PrEP to Party: Exploring MSM’s PrEP Use and Interest in the Context of Sexually Themed Events

Abstract

Sexually themed events present a unique opportunity for scaling up pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM). This study descriptively explored PrEP uptake among MSM who anticipated attending a week-long major South Florida sexually themed event and examined potential facilitators and barriers to PrEP engagement among potential attendees. Of the participating HIV-negative MSM (n = 96), 66.7% were currently taking PrEP. Prior attendance at sexually themed events was significantly associated with current PrEP engagement and almost 75% of HIV-negative MSM not on PrEP reported high interest in taking PrEP if offered for free at future events.

Introduction

Despite significant advancements in biomedical HIV prevention (e.g., pre-exposure prophylaxis; PrEP) and treatment (e.g., antiretroviral therapy; ART), HIV remains an urgent public health issue in the United States (U.S.), particularly among men who have sex with men (MSM). MSM made up approximately 70% of all new HIV diagnoses in 2020 [1] and currently comprise 63% of all people living with HIV nationwide making them a priority group for the U.S. Ending the HIV Epidemic (EHE) plan [2].

Despite high levels of PrEP awareness among MSM in urban areas [3], several psychosocial and structural factors contribute to their suboptimal access to and engagement with PrEP. Barriers such as mental health challenges, economic marginalization, lack of health insurance, internalized stigma, discrimination from medical providers, and inconsistent PrEP-related knowledge are all consistently implicated in lower PrEP uptake and adherence among MSM [4]. Given these multilevel drivers of insufficient PrEP use, there is a need to develop implementation strategies that overcome these barriers to extending PrEP to MSM who are most in need.

Sexually themed events [5] present a unique opportunity for scaling up and disseminating PrEP to MSM who may particularly benefit. Sexually themed events such as Folsom Street Fair (San Francisco, CA), International Mr. Leather Event (Chicago, IL), and Pig Week (Fort Lauderdale, FL) have the potential to draw thousands of attendees from the local community, nationally, and even internationally and are often housed in EHE jurisdictions with heightened HIV incidence compared to other geographic regions of the U.S. [5]. Prior research has shown that MSM across racial and ethnic groups attend sexually themed events at similar rates; 23–45% of MSM in past studies reported attending at least one sexually themed event in their lives [6]. Further, MSM who attend these events engage in a variety of sexual behaviors across the spectrum of risk such as sex with a higher number of sexual partners, more frequent condomless anal sex acts, and sex with partners of unknown status [5-7].

In addition to being a EHE jurisdiction [2], South Florida is home to several large-scale sexually themed events including one major event which draws more than 4,000 MSM across the gobe to participate in a week of 70 + sexually themed events hosted at several participating venues (e.g., gyms, clubs, hotels). Because of its size and location, this event which, for the purpose of this study we will call “The South Florida Sexually Themed Event”, is an ideal setting to explore new ways to expand PrEP’s reach to MSM in a context where HIV acquisition likelihood is relatively high. Therefore, to explore potential opportunities to scale up and disseminate PrEP to MSM attending sexually themed events, this study aimed to (a) describe MSM who attend the South Florida Sexually Themed Event (b) examine what proportion of HIV-negative anticipated attendees are taking PrEP or would be interested in initiating PrEP at the South Florida Sexually Themed Event, and (c) explore potential facilitators and barriers to PrEP engagement among attendees.

Methods

Participants and Procedures

Authors distributed a survey via a listserv to past and potential future attendees of the South Florida Sexually Themed Event. Recruitment materials explained that the purpose of the 10 minute survey was to learn more about gay, bisexual, and other MSM’s experiences with the event and interest in using PrEP at sexually themed events. All study procedures were approved by the University of Miami IRB with a waiver of signed consent. There was no compensation for participating. All data was collected and stored via secure REDCap.

A total of 142 individuals opened the survey link and were shown the consent information. Of these, 139 consented and were shown the screening questions, which assessed inclusion criteria for the full survey: (1) age 18 years or older and (2) identifying as a gay, bisexual, or other MSM. Of these, 136 were eligible and shown the full survey with 113 completing the survey and included in the current analyses. Recruitment took place from May 31 through November 18, 2020.

Measures

A self-report survey assessed demographics, attendance at sexually themed events, sexual behavior, and interest in and engagement with PrEP.

Demographics.

Participants were invited to report their age, ethnicity, race, and country in which they reside. If they lived in the U.S., they were also asked in which state they live.

