Reassessing the importance of PrEP use given reduced sex during the COVID-19 pandemic: Perspectives from a sample of young sexual minority men

Abstract

Research has begun to examine sexual behavior during the COVID-19 pandemic using quantitative methods, but less is known about the context surrounding these changes using qualitative methods, including corresponding changes in risk reduction methods. This qualitative study, guided by the Integrated Behavioral Model, examines the pandemic’s impact on PrEP adherence among young men who have sex with men in Chicago. PrEP-using participants from a cohort study were recruited into a 90-day diary study measuring sexual behaviors and PrEP use. Between April-September 2020, a subset of participants was recruited for qualitative interviews (n=28) exploring prevention strategies including the impact of the pandemic. Although most were highly adherent pre-pandemic, many took fewer pills or discontinued during the pandemic due to decreased sex. Findings suggest the importance of counseling for PrEP reinitiation as “seasons of HIV risk” increase, as well as use of telehealth as a facilitator of PrEP use throughout the pandemic.

Introduction

The onset of the COVID-19 pandemic in 2020 quickly changed daily life. Researchers began observing shifts in the economic conditions, mental wellbeing and sexual health of sexual and gender minorities (e.g., Human Rights Campaign, 2020; Gonzales, 2020; Dyar, 2021; Zubizarreta, 2021). In particular, shelter-in-place orders increased feelings of isolation and deteriorated mental health (Gonzales, 2020). Moreover, concern arose that the pandemic might create opportunities for HIV transmission among MSM by making it more difficult for them to access HIV-prevention resources, such as Pre-Exposure Prophylaxis (PrEP) (Doring, 2020).

Pandemic conditions and sex behavior

Research on the sexual behavior of MSM in the United States during the COVID-19 pandemic is limited. With only one exception, cross-sectional studies indicate that many MSM report decreases in sexual frequency and number of sexual partners (McKay et al., 2021; Sanchez, Zlotorzynska, Rai, & Baral, 2020). McKay et al (2021) reported 58.2% of MSM surveyed reported no engagement in sex acts of any kind from April-May 2020; only 9.4% reported having multiple sex partners, versus 18.7% pre-pandemic. The even more limited longitudinal research on MSM sexual behavior during the COVID-19 pandemic is somewhat equivocal. Longitudinal data collected from a PrEP clinic in Rhode Island from February to July of 2020 indicate that frequency of sex and number of sex partners decreased during the first months of the pandemic and remained suppressed throughout the summer plateau in COVID-19 cases (Rogers et al., 2021). In contrast, Stephenson et al (2021) found that on average, MSM surveyed from February to April-May of 2020 reported an increase in number of anal sex partners.

This longitudinal data highlights the complexity of the relationship between the COVID-19 pandemic and patterns of sexual behavior that likely evolved over time and were influenced by local norms.

MSM make appraisals about the risk associated with sexual behavior in different contexts and adjust their behavior accordingly, including during the COVID-19 pandemic. For example, a study of coupled MSM observed changes in (non)-monogamy agreements during the initial wave of the COVID-19 pandemic; couples with monogamous agreements remained monogamous, while many couples with a non-monogamous agreement, or who lacked a formal agreement, shifted to a monogamous agreement (Walsh, Sullivan, & Stephenson, 2021). Additionally, McKay et al. (2021) found that 16% of MSM in their study began asking potential partners about their use of COVID-19 safety precautions and potential exposures. While there have been a number of quantitative studies that have addressed the question of changes in sexual risk during the COVID-19 pandemic, we are not aware of any qualitative studies exploring how MSM make decisions about HIV risk reduction during the COVID-19 pandemic. Given the ongoing nature of the COVID-19 pandemic, including fluctuations in case rates, these data will help to inform HIV prevention messaging and how it relates to patterns of PrEP use among MSM.

Pandemic and PrEP

Research about PrEP engagement during the COVD-19 pandemic remains limited. A recent study observed that one third (32%) of a sample of MSM discontinued PrEP after shelter-in-place orders were issued (Brawley, 2020). Possible explanations include a reduction in perceived HIV risk as well as issues of medication access. Additional research observed that issues of healthcare access played a role in PrEP use changes during the COVID-19 pandemic. Daily PrEP users struggled to get their medications due to difficulty scheduling medical appointments and navigating new COVID-19 guidelines within healthcare systems (Shaw, 2020). Among those who lost healthcare access, many of these people also lost jobs and health insurance (63.6%), could not receive a prescription or refill (36.4%), or had interrupted lab routines and tests (27.3%). At the same time, healthcare providers and PrEP users adapted. