Sexual Networking and HIV/STI Prevention among Men Who Have Sex with Men and Identify as Persons of Color in the Era of COVID-19 in Boston, MA: Qualitative Findings from the National HIV Behavioral Surveillance Project

Abstract

Men who have sex with men and identify as persons of color (MSM of color) are significantly impacted by HIV in the United States. The COVID-19 pandemic may have disproportionately exacerbated HIV-related disparities among MSM of color by affecting sexual networking behaviors and disrupting access to sexual health care. The current study explored the impact of COVID-19 on sexual networking and HIV/sexually transmitted infection (STI) prevention behaviors among MSM of color in Boston, MA. Eighteen semi-structured interviews were conducted via the 2020–2021 Boston sample of the National HIV Behavioral Surveillance (NHBS) project. Eligible participants were at least 18 years old, identified as a man or non-binary person assigned male at birth and as a person of color, and endorsed ever having sex with men. Interviews were coded using inductive and deductive approaches, and themes were extracted using thematic analysis. When participants were asked about the impact of COVID-19 on sexual networking and HIV/STI prevention, the following themes emerged: (1) differing interpretations of COVID-19 public health guidance, (2) behavior change to meet social and sexual needs, (3) limited or changed access to HIV/STI prevention services; and (4) avoidance of healthcare appointments. Overall, the pandemic affected sexual networking and HIV/STI prevention behaviors among MSM of color. Though changes in sexual networking varied, most participants decreased in-person networking, increased dating app use, and prioritized longer-term relationships. Despite loosening of restrictions, these impacts may persist and should inform the adaptation of sexual networking guidance and interventions to mitigate HIV-related disparities in communities of color.

Introduction

In the United States, men who have sex with men (MSM) are at disproportionate risk for acquiring HIV, accounting for 70% of all new HIV diagnoses in 2019 [1]. This disparity is most pronounced among MSM who identify as persons of color, as HIV incidence rates are highest among Black MSM relative to all other groups (26% of all new HIV diagnoses, and 37% of new diagnoses among all gay and bisexual men). Disparities in HIV incidence rates are also evident among Hispanic/Latinx MSM, who account for 24% of all new diagnoses.

HIV-related disparities are particularly profound in Massachusetts, where the current study was conducted, among both persons of color and MSM. Between 2018 and 2020, 32% of new HIV diagnoses were among Black (non-Hispanic) individuals and 27% were among Hispanic/Latinx individuals, corresponding to age-adjusted diagnosis rates eight and four times greater than rates in White (non-Hispanic) individuals, respectively. Male to male sexual activity was the most frequently cited HIV exposure mode in both Black (43%) and Hispanic/Latinx (62%) individuals assigned male at birth. Notably, 44% of new HIV diagnoses in the city of Boston during this timeframe were among Black (non-Hispanic) individuals [2]. These data contextualize the challenges faced by BIPOC (Black, Indigenous, and other People of Color) individuals in Massachusetts and suggest that Boston-based programs and health services may not be reaching those at greatest risk.

COVID-19, associated health disparities, and racism

As COVID-19 cases increased in the United States, stark racial disparities in morbidity and mortality emerged. At the height of the pandemic, Black Americans, who represent 13% of the population, had 30% of the COVID-19 cases [3]. Once infected with COVID-19, people of color and other individuals who have been historically marginalized are at greater risk for hospitalization and mortality [4], in part due to lower rates of vaccination [5]. Based on July 2020 data from the Kaiser Family Foundation and the EPIC health network, the hospitalization rates and death rates per 10,000 were 24.6 and 5.6, respectively, for Black patients, 30.4 and 5.6 for Hispanic patients, and 7.4 and 2.3 for White patients [6].

COVID-19 also exacerbated health disparities among populations at elevated risk for acquiring HIV, with systematic racism emerging as a likely cause of race-based inequities. Patients from BIPOC communities have an increased prevalence of common medical conditions, and patients may avoid treatment for these conditions to reduce risk of COVID-19 exposure, thereby increasing risk for complications [7]. Importantly, socioeconomic disparities in low-income communities of color may further exacerbate disparities in health outcomes for people affected by COVID-19 [8]. Systemic racism has been identified as a fundamental cause of racial inequities in disease concentration [9,10], deriving from centuries of settler colonialism, slavery, race-based segregation, and mass incarceration [11]—all processes that have shaped the social and spatial distribution of risk and resources [12] in communities of color (e.g., quality of schools; employment opportunities or levels of unemployment; unstable or substandard housing, as well as density of housing; food insecurity; access to healthcare) and may therefore increase exposure to COVID-19. The distribution of these resources has, in turn, affected the development of cardiometabolic conditions via pathways like unequal nutritional status and inflammation [13,14], also potentially increasing susceptibly to the virus [11].

The impacts of COVID-19 on sexual health among MSM

Recent data from MSM with a range of racial backgrounds indicate that this population has experienced interruptions to HIV prevention, testing, and HIV care/treatment services [15]. Further, COVID-19 has also led to decreased virologic suppression, which can only result in worsening HIV prevention and epidemic control [16]. In a sample of over 10,000 MSM across 20 countries who used the social networking app Hornet, 38% of participants (n = 3992) reported perceived interruptions to in-person HIV testing, 55% (n = 5178) reported interruptions to HIV self-testing, 56% (n = 5171) indicated interruptions in PrEP use, and 10% (n = 990) specified interruptions to condom access [17]. In other samples, there were fewer reports of PrEP interruptions and discontinuation, but participants noted that securing PrEP refills was difficult [18], and some chose to switch to event-driven PrEP or PrEP on demand [19], an effective strategy which involves taking two tablets 2–24 hours before sexual activity, one tablet 24 hours after the first dose, and one tablet 24 hours after the second dose [20].

