The Impact of Pre-Exposure Prophylaxis on Sexual Communication and Sexual Behavior of Urban Gay and Bisexual Men

Abstract

Pre-exposure prophylaxis (PrEP) has altered the public health landscape for gay, bisexual, and other men who have sex with men (GBM) by significantly increasing protection against HIV infection. Early epidemiologic data showed GBM generally used PrEP as prescribed, i.e., as an additional protective tool over and above barrier protection, although subsequent reports have been equivocal. Irrespective of population-level trends, some GBM appear to have reevaluated their HIV risk tolerance and changed their interactions with sex partners. Scant published data have focused on factors that influence PrEP-using GBM's decisions about sexual behavior-including condom use as well as sex with HIV-positive partners-and sexual communication practices. Thus, in this study, we investigated those research concerns qualitatively via content analysis of individual interviews conducted with 103 GBM in New York City (M age 32.5 years, 50% White, 64% on PrEP > 6 months). Emergent themes reflect (1) participants' strong HIV knowledge; (2) changing GBM community norms about condom use on PrEP; (3) increased focus on risk tolerance with individual differences in post-PrEP condom use; (4) appreciation for routine sexually transmitted infection (STI) screening in PrEP care concomitant with some STI knowledge deficits; (5) decreased stigma concerning, and greater comfort with, HIVpositive sex partners; and (6) increased confidence discussing HIV status and condom use preferences with partners. Findings have implications for future research as well as for clinical practice, such as enhanced STI education and provider-initiated discussions about risk compensation, serosorting, and sexual communication skills.

How Has HIV Pre-Exposure Prophylaxis (PrEP) Changed Sex? A Review of Research in a New Era of Bio-behavioral HIV Prevention

“…Participants described the near-ubiquitous knowledge among their peers that having anti-HIV medications in their bloodstream, be it for PrEP or HIV treatment, put them "at a very low chance of contracting HIV." These points are consistent with some of our own qualitative work with 103 PrEP-taking GBM in New York City (Pantalone et al, 2020). Although there was no explicit question about HIV knowledge, our inductive coding process produced a theme, The men are generally knowledgeable about the science of HIV and behavioral risk reduction, reflecting the advanced HIV knowledge that the men showcased in answering other questions.…”

“…Findings related to STIs from our qualitative work with PrEP-taking GBMSM echo several of these points, and raise some novel points as well (Pantalone et al, 2020). Despite the relatively large number of studies reporting on the associations between PrEP use and STI incidence for GBMSM, we could identify almost no published work that presented a first-person account of those experiences and the decision-making process that undergirds it.…”

“…Some men describe using condoms less because of the increased protection of PrEP. In some relevant qualitative work, participants described their experiences of taking PrEP as leading them to reconsider their decisionmaking about condom use and clarify their risk limits, whether they changed them post-PrEP (Pantalone et al, 2020). Participants, all of whom were taking PrEP, noted a number of factors that they considered in making decisions about condom use for themselves or insistence on condom use by their sexual partners.…”

“…Although they found some mental health benefits (discussed below), there were null findings related to increases in sexual satisfaction. In other studies, participants extolled the benefits of PrEP-protected condomless sex (e.g., Pantalone et al, 2020).…”

“…Paradoxically, two qualitative studies reported that while PrEP had the potential to allay HIV-related stigmas, participants also reported experiencing stigmatizing reactions as a result of their PrEP use (Grace et al, 2018;Pawson & Grov, 2018). Likewise, participants expressed frustration in seeing decreases in condom use and increases in frequent multipartner sex among GBMSM, and attributed that decrease primarily to increases in PrEP-taking (Hammack et al, 2019;Pantalone et al, 2020). Moving forward, it will be necessary to continue to assess HIV-negative and HIV-positive men alike, and those taking medications (PrEP or HIV treatment) and not, about their perceptions of the GBMSM communities they inhabit.…”