Sexual Partnerships and Considerations for HIV Antiretroviral Pre-Exposure Prophylaxis Utilization Among High-Risk Substance Using Men Who Have Sex with Men

Abstract

Men who have sex with men (MSM) remain at great risk of HIV in the United States, representing 65 % of incident HIV infections. One factor contributing to the high rate ofHIV infectionamongMSM isuse of“recreational”drugsthat are highly associated with unprotected anal sex. Pre-exposure chemoprophylaxis(PrEP)isanovelbiomedicalHIVprevention strategy that has the potential to reduce HIV transmission in MSM. Main and casual sex partners play a role in HIV prevention efforts for MSM. The study aimed to qualitatively explore the perceived influences of sexual relationships on promoting and inhibiting PrEP use among high-risk MSM who report regular drug use. Semi-structured qualitative interviews were conducted with 40 participants recruited in Boston, Massachusetts. Data were analyzed using descriptive qualitative analysis. Casual partners presented a distinct set of concerns from primary partnerships. MSM generally viewed main partners as a potential source of support for taking PrEP. Given their informal and often temporary nature, PrEP disclosure to casual partners was considered unnecessary. HIV-related stigma and substance use were also perceived as barriers to discussing PrEP use with casual partners. MSM articulated a high degree of personal agency regarding their ability to take PrEP. Findings suggest that behavioral interventions to improve PrEP utilization and adherence for high-risk MSM should be tailored to sex partner type and the parameters established between sex partners. Approaches to PrEP disclosure and partner engagement should be informed by the relative benefits and limitations characterized by these different types of relationships.

Introduction

Men who have sex with men (MSM) are at great risk for HIV infection and represented 65 % of incident HIV infections in the United States between 2008 and 2011 (Centers for Disease Control and Prevention, 2013). One potential contributing factor to the high rate of HIV infection among MSM is the use of “recreational” drugs, often collectively referred to as “club drugs.” Club drugs include cocaine/crack, crystal methamphetamine, amphetamines, methylenedioxymethamphetamine (MDMA/ecstasy), gamma hydroxybutyric acid (GHB), and ketamine. Club drugs are known to enhance sexual encounters and are highly associated with engaging in unprotected anal sex (UAS) in MSM (Halkitis & Parsons, 2002; Mansergh et al., 2001; Mattison, Ross, Wolfson, & Franklin, 2001; Ross, Mattison, & Franklin, 2003). The disinhibitory effects of these drugs result in greater number of partners, increased number of sexual encounters, decreased condom use, and increased condom failure while“high.”These behaviors are known to facilitate the spread of HIV (Halkitis, Green, & Mourgues, 2005; Jerome, Halkitis, & Siconolfi, 2009; Stone et al., 1999).

Another factor to consider is the role of couples—or sexual partnerships—in fueling the HIV epidemic among MSM in the U.S. A recent CDC evaluation found that 68 % of new infections among MSM in the U.S. were ascribed to main sex partners and the proportion of new infections from main sex partners was even higher among younger MSM (Sullivan, Salazar, Buchbinder, & Sanchez, 2009). The reasons for this are threefold: (1) MSM are more likely to engage in anal sex with their main partners; (2) MSM are more likely to have unprotected sex with main partners; (3) MSM have been shown to have greater frequency of sexual acts with main partners. The HIV prevalence was greater for those in casual relationships; however, the aggregate risk from main partners was more than offset by the higher rates of UAS. Understanding sexual partnerships among MSM is an important and necessary component to HIV prevention efforts with this group.

Without an effective HIV vaccine, research has focused on the development of alternative biomedical prevention strategies as a way to curtail the spread of the virus in high-risk populations. The use of antiretroviral (ART) therapy as pre-exposure prophylaxis (PrEP) is a novel biomedical HIV prevention strategy. The safety and efficacy of PrEP in HIV uninfected MSM and transgender women was established in the multinational iPrEx study where it resulted in a 44 % reduction in the incidence of HIV infection (95 % confidence interval; p = .005). Among participants who reported using PrEP on 90 % or more of the days, a 72.8 % reduced acquisition risk was evidenced (Grant et al., 2010). PrEP will likely prove to be a valuable tool in reducing incident HIV cases among at-risk MSM in the U.S. Non-adherence significantly limits the overall effectiveness of this prevention modality and the once daily regimen. As research with HIV infected MSM on ART suggest, substance use may be a particularly significant barrier to PrEP adherence (Hinkin et al., 2007; Reback, Larkins, & Shoptaw, 2003).