Importantly, the sexual health of MSM of color may also be disproportionately impacted by COVID-19, due to potential disruptions in access to care. In the few studies that have explored the effects of COVID-19 among MSM of color, the pandemic interfered with both PrEP and antiretroviral therapy (ART) use, as well as ability to follow public health guidance to reduce the spread of the virus. In an examination of race/ethnicity and COVID-19-related changes in HIV prevention behaviors and access to prevention services, participants who identified with racial or ethnic minority groups reported feeling less confident in their ability to access condoms and HIV self-tests than those who did not identify with minority groups [15]. Among Black MSM and transgender women in Chicago who were interviewed between April and July of 2020, multiple COVID-19 stressors compromised access to HIV prevention and treatment options; specifically, intimate partner violence and losing health insurance in the context of the pandemic were associated with reduced ART access, and travel-related financial burden was associated with challenges accessing PrEP [21]. In a Brazilian sample of MSM, transgender, and nonbinary individuals, non-white race was associated with inability to maintain social distancing, and inequities in COVID-19 prevention and care were drawn across racial lines [22]. Though little is known about the impacts of COVID-19 among racial and sexual minority groups, other disparities research has also demonstrated that public health challenges are often compounded in individuals with intersecting minority statuses, including MSM of color and other multiply marginalized groups (e.g., Black transgender women) [23,24].

The impact of COVID-19 on sexual networking among MSM

COVID-19 might also be leading to changes in sexual networking behaviors. Once more, research has not focused on MSM of color. Studies on the effects of COVID-19 on sexual networking and sexual behavior among general samples of MSM demonstrate profound changes in dating and other sexual networking behaviors. During the pandemic, MSM reported engaging with fewer sexual partners, or if they continued to interact with sexual partners at pre-pandemic levels, they took fewer risks (e.g., limited physical contact) and/or moved both sexual networking and sexual activity online [25,26], initiating interactions with potential partners via apps and engaging in sexual behaviors via videoconferencing. Data from high-income countries other than the US, including Belgium and Australia, demonstrate similar patterns [18,19], including decreases in sexual activity outside of committed relationships and decreases in specific in-person sexual behaviors, such as group sex. Not perceiving COVID-19 as a serious health threat often led to continued in-person sexual activity, or reduced willingness or desire to comply with social distancing guidelines [27,28].

The current study

Given the historic underrepresentation of MSM of color in HIV-oriented research and the HIV prevalence disparities in this population, it is critical to understand the ways in which COVID-19 may have uniquely affected behaviors that both mitigate and exacerbate risk for HIV acquisition in this population. The National HIV Behavioral Surveillance (NHBS) Project, a program established by the Centers for Disease Control in 2003, conducts behavioral surveillance among three different populations at high risk for HIV infection: gay, bisexual, and other men who have sex with men (known as the MSM cycle); persons with injection drug use (the IDU cycle); and heterosexual individuals who are at increased risk for infection (the HET cycle). To increase the representation of cisgender, transgender, and nonbinary MSM of color, the current study used selective sampling and qualitative methods to explore the impact of COVID-19 and associated public health restrictions on sexual networking and HIV/STI prevention behaviors. These data, which were pulled from the 2020–21 MSM cycle in Boston, will help guide future NHBS implementation and best practices, as well as highlight opportunities to increase virtual or remote access to HIV/STI prevention services as well as tailor these services to MSM of color.

Methods

National HIV Behavioral Surveillance Project

This qualitative data analysis used individual interview data collected from the 2020–2021 (cycle 6) Boston sample of the NHBS project, which consists of a standardized protocol for surveying and providing HIV-testing services for individuals who engage in behaviors that are associated with increased risk for HIV acquisition and transmission [29]. The NHBS project rotates among three key populations on a three-year cycle: MSM, people who inject drugs, and heterosexuals at increased risk of HIV infection. The current analysis used all available data from the latest completed MSM cycle. Recruitment and data collection activities were conducted confidentially, such that identifying information was only accessible to approved research study staff for scheduling and payment purposes. The Institutional Review Boards at The Fenway Institute and Massachusetts Department of Public Health approved all study procedures.

Participants and Recruitment

This MSM cycle used respondent-driven sampling (RDS). A small number of initial participants, or “seeds,” were selected through key informants, community partners, posting flyers, and consulting with health department advisory groups and colleagues. Seeds completed the interview and then recruited their peers to participate. Potential participants were screened to determine whether they met study eligibility criteria, which were as follows: a) aged 18+ years old, b) resided in the greater Boston area (i.e., Middlesex, Suffolk, Norfolk, Essex, and Plymouth counties) at the time of the study, c) identified as a cisgender man, transgender man, or non-binary person assigned male at birth, d) identified as a person of color, e) endorsed ever having oral or anal sex with another man; f) able to complete an interview in English, and g) able to provide informed consent.

Procedures

Our approach to data collection and analysis was informed by the interpretive/constructive approach [30,31], given our concern with understanding the experience and impressions of the COVID-19 pandemic and sexual health among our target population. Research staff conducted semi-structured, open-ended qualitative interviews remotely via the Health Insurance Portability and Accountability Act (HIPAA)-compliant Zoom online video-conferencing application. A total of 18 interviews were completed between November 2020 and January 2021, the time allotted for accrual. Post-hoc data review confirmed that no new themes emerged in the final five interviews, indicating that saturation had been reached [32,33] and yielded a sample size consistent with other qualitative studies and adequate for thematic analysis [34]. All procedures and analysis processes described here were conducted in alignment with the COREQ guidelines [35].

Each visit began with a scripted introduction and proceeded through to the consent form, brief demographic survey, semi-structured open-ended interview guide, and recruiter training (i.e., participants were encouraged to recruit their friends to participate and provided study eligibility, a unique code to give others to enable them to sign up for an interview, and $10 compensation for each successful referral). In total, the process took between 40–60 minutes. Participants were compensated with $75 for completing the interview, paid through Venmo or via cash. Interviews were recorded via the Zoom application local recording feature and the data were uploaded to a secure transcription service. Transcribed interviews were subsequently reviewed for translation quality and fidelity by a NHBS study team member and imported into the NVIVO (version 12) qualitative analysis software.

