Men who have sex with men (MSM) in Seattle who had recently begun to take pre-exposure prophylaxis (PrEP) described profound impacts on their sexual health and wellbeing that go beyond PrEP’s primary function of preventing HIV infection, according to a qualitative study recently published in the International Journal of Sexual Health.
“By lowering HIV risk and offering an alternative form of protection for MSM with low or inconsistent condom use, PrEP helped participants assuage feelings of anxiety and shame surrounding their sexuality, and facilitated greater sexual satisfaction, intimacy, and self-efficacy,” Shane Collins and colleagues say. However, it also exposed users to PrEP stigma. Both positive and negative impacts are likely to be key to PrEP’s acceptability, demand and patterns of use.
It's important to note that ‘sexual health’ is not defined simply by the absence of disease. “Sexual health is a state of physical, mental and social well-being in relation to sexuality,” according to the World Health Organization. Clinicians and practitioners wishing to promote gay men’s sexual health should consider the full range of impacts that PrEP may have, the authors suggest.
In 2014, the researchers conducted in-depth interviews with 14 PrEP users in Seattle, Washington. Participants were obtaining PrEP from a range of public and private healthcare providers, in a context of the early stages of PrEP implementation in a state which had lowered financial and administrative barriers to using PrEP.
Most men were white; one was black and one was Latino. One transgender MSM took part. Most participants were in their thirties or forties, while the youngest was 26 and the oldest 66. Half had been using PrEP for three months or less at the time of the interview (only two had used PrEP for more than a year).
The researchers used a qualitative research method known as interpretative phenomenological analysis (IPA). Rather than attempting to produce findings that are generalisable, this approach focuses on the particular experience of small samples of people in similar circumstances. It attempts to explore how people make sense of their experience, analysing the thoughts and emotions that interviewees ascribe to particular situations.
A desire for lower-risk, condomless sex was the predominant driver of PrEP use among the respondents. Most had sought out PrEP because they had a history of inconsistent condom use (or no condom use) and recognised that this pattern was unlikely to change, regardless of their intentions, as this man explained:
“It’s the best choice for the behaviour that I know is my behaviour … While I’m not always safe, I certainly always want to stay HIV-negative.”
Many men expressed an aversion to condoms. They complained of reduced physical sensation, less spontaneity, erectile dysfunction and a loss of intimacy.
While most men felt that PrEP alone provided strong protection against HIV, they also recognised that unlike condoms, PrEP does not offer protection against other sexually transmitted infections. Some men described selectively using condoms based on their perceptions of partners, while other men saw being exposed to other sexually transmitted infections as an acceptable risk.
“There are times when I think to myself, ‘Well, even though I’m on PrEP, maybe I shouldn’t have unprotected sex because I might catch something else.’ But there’s another part of me that says, ‘Well, those aren’t so terminal. If I got those, I could easily just get them cleared.’”
By lowering HIV risk and offering a more acceptable form of HIV prevention than condoms, PrEP helped participants lessen feelings of vulnerability, fear, and shame associated with pre-existing sexual behaviours. Men described the anxiety they had felt about sex before using PrEP and the stress this placed on their mental and emotional wellbeing.
“I had done the best that I could and I still just felt like there was no winning, like every day was a constant battle against this invisible thing that lives in our blood and kills us. And I felt powerless. And it wasn’t just when I got tested. It wasn’t just when I had sex. It was six days after I had sex. It was, ‘Should I have done that? Should I have not?’”
Despite these intense feelings, they typically had not resulted in sustained changes to sexual behaviour. Instead men tended to feel more shame and self-judgement about their sexual lives. Moreover, they often led men to become fatalistic about the likelihood of acquiring HIV. The man quoted in the previous paragraph continued:
“I’d gotten to a point where I was having sex almost with resignation of the fact that I was probably eventually just going to get HIV. Like, it was just gonna have to happen because the alternative is not to be intimate with anybody.”
Taking PrEP allowed men to experience their sexuality in new ways. The interviewee who had the greatest experience of PrEP in the sample (19 months of PrEP use) described it in these terms:
“Being a gay man—especially one as promiscuous as I am—there was always a very real possibility of seroconverting. And so, while PrEP may not be 100 percent effective, it’s still very effective. And being able to live without that stress and fear was very liberating.”