It is important to understand the factors most salient to perceived PrEP adherence among high-risk MSM. As evidenced by research on condom negotiation among MSM (Lightfoot, Song, Rotheram-Borus, & Newman, 2005), the types of sexual relationships (e.g., sexual relations with main versus casual partners) men are involved in will likely influence their ability to take PrEP. The present study aimed to qualitatively explore the perceived partnership-level influences that may impact PrEP utilization and adherence among high-risk MSM who report regular club drug use.

Method

Participants

Between November 2011 and April 2012, semi-structured qualitative interviews relevant to perceived acceptability and implementation of PrEP were conducted with a convenience sample of 40 MSM. Participants were actively recruited at gay-oriented bars and nightclubs in Boston, Massachusetts. Recruitment efforts also extended to community-based HIV prevention organizations throughout the city. Participants were over the age of 18 years and HIV—as confirmed by a HIV rapid antibody test. Eligible men reported at least two episodes of UAS with a casual partner or HIV serodiscordant main partner while under the influence of club drugs in the prior 3 months to enrollment. Previous experience taking PrEP was not a study criterion.

A total of 40 HIV seronegative MSM participated in the study. Table 1 provides the basic descriptive characteristics of the study participants. The mean age was 39 years (SD = 11.23) and 33 % were an ethnic or racial minority. Notably, 25 % identified as bisexual and 15 % asheterosexual/straight. Eighty-three percent met DSM-IV screening criteria for club drug abuse or dependence (Sheehan et al., 1997). In the 3 months prior to enrollment, the mean number of times that participants engaged in UAS with an HIV infected male partner was 1.25 (SD = 5.3) and 4.33 times (SD = 7.16) with a male partner of unknown HIV serostatus. Sixty percent of the sample had previous knowledge of PrEP and 10 % said that they had used PrEP as part of a clinical trial. The experiences of participants who had taken PrEP were not thematically different from those who had not. Data from the four PrEP experienced participants served to further triangulate findings.

Table 1.

Self-reported sociodemographic characteristics of study participants (N=40)

M age (in years) (SD)	39 (11.23)
	N	%
Race/ethnicity
American Indian or Alaska Native	2	5
Black or African American	10	2
White	28	70
Hispanic/Latino	4	10
Sexual orientation identity
Gay/homosexual	22	55
Bisexual	10	25
Straight/heterosexual	6	15
Other sexual orientation identity	2	5
Unemployment	15	37
Annual income less than $24,000	22	55
Club drug use
Dependence or abuse	33	83
Infrequent use	7	17
Relationship status
Primary partner in monogamous relationship	0	0
Casual partner(s) only	29	73
Primary partner in non-monogamous relationship	11	27
PrEP experience and awareness
Previously heard of PrEP	24	60
Previously taken PrEP as part of clinical trial	4	10
Diagnosis of STI within the past year	16	40
Sexual risk (within 3 months prior to enrollment)
Mean number of male partners in past 3 months (SD)	10 (16.34)
Mean number of times UAS with male partner known to be infected with HIV	1.25 (5.37)
Mean number of times UAS with HIV male partner of unknown HIV serostatus	4.33 (7.16)

STI sexually transmitted infection, UAS unprotected anal sex

Procedure

Before data collection commenced, participants were screened for eligibility and completed a written informed consent process. Participants were compensated $50 for their time. All study procedures were conducted in a private room at The Fenway Institute, Fenway Health in Boston and were approved by the Institute's institutional review board.

Participants completed a brief interviewer-administered quantitative assessment that surveyed basic demographic information, sexual risk behavior, and knowledge of PrEP. Information about PrEP and the results of the iPrEx study were reviewed with all participants so that everyone had the same basic minimum understanding of PrEP.