The interview guide was developed based on a review of the literature on HIV/STI prevention among MSM with input from both local and national experts (e.g., from the Centers for Disease Control and Prevention, Massachusetts Department of Public Health, and The Fenway Institute) in sexual and gender minority health and qualitative methods. We piloted the interview guide initially with approximately two study staff to assess its clarity and content and revised accordingly. The interview guide first explored sexual networking (i.e., how person socializes and meets sexual partners) with prompts to assess differences between meeting sexual partners in-person versus on smart phone applications (apps), as well as how things have changed since the COVID-19 mandatory stay-at-home order. Next, the interview guide prompted participants to comment on what strategies they use to protect themselves from HIV and other STIs and how they discuss HIV/STI prevention with sexual partners. Participants were also prompted to consider how COVID-19 had changed prevention strategies or affected one’s ability to get prevention services or materials (see Supplemental Material 1).

Data Analysis

Transcripts were read and discussed as a team (CO, JF, AS, SM, CP) to inform the development of a coding scheme (see Supplemental Material 2), which was used to organize data and facilitate the identification of themes. Three coders (JF, AS, SM) engaged in an iterative, structured, and consensus-driven process, which applied a flexible, inductive, and deductive approach to the generation of codes [36]. Deductive codes were derived from a priori interview guide categories (e.g., sexual networking before COVID-19, HIV/STI prevention since COVID-19) and inductive codes were derived from the data (e.g., preference for committed relationships over hook-ups, concealing in-person sexual activity) to allow for analysis around domains identified as potentially important by content experts who helped develop the interview guide, but to also facilitate the categorization of data that was not contained in the interview guide. The three coders independently read three transcripts and then met as a team to discuss and refine agreed upon codes and their respective definitions. This process was repeated after reading an additional three transcripts to ensure completeness of the coding scheme.

The codebook was then finalized in the double-coding process. Six total interviews (33%) were then double-coded by the three coders who compared their coding to ensure coding reliability, verify understanding of the codebook and resolve any discrepancies, which were discussed among the coders and resolved through consensus [37,38], producing a final set of codes based on multiple researchers’ input. The team planned to use third-party resolution [38] (i.e., have the third coder resolve any discrepancies for which consensus could not be reached among the two coders who were double-coding), but consensus was reached for all discrepancies, so this approach was ultimately unnecessary. An audit trail was maintained throughout the coding process. After reliability was established, the same three coders coded the remaining 12 interviews independently. After coding was completed, data within and across codes were reviewed by the core data analysis team (CO, JF, AS, SM, CP) to identify themes and subthemes related to sexual networking and HIV/STI prevention, in alignment with the methods of thematic analysis [36]. Data reduction methods were employed to extract the overarching narrative from the most pertinent data [39].

To ensure the quality of the data, we followed the eight criteria (worthy topic, rich rigor, sincerity, credibility, resonance, ethical, significant contribution, meaningful coherence) established by Tracy [40]. We determined that the topic was worthy of scholarly attention given its relevance and timeliness to the COVID-19 pandemic, especially given the disparities in COVID-19-related hospitalization and mortality rates among persons of color [4,6]. We achieved rigor during the data collection process by pilot testing the interview guide prior to deploying it. The guide was reviewed by all members of the study team twice to ensure adequate breadth (i.e., coverage of all important domains associated with the research question). Staff pilot tested the interview guide three times with each other to evaluate length and ensure that the guide achieved adequate depth (i.e., ensuring completeness of participants’ responses). Additional probes were included, and interviewers were coached on how to use general probes to clarify and/or gather more details (e.g., “tell me more about…”). The first two to three transcripts were reviewed within two weeks of delivery, and line by line feedback provided to the interviewers on effective use of the guide, particularly probes, and more general interview strategies, like maintaining a neutral style.

We continued to follow Tracy’s criteria [40] throughout the data analysis process. Rigor was achieved through triple coding of the first six transcripts, transparent review of each coder’s transcripts, in-depth discussion of the codes among the three-coders, and iterative refinement of the coding structure based on these discussions. To ensure sincerity throughout data collection and analysis, we recognized the ways in which our backgrounds and experiences might bias our attention to specific aspects of participants’ experiences and/or influence our interpretation of those experiences. We worked to approach credibility through triangulation, as multiple members of our team typically converged on the same conclusions and interpretations, and we conducted two meetings with our three-person coding team to assess reliability and consistency of interpretations. Importantly, our data collection team included a member who identified as a person of color; this individual conducted a significant portion of the interviews. In addition, a member of our data analysis team, who assisted with data interpretation and contributed to the writing of the manuscript, identified as an MSM of color.

In our analyses, we were mindful of the potential impacts of these data and of important ethical considerations around sensitive content. Based on Tracy’s definition of “resonance” as the ability of the work to meaningfully impact an audience [40], we selected salient quoted text from our participants’ interview data in hopes that readers might be emotionally impacted by their experiences. We collected the data in accordance with a protocol that was approved by several ethics boards and therefore deemed it to be ethical procedurally; we also concluded that the protocol was ethical from a relational perspective, as our data collection and analysis procedures were designed to respect the dignity of our participants and their experiences. These analyses significantly contribute to the literature by offering new perspectives on sexual networking and HIV/STI risk reduction among MSM of color who were affected by COVID-19, generating material that may inform future research.

Finally, we achieved meaningful coherence through data collection and analysis by accomplishing the stated goals of the study, with face validity, and by situating our findings in context of the COVID-19 pandemic in Boston, MA at the end of 2020 and beginning of 2021. Results are organized chronologically (i.e., pre-COVID, then post-COVID) and in accordance with our interview guide (see Supplemental Material 1), which was developed in collaboration with the Massachusetts Department of Public Health. Understanding the impacts of COVID-19 on sexual networking among populations at high risk for HIV acquisition or living with HIV was a priority area for the Department.

Results

Participants

Participants’ ages ranged from 18 to 35 years (M = 26.4, SD = 5.7), and 50% of the individuals in the sample identified as both White and Latinx. Most reported a college education (83%), and half (50%) indicated an income above $40,000 (Table 1).

Table 1.

Sample Characteristics

	N (%)
Age
Under 30 years old	11 (61.1%)
30 years or older Mean (range)	7 (38.8%) 26.4 (18–35)
Race/Ethnicity
Black and Hispanic/Latinx^	1 (5.5%)
White and Hispanic/Latinx	9 (50.0%)
Asian and Hispanic/Latinx	1 (5.5%)
Multi-Racial and Hispanic/Latinx	1 (5.5%)
Multi-Racial and Non-Hispanic/Latinx	3 (16.6%)
Asian and Non-Hispanic/Latinx	2 (13.3%)
American Indian and Non-Hispanic/Latinx	1 (5.5%)
Education
Postgraduate Degree	3 (16.6%)
Bachelor’s Degree	6 (33.3%)
Associate’s Degree	2 (11.1%)
High School Graduate	7 (38.8%)
Income
$0 - $20,000	4 (22.2%)
$20,001 - $40,000	5 (27.7%)
$40,001 - $60,000	3 (16.6%)
$60,001 - $80,000	2 (11.1%)
$80,001 - $100,000	0 (0%)
$100,001+	4 (22.2%)

Note.

^{^}No participants identified as Black, Non-Hispanic.

Our results are organized across three primary content areas: A) participants’ discussion of key pre-COVID HIV/STI prevention strategies, B) participants’ discussion of COVID-19 impact on their sexual networking behaviors, and C) participants’ discussion changes in their HIV/STI prevention practices during the COVID pandemic.

A). HIV/STI Prevention Before COVID-19

Initially, participants were asked to talk about their sexual networking and HIV/STI prevention behaviors prior to the COVID-19 pandemic. In summary, participants characterized their pre-COVID-19 sexual networking as primarily online and through Apps and sometimes out of state due to a lack of diverse partners in the Boston-area both in local bars and clubs but also online. Against this context, participants were asked about their HIV/STI prevention practices prior to COVID.

Six HIV/STI prevention strategies were identified across the qualitative interviews: condom use, PrEP, HIV/STI testing, limiting sexual activity, checking partners for visible STI symptoms, and discussing HIV/STI prevention with sexual partners. In addition to inquiring about participant engagement in specific HIV/STI prevention strategies, we explored the ways in which participants made decisions about their sexual health and associated prevention behaviors. Two major subthemes captured the processes by which participants reported making these decisions: integrating knowledge (e.g., of prevention strategy efficacy, new learning about prevention strategies, side effect profiles, testing requirements) and considering partner, contextual, and community factors. These are elucidated below.

Knowledge matters when making decisions about HIV/STI prevention.

Participants reported that they chose HIV/STI prevention strategies after weighing the pros and cons of different options. For example, participants’ decisions to use condoms, PrEP, or a combination of both might be made based on their knowledge of the efficacy of each prevention strategy:

Condoms is the most effective…Because PrEP just prevents HIV, in my opinion. And all the other STDs that can come through your body. So I believe that the condom is more safe. (32 years old, identified as American Indian and Hispanic/Latinx)

Participants also described the ways in which they processed new information about efficacious HIV prevention strategies. For example, one participant had only recently been introduced to PrEP and was in the process of learning more about this strategy from his friends:

I actually just recently heard about PrEP, because all my other friends do it. So they started introducing that to me, but I havenť actually gotten into that, no. (21 years old, identified as Black and Hispanic/Latinx)

Another participant described that his conceptualization of HIV/STI prevention and choice of prevention strategies have evolved over time with increased knowledge of HIV. He explained that, when he was younger, he was more cautious about engaging in sexual activity with people living with HIV. As he aged and learned more about HIV treatment, he adjusted the language that he uses to talk with potential partners about their status, and these conversations then inform his choice of prevention strategy:

I used to be more paranoid, I would say…But as you get older, it’s not that you don’t care, but I would say I’m more open-minded about people who has HIV and people who lives with that. Because nowadays, people have treatment for that, and people can live their lives for a long time even without it. So I would never be—I would never discriminate anyone who has it. But I also respect, and before I talk to someone, I always ask them if they’re negative. Because I don’t like the term to use clean, because you’re not a dirty person if you have it. So I usually ask them if they’re negative and then go from there. (22 years old, identified as White and Hispanic/Latinx)

Some participants reported that they refrained from using PrEP, acknowledging that it may not offer enough protection. For example, one participant chose not to use PrEP based on his observations that those who do use the medication seem to over rely on PrEP as a complete HIV/STI prevention strategy:

And I have a point about PrEP and people that use PrEP. That is when they are on PrEP, they just like, “Oh, I'm on PrEP. I'm immortal”. (32 years old, identified as American Indian and Hispanic/Latinx)

Social and interpersonal factors also influence decisions about HIV/STI prevention strategies.

Participants emphasized that decisions regarding HIV/STI prevention are not made alone. Several partner-level factors appeared to influence how participants approached HIV/STI prevention.

