The Impact of Pre-exposure Prophylaxis on Sexual Well-Being Among Men Who Have Sex with Men

Gay and Bisexual Men's Perceptions about a Potential HIV Vaccine within a Post-COVID-19 Era: A Qualitative Study

To end the HIV epidemic, there is need for targeted strategies to reduce HIV incidence for those most vulnerable, including an HIV vaccine. This study seeks to understand the perceptions that non-PrEP using gay and bisexual men and other men who have sex with men (GBMSM) have about a potential HIV vaccine, while contextualizing their perspectives within the context of heightened vaccine hesitancy that has emerged since the COVID-19 pandemic. Between March and May of 2022, GBMSM (N = 20) participated in in-depth interviews, which assessed their perceptions about an HIV vaccine. Interviews were analysed using a codebook approach to thematic analysis. We oversampled for those unvaccinated against COVID-19 as a proxy for vaccine hesitation. Participants expressed a range of enthusiastic support, cautious optimism and skepticism when presented with the possibility of an HIV vaccine. Factors that drove willingness to receive an HIV vaccine included community-oriented altruism, individualized risk-benefit assessment, and/or the perception that a vaccine could provide a beneficial shift in sexual experiences. Participants also expressed hesitations about receiving an HIV vaccine, including concerns about potential side-effects and efficacy, as well as mistrust in the vaccine development process. Notably, participants often evaluated the vaccine in comparison to PrEP and condoms. Participants offered specific insights into information they would like to receive about an HIV and where/how they would like to receive it. Our findings can help inform future HIV vaccine implementation efforts by offering insights into the factors that motivate and deter GBMSM to receive an HIV vaccine.

The Best Predictor of Future Behavior May Be the Past: Exploring Behavior Change in Men Who Have Sex with Men Using Pre-exposure Prophylaxis in the Netherlands

Pre-exposure prophylaxis (PrEP) use prevents HIV transmission, and may lead to changes in sexual behavior. We aimed to explore sexual behavior over time, and identify predictors of behavior change in men who have sex with men (MSM) using PrEP at sexual health centers (SHC) in the Netherlands. We used longitudinal data from the national STI surveillance database (January 2018-June 2021) of HIV-negative MSM who first initiated PrEP in the national PrEP pilot. We modelled behavior change after PrEP initiation, and identified predictors of behavior change using multi-state Markov models. The probability of stopping group sex, chemsex, use of poppers or erection stimulants, and having ≥ 10 partners in the past 6 months among included MSM (n = 4,349, n SHC visits = 21,820) was higher compared to the probability of starting with these behaviors after PrEP initiation. However, MSM who used condoms consistently during anal sex had a high probability of changing to inconsistent condom use (0.8) at the next visit, and inconsistent condom users mostly remained inconsistent (0.8). First visit, visiting the SHC more often (vs. regular), and STI diagnosis were predictors of starting or continuing with most of the behaviors associated with increased risk. Behavior change was less likely among older participants (> 34 compared to ≤ 34 years), and during COVID-19 lockdown and post-lockdown periods compared to pre-COVID-19. Although condom use decreased over time, transitions towards stopping with other behaviors associated with increased likelihood of acquiring an STI after PrEP initiation were common. This may suggest increased sexual empowerment, especially among younger MSM. Predictors of behavior change may help to identify MSM who are likely to start with or continue to engage in these behaviors in the near future and to provide suitable and timely counselling about behavior and PrEP adherence.

A psychosocial network approach studying biomedical HIV prevention uptake between 2017 and 2019

Biomedical HIV-prevention strategies (BmPS) among men who have sex with men (MSM), such as pre-exposure prophylaxis (PrEP) and viral load sorting (VLS), are essential but relatively new and their uptake gradual. Using an extension of the causal attitude network approach, we investigated which beliefs are related to uptake of PrEP and VLS at each time-point. We included 632 HIV-negative MSM from the Amsterdam Cohort Studies from four data-waves between 2017 and 2019. We estimated weighted, undirected networks for each time-point, where we included pairwise interactions of PrEP and VLS uptake and related beliefs. PrEP use increased from 10 to 31% (p < 0.001), while VLS was reported by 7-10% at each time-point. Uptake of both BmPS was directly related to the perceived positive impact of the strategy on one's quality of sex life and perceived supportive social norms. Overall network structure differed between time points, specifically in regard to PrEP. At earlier time points, perceptions of efficacy and affordability played an important role for PrEP uptake, while more recently social and health-related concerns became increasingly important.The network structure differed across data-waves, suggesting specific time changes in uptake motives. These findings may be used in communication to increase prevention uptake.

