Introduction
Methods
Results
Median age (interquartile range) | 37.4 (31.9, 42.7) |
Clinic of enrolment
| |
London | 24 |
Sheffield | 9 |
Manchester | 5 |
Brighton | 3 |
Ethnicity
| |
White/Irish | 34 |
BAMEa | 7 |
Place of birth
| |
UK | 26 |
Otherb | 15 |
University degree education
| |
Yes | 25 |
No | 16 |
Employed
| |
Yes | 36 |
No | 5 |
In a relationship
| |
Yes | 17 |
No | 24 |
Sexuality
| |
Gay | 40 |
Bi-sexual | 1 |
Gender
| |
Cis-male | 40 |
Trans-female | 1 |
Circumcised
| |
Yes | 10 |
No | 31 |
Symptoms of depression
| |
Yes | 6 |
No | 35 |
Chemsex use in the past 3 months
| |
Yesc | 13 |
No | 28 |
PEP use in last year
d
| |
Yes | 14 |
No | 26 |
Self-reported STI in last year
e
| |
Yes | 18 |
No | 21 |
Median number of anal sex partners (interquartile range) | 10 (3, 20) |
Had anal sex with a new partner
| |
Yes | 35 |
No | 6 |
Been passive partner
| |
Yes | 39 |
No | 2 |
Been passive partner and condomless
| |
Yes | 37 |
No | 4 |
Been passive during condomless sex with HIV positive man
| |
Yes | 14 |
No | 27 |
Been passive during condomless sex with HIV positive man who you didn’t know was on treatment
| |
Yes | 1 |
No | 40 |
Been active partner
| |
Yes | 40 |
No | 1 |
Been active partner and condomless
| |
Yes | 40 |
No | 1 |
Been active during condomless sex with HIV positive man
| |
Yes | 20 |
No | 21 |
Been active during condomless sex with HIV positive man who you didn’t know was on treatment
| |
Yes | 2 |
No | 39 |
Risk Behaviour and Management Strategies Before Using PrEP
Participants often described their risk reduction strategies in terms of the ‘rules’ that they applied to their sexual activity before they started using PrEP, which included condom use, strategic positioning, sero-sorting, avoiding ejaculate, and the use of PEP, as described below.“Here I am quantifying different risks at the high risk end of the spectrum, and I know there are different levels of risk in the high risk end, although I am not making the most sensible decisions I think I am at the lower end of the higher risk end, er.. sometimes anyway” (Deferred, decreased risk, not on PrEP, London clinic, age 35-39).
Condoms
“The use of a condom is really inhibiting my sexual pleasure, being passive but especially being active, and one and a half years ago I decided to stop being afraid, and that doesn’t mean I am a bug chaser… I would like to postpone (acquiring HIV) as long as possible, but what I absolutely want is not to be afraid anymore… you may think well why are you doing this, well because it is impacting how I experience sex and how I experience my sexuality” (Deferred, decreased risk, not on PrEP, London clinic, age 35-39).
Strategic Positioning
“I wouldn’t be passive for anyone, and this was obviously when I was compos mentis, because obviously when I was pissed or on a rare occasion, I would you know just be passive” (Deferred, low risk, on PrEP, out of London clinic, age 25-29).
Sero-Sorting
“I tend to only play bareback with undetectable guys who I know are kind of trustworthy and taking their medications, they aren’t absolute drug heads who go on benders for weekends and don’t take their meds” (Deferred, increased risk, on PrEP, London clinic, age 25-29).
Ejaculation
Post Exposure Prophylaxis (PEP)
“Some of the PEPs were coming close to each other and there were times that I should have been coming in but was too embarrassed because I had it quite recently” (Immediate, high adherence, decreased risk, on PrEP, London clinic, age 40-49).
Many participants who hadn’t used PEP, described circumstances where they probably should have accessed it and would have met the eligibility criteria for it. Participants clearly only perceived PEP as an emergency response to a specific incident and not as a regular HIV prevention option.“One member of staff said to me at one point ‘Well you say all these things, these wonderful things, but then you end up back and doing it again’ … that’s when you think that you can’t go back” (Deferred, high risk, on PrEP, out of London clinic, age 35-39).
Limited Risk Reduction
For others, the decision of whether or not to use a condom largely relied on trust, even with casual sexual partners. This seemed to mainly emerge in the interviews outside of London and Brighton, whereby participants tended to trust that the ‘friends’ who they had regular casual sex with, would not put them at risk and therefore expected them to use condoms with ‘other’ partners. As such they considered their friends a safe group with whom to have condomless sex and in a few cases, were genuinely surprised when they contracted an STI from them.“It depends on how you have met them and how they come across and you just go with your gut on that” (Deferred, increased risk, on PrEP, London clinic, age 35-39).