The brief assessment was followed by a semi-structured qualitative interview that lasted approximately 60 min. A primary domain of the interview focused on the perceived role of sexual partnerships in PrEP utilization and adherence. All participants were asked to reflect on how the type of sex partner (i.e., main or casual) and the serostatus of the partner (i.e., uninfected or infected) could potentially influence their use of PrEP. In this case, a main partner was defined as a sex partner to whom the participant felt emotionally committed; a casual partner was a sex partner to whom the participant felt no such commitment. For the purposes of this analysis, anonymous partners (unknown sex partners) were included under the term casual partner (Rosenberg, Sullivan, Dinenno, Salazar, & Sanchez, 2011).

Data Analysis

Quantitative Analysis

Survey data were used to provide a more comprehensive portrait of MSM interviewed.

Qualitative Analysis

Data were analyzed using qualitative descriptive analysis whereby core themes emerged from the data without applying a pre-conceived theoretical framework (Altheide, 1996). Using the qualitative interview guide as a foundation, concepts and themes related to the central research questions were identified. These initial themes were used to construct categories and to develop a codebook comprised of a label, a definition, and an illustrative quote from the data (Silverman, 2010). Transcripts were reviewed for errors and omissions and a research staff member organized the data categorically using Atlas.ti^® qualitative analysis software (version 6.2). The coded data were continuously reviewed by investigators to resolve any coding inconsistencies and conceptualize interconnections between the research questions and raw data. Coding schema categories were considered saturated when no new associated codes were identified. Quantitative reliability was not assessed. To establish overarching themes, research staff extracted and sorted interview text according to codes and created matrices to note similarities and account for discrepancies between source types. The extracted interview text was then summarized and organized in a way that best fit the emergent themes.

Results

Participants were asked to discuss the potential influence of sex partner support on their ability to take PrEP. Men in the sample articulated a wide range of perceived barriers and facilitators regarding PrEP use in the context of their sexual partnerships. Table 2 offers a thematic comparison between the perceived roles that main and casual sex partners could play in PrEP utilization and adherence.

Table 2.

Predominant themes and supporting quotations

Theme	Quotation
Main sex partners
Comfort with PrEP disclosure	...he loves me unconditionally. I tell him everything. You know, we don't really keep secrets from each other. So I mean he'd definitely support me I'd probably try and talk him into using it too
PrEP and infidelity	My biggest fear is not the sex that I have control of, but the sex I don't have control of. If my boyfriend is out and about without me, taking risks, and then bringing that home... knowing that I have the PrEP would make me a little more like OK, if you were out playing last week while I was out of town, maybe I would be a little less concerned
Value of PrEP in non-monogamous primary partnerships	I would definitely [be] like ‘Why don't we just both take this?’ Because I don't know what he's doing when I'm not around. He might be having sex with other people. So hey, protect yourself, that way you can protect yourself and you won't give nothing to me. Why don't we both use it?”
HIV serodiscordant main partnerships	If somebody is HIV positive, we're still going to use protection and probably PrEP. [PrEP] might establish a little bit more of a peace of mind if you are having sex with somebody that's HIV, it might establish a little bit more of a peace of mind
Casual sex partners
Limited support of a casual partner	I wouldn't want them to be either. Like ‘oh so, I'm on PrEP, so hey let's, lets bareback. And... yeah, it's fine that you're positive.’ If you're having sex with someone, they don't need to know. It's none of their business; it's only meant for your protection. It's not for them, it's for you
Communicating with casual partners about PrEP use	With strangers I think it would be probably just, you know, just as easy as talking about condoms. You know? Or status. You know? Um, I, I don't deem it being a real issue
PrEP disclosure in the context of drug use	With people that I use crystal with we don't talk about HIV very much. I would not talk about HIV or PrEP because I know they are probably positive, and if they see me so scared of HIV they would probably insist more that they are negative
HIV-stigma	I wouldn't tell them (casual partners) because I don't want them to think I actually have HIV. Which I don't, I'm just trying to prevent from getting it
Pressure to engage in increased sexual risk behavior	I think that a few of them (casual sexual partners) would probably press me, if they knew that I was on it [PrEP]. They would probably press me to have unprotected anal sex. They would probably be supportive [of me taking it] because they'd want me to have unprotected anal sex with them
Personal responsibility for PrEP use	If I make the decision to do something, I'm still going to do it, regardless of an outside opinion. Like, I'll allow opinions to be given to me, but I won't allow them to influence my decision

The Role of Main Sex Partners

Comfort with PrEP Disclosure

Generally, most participants said that they would feel comfortable discussing PrEP use with a main partner and anticipated that this person would likely support their ability to take PrEP. As a 30-year-old participant said:

...he loves me unconditionally. I tell him everything. You know, we don't really keep secrets from each other. So I mean he'd definitely support me...I'd probably try and talk him into using it too.

However, not all participants thought that discussing PrEP with a main partner would be easy. A 44-year-old participant in a monogamous relationship feared that his partner would question his fidelity if he were to discuss his PrEP use with him:

I believe if it was somebody that didn't have HIV, they wouldn't believe—“you're with me, I don't have HIV, well are you out there having sex with other people?”

Similarly, a 28 year-old participant said:

My partner would not feel comfortable with me taking it [PrEP]. He does not know I am having sex outside our relationship, so I would have to hide it from him.

Partner Infidelity in“Monogamous”Primary Partnerships

Participants were interested in taking PrEP for protection against possible transmission from their seroconcordant (HIV uninfected) main partner within the context of a monogamous or perceived to be monogamous relationship. For example, a 25-year-old participant said:

There might be people that are in monogamous relationships, but they're not in control of the other person. No one's with anyone 24 h a day. So you want to have more fulfilling experience with your monogamous partner, but at the same time, you want to protect yourself.

Some participants described PrEP as a method for reducing the fear of becoming infected with HIV because of their main partner having sexual“slips”outside of their relationship. A 34-year-old participant with similar feelings said:

He's a man and he will mess up, and so you're prepared, you're protecting yourself against everything, even his mess ups.

Non-Monogamous Primary Partnerships

Men engaged in non-monogamous “open” relationships with a main partner considered PrEP to be an especially valuable HIV prevention tool that would reinforce trust in their relationship but also allow them to feel more comfortable about engaging in sexual risk behavior outside of the partnership. According to a 52-year-old participant:

I think that he (main partner) would support it [PrEP use], based on the fact that if we're having sex with each other and we're also engaging in sex with other people, we can both be honest about our behaviors with each other.

Relatedly, for seroconcordant open relationships, some participants thought it would be helpful if their partners were also prescribed PrEP. For these men, taking PrEP was more appealing if it could be a couple's activity.

HIV–Serodiscordant Main Partnerships

Participants involved in serodiscordant relationships maintained that their HIV infected main partner would be more understanding and supportive of them taking PrEP than an HIV uninfected partner. According to one 31-year-old man,

Basically, if I was with a positive guy I would think he'd be supportive. I would hope he would be so as not to infect me. I would take it under this situation.

A 32-year-old with experience taking PrEP discussed the adherence benefits of having a partner who was also taking HIV medications.

My partner has HIV. He encouraged me to start PrEP and is always reminding me of the importance of being adherent to it, and the importance of using it. We take the medication at the same time, which helps us both remember to take it.

The Role of Casual Sex Partners

Comfort with PrEP Disclosure

Participants generally described wariness about disclosing PrEP use to casual sex partners. Due to the temporary nature of casual relationships, the majority of participants thought that disclosure of PrEP use to casual partners was unnecessary. For example, a 53-year-old participant said:

I don't care what they (casual partners) think one way or the other. I wouldn't discuss it. No. I just wouldn't. I wouldn't think it is any of their business.

However, a few participants said that they would be relatively comfortable speaking with a casual partner about PrEP. A 38-year-old man likened it to talking about condom use, saying:

With strangers, I think it would be probably just, you know, just as easy as talking about condoms or status. You know? I don't deem it being a real issue.

Some men in the sample acknowledged a potential benefit in speaking with a casual sex partner about PrEP. As a 19-year-old participant remarked:

I don't think they would think that I had HIV or anything. I'm sure it would probably make them a little more comfortable. Like “Alright, this kid has been taking this [PrEP], so obviously he takes precautions, as far as not contracting HIV.”

PrEP Disclosure in the Context of Drug Use

Based on previous experiences, most participants thought that it would be difficult to speak about PrEP in a setting where club drugs were used. Some men described the intense sexual arousal while being high on meth as a deterrent from talking about PrEP before sex with a casual partner. As a 34-year-old aptly put it:

I'm a fucking whore. Like, I sleep around...if I get high and I'm somewhere and I bump into somebody and they want to have sex, like, we're going to have sex there. Like, it's going to happen. Like, that's just the reality. Not going to be talking about PrEP.