Participants reported forgoing condoms, in the context of emerging intimacy with sexual partners or in primary sexual partnerships. The participant below described distinct rules that he follows prior to engaging in condomless sex:

I kind of have set rules for myself, and one of the rules is I had to have sex with a guy three times before I'd have unprotected sex with them. I wouldnť have sex on the first date type stuff. (21 yrs old, identified as White and Hispanic/Latinx)

After using condoms at least three times, the participant above noted that he typically has a conversation with the partner about testing and status, establishing a sense of trust before moving forward with condomless sexual activity. Relatedly, participant reasons for not using condoms included having a steady partner, with some participants reporting that they stopped using condoms once they had established a committed, long-term relationship:

If iťs just a hook-up or a friends-with-benefits-type deal, I make them [use condoms]. But if I'm actually in a relationship with the person, I kind of donť bother with that as much. (23 years old, Native Hawaiian/Pacific Islander, White, and Hispanic/Latinx)

Several participants reported that condom-use decision-making were based on partner reports of PrEP use. For example, when participants inquired about PrEP use—often very early on in the interaction—and the potential partner reported not using PrEP, condom-use was non-negotiable:

I tell them that I'm not on PrEP if they ask me. Even if they donť ask me and they want to do bareback, I tell them, “I'm not on PrEP. Are you on PrEP?” If they are not on PrEP, and I'm not on PrEP, we donť do it without condoms. Thaťs always for sure. (33 years old, identified as White and Hispanic/Latinx)

If they are not on PrEP…I usually not even touch that even or I'm going to protect myself, using condoms. (28 years old, identified as White and Hispanic/Latinx)

Further, participants reported that the ways in which they approach discussing HIV/STI prevention strategies with their partners differed based on context. Mobile sexual networking apps appeared to facilitate open conversations about sexual history by removing social barriers to communication. For example, one participant reported directly inquiring about HIV status and associated prevention strategies with potential partners when introducing himself on apps:

I think for my hookup app iťs more straightforward. It’s like “Are you HIV free”, are you on PrEP”. Iťs more of a questionnaire, at least that’s how I see it. (33 years old, identified as White and Hispanic/Latinx)

When describing the ways in which he initiates conversations about HIV prevention, one participant noted the advantages of directly inquiring about HIV status and PrEP use in writing versus in person at a club, especially in the context of substance use:

Because we can chat about it first on Grindr and I have a sense—when I can read something, I feel like I understand versus speaking [because] things kind of get lost in person…At the clubs, for example, because where gay men connect, I would kind of lose track. I'd be drinking or something. (31 years old, identified as White and Hispanic/Latinx)

Participants also reported public health/community-level motives for engaging in HIV/STI prevention strategies. For example, one participant expressed his desire to implement an established HIV/STI testing regimen to keep the community (and himself) safe.

I really want to implement one [testing regimen]. I have none. I really want to get tested just to make sure I donť give some kind of disease to everybody else. Thaťs the reason why. But I would like to also prevent myself from getting a disease to begin with…” (34 years old, identified as Asian)

Not only were participants altruistically motivated to practice HIV/STI prevention for the sake of their community, but they also benefited from others supporting them to make their sexual health a priority. One participant expressed gratitude for his provider’s and family member’s encouragement of HIV prevention strategies. These comments remind him that he is a person of value; when growing up, he perceived that many people like him lacked a sense of self-worth.

But I donť use PrEP, and thaťs an issue of contention with my family health people, navigators, nurses, and with a good reason because they mean the best…I understand when health physicians and others feel the need to remind me that my health is important. And I guess I appreciate it. Because growing up, when individuals like my uncle would say, “Stay safe,” it was because individuals [like me] didn’t feel like they had a sense of worth or a sense of reason to stay safe and healthy. (31 years old, identified as White and Hispanic/Latinx)

B). Impact of COVID-19 on Sexual Networking

In order to provide a context for a discussion of changes in STI/HIV prevention practices participants were asked about changes in their sexual and social networking. Participant discussion of changes in their networking behavior during the COVID era were characterized through the following themes: (1) varied interpretations of COVID-19 public health guidance (e.g., avoidance of all in-person activity vs. proceeding with caution) and (2) behavior change to meet social and sexual needs (e.g., decreased in-person sexual networking, increased use of dating applications, prioritization of longer-term relationships over hook ups).

Varied interpretations of COVID-19 public health guidance.

As noted previously, qualitative interviews were conducted between November 2020 and January 2021, when Massachusetts saw an increase in COVID-19 cases and the first cases of the Alpha variant were reported. At this time, there was a reinstatement of state-wide curfews and a stay-at-home order, which coincided with the initial rollout of the COVID-19 vaccine [41–44]. Participants expressed varied levels of understanding of the COVID-19 public health guidance and interpreted the stay-at-home order differently. For example, some interpreted the guidance to mean that they were not allowed to socialize, and so they stopped all in-person sexual networking activities:

Well, [sexual networking] changed a lot because you're not even allowed to go out anymore. Everybody is concerned about the virus as well as myself. So it changed because we donť go to clubs anything, like that. Clubs are not open. (28 years old, identified as White and Hispanic/Latinx)

In contrast, other participants determined that in-person socialization and sexual activity were acceptable if they increased their level of vigilance, took necessary safety precautions (e.g., wearing a mask), and checked in with each other to identify symptoms:

I'm more vigilant with regards to spreading the infection, and we follow protocol. And we make sure that no one is sneezing, coughing. You're feeling okay. You're feeling all right. And then we generally hook up. I’ve also hooked up with boys who wear a mask all the time throughout this pandemic…We just make sure [everybody is] well. And then we meet up. (34 years old, identified as Asian)

Similarly, another participant explained that sexual activity in the context of COVID-19 was characterized by increased caution rather than an absence of interaction. He drew a direct parallel between the COVID-19 pandemic and the HIV epidemic, noting that, in the HIV era, individuals are generally aware of and attentive to the importance of PrEP use and frequent testing for HIV prevention:

People are safer, and I guess that goes with what I suggested before, that people are becoming more cautious, I feel. I'm not sure if it means that everyone is safer, because I see in the news that the COVID numbers are increasing, especially during the holidays, but I feel that just generally, people have a sense, especially after the HIV epidemic, to be on PrEP and to generally have a mindset of safety, to be tested regularly, and to know how to stay safe. (31 years old, identified as White and Hispanic/Latinx)

Another participant verbalized his interpretation of the public health guidance: he asks potential partners numerous questions about their interpretations—for example, are they social distancing? Are they wearing masks?—to determine if it is safe to proceed with the interaction:

Participant: I think, yeah, these days, if I want to meet someone, I ask them a whole bunch of questions about how safe they've been and stuff like that.