Non-Consensual Sex and Help-Seeking Behavior Among PrEP Users in Belgium: Findings from an Online Survey

Non-consensual sex poses a threat not only to sexual health but also to mental and physical health in general. HIV pre-exposure prophylaxis (PrEP) users might be particularly vulnerable to non-consensual sex because of interplaying factors such as mental health disorders, a high number of sex partners, engagement in chemsex, and the widespread use of dating apps. The objectives of this study were to assess the occurrence of non-consensual sex, its associated factors, and related help-seeking behavior among PrEP users. We analyzed data from an online survey among PrEP users in Belgium (09/2020-02/2022). Almost one in five participants (34/187, 18.2%) reported having ever experienced non-consensual sex. The most reported form was having sex against one's will, followed by having been given drugs against one's will, and having had sex without a condom against one's will. The vast majority of those who had experienced non-consensual sex (29/34, 85.3%) did not seek help afterward, mostly due to a lack of perceived need (21/29, 72.4%). Reported barriers to seeking help were shame (6/29, 20.7%) and lack of awareness of help services (3/29, 10.3%). Having experienced non-consensual sex in the past five years was associated with younger age and suicidal ideation in a multivariable logistic regression model. We conclude that addressing barriers to non-consensual sex help services is crucial to maximize their use and minimize the consequences of non-consensual sex experiences. PrEP consultations also represent an opportunity to offer such help given PrEP users are already familiar with these PrEP services and engaged in care.

Patterns of PrEP and condom use among PrEP users in Belgium: a web-based longitudinal study

BACKGROUND

Tailoring pre-exposure prophylaxis (PrEP) service delivery is key to scaling-up PrEP uptake. Optimal implementation of tailored services requires, among other things, insights into patterns of PrEP use, sexual behaviours and condom use over time.

METHODS

Between September 2020 and January 2022, we conducted a web-based, longitudinal study among PrEP users in Belgium. In three questionnaire rounds every six-months, we assessed PrEP and condom use, and sex with steady, casual and anonymous partners in the preceding three months. Based on the patterns of PrEP use in the preceding three months, we identified distinct PrEP use categories. We investigated differences in baseline socio-demographics and sexual behaviours by PrEP use category using Fisher's exact and one-way ANOVA tests. Patterns in PrEP and condom use over time were examined using descriptive analyses and visualised in alluvial diagrams.

RESULTS

In total, 326 participants completed the baseline questionnaire, and 173 completed all three questionnaires. We identified five distinct PrEP use categories: daily (≥ 90 pills), almost daily (75-89 pills), long period (> 7 consecutive days and < 75 pills) with or without additional short period use, short period (1-7 consecutive days and < 75 pills) and no PrEP use (0 pills). During the study, percentages of individuals in each PrEP use category varied, but did not change significantly over time. At baseline, daily and almost daily users were more likely to report five or more casual sex partners, ten or more anonymous sex partners and anal sex on a weekly basis with casual or anonymous partners compared to those using PrEP for long or short periods. Up to 12.6% (n = 16/127) of participants reporting anal sex with casual or anonymous partners, indicated always using condoms and PrEP with these partners. One in three (n = 23/69) participants who reported anal sex with steady partners had condomless anal sex and did not use PrEP with these partners; with casual or anonymous partners less than 3% reported this.

CONCLUSIONS

Our findings show that there is little variation in PrEP use over time and that PrEP use was associated with sexual behaviours, which could be taken into account when designing tailored PrEP care.

Between risk and pleasure: reflections on HIV prevention and care in the current context of PrEP use by men who have sex with men

This study offers a set of reflections on the relationship between risk and pleasure in the field of HIV prevention and care, as it mediates new biomedical prevention/care technologies, particularly pre-exposure prophylaxis (PrEP), among men who have sex with men (MSM). We begin by investigating some studies about condomless sex between men, more specifically barebacking and PrEP use among young MSM. We base our analysis on the assumption that PrEP, as one of these new actants, has reconfigured the field of HIV prevention/care, especially in relation to the dimensions of risk and pleasure, with the potential to considerably reduce the chances of HIV infection while enabling maximum pleasure and a sense of greater safety and freedom. Despite this progress, we also problematize some of the ambivalences, tensions, and moral conflicts that still exist in the field of prevention, especially the potential for condomless sex. Finally, taking a praxiographic perspective on health care and foregrounding the situated practices of human and non-human actors/actants in interaction, we consider HIV/AIDS prevention as a more fluid, non-linear, erratic phenomenon that involves multiple types of knowledge, feelings, and participations, and is open to different kinds of experimentation. Besides a “logic of choice”, we hold that health care is a permeable, continuous process that is enacted in situated practices and may produce different effects in response to a heterogeneous network of interactions.

HIV Pre-Exposure Prophylaxis (PrEP) among men who have sex with men: peer communication, engagement and social networks

Abstract HIV Pre-Exposure Prophylaxis (PrEP) has renewed optimism in controlling the HIV epidemic, despite its continued growth among men who have sex with men (MSM). The popularity of dating-sexual dating apps and digital media platforms in exchanging information and experiences about PrEP on peer social networks is recognized. However, studies on contexts, motivations, and scope in HIV prevention are scarce. The article aims to understand the dynamics of virtual and face-to-face peer networks among MSM for the decision to use PrEP, its disclosure, and publicity. Qualitative study using semi-structured interviews with 48 PrEP users from five Brazilian cities. Most interviewees share information and experiences about PrEP in peer social networks. However, its publication reveals tensions arising from the permanence of stigmas associated with homosexuality and HIV. The protagonism in exposing the use of PrEP expresses commitment to attracting new users. The relevance of peer social networks in sharing experiences and information about PrEP has the potential to diversify the target audience and expand and democratize PrEP coverage in the country.

HIV Pre-Exposure Prophylaxis (PrEP) among men who have sex with men: peer communication, engagement and social networks

HIV Pre-Exposure Prophylaxis (PrEP) has renewed optimism in controlling the HIV epidemic, despite its continued growth among men who have sex with men (MSM). The popularity of dating-sexual dating apps and digital media platforms in exchanging information and experiences about PrEP on peer social networks is recognized. However, studies on contexts, motivations, and scope in HIV prevention are scarce. The article aims to understand the dynamics of virtual and face-to-face peer networks among MSM for the decision to use PrEP, its disclosure, and publicity. Qualitative study using semi-structured interviews with 48 PrEP users from five Brazilian cities. Most interviewees share information and experiences about PrEP in peer social networks. However, its publication reveals tensions arising from the permanence of stigmas associated with homosexuality and HIV. The protagonism in exposing the use of PrEP expresses commitment to attracting new users. The relevance of peer social networks in sharing experiences and information about PrEP has the potential to diversify the target audience and expand and democratize PrEP coverage in the country.

Pleasure and PrEP: A Systematic Review of Studies Examining Pleasure, Sexual Satisfaction, and PrEP

Pre-exposure prophylaxis (PrEP) is an effective form of Human Immunodeficiency Virus (HIV) prevention for people at potential risk for exposure. Despite its demonstrated efficacy, PrEP uptake and adherence have been discouraging, especially among groups most vulnerable to HIV transmission. A primary message to persons who are at elevated risk for HIV has been to focus on risk reduction, sexual risk behaviors, and continued condom use, rarely capitalizing on the positive impact on sexuality, intimacy, and relationships that PrEP affords. This systematic review synthesizes the findings and themes from 16 quantitative, qualitative, and mixed methods studies examining PrEP motivations and outcomes focused on sexual satisfaction, sexual pleasure, sexual quality, and sexual intimacy. Significant themes emerged around PrEP as increasing emotional intimacy, closeness, and connectedness; PrEP as increasing sexual options and opportunities; PrEP as removing barriers to physical closeness and physical pleasure; and PrEP as reducing sexual anxiety and fears. It is argued that positive sexual pleasure motivations should be integrated into messaging to encourage PrEP uptake and adherence, as well as to destigmatize sexual pleasure and sexual activities of MSM.

