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Qualitative data from the PROUD study revealed that pre-exposure prophylaxis (PrEP) is an important added prevention tool to strategies already in place for men in England having frequent condomless sex, according to a recent article in AIDS and Behavior.

While approximately half of the participants indicated that they had made changes to other risk reduction strategies after starting PrEP, the other half did not alter their behaviours. In the context of sexualised drug use, online sex apps and changing social norms around sex, the authors assert that PrEP offers an important additional preventative option that can be tailored to the changing needs of men who have sex with men (MSM).

Results from the PROUD trial, published in The Lancet in 2015, indicated that PrEP reduced HIV acquisition by 86%, with no infections among participants taking PrEP at the likely time of exposure. The PROUD trial details and findings can be viewed here.  

In the main trial analysis, although a larger proportion of those allocated to the immediate arm reported receptive condomless sex than those in the deferred arm, there was no statistically significant increase in STIs for those taking PrEP versus those not taking it. The conclusion from the trial was that PrEP is a highly effective tool for preventing new HIV infections and does not necessarily contribute to an increase of other STIs.

For the qualitative component of PROUD, purposive sampling identified a subset of 41 trial participants for in-depth interviews from February 2014 to January 2016. Participants were selected based on trial arm allocation (immediate or deferred), changes in self-reported risk behaviour (high risk or low/medium risk) and self-reported adherence for those in the immediate arm (high or low). Areas explored included sexual risk behaviour as well as perceptions, experiences and usage of PrEP.

By the time of the interview, 33 people were or had been using PrEP: either as a result of the trial or from other sources. Average time using PrEP was 14.3 months, with high adherence. Participants mainly came from London clinics, with some from Sheffield, Manchester and Brighton. Median age was 37.4, the majority were white and university educated. Nearly half the men reported contracting an STI in the previous year, with a median number of 10 anal sex partners. The majority (90%) had had receptive anal sex without a condom in the last 90 days.

Many participants described fluctuating patterns of sexual risk taking over time. This was influenced by various personal factors (such as age, stage of life, relationship status, engaging in chemsex or not, depression and so forth), with PrEP not necessarily playing the main role. In certain instances, there were unexpected decreases in sexual risk-taking after starting PrEP:

“At first, I think I stopped having sex, I can’t quite explain that. When I first started taking PrEP it was a couple of months before I really had anything penetrative… it might be coincidence… I think part of it was being a bit over aware of my behaviour and whether it was going to change.” (Immediate, high adherence, high risk, London, aged 40-44)

Some participants reported increases in risk-taking when they initially started PrEP, but these dissipated over time:

“It all spiked and then suddenly it tailed off, I had this relationship and it’s not really spiked back up since.” (Deferred, high risk, out of London, 20-24).

As with the quote above, relationship status played an important role when it came to fluctuating risk-taking behaviour. For most participants, PrEP represented a temporary risk-reduction strategy during periods of higher-risk behaviour. However, for some, it provided a release from the need to use condoms and was perceived as sexual freedom:

“I was in an awful place and I just felt like I was holding the lid on a boiling pot of water so hard that I just couldn’t hold it anymore (trying to avoid sex without condoms).” (Deferred, increased risk, London, 25-29).

Approximately half of the participants who had used PrEP indicated changed sexual behaviour since starting it. For some, they had previously struggled with condom use and thus PrEP was a welcome addition:

“Clearly I wanted to participate in unsafe sex and obviously because of the risk I have had some resistance to unsafe sex, obviously not entirely 100%. But in taking the medication the levels of anxiety over that diminished.” (Immediate, high adherence, increased risk, London, 50-54). 

In most instances, PrEP was added to the pre-existing set of sexual rules that men had in place, for example regarding sero-sorting or strategic positioning to avoid infection. Some men became more comfortable having sex or condomless sex with HIV-positive partners or being the passive partner (bottom). For a few participants, there was also discomfort around reduced condom use, largely due to social norms regarding condom use for gay men.

“There is no doubt that I have also had more unprotected sex than before, for sure…it doesn’t mean that I only have unprotected sex , but it does mean that I have more.” (Deferred, high risk, out of London, 45-49)

“It has definitely made me more likely to take risks, definitely I must admit this, as I don’t tend to worry about what the status of the person is… now.” (before PrEP, serosorted for negative partners and never used condoms) (Deferred, decreased risk, out of London, 35-39).

For the other half of interviewees, they reported that PrEP use had not altered their sexual behaviour. Thus, PrEP was seen as added protection to existing risk reduction strategies.

“I’ve taken the medication and obviously I’ve still had intercourse in the way that I would if I’ve not taken the tablet really.” (Immediate, high adherence, low risk, out of London, 20-24)

As the authors point out, many interviews were carried out prior to the PROUD trial results coming out, and thus participants may not have known how effective PrEP was at the time.

There were also men who reported that they had already been engaging in high-risk condomless sex prior to starting PrEP and that this remained the same.

“I was having a huge amount of condomless sex before PrEP… I am not going to not bareback and always use condoms” (Immediate, high adherence, decreased risk, London, 45-49).

This qualitative study indicates that for MSM at high risk of HIV infection, PrEP is an important addition to existing risk-reduction strategies. While half of the men altered their sexual risk behaviour, the other half did not regardless of PrEP use. However, all participants acknowledged that their existing risk reduction strategies were insufficient and that is why they wanted to access PrEP.

The study shows that the impact of PrEP on sexual behaviour is diverse and that PrEP use can be tailored to the specific needs of diverse MSM. The authors stress that PrEP should not be positioned in opposition to existing preventative methods but rather be seen as a powerful, additional tool that has a substantial impact on reducing new infections.

Gafos, M. et al. The Context of Sexual Risk Behaviour Among Men Who Have Sex with Men Seeking PrEP, and the Impact of PrEP on Sexual Behaviour. AIDS Behav (2018). (Full text freely available).