Interviewer: What does safe mean to you?

Participant: If they've been following the social distance orders, and if they've been wearing masks everywhere they go, and stuff like that…I also ask if they've been tested recently. (23 years old, identified as Native Hawaiian/Pacific Islander, White, and Hispanic/Latinx)

Behavior change to meet sexual and social needs.

People changed their sexual networking behavior – via decreased in-person sexual networking, increased use of mobile dating applications (apps), and prioritization of longer-term relationships over “hook ups” (i.e., short term, uncommitted relationships) – to meet their needs. These changes are specified in the subthemes below.

Decreased in-person sexual networking.

Though interpretations of COVID-19 public health guidance varied, most participants reported some degree of decreased in-person networking due to venues closing:

[Sexual behavior changed in] every way, because now we have to stay at home, and there is nothing open, like those kind of places, bars or clubs. (20 years old, identified as White and Hispanic/Latinx)

Others reported decreased in-person sexual networking due to restricted travel, as several participants described leaving the Boston metropolitan area pre-COVID to meet potential partners:

Well, I obviously donť travel. And I stay home more often. There have been times where I have hooked up with people. I would have them over and it has happened a few times…I think my sexual activity has decreased, but it hasnť stopped. (33 years old, identified as White and Hispanic/Latinx)

In addition, fear of contracting COVID-19 also motivated changes in sexual networking. This participant highlighted the ways in which COVID-related fears affected intimacy between partners, especially in the early phases of the pandemic:

At the beginning of the pandemic, they were freaking out, and they didnť want to meet, of course. And sometimes they were just like, “Oh, no kissing. No touching.” So a lot of things changed. (26 years old, identified as White and Hispanic/Latinx)

Increased use of mobile dating apps.

Participants expressed that, since they had either stopped making social connections via in-person activities or had dramatically reduced their in-person sexual networking, they started using mobile dating apps more frequently to fill that gap. For some participants, their increased use of apps was driven by loneliness, and communicating with potential partners (in some cases, with more partners than they engaged with prior to the pandemic) on apps helped them cope with that loneliness.

So the quarantine actually brought me more partners, because since the quarantine started, we went on lockdown, and anxiety started to kick in. And the loneliness also was super bad. It was brutal. And going on apps and finding people was the only escape that I found at first before I was able to see friends again and before I was able to go out again. (22 years old, identified as White and Hispanic/Latinx)

For others, the sense of isolation associated with quarantine led to increased sexual desire, which then facilitated increased app use. For example, one participant noted that, as people became more secluded, they turned to apps more frequently, whether this was because of increased “horniness” in the context of being alone or just to initiate a conversation:

Yeah, I think everyone's online now. Everyone's working from home, but, at the same time, kind of looking, just seeing whaťs up. Yeah, because I feel people feel secluded and isolated or maybe just also horny. So especially during the first months, everyone was on. A lot of people were not doing anything. They were just like, “Oh yeah, I'm just chatting and saying hi and exchanging texts. (34 years old, identified as American Indian, White, and Hispanic/Latinx)

One participant reflected on the ways in which increased technology use in sexual networking may permanently change social interactions in the future, such that engaging with potential partners via apps may be preferable to in-person introductions. He noted that, when communicating with partners via apps in his own home, he may feel safer and more comfortable “being himself” and setting appropriate boundaries, whereas that might not be the case in-person, especially in the context of alcohol use.

“So sometimes technology and Grindr overlaps with real human contact, but the need is still there. And in the future, I think, too, it might change now to where we're all in bubbles or something crazy like that. So we're still trying to find that essential need, but sometimes from before, the intersections overlap. And I'm seeing I'm more, I guess, fluent in the language of technology where I can build relationships through text and through the Grindr app and through video, through Zoom, where I'm more knowledgeable of how to do this, where when I first started using Grindr, I wasn’t sure if it was safe or not sure how to navigate the safety. And in-person there is alcohol involved, and then at home, I can say, I feel more comfortable just to be myself in some non-social way. (31 years old, White and Hispanic/Latinx)

Prioritization of long-term vs. short-term relationships.

In general, participants described seeking out long-term, more committed sexual relationships over short-term, less committed relationships. For example, one participant noted that relationships made during the pandemic felt more “substantial” or meaningful than relationships made prior to COVID-19, as these relationships had more of a stable foundation, more substance, and felt more “real” than hook ups. This participant also identified a shift in the types of relationships that he developed through mobile apps:

I happened to meet my husband too during the pandemic. So I thought relationships which were made during the pandemic were more substantiated than relationships which were not during the pandemic. Those are just hookups. But now, because of the pandemic, I felt the hookups are more materialistic. For example…we have a neighbor now, and we met him in Grindr. Iťs real relationships. There's no more just hooking up, and thaťs how the pandemic changed our perspective on using the application itself. (34 years old, identified as Asian)

Another participant verbalized his preference for quality over quantity of partners. The pandemic context (i.e., remote work, decreased in-person social and sexual interactions) enabled him to develop a long-lasting sexual relationship and a pattern of fewer, but more established sexual partners:

So iťs easier for me, in this moment-- I met one guy that came from New York. And this guy, I had sex with him at this time. He went back. He came and stayed in my house for one more week, because he wasnť working in person. He came for the third time. So basically, I had sex with three, four people the entire year…I'm never when the person is looking for a lot of numbers, but I prefer to have some quality most times. (32 years old, identified as American Indian and Hispanic/Latinx)

Regardless, the overall sentiment was that intimate interactions and feelings of “closeness” remained essential, and participants actively changed their behaviors to ensure these needs were met.

C). Impact of COVID-19 on HIV/STI Prevention.