Trends in Sexual Behavior and Sexually Transmitted Infections After Initiating Human Immunodeficiency Virus Pre-Exposure Prophylaxis in Men Who Have Sex with Men from Amsterdam, the Netherlands: A Longitudinal Exposure-Matched Study

Men who have sex with men (MSM) initiating human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) may increase condomless anal sex (CAS) and number of partners, and, consequently, more often acquire sexually transmitted infections (STIs). Using data from the Amsterdam Cohort Studies, we compared sexual behavior and STI among MSM after PrEP-initiation with controls not initiating PrEP. The MSM reported on sexual behavior and were tested for HIV, chlamydia, gonorrhea, and syphilis semi-annually. We matched MSM who initiated PrEP between January 1, 2015 and December 31, 2019 1:1 to MSM who did not use time-dependent propensity scores based on age, sexual behavior, and STI. Primary end-points were number of casual partners, and proportion with CAS and receptive CAS (rCAS) with casual partners, sexualized drug use (SDU), any STI, and anal STI. We modeled end-points during the 4 years before and 2 years after PrEP-initiation or matched PrEP-initiation timepoint by using logistic regression (dichotomous end-points) or negative binomial regression (count end-point), adjusted for calendar year. Two hundred twenty-eight out of the 858 (26.6%) MSM initiated PrEP. We matched 198 out of 228 (86.8%) to a control. Before PrEP-initiation, end-points increased over time in both groups, with no statistically significant difference. The odds of CAS, rCAS, and anal STI were on average higher after than before PrEP-initiation in PrEP initiators, whereas after versus before differences were not observed in controls. After PrEP-initiation, PrEP initiators had statistically significantly more casual partners, and higher odds of CAS, rCAS, SDU, any STI, and anal STI than controls. These findings support frequent STI screening and counseling in MSM using PrEP.

Increase in recreational drug use between 2008 and 2018: results from a prospective cohort study among HIV-negative men who have sex with men

AIMS

To test whether recreational drug use (RDU) and sexualized drug use (SDU) changed in the Amsterdam area between 2008 and 2018 and quantify associations of SDU with condomless anal sex (CAS), recent human immunodeficiency virus (HIV) or sexually transmitted infections (STI) among human immunodeficiency virus (HIV)-negative men who have sex with men (MSM).

DESIGN

Open prospective cohort study.

SETTING

Public Health Service of Amsterdam, the Netherlands.

PARTICIPANTS

A total of 976 HIV-negative MSM, aged ≥ 18 years.

MEASUREMENTS

Self-reported RDU and sexual behaviour in the past 6 months. Laboratory-confirmed HIV and STI (chlamydia, gonorrhoea and syphilis). We studied: any RDU; any SDU (i.e. any RDU during sex); specific SDU (i.e. use of mephedrone, methamphetamine, gamma-hydroxybutyric acid/gamma-butyrolactone, ketamine, amphetamine, cocaine and/or ecstasy during sex); use of individual drugs; and use of individual drugs during sex. We evaluated changes over calendar years in the proportion of individuals with these end-points [using logistic regression with generalized estimating equations (GEE)] and number of drugs (using negative binomial regression with GEE), adjusted for current age, country of birth and education level.

FINDINGS

Median age of participants in 2008 was 33.2 years (interquartile range = 27.8-40.1); 83.1% were born in the Netherlands. The proportion of any RDU increased from 67.2% in 2008 to 69.5% in 2018 [adjusted odds ratio (aOR) = 1.25; 95% confidence interval (CI) = 1.03-1.51]. Any SDU increased from 53.8% in 2008 to 59.8% in 2013 (aOR = 1.23; 95% CI = 1.07-1.42) and remained stable afterwards. Specific SDU increased from 25.0% in 2008 to 36.1% in 2018 (aOR = 2.10; 95% CI = 1.71-2.58). The average number of drugs used increased for those reporting any RDU, any SDU and specific SDU (all P < 0.05. Among those engaging in sex, any SDU was associated with CAS (aOR = 1.36; 95% CI = 1.19-1.55), HIV (aOR = 5.86; 95% CI = 2.39-14.4) and STI (aOR = 2.31; 95% CI = 1.95-2.73). Specific SDU was associated with CAS (aOR = 1.58; 95% CI = 1.37-1.81), HIV (aOR = 6.30; 95% CI = 3.28-12.1) and STI (aOR = 2.15; 95% CI = 1.81-2.55).

CONCLUSIONS

Among human immunodeficiency virus (HIV)-negative men who have sex with men in Amsterdam, recreational drug use, including sexualized drug use, increased between 2008 and 2018. Sexualized drug use was strongly associated with condomless anal sex, HIV and sexually transmitted infections.