Contexts of Risk Taking
Sexualised Use of Recreational Drugs
“The drug that has made the biggest difference to my sexual behaviour is mephedrone… It’s a cheap drug which has become more readily available around London over the last couple of years and I have noticed that for me it has a high association with bad methods of protection whereby I will do much more reckless things … I would identify that for me, as a particular drug associated with chemsex and high-risk behaviour” (Immediate, high adherence, low risk, on PrEP, London clinic, age 45-49).
Geographic Spaces
“I have moved to Brighton from a different part of the country. I have had a bit of a culture shock. There have been times that I have actually felt that I almost needed to get away from Brighton because it seems to be a bit of a hot bed of unprotected sex, substance abuse and I know that it is a bit of a HIV hotspot” (Deferred, increased risk, on PrEP, out of London clinic, age 35-39).
Sexual Networking Apps
“If you log onto Grindr, you look through these things and there are quite a few instances which I feel like I see more often more recently …. Of people talking about meth and group sessions and G and all this kind of stuff “(Deferred, increased risk, on PrEP, London clinic, age 20-24).
Psychological Factors
“For 20 plus years I had perfect adherence to condoms. Then about 4 or 5 years ago there were two things that happened, well three really. Firstly, I noticed that sexual behaviours were changing around me with far less condom use… real generational issue… Secondly, I went through a number of bereavements and started experiencing depression. This impacted on my sexual behaviour and I started having more unsafe sex. Thirdly, I started using drugs. So, it was all those three things that resulted in me having unsafe sex and seeking out the PROUD study” (Immediate, high adherence, low risk, on PrEP, London clinic, age 45-49).
Impact of PrEP on Sexual Behaviour
Fluctuating Patterns of Sexual Behaviour
“Since I started PrEP, this is a complete coincidence, my sexual life had died off a bit, I’d been through a bit of a depression for the last couple of years, nothing to do with the PrEP it’s just my life had taken a few turns for the worse basically and so sexual relations had died off for me” (Immediate, low adherence, high risk, on PrEP, out of London clinic, age 30-34).
“This is the really bizarre thing, whereas I was being passive very often with a number of people who were acquaintances … but since PrEP I have actually only been passive with one person in the last year, on multiple occasions but even so I thought with PrEP oh yes I’ll be able to have sex as much as I want now but it’s not kind of logical like that, I just started taking it at a time when I was taking a lot of risks, and my life for whatever reason has gone down a less risky path… I’ve bottomed less, and with less partners” (Deferred, low risk, on PrEP, out of London clinic, age 25-29).
Conversely a few other participants described spikes in risk taking when they started PrEP, which dissipated over time as their personal circumstances and relationships changed, sometimes linked to drug use as in this quote:“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… and it could just be that I was getting paranoid… as time passed I was clearly less worried about condom use… they were never great for me, but I used them intermittently” (Immediate, high adherence, high risk, on PrEP, London clinic, age 40-44).
“At some subconscious level, I think it’s supporting me to get to that relationship, and the unprotected sex went down after it spiked… it all spiked and then suddenly it tailed off, I had this relationship and it’s not really spiked back up since. I’ve not used drugs for about five months now” (Deferred, high risk, on PrEP, out of London clinic, age 20-24).
While most participants perceived PrEP as a temporary risk reduction strategy for periods in their life of heightened risk, a couple of participants described it in the context of an immediate release from an overwhelming need for sexual freedom:“There used to be a point where… somebody was like ‘oh we are going to have safe sex’ and I was like ‘no I don’t want it’… whereas now I’d be thinking yeah okay that’s totally fine, because I want to meet somebody where you start, and you have the discussions and you have safe sex and then through time … if you want to have unprotected sex … that they know …I’m negative and… that this is somebody who is maybe responsible and they want a long term relationship” (Deferred, increased risk, on PrEP, London clinic, age 25-29).
“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)… so I started on PrEP in the middle of March … and in that time … I feel like I have come full circle, I feel like I have slowly released that pressure on that pot of water to the point that it’s OK now, it is just simmering it’s fine, I have had all my release that I needed to and I have almost come full circle that I don’t feel that strange obsessional necessity for bareback sex like I was before” (Deferred, increased risk, on PrEP, London clinic, age 25-29).
Changes in Sexual Behaviour Since Using PrEP
In the majority of cases participants added PrEP to their existing set of rules and PrEP influenced these rules in complex and often subtle ways. For some participants, using PrEP meant that they reduced their use of condoms or changed their rules about when to use condoms:“It is a question of pushing against an open door, 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. So where I may have hesitated previously, I dont hesitate any further…. But even now there is a bounded risk analysis” (Immediate, high adherence, increased risk, on PrEP, London clinic, age 50-54).
“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… it is probably 80% more, much more than protected” (Deferred, high risk, on PrEP, out of London clinic, age 45-49).