Participant consideration of COIVD related changes in their HIV/STI prevention practices are characterized according to the following themes (1) limited or changed access to HIV/STI prevention services; and (2) avoidance of healthcare appointments.

Limited or changed access to HIV/STI prevention services.

When asked about the degree to which access to HIV/STI prevention services changed during the early phases of the pandemic, participants generally described limited access to HIV/STI testing services through their usual providers or usual testing sites. The following two participants indicated challenges accessing STI testing, increased time between tests, and decreased communication with providers around testing:

I really get paranoid really easily. So before, when I used to feel like, “Oh, I got something, STD,” I used to just walk into the clinic. And nowadays you canť anymore. You have to make an appointment, and sometimes it takes long. (20 years old, identified as White and Hispanic/Latinx)

Well, I did have an instance a month ago where it was just really hard to go get tested because of COVID. Iťs like I had symptoms of an STI, and on a Sunday noticed. Then on Monday, I called [deidentified] to see if I could get a—usually you just get—now with COVID, you get a Zoom appointment with your doctor or nurse practitioner, and they just ask you a bunch of questions. They put in the labs; you go get tested. But this time, I couldnť get appointment with anyone. I couldnť talk to my doctor, my primary healthcare, or a nurse. (34 years old, identified as American Indian, White, and Hispanic/Latinx)

Another participant described that his primary source of STI testing was no longer available to him during the pandemic. For him, losing access to testing outside of clubs led to ceasing tests altogether.

I used to do my tests more in front of the clubs. They are closed, so I havenť been doing the test anymore. (32 years old, American Indian and Hispanic/Latinx)

Though participants found that COVID-19 challenged their prevention efforts, the majority of participants expressed that their sexual health and consistent engagement with HIV/STI prevention services remained a priority, such that adjustments were made by both participants and providers to ensure that the negative effects of pandemic circumstances on access were mitigated. One participant described his ability to identify testing sites that were still open, indicating high levels of resourcefulness as he navigated COVID-related challenges; he was able to maintain testing despite decreased access:

Yeah, testing's still open in places. You just have to know where to go and make appointments and that kind of stuff. Iťs been actually pretty seamless in that regard, just the access issue. (35 years old, American Indian, Black, White, and Hispanic/Latinx)

Two other participants identified the adjustments in HIV prevention and testing service delivery that were made by their providers, health care teams, and clinics to maintain access to PrEP and STI testing:

Actually, I went only once and they sent me three Truvada’s at once. Usually they send just one, and with the COVID they sent three. So I'm good until next month, I think. It was even better too. (21 years old, identified as White and Hispanic/Latinx)

I was actually super lucky, because my hospital, they were really careful…They would always check up on me. And I have my doctor's number, so I can always call him and be like, “I want to get tested.” (22 years old, identified as White and Hispanic/Latinx)

Avoidance of HIV/STI prevention services during the early pandemic.

Finally, some participants reported that they avoided healthcare appointments, inclusive of HIV/STI testing due to fear of contracting COVID-19 prior to the release of the vaccine. One participant rationalized the choice to avoid clinics and HIV/STI testing appointments by recognizing that his in-person sexual activity had decreased, therefore his risk of HIV/STI acquisition had also decreased:

I knew a lot of the [deidentified] hospitals are also COVID hospitals. So I just didnť want to—if it wasnť anything that was an emergency—I wasnť really having sex that often. I wasnť really seeing anyone. I didnť think that I need to put myself in an ambience or an environment in which there was COVID. (21 years old, identified as White and Hispanic/Latinx)

Another participant described the toll that COVID-19 and efforts to manage its spread took on his mental health. Though he did seek out mental health services on several occasions, he noted that his fear of COVID prevented him from continuing to reach out for help when he knew that he needed additional support.

COVID definitely messed with my head, my emotions, the quarantine, everything. And so I was in the hospital, mental hospital, twice this year…I probably should have went back another time, but I didnť just because I was freaked out. I was like, “ COVID is really—” it was in March or April, and COVID was just really bad, especially where I was. So I was like, “Yeah. I'm just going to keep this to myself and go through it.” And I guess I'm here now. So in that way, COVID has kind of affected me, yeah. (18 years old, identified as White and Hispanic/Latinx)

Discussion

In this analysis of qualitative data collected from MSM of color, the majority of whom identified as Hispanic, participants reported that the COVID-19 pandemic increased online sexual networking and reduced access to HIV prevention behaviors. Specifically, participants described COVID-related behavior changes to meet evolving social and sexual needs throughout the pandemic, including less in-person networking, increased use of dating apps, and the prioritization of long-term over short-term relationships. In addition to less access to HIV prevention services, participants also emphasized the importance of integrating knowledge of prevention strategy efficacy with partner, contextual, and community factors, including level of intimacy, substance use, and wider public health concerns to make decisions about HIV prevention strategies.

Participants in our sample had varied interpretations of COVID-19 public health guidance, as well as differences in perceived risk and perceived ability to manage risk. As the pandemic evolved, COVID-19 public health guidelines shifted, leading to differences across recommendations from reputable public health agencies (i.e., between the World Health Organization and the Infectious Disease Society of America, for example). Though participants did not indicate confusion due to conflicting guidelines, there was evidence in our data that they may have been attending to or receiving different information (e.g., lack of clarity around which in-personal interactions were “allowed” or “not allowed”).

Perhaps more importantly, levels of perceived risk and perceived ability to manage risk differed across the sample. Perceived risk around COVID-19 is influenced by several factors, including risk communication at local and state levels, political ideology, and other individual-level variables [45]. In this sample of MSM of color, a population disproportionately affected by the HIV epidemic [46], perceived COVID-19 risk and ability to manage that risk was likely also impacted by individuals’ experience navigating and managing HIV acquisition risk. When rationalizing his choice to proceed with caution rather than to stop sexual networking altogether, one participant compared COVID-19 risk to HIV-risk, suggesting that the HIV era socialized him to be attentive to safety in the context of sexual activity and led to increased self-efficacy to manage risks of COVID-19 infection. Indeed, COVID risk management self-efficacy has been associated with COVID-19 related beliefs, including perceptions of disruption, health importance, and response effectiveness [47].

