Risk Perception, Sexual Behaviors, and PrEP Adherence Among Substance-Using Men Who Have Sex with Men: a Qualitative Study

Abstract

The antiretroviral drug combination emtricitabine and tenofovir disoproxil fumerate (TDF/FTC) taken as preexposure prophylaxis (PrEP) is effective in preventing HIV infection, yet it also requires adherence and potentially decreases condom use. This study sought to examine these issues among a key population at risk for HIV, substance-using men who have sex with men (MSM). We conducted semi-structured interviews with an ethnically diverse sample of 30 young (aged 20–35) MSM prescribed PrEP within a large integrated healthcare system in San Francisco, who had reported recent drug use or hazardous drinking and one or more missed doses of PrEP. We explored participants’ risk perception and sexual risk behavior, drug and alcohol use, and PrEP adherence in the context of substance use. Interviews were transcribed and coded using a directed content analysis approach to identify key categories and commonalities, and differences across participants. Salient sub-categories included positive psychological effects of being on PrEP (e.g., decreased anxiety, feelings of empowerment), social effects (e.g., reduced HIV stigma), and reduction in overall perceptions of HIV risk. While overall reported use of condoms went down and many reported a brief period of increased condomless sex following PrEP initiation, others continued condom use with most of their sexual partners. Contextual factors influencing their decision to engage in condomless sex included how well they knew the partner and whether the partner was on PrEP or HIV antiretroviral treatment. Factors associated with poor adherence included disruptions in daily routine and use of alcohol and methamphetamine. PrEP-prescribing clinicians should support their patients in making informed decisions about condom use and identifying strategies to maximize adherence in the context of substance use.

“Little Tablets of Gold”: An Examination of the Psychological and Social Dimensions of PrEP Among LGBTQ Communities

“…Additionally, our results reinforce and expand on previous studies that have started to demonstrate the individual positive outcomes of PrEP use beyond biomedical outcomes (Grant & Koester, 2016). For instance, previous qualitative research reported relief from stress and fear associated with PrEP use among participants in clinical trials, substance-using men who have sex with men (MSM), and MSM in Seattle (Collins et al, 2017;Koester et al, 2017;Storholm et al, 2017). Furthermore, a previous study of real-world patient experiences identified increased HIV and STI screening as a frequent outcome of PrEP adoption (Parker et al, 2015).…”

“…In our and other studies, PrEP stigma is closely tied to stigma around HIV, "risky" sexual behavior, and sexual and gender identity (Franks et al, 2018;Grace et al, 2018;Haire, 2015). Just as we found, other researchers have observed that stigma can be an obstacle to PrEP use, but that PrEP is also an opportunity to expose and combat stigma around HIV and sexuality (Grace et al, 2018;Storholm et al, 2017). Additionally, we noted, as did others, that PrEP users had a sense of pride around PrEP (Grace et al, 2018).…”

“…Although previous studies have examined attitudes about PrEP uptake (Bauermeister, Meanley, Pingel, Soler, & Harper, 2013;Brooks et al, 2011;Dolezal et al, 2015;Galindo et al, 2012;García & Harris, 2017;Goedel, Halkitis, Greene, Hickson, & Duncan, 2016;Grov, Whitfield, Rendina, Ventuneac, & Parsons, 2015;Holt et al, 2012;Peng et al, 2018;Thomann, Grosso, Zapata, & Chiasson, 2018;Young, Flowers, & McDaid, 2014), and impact of PrEP on sexual risk behaviors (Freeborn & Portillo, 2018;Grov et al, 2015;Holt et al, 2012;Koester et al, 2017;Storholm, Volk, Marcus, Silverberg, & Satre, 2017), there is little understanding of the sociocultural dimensions of actual PrEP use. Most previous U.S. studies about the emotional or psychological effects of PrEP have asked participants to consider hypothetical situations or have enrolled participants of clinical trials and demonstrations projects (Gilmore et al, 2013;Grace, Jollimore, MacPherson, Strang, & Tan, 2018;Koester et al, 2017).…”

Increasing methamphetamine injection among non-MSM who inject drugs in King County, Washington

“…Routine HIV testing, keeping HIV-infected PWID virally suppressed, and efforts to diminish injection drug use are also essential components of HIV prevention efforts in this population. MSM who use methamphetamine remain a priority population for HIV pre-exposure prophylaxis (PrEP), yet PrEP use and adherence in this population can be challenging (Storholm et al, 2017). Data from the present study suggest that non-MSM who inject methamphetamine may also benefit from PrEP.…”

Motives for choosing, switching and stopping daily or event‐driven pre‐exposure prophylaxis – a qualitative analysis

“…While there are data on the motives to use daily PrEP , little is known about the reasons to choose between daily and event‐driven PrEP, to switch between these regimens, or to discontinue PrEP use altogether in a setting that offers both regimens. The majority of previous studies reported on situations in which event‐driven PrEP was only a hypothetical option , and where stops were associated with daily adherence problems and reduced risk . Data on actual choices between daily and event‐driven PrEP among MSM are only available from three studies in the European setting, the roll‐out programme in France , the Be‐Prepared study in Belgium , and our own study, the Amsterdam PrEP (AMPrEP) demonstration project in the Netherlands .…”