Background
Methods
Recruitment and sample
Procedure
Circumstances of HCV diagnosis | - Knowledge about HCV prior to diagnosis - Sexual behaviour prior to diagnosis - Feelings about HCV diagnosis |
HCV infection | - Current HCV status - Perception of HCV since diagnosis - Experiences with treatment of HCV - Knowledge about reinfection |
Sexual behaviour | - Current sexual behaviour - Sexual behaviour between diagnosis and treatment - Sexual behaviour during HCV treatment - Sexual behaviour after HCV treatment |
Risk reduction strategies | - Risk reduction strategies prior to HCV infection - Risk reduction strategies after HCV infection - Influences of HCV infection on risk reduction - Perception of HCV risk in future - Perception of self-efficacy of risk reduction |
Theoretical background
Analysis
Ethical framework
Results
Characteristics
Interview results
Implemented HCV risk reduction strategies
Preventing direct transmission
“No sharing of gloves, condoms, toys, et cetera (….), surely these kind of essential things, which may give blood-to-blood contact (.….). Well, using a toy or something like that, while being with more persons at the same time, it could happen that we exchanged it. But now [after HCV diagnosis] I’m very cautious that this won’t happen to me again.” (MSM 5).
“Sometimes Crisco [lubricant] is being used. So then you should be using your own jar. If you go through it [Crisco] and then someone else goes through it, you could just as well have unsafe sex.” (MSM 4).
“Using drugs anally is something I definitely don’t do anymore (…). I suspect it is unhealthy for the mucosa, by which you increase the risk of being more susceptible to not only HCV but also other STI.” (MSM 8).
HCV serosorting
“When someone is HCV-infected, I don’t want sex with him. Just because of the risk of infection.” (MSM11).
“Well, we still have unsafe sex with each other, but not at the moment, because he is HCV-infected and I absolutely don’t want to become infected again.” (MSM5).
Avoiding risk-related contexts
“During group sex at a club, you are more likely to meet somebody with HCV, because you have sex with more men. Also it is more likely to skip the use of a condom, especially near the end of the evening after four glasses of vodka. So I am eliminating that kind of group sex at those clubs. I am going one-on-one. That lowers the risk of contracting HCV.” (MSM19).
“I think drugs are a risk factor anyway, and that is why I would like to eliminate them.” (MSM11).
“I’m totally done with drugs. You know, I can say that drugs were partly the cause, and that’s true, but in the end I myself am responsible for my actions. So I did it myself. So I don’t want to blame it all on drugs, but drugs have certainly been a catalyst. If I hadn’t used it, I would have certainly used a condom during sex.” (MSM17).
Being cautious on the internet
“I will never date somebody who fills in ‘needs discussion’ [answer to question about safe-sex intention on internet profile], because that means that they do not always have safe sex. And I can’t trust them, especially when drugs are involved.” (MSM18).
“Do you make new contacts through the internet?” (interviewer).
“We really don’t feel like that anymore. We think that world can’t be trusted. They never say what’s going on, what they have. That risk is too big for us. You never know what you get into your home. No, we don’t do that anymore.” (MSM2).
Motives for implementing risk reduction strategies
Effect of diagnosis and treatment on sexual desire and self-perceived attractiveness
“The medication is heavy, I agree; because of that you don’t have sex anymore, you don’t feel like going out, you don’t do any drugs. So, the medication is heavy, but the choices you have to make are actually made for you, which is very easy. But what happens when you have finished the treatment?” (MSM 5).
“You get a lot of side effects, you feel really sick, every weekend again, so you won’t be able to do a thing.” (MSM15).
“Did the HCV diagnosis influence your sexual life? You mentioned that at the beginning you did not feel like it [having sex].” (interviewer).
“Well, I felt dirty. You know, dirty not in a sense that nobody was allowed to touch me but, well, there is quite a taboo against HCV. It is also being called the new HIV, comparable to some years ago. HIV is sort of seen as something normal, but HCV is not.” (MSM 6).
Fear of HCV treatment side effects
“Well, you see, I always say I would a hundred times rather have an HIV infection than an HCV- infection, and I really mean it. Because HIV really means nothing compared to it [HCV].” (MSM9).
“That’s what [HCV] changed my behaviour. You see, an infection with gonorrhea or chlamydia sometimes means taking a pill, not a treatment you want very often, but it’s not a disaster when it sometimes happens. But this [HCV] is really something that has great impact and simply takes six or, when unlucky, twelve months of your life. It’s not worth it.” (MSM5).
“It is such a demanding treatment, if I were to go through it again, I fear things might go wrong. I simply don’t want that to happen. So from now on I do it safe or not at all.” (MSM3).
Fear of infecting others
“both times that I was HCV-infected I did not have sex during the treatment period...[tells reasons]. I also wanted to be sure that I did not infect anybody with HCV.” (MSM19).
