Changes in Risk Perception and Behavior, and Adherence Patterns Among a Diverse Sample of YMSM Substance Users Taking Pre-Exposure Prophylaxis (PrEP) to Prevent HIV Infection

Introduction: Recent evidence suggests that the antiretroviral drug combination emtricitabine and tenofovir (i.e., Truvada®) taken as pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV infection. A significant public health development, PrEP is now widely promoted as a prevention strategy for individuals in high-risk groups. While this is an exciting development, adherence to PrEP remains a major concern as well as possible increases in high-risk behaviors such as condomless anal sex. As such we conducted a small (N = 30) semi-structured interview study exploring possible changes in risk perceptions and sexual risk behavior, patterns of drug and alcohol use, adherence patterns, and examined the willingness of substance using, HIV-negative MSM taking PrEP (PMSM) to engage in a smartphone based application intervention designed to increase PrEP adherence and deliver important behavioral risk-reduction information.

Methods: We conducted 60-minute semi-structured interviews with 30 HIV-negative, substance using PMSM recruited by provider referral from the same Kaiser Permanente Medical Center in San Francisco where they were prescribed PrEP. Inclusion criteria for the proposed study included reporting that they were: biologically male, reported drinking five or more drinks on a given occasion and/or using illicit substances during the past 3 months, had been prescribed and reported taking PrEP for at least 6 months, reported less than 100% adherence to their PrEP medication in the last 6 months, and reported currently owning a smartphone. Racial/ethnic minorities were oversampled in order to constitute 2/3rds enrollment. Interviews were transcribed and coded using a modified grounded theory approach to identify key themes and commonalities, and salient differences across participants.  

Results: Results revealed several salient themes among these PMSM. These themes included the positive psychological and social effects of being on PrEP (e.g., decreased anxiety, feelings of empowerment), reduced stigma towards HIV-positive individuals, and significant changes in overall perceptions of risk. With respect to changes in sexual behavior findings were mixed. While the majority of participants reported decreased condom use, there was significant variation and nuances in increases in condomless anal sex after starting PrEP. Many participants reported a brief period of increased condomless sex immediately following PrEP initiation (i.e., “honeymoon phase”). Participants discussed contextual factors the lead to problematic adherence and expressed interest in a smartphone based intervention targeting risk-behavior and adherence.

Conclusion: PrEP is highly effective in preventing HIV infection among HIV-negative MSM. This study demonstrates that changes in risk perception and behavior are nuanced and there is a high-degree of individual variation. Aside from decreases in new HIV-infections, there are psychological and social benefits of taking PrEP. Substances such as alcohol and stimulants had a deleterious impact on adherence for some PMSM. Overall, participants reported interest and willingness to engage in a smartphone based intervention targeting risk-behavior and adherence.