Consequences of PrEP Use Disclosure with Casual Partners

Participants indicated that they would not share their PrEP use with casual sex partners because of HIV-related stigma. Some participants worried that their casual partners may not understand the preventative motivation for taking the medication and make the assumption that they were HIV infected. They worried that such a reaction from a casual partner may lead to premature termination of the sexual encounter or worse—spread gossip in the community. A 22-year-old participant said:

Well I think bringing up an HIV medication during any kind of sexual intercourse, you know, um with a person would just scare them, and make them not even want to do anything with me. Because they might think that ‘Oh my God, if he has this PrEP pill or whatever, he, he might have HIV, so let me not fuck him, let me not have sex with him’. So I think bringing it up to them would not be such a good idea.

A few participants wondered if telling a casual partner might unwittingly invite increased sexual risk taking. A 35-year-old man foresaw a potential scenario where his casual partner would pressure him into having unprotected sex because he was taking PrEP.

Personal Responsibility for PrEP Use Regardless of Sex Partners’ Opinions

While men in the sample identified a number of potential influences that different types of sex partners may have on PrEP utilization, in general, the support of casual or main partners was not perceived as a significant determinant of using PrEP. Indeed, many men viewed PrEP use as an inherently independent task that would not (perhaps even should not) be affected by the negative or positive influences of a sex partner.

Discussion

The primary prevention of HIV infection remains an imperative priority. In the U.S., HIV infections are estimated to be increasing at 8 % per year. Equally as alarming is the rate of incident cases, which continues to outpace the rate that HIV infected individuals enter treatment (Centers for Disease Control and Prevention, 2010). Findings from this formative study are responsive to recent calls for additional research to more accurately and comprehensively assess factors that will potentially affect PrEP utilization and adherence. The current study focused on the role of sexual partnerships among substance-using MSM, a group that may be a particularly appropriate candidate for PrEP.

Our qualitative data indicated that participants would consider taking PrEP to protect against possible future transmission from their HIV–seroconcordant main partner within the context of an open or perceived to be monogamous relationship. MSM were generally comfortable discussing PrEP with main partners and thought that these partners would be a source of support for taking PrEP. However, the level of support seemed to vary according to the sexual parameters of their partnerships. Participants who had pre-established open relationships generally thought that main partners would assist and/or encourage PrEP utilization. Discussing PrEP was perceived as problematic for those involved in relationships where sex with other people was not openly discussed.

Epidemiological data show that infidelity among MSM who report involvement in “monogamous” relationships is not uncommon (Gomez etal., 2012; Hoff & Beougher, 2010). Given that not all MSM in main partnerships will be faithful under a presumed monogamous status, PrEP would serve to further protect both sexual partners from HIV infection. Furthermore, reluctance to disclose sexual encounters outside a presumed monogamous partnership (or discuss the potential of infidelity) is a consideration for MSM who may want to use PrEP. Research studies and non-research programs that provide PrEP to MSM should incorporate communication skills training via role plays with different applicable scenarios. Being able to effectively communicate one's interest in PrEP to sexual partners may help mitigate additional barriers to using PrEP effectively.

Research conducted among serodiscordant couples where the HIV infected person was taking ART confirms that relationships can foster treatment adherence and reduce sexual risk behaviors. In a cohort of 210 male–male HIV–serodiscordant couples, it was found that both the patient's positive appraisal of his relationship and his partner's positive treatment efficacy beliefs were linked to greater self-reported ART adherence (Johnson et al., 2012). HIV-specific social support within couples has been associated with fewer reported HIV risk behaviors, including unprotected anal intercourse outside the relationship. Couples who report higher relationship satisfaction are more likely to concur about the nature of their sexual agreement and are more likely to report not breaking the agreement (Gomez et al., 2012; Mitchell, Harvey, Champeau, Moskowitz, & Seal, 2012). Irrespective of serostatus, promoting positive relationship dynamics and effective communication between partners should be considered an important aspect of future PrEP adherence interventions.

The majority of participants described wariness about disclosing PrEP use to casual sex partners and only a few acknowledged the benefits of disclosure with these partners. Further exploration is needed regarding the potential role of casual sexual partnerships in the promotion of PrEP use and other health-seeking behaviors.