Knowledge and high perceived susceptibility
“Well, on the other side, I wasn’t totally aware how easy you can become infected with HCV. I always assumed you really had to do a lot: so really have rough sex or long-lasting sex, you know, that there really should be blood. That’s what I thought, about the way you get HCV through sex, and that’s not what I did. Now that I know that the HCV virus can stay alive outside your body for a long time, it becomes a whole different story […] If I had known that back then, I would not have done that.” (MSM11).
Barriers to implementing HCV risk reduction strategies
Lack of HCV knowledge and low response efficacy
“Well of course you have this idea, you can contract anything, when you don’t know how you contract it, you can’t prevent it anyway. I might better live in a bubble then. I mean, you can’t protect yourself if you don’t know what to protect yourself against. It’s no use.” (MSM7).
“I should stop having any sex at all, because it really doesn’t matter what I do to prevent HCV. Whether I am having safe sex or not, I will contract it either way.” (MSM19).
Heat of the moment
“It’s like, postponing thinking about the possible consequences at the moment you have sex; the heat of the moment, but also thinking that you won’t catch it again. Afterwards, you naturally think ‘how stupid of me’.” (MSM19).
Negative impact on sex quality
“With a condom, it’s always difficult and because it’s a hassle, you lose your erection. It makes me nervous because I’m not used to it.” (MSM 11).
Challenging settings
“Sometimes I go to certain clubs. It’s much easier there to let go of certain things and to be less careful than you normally are [….] It’s the group process and also exhibitionism, to a certain extent.” (MSM19).“[...] sometimes such a party goes on for two days and at a certain point people just go on, and things get a bit, well, messy: a hand goes in or a dildo, I don’t know. Thinking becomes less sharp.” (MSM17).
“No, you’re not with the same partner the whole evening. It happens, but mostly not. No, four, five, six....At a certain point, hands don’ t get washed that well anymore.” (MSM12).
Drug use
“During which situations did it [safe sex] go by the board?” (interviewer).“When you’re under influence of drugs, I would say. You become less careful, you’re not really aware anymore.” (MSM2).
Sexual risk habits and peer pressure
“In a very short period, the behaviour of many people changed [to bare sex], including mine.”Do you have an explanation for that?“Yes, I do. Firstly I think that at a certain moment it’s almost strange to use a condom if everybody does it [bare sex]. That’s because the risks and the quality of [HIV] treatment have improved. It’s kind of backwards: just because you know that your life is not (or less) at stake, you start taking more risks.” (MSM5).
“Every person that’s [HIV] positive, in my surrounding, does it unsafe.”“So, unsafe sex is actually the norm?”“Yes, for positive persons it is.” (MSM6).
“It’s not like just using a condom again, it’s a total switch in your behaviour.” (MSM14).
Disclosure-related barriers
“It’s not desirable to contract HCV, certainly not since most are already HIV-positive. They feel like, ‘That’s something I can’t handle [on top of HIV] as well, and I won’t tell it once I have it.’ It’s like that for me, because I don’t tell it either. I feel like, no one is talking about it, why should I? If I would, I know for sure that I won’t receive any invitations [for sexual contact] anymore.” (MSM17).
“When someone hears hepatitis C and starts googling it, then it becomes evident that the person in question is also HIV-positive […] That feels like a nasty blow. I thought, I’m doing it the wrong way, I should not disclose it this easily.” (MSM18).
“It’s not like, when somebody says safe sex [preferred type of sex expressed on the internet profile], it will automatically be like that.” (MSM5).
“Well, then [when posting you want condomless sex] you actually show you are HIV- seropositive. Consequently you also sort of admit you are HCV-positive. So, you actually contradict your own status. Many rather not do that. So, you post ‘safe’.” (MSM17).
“On the other side, I have also had a chat session with somebody literally asking me ‘you don’t have an STI?’ My thoughts at that moment were: I’m not going to tell you I have HCV, I don’t even know you. I mean, you will pull out, but what will you do with that information? You’ve got my chat name, perhaps we have contacts in common, so it’s easy to blab to others about it.”“So what did you do?” (interviewer).“I told him I did not have anything.” (MSM18).“And you met up with him?” (interviewer).“Yes.” (MSM18).“And the subject was not brought up again?” (interviewer).“No.” (MSM18).“(…..) So, it’s difficult to make it open to discussion?” (interviewer).“Yes, it’s really very complicated.” (MSM18).
Mental health
“(…) when you care less about yourself, (…), a sort of neglect [takes place]. That’s in fact what in a way also happened to having safe sex.” (MSM 16).
Declining perceived severity due to decline of side effects
“I mean, the first months [after HCV treatment] you start feeling better and you have good intentions; it’s not going to happen to me again. But I know what I’m like. At a certain moment, when it’s a year later, you start crossing your boundaries again, doing this and that.” (MSM5).