Sexually Themed Event Attendance.

Participants were asked if they previously attended the South Florida Sexually Themed Event (binary: yes/no). They were also asked how many events like this one they typically attend per year (continuous, number per year). With the emergence of the COVID-19 pandemic, we also asked participants whether COVID-19 impacted their plans to attend the South Florida Sexually Themed Event or other similar sexually themed events in the coming year (after social distancing ended). Response options included: (1) Yes – I am less likely to attend, (2) Yes – I am more likely to attend, (3) No – I wasn’t planning to attend and still don’t plan to attend, or (4) No – I still plan to attend.

PrEP Use and Interest.

Current PrEP use for HIV prevention (binary: yes/no) was also assessed. Of those who indicated that they were not currently taking PrEP, they were asked to select reasons they were not taking PrEP: (1) not being at risk for HIV, (2) not being able to afford PrEP, (3) not wanting to take a daily medication, (4) being HIV positive, or (5) an open text “other reasons” field. Participants not currently taking PrEP were then asked whether they would be interested in taking PrEP at an event like the South Florida Sexually Themed Event if it were made available to them for free at that event, with their interest rated on a Likert scale from 1 (definitely) to 5 (definitely not). Those who were currently taking PrEP were asked about their adherence, with response options including: (1) every day, (2) 4 or more days per week, (3) less than 4 days per week, and (4) on demand.

Sexual Behavior.

Participants reported the number of times in the past 30 days they had condomless anal sex.

Analytic Plan

Using descriptive statistics, we report on sample demographics, sexual behavior, and PrEP use and interest. Backward entry logistic regression models were employed to assess factors associated with PrEP adherence and engagement among HIV-negative participants currently using PrEP. All analyses were done using IBM SPSS version 27.0.1.

Results

Participants (N = 113) were between the ages of 21 and 74 years (M = 52.54, SD = 11.23). Most identified as White and non-Hispanic (75.2%). Furthermore, most were born in (90.2%) and currently resided in the U.S. (87.5%). Among U.S. residents, the majority reported living in the U.S. geographic South (58%) with just under 40% of the entire U.S. sample residing in Florida. Although many MSM in our study attested that they had never attended this specific South Florida Sexually Themed Event prior to 2020 (53.1%; the year the survey was administered), MSM reported attending an average of 3.12 (SD = 4.39) sexually themed events in the past year with 83.2% of participants reporting that they had attended at least one sexually themed event in the past 12 months. Complete descriptive statistics are in Table 1.

Table 1.

Participant Characteristics for MSM Interested in Attending a Major Group Sex Event in Fort Lauderdale, Florida in 2020 (N = 113)

Variable	Frequency (%) / Mean (SD)
Demographics
Age (years)	52.54 (SD 11.2)
Ethnicity
Not Hispanic, Latino, Haitian/Creole or Afro- Caribbean Black	90 (79.6%)
Hispanic or Latino	12 (10.6%)
Missing/Decline to answer	11 (9.7%)
Race
White	104 (92.0%)
Asian	3 (2.7%)
African-American or Black	3 (2.7%)
Multiracial	1 (1%)
Missing	2 (1.8%)
Geographic Location (N = 112)
Living in U.S.	101 (90.2%)
Living outside of U.S.	11 (9.8%)
U.S. Geographic Location
Northeasta	15 (13.3%)
Southb	58 (51.3%)
Midwestc	16 (14.2%)
Westd	11 (9.7%)
Missing	13 (11.5%)
History of Attending Major South Florida Sex Party
Planned to attend for the first time	60 (53.1%)
Attended before	53 (46.9%)
Average number of group sex events attended annually	3.12 (SD 4.39)
Study Variables
Condomless Anal Sex Acts in Past Month	4.59 (7.31)
Currently on PrEP
Yes	64 (56.6%)
No	49 (43.4%)
HIV Status
Positive	18 (15.9%)
Negative	95 (84.1%)
Reasons for not taking PrEP for People who are HIV-Negative (n = 31)
Not at risk for HIV	8 (25.8%)
Cannot afford it	9 (29%)
Don’t want to take medication everyday	5 (16.1%)
Other	8 (25.8%)
Missing	3 (9.7%)
PrEP Adherence (n = 64)
Every day	56 (87.5%)
4 or more days	2 (3.13%)
Less than 4 days	1 (1.56%)
Only when I’m going to have sex	5 (7.81%)
Interest in Taking PrEP if Available Free at Sex Party among MSM not currently on PrEP (n = 31)
Definitely	18 (58.1%)
Probably	5 (16.1%)
Maybe	6 (19.3%)
Probably Not	1 (3.2%)
Definitely Not	1 (3.2%)