As with the last sentence in the quote above, a few participants were not comfortable with their reduced condom use. However, this discomfort was not about the risk of STIs but seemed to be solely related to social norms about condom use for gay men. The following quote is another example of this discomfort when asked by the interviewer “Have any of your decisions around sex changed?”“I felt like it gave me the green card to do whatever the hell I wanted…I don’t use condoms at all any more. I’m starting to notice that its actually bad where, not that I’m encouraging people to not use condoms with me, but it’s like if I’m going to be a top there is no point in me wearing a condom, because I just can’t do it anymore, it won’t work so if they want to have sex with me, then it’s a level of risk that they have to accept and I won’t push it on them, but I can’t do it anymore (use condoms). And I don’t know whether I like that development” (Immediate, high adherence, high risk, on PrEP, London clinic, age 30-34).
“Yes I would say so and I am not always convinced it has been for the better… So there have been a couple of occasions where I haven’t used condoms with completely random one-off partners … when I have felt pretty shitty for some reason or another, and I have acted out sexually” (Immediate, low adherence, low risk, on PrEP, London clinic, age 30-34).
“I have a partner that is HIV positive, we have gone without condoms since being on the study, which we wouldn’t do before” (Immediate, high adherence, increased risk, on PrEP, London clinic, age 35-39).
For some participants PrEP use influenced the ‘rules’ that they had previously applied to their sexual activity in terms of sero-sorting and strategic positioning:“We don’t use condoms since I’ve been on PrEP… he’s undetectable anyway and with me being on PrEP, so no we don’t use condoms anymore… that is something we still don’t do, we don’t cum in one another, it would just seem silly given the circumstances” (Immediate, high adherence, low risk, on PrEP, out of London clinic, age 40-44).
“It has definitely made me more likely to take risks, definitely I must admit, as I don’t tend to worry about what the status of the person is … now” (before PrEP, sero-sorted for negative partners and never used condoms) (Deferred, decreased risk, on PrEP, out of London clinic, age 35-39).
“I have always been more top, however it is true that I have definitely experienced more as a bottom since (PrEP)… now I am more relaxed about letting a guy fuck me, I just don’t desire it that much, it takes a special kind of person to make me want to do it” (Deferred, high risk, on PrEP, out of London clinic, age 40-44).
“I have a friend … we are effectively dating but there has been no attempt at a long-distance relationship. We use condoms but at the end of this trip … I was like, okay I know you have been tested recently, I know you have been on PrEP as well… and I thought I see you so rarely it would be fun to have unprotected sex… I knew it was a risk and at the end of the three weeks I thought I’m going to have unprotected sex with this guy and I did … I can’t remember any other occurrence where I made an active decision” (Deferred, low risk, on PrEP, out of London clinic, age 25-29).
Consistent Sexual Behaviour Before and After PrEP
For most of the participants who didn’t change their behaviour, PrEP was the ‘additional’ protection that they added to their existing risk reduction strategies in an attempt to minimise the risk of HIV acquisition while having the sex that they desired:“I haven’t changed the way I think because I am taking this pill… having these pills doesn’t give me an excuse to be more crazy than I already am” (Immediate, high adherence, increased risk, on PrEP, London clinic, age 35-39).
“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, so it’s not done anything with the behaviour side of it, my behaviours have remained the same throughout the full 24 months of me taking the tablet, I’d still behave in the way that I would” (estimates he has condomless sex with about 10% of partners) (Immediate, high adherence, low risk, on PrEP, out of London clinic, age 20-24).
For others, their risk taking was relatively low before they started using PrEP and it remained so:“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, on PrEP, London clinic, age 45-49).
“I have a partner who is positive… and undetectable… prior to going onto this programme anyway we had been having unprotected sex, so for me it is more a belt and braces thing” (Deferred, low risk, stopped PrEP, London clinic, age 50-54).
“I don’t know if it works, I’m hoping it does, but I’m not going to change and be more reckless because of it” (Immediate, low adherence, high risk, on PrEP, out of London clinic, age 30-34).
In relation to this last quote, it was clear throughout the interviews that participants were concerned about HIV but largely viewed STIs as a treatable problem. A few participants were particularly concerned about Hep C mainly in relation to fisting and sex toys, but in the main the aim was to avoid the risk of HIV acquisition with little concern for other STIs. Considering this, it was noteworthy that in the majority of the interviews participants still referred to sex on PrEP without a condom as ‘unprotected’ sex and therefore did not change their language in terms of defining this as condomless sex protected by PrEP, at least in terms of HIV.“If you said Truvada was 100% effective, I would abandon condom usage I think because as I said all of the other STIs are treatable” (condom use reduced after starting PrEP) (Deferred, high risk, on PrEP, out of London clinic, age 45-49).