Many men described how using PrEP helped them improve their sense of self-efficacy. They saw their use of PrEP as empowering and proactive, in contrast to previous experiences of constrained agency.
“I’d say it’s affected me pretty profoundly. There are very few situations where I find myself feeling like a victim anymore… I don’t feel like anything’s being done to me from the outside that I’m not choosing to let happen.”
The lessening of shame and anxiety led to more satisfying sexual encounters.
“In the past, when I was having these condomless episodes with people, there was a bunch of excitement and great physical feeling, but at the same time I was having this internal turmoil and horrible feeling about what I was doing… Now on Truvada there’s at least the opportunity for me to quiet some of that really fearful conversation that’s going on through my head, and feel more connected and good about what I’m doing.”
Men saw PrEP as ‘sexually liberating’ in the sense that it enabled them to explore sexual desires they had previously suppressed. For many, PrEP allowed them to enjoy being the receptive partner.
“That’s something that I never thought I would do and I never thought I could do without fear… Because I’m on PrEP, allowing myself to bottom became an option. And then once I did, I was like, ‘Okay, I actually like that!’”
Others talked about how they could now imagine themselves having relationships with HIV-positive men. At the same time, men who had been in long-established relationships with HIV-positive men talked about how PrEP had improved sexual satisfaction by providing peace of mind and allowing the couple to stop using condoms.
“[My partner] felt obligated to protect me and to do everything in his power to make sure that he didn’t transmit an infection to me. And while there still is a possibility, that fear is gone. And it has improved our sexual relations, our intimacy, and I think it’s had a positive influence on our relationship together.”
Alongside these positive effects, the interviewees also experienced or worried about being stigmatised for their use of PrEP.
“Talking online with other people that are cruising online websites and you tell them you’re on PrEP, there was somewhat of that shaming, ‘Oh, you’re on PrEP, you must be a slut. You must be irresponsible. You must be making really bad choices to think you need to be on this.’”
There was evidence in a few mens’ accounts of this stigma being internalised, with some expressions of shame, regret and internal conflict in relation to their sexual behaviour while on PrEP. Stigma was also experienced in healthcare settings, with men feeling judged by staff for using or requesting PrEP. Doctors’ insistence that condoms should be used together with PrEP was often felt to be impractical and paternalistic, and led some men to misrepresent their condom use to their doctor.
The interviewees’ accounts draw attention to the range of sexual health priorities that gay men consider when deciding to use PrEP, including staying HIV negative, preserving sexual function, maintaining sexual satisfaction and fostering intimacy with partners. The profound impact of reducing shame and anxiety surrounding sex highlights the psychological burden of living with an elevated risk of contracting HIV, comment Shane Collins and colleagues.
Similar themes are picked up in a separate qualitative study of PrEP users, published by Kimberley Koester and colleagues in Culture, Health and Sexuality. (Initial findings from these iPrEx OLE study participants were reported in 2014).
In her paper Koester notes that, before PrEP became available, there was an under-acknowledgement of the stress and burden caused by the threat of HIV. Taking PrEP alleviated her interviewees’ longstanding fears about contracting HIV but also created a space for them to voice those fears.
Both authors are critical of how most research on PrEP and sexual behaviour has focused on concerns about ‘risk compensation’ (individuals using condoms less often or having more sexual partners while taking PrEP). The language of ‘risk compensation’ is out of sync with and does not reflect the experiences of PrEP users, says Koester. The changes that men described as a result of PrEP use tended to be emotional rather than behavioural – PrEP changed their internal story about fear about HIV; they felt more comfortable and relaxed during sex.
“Men using PrEP experienced the freedom to practise sex in ways that provided greater fulfilment emotionally, physically or otherwise,” says Koester. “Labelling these practices as evidence of risk compensation runs counter to how men explained what was happening.”
Collins SP et al. The Impact of HIV Pre-exposure Prophylaxis (PrEP) Use on the Sexual Health of Men Who Have Sex with Men: A Qualitative Study in Seattle, WA. International Journal of Sexual Health 29: 55-68, 2017. (Abstract).
Koester K et al. Risk, safety and sex among male PrEP users: time for a new understanding. Culture, Health & Sexuality, online ahead of print, 2017. (Abstract).