Note: Geographic regions are defined by CDC distinctions. ^aNortheast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. ^bSouth: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. ^cMidwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. ^dWest: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming

Of the HIV-negative MSM (n = 96) who participated, 66.7% were currently taking PrEP. PrEP adherence was high among MSM on PrEP with 87.5% reporting daily PrEP adherence on average. There was variability in PrEP use when examining PrEP engagement by average number of sexually themed events attended per year. Just over 1% of MSM who attended 0 sexually themed events per year were on PrEP compared to 38.9% of MSM who attended 1 sexually themed event on average per year. PrEP use was similar amongst MSM who attended 2 sexually themed events per year (80%) and 3 or more sexually themed events per year (76.9%). In a logistic regression model assessing potentially significant correlates of PrEP use, attendance at sexually themed events over the past year was significant such that for every additional sexually-themed event attended over the past year, participants had 1.30 times the odds (CI: 1.01–1.68) of being on PrEP. Attendance at this specific South Florida Sexually Themed Event in the past, age, and frequency of condomless anal sex in the past month were not statistically significant correlates of PrEP use.

Furthermore, among HIV negative MSM not currently taking PrEP (n = 31), interest in taking PrEP if it were available for free at a sexually themed event was high (M = 1.77, SD = 1.09). Almost 75% reported they were “definitely” or “probably” interested in this PrEP delivery model while less than 7% expressed “probably not” or “definitely not” being interested in initiating PrEP in this way. Major barriers to wanting to receive PrEP at sexually themed events included lack of perceived HIV risk (25.8%), not being able to afford PrEP (29%), being disinterested in taking daily medications (16.1%), and pre-existing health conditions (12.8%).

Exploratory analyses suggested there were no statistically significant differences in frequency of condomless anal sex or the average number of sexually themed events attended in the past year between HIV-negative (n = 95) and HIV-positive participants (n = 18).

Discussion

This brief cross-sectional study sought to describe a group of MSM who attend sexually themed events and explore their PrEP engagement and interest, with an overarching goal of informing strategies to improve uptake of PrEP among those at risk for HIV. Findings indicate that many MSM within this subgroup are currently using PrEP, and that for those who are not, there is substantial interest in initiating PrEP. Of the 96 MSM who were eligible for PrEP, just over two thirds were already taking PrEP, with reported PrEP adherence quite high among participants. The only factor that we identified as associated with PrEP engagement among MSM in the current study was prior attendance at sexually themed events, suggesting that MSM who attend these events may be particularly likely to use PrEP for HIV prevention. MSM who attended 2 or more sexually themed events per year had more comprehensive PrEP engagement compared to MSM who attended less than 2 sexually themed events on average per year with the lowest PrEP coverage observed among MSM who attended 1 sexually themed event on average per year. For participants who were not taking PrEP, the vast majority reported strong interest in taking PrEP if readily available to them. The most common reasons cited for not taking PrEP currently were prohibitive cost and low perceived risk for HIV.

Importantly, among the HIV-negative MSM not taking PrEP, 74.2% reported that they were “definitely” or “probably” interested taking PrEP should it be available at sexually themed events, suggesting the relevance and potential impact of scaling up and disseminating PrEP at events such as The South Florida Sexually Themed Event. This high interest is consistent with past literature indicating that subgroups at increased likelihood for HIV acquisition are open to starting PrEP within these contexts, especially as a potential solution for promoting MSM’s sexual health during these events, which have been described as “season of risk” events based on sexual behavior reported in prior studies [8]. Furthermore, since many MSM repeatedly participate in sexually themed events, as evidenced by the fact that MSM in this study reported attending on average 3 or more sexually themed events yearly, the ability to initiate (or re-engage with) PrEP at these types of events may offer targeted HIV protection at a time of increased vulnerability.

