always “behave” the way health promotion models would predict.…”

“…As Holt et al (2020) state about the PrEP Cascade, “there are tensions between top–down or researcher-driven measures and participant or user perceptions of HIV risk, which may not match” (e17). A social actor’s perceptions of HIV risk are not merely guided by rational, “objective” facts, but are informed by their understandings of what it means to be a moral and responsible sexual citizen in the context of a continually evolving and stigmatized epidemic (Gaspar, 2017; Gaspar et al, 2022 ; Williamson et al, 2019 ).…”

LGBTQ+ Loss and Grief in a Cis-Heteronormative Pandemic: A Qualitative Evidence Synthesis of the COVID-19 Literature

“…Theme 2: Loss of Social and Kinship Connection. The loss of social and kinship connection was reported across eight articles (Braksmajer & London, 2021;Gaspar et al, 2021;O'Brien et al, 2021;Pereira et al, 2021;Philpot et al, 2021;Quinn et al, 2021;Riggle et al, 2021;Westwood et al, 2021). This type of loss largely related to losses in the quality and quantity of friendships, LGBTQ+ people's Family of Choice, their Family of Origin and romantic or sexual partners (Wheat & Thacker, 2019).…”

HIV pre-exposure prophylaxis (PrEP) should be free across Canada to those meeting evidence-based guidelines

“…Furthermore, observational research demonstrates that GBQM take PrEP when they feel that they need it, others avoid taking PrEP if they do not perceive a benefit over their current safer sex practices, and many discontinue PrEP if they feel that their risk for HIV has lowered substantially (Newman et al, 2018). For instance, many GBQM stopped taking PrEP when COVID-19 protocols prohibited them from having casual sex (Gaspar et al, 2022a). GBQM do not tend to use PrEP in a cavalier fashion.…”