Though changes in sexual networking behaviors in response to COVID-19-related regulations varied, most participants in our sample decreased in-person networking activities, increased their use of dating apps, and prioritization of longer-term relationships. These data both align with and deviate from other studies that have examined sexual activity among MSM during the pandemic. Like the men in the current study, Latinx-identifying sexual minority men in south Florida reported increased sexual activity with their primary partners, suggesting some prioritization of long-term over short-term relationships [48]. The men in the Florida-based sample also described increased engagement with sexual networking apps, but for different purposes than prior use; for example, they reached out to others for distraction and social connection, instead of solely seeking to initiate sexual activity. In another sample of majority White MSM who were also surveyed earlier in 2020 (April, May) than the MSM in our study, nine out of 10 participants either had one sexual partner or no sexual partner in the past 30 days, and they reported using sexual networking websites and apps to seek out partners for virtual rather than in-person sexual activity [49]. In two other studies with similarly majority White samples, however, MSM indicated that there were no changes in their use of apps and websites to find sex partners [50], and either no change [50] or an increase in [51] the number of sex partners, suggesting that longer-term relationships may not have been prioritized in those samples. Participants also reported changing their attitude and negotiation with potential partners based upon their increasing knowledge of HIV treatment and prevention over time. These observations underline the importance of disseminating the results of our science where they can used to inform sexual networking and sexual decision making of young MSM of color.

Clinical implications

Previous studies that assessed access to HIV/STI prevention services during the height of the pandemic among MSM in the US have had mixed results. Some reported that the majority of participants (in a primarily White sample) had no change in access to (98%) or use of (92%) condoms [50], while others described significant interruptions across the HIV prevention and treatment cascade [15]. Notably, Santos and colleagues found that the negative consequences of the pandemic on HIV prevention (e.g., reduced access to condoms, HIV testing sites, HIV self-testing, PrEP) were significantly greater among racial/ethnic minority populations, immigrants, and other socio-economically disadvantaged groups, although disturbances in HIV prevention services were also documented in predominantly white samples [15].

Participants in our sample of MSM of color described decreased access to HIV/STI prevention services and decreased communication with their providers, with some indicating that they avoided healthcare appointments due to COVID-related concerns. However, a few participants did explain that their clinics or doctors adjusted their services (e.g., prescribed additional PrEP to cover longer time periods, offered personalized attention) to support their patients. The possibility of differential COVID-related disparities in access to HIV/STI prevention in minority populations is concerning. This disparity may have exacerbated already disproportionately higher risk for HIV acquisition among racial minority or immigrant MSM [1], and may be driven in part by their exposure to structural challenges and intersecting stigmas [52–54]. Avoidance of healthcare appointments during the pandemic, due to fear of COVID acquisition or anticipated difficulties accessing services, may have further increased HIV risk among MSM of color.

The current qualitative findings have important clinical implications. First, providers need to be cognizant of ensuring continuation of prevention services when clinics may need to close. This might include public service announcements relaying information on operational clinics and how to schedule HIV prevention care appointments. This may also include novel strategies for increasing access to testing and prevention services, for example, further investment in mobile prevention units that are not based or reliant on social clubs or bars. Second, increased sexual networking online and on dating apps creates a unique opportunity for evidence-based intervention dissemination, particularly in the context of persisting behaviors that are associated with increased HIV risk. Further, interventions may be adapted to meet the needs of couples, rather than individuals, if the prioritization of longer-term relationships remains in the changing COVID-19 landscape.

Limitations

Several limitations of the current study should be noted. Though small sample sizes are typical of qualitative work, the size of our sample made it challenging to explore differences by race or ethnicity. Given the multiracial, multiethnic identities of many of our participants, we may have lost some of the nuance and richness of the data by confining participants to specific racial groups. The individual, semi-structured interviews were offered in English only, not in other common languages like Spanish, limiting participation to English-speakers. Another limitation was the lack of probing specific to experiences of racism. The legacy of Boston’s racially segregated history is still very much apparent today. From 2017 to 2021 in Suffolk County–where Boston is located–there was a segregation index of 70 [55]. This number reflects the percentage of Black residents who would need to relocate to be fully integrated with White residents across metropolitan neighborhoods; a score of 100 on the scale indicates complete segregation. It is well established in the literature that structures of racism are associated with health disparities for marginalized groups [12,56]. Keeping this context in mind, our interview guide may have limited our ability to frame responses within a nuanced understanding of inequities faced by MSM of color living in and around Boston.

Our research findings may have been further limited by our recruitment methods. Initial participants, or “seeds” were selected through key informants and community partners; therefore, it is likely that they were already linked to community resources and engaged in HIV/STI prevention activities through those resources. This recruitment strategy may have also contributed to the high education and income level of the sample, with 83% reporting a college education and 50% reporting an income above $40,000. There may therefore have been a selection bias towards a more resilient sample, with the understanding that MSM of color who are not connected to community supports or healthcare providers may also have had different or worse experiences with both sexual networking and access to HIV/STI prevention services than those who participated in the interviews. We were also only able to capture the experiences of our sample at a particular point in time: between November 2020 and January 2021. Therefore, these data do not describe the totality of their experiences across the duration of the pandemic.

Conclusion

In conclusion, the sexual networking and HIV prevention behaviors of MSM of color changed during a particularly difficult period in the first year of the COVID-19 pandemic. As the pandemic persists and as other public health crises emerge, providers and community agencies that serve this population should consider the impact of these sexual networking changes on HIV risk and ensure continuation of prevention services when clinics may need to close. Most importantly, these data from this study may inform provider- and system-level efforts to proactively plan for future public health emergencies, as these crises disproportionality impact minority populations that already face significant health disparities.