One way to increase community buy-in for PrEP at sexually themed events may be through promoting “event-driven PrEP” (also known as episodic dosing, PrEP 2-1-1, or on-demand PrEP) via mobile PrEP clinics. Over the past few years, various large metropolitan areas across the country (e.g., New York City, Miami, Chicago) have successfully implemented mobile PrEP clinics reaching groups often marginalized in HIV prevention services (e.g., immigrant and racially/ethnically diverse MSM) [9-11]. This delivery model removes some of the structural barriers (e.g., cost, fear of stigmatization, getting to a PrEP related medical appointment) that make accessing PrEP difficult among groups most affected by HIV [11]. Furthermore, because of the large attendance at many of these sexually themed events, mobile PrEP clinics have the potential to become “one-stop shops” for sexual health that offer other services in addition to on-site PrEP start kits, such as Mpox, Hepatitis, HPV, and meningitis vaccines as well as HIV and STI testing. Future research is well positioned to explore the feasibility of these on-site, on-demand mobile PrEP clinics and evaluate whether this approach can improve the sexual and physical health of MSM who attend sexually themed events.

Although reported PrEP adherence (90.1% with 4 or more doses per week) was high among PrEP-using MSM in this study, there were still 33% (n = 31) of HIV negative MSM not on PrEP. These statistics underscore opportunities to not only improve PrEP coverage, but also foster even more consistent PrEP adherence among MSM currently on PrEP. Although participants cited cost as the most common barrier to PrEP (29%), the majority identified other reasons, including low perceived risk for HIV (26%), aversion to daily medication (16%), and fear of stigma or side effects (10%). It is notable that within each of these barrier categories, most participants still reported being highly interested in initiating PrEP at a sexually themed event. This suggests that there is a cohort of HIV-negative MSM who are aware that they may benefit from PrEP, are willing to take PrEP, but, for a variety of reasons, have not yet taken action to obtain PrEP on their own. Although providing PrEP for free is a direct way to address financial concerns in obtaining PrEP, making PrEP available at events where sex risk is likely [5-7] may also help overcome more intractable barriers, including ambivalence about PrEP and low perceived risk that contribute to PrEP initiation hesitancy. In addition to capitalizing on PrEP delivery at the time and place of most likely risk, this strategy may leverage peer influence in such social events, thus facilitating PrEP initiation among individuals whom are more difficult to engage, and those who have intermittent and unpredictable periods of risk.

This study possessed several limitations. First, because participants were not compensated for completing this survey, the sample size of HIV-negative MSM not on PrEP was small which may have impacted authors’ abilities to identify significant correlates of PrEP uptake. Second, because the survey was designed to be extremely brief due to not offering incentives, authors were limited in the analyses they could run due to the scarcity of potential predictors. Third, the sample was overwhelmingly White and non-Hispanic/Latino (75%) which impedes generalizability to more racially and ethnically diverse MSM. There are several reasons why this particular group of participants may have been less racially/ethnically diverse than prior studies of similar events [5, 7]. For example, as an international event, the cost of travel may be more limiting for racially/ethnically diverse potential attendees. Furthermore, the fact that this survey was only distributed to likely attendees, it is possible that local attendees who are more racially/ethnically diverse did not see the survey since they do not need to plan ahead to travel to the event. Additionally, past research suggests uncompensated surveys may result in a less racially/ethnically diverse pool of participants which may have influenced this sample’s racial/ethnic diversity [12]. Finally, the fact that this survey was collected prior to the actual occurrence of the South Florida Sexually Themed Event, we were unable to collect data on actual behavior that may exacerbate HIV risk among attendees.

Despite the study’s limitations, several strengths should be noted. First, despite the small sample size, participants haled from 29 U.S. states and 10 countries, expanding the generalizability of our findings. Additionally, by focusing on a subgroup of underexplored MSM (i.e., MSM who attend sexually themed events), findings uniquely highlight opportunities in which these settings may help to promote HIV prevention and sexual well-being among a population at increased susceptibility for acquiring HIV.

Conclusion

This brief cross-sectional study sought to describe a group of MSM who attend a major annual South Florida Sexually Themed Event, examine interest among MSM not on PrEP on initiating PrEP at sexually themed events, and explore potential facilitators and barriers to PrEP engagement among attendees. Findings suggest that PrEP uptake and adherence was high among enrolled participants, and that there was an overwhelming interest in initiating PrEP at sexually themed events among the 33% who were non-PrEP users. Future research that build off these analyses could benefit in further exploring PrEP use patterns among sexually themed event attendees in more racially/ethnically diverse samples and by developing and testing strategies for implementing and disseminating PrEP through sexually themed events (e.g., mobile PrEP clinics, on site PrEP start kits, peer ambassador initiatives).

Data Availability

The data that support the findings of this study are available within the article and/or its supplementary materials. All other data are available from the corresponding author, EW, upon reasonable request.

Code Availability

All code for data cleaning and analysis is available upon request from EW.