Recent studies have underscored the extent to which HIV-related stigma is experienced within communities of MSM (Smit et al., 2012). Concern about being perceived as HIV infected convinced many men that disclosure of PrEP use to casual partners was problematic. Furthermore, HIV-related stigma and substance use emerged as closely connected themes within the context of PrEP disclosure to casual partners. Participants perceived discussions about PrEP use as particularly difficult in scenarios involving substance use such as clubs or private sex parties. Indeed, higher levels of HIV-related stigma may be experienced in similar settings. One study among a large sample of HIV infected MSM in the U.S. found that those who perceived higher levels of HIV/AIDS stigma in the gay community were more likely to seek partners in settings that facilitate anonymous sex, such as sex parties and clubs (Courtenay-Quirk, Wolitski, Parsons, & Gómez, 2006). This finding correlates with previous literature showing that venues associated with anonymous sex are often used by men looking for minimal emotional connection and limited personal interaction with their sex partners. In such scenarios, discussions related to HIV status or prevention measures (i.e., condoms or PrEP use) are socially prohibitive (Vicioso, Parsons, Nanin, Purcell, & Woods, 2005).

As we prepare for the mass dissemination of this new biomedical approach, careful consideration should be given to the development of public health messaging for PrEP. Lessons learned from information campaigns for existing behavioral and biomedical HIV prevention tools (e.g., condoms and post-exposure prophylaxis) should inform the content of promotional materials aimed at heightening public awareness about the safe and effective use of PrEP. Messaging about post-exposure prophylaxis (PEP) has emphasized good communication between providers and patients as well as the primary role of safer sex in HIV prevention, with PEP presented as a back-up option when safer sex practices fail (Katz, Gerberding, & Boswell, 1998; Mansergh et al., 2010). In a study on attitudes to PEP among MSM, it was found that both individual agency and social support contributed to self-efficacy of PEP access, management, and usage disclosure (Korner, Hendry, & Kippax, 2005). Rather than a substitute for safer sex, PEP was considered a“wakeup call” for reevaluation of sexual risk taking behavior. When expanding the scope of PrEP messaging campaigns and adherence interventions, experiences with PEP suggest that social relationships, self-perceived risk, and personal valuations of self will likely influence effective PrEP use. Including current PrEP users into awareness campaigns may serve to normalize its use and dispel HIV stigmatization. Outreach at non-clinical settings that draw on MSM social networks, will be particularly crucial for effectively communicating this information to high-risk MSM who may not regularly access medical care.

Our study had some limitations. Given how recent the FDA approval of PrEP had been in relation to when interviews were conducted, the majority of participants had no experience taking the medication. Participant responses were based on anticipated behavior or experiences taking other prescription medications. Additionally, few participants were in HIV–serodiscordant relationships. Interviewers, therefore, explored hypothetical scenarios about the potential influence of HIV infected main partners with participants who reported current or previous involvement in this type of relationship. The sample may be representative of MSM who engage in positive health-seeking behavior since some participants were recruited through primary care and HIV service organizations. This may serve to partially explain the higher degree of PrEP awareness (60 %) compared to findings in prior studies. Given the relatively small sample size, we were not able to identify factors specifically relevant to the 30 % of participants who identified as heterosexual/straight or bisexual. Nevertheless, special attention should be given to these men, who are less likely to be targeted or have access to information directed at self-identified gay men (Wolitski, Jones, Wasserman, & Smith, 2006).

With recent failures in HIV vaccine and non-specific microbicide trials, attention has focused on the use of oral chemoprophylaxis to prevent HIV spread among high-risk groups. HIV risk behavior and the use of prevention strategies are significantly influenced by the nature and type of sexual relationships. The present study sought to contribute to the existing literature by exploring how characteristics of sexual relationship dynamics and the resulting sexual risk environment may promote or inhibit PrEP use. These findings suggested that behavioral interventions to improve PrEP utilization and adherence for high-risk MSM should be tailored to sex partner type and the parameters established between sex partners. Approaches to PrEP disclosure and partner engagement should be informed by the relative benefits and limitations characterized by these different types of relationships. Accordingly, PrEP uptake will ultimately be supported by constructive communication patterns between sex partners that ensure safety and the provision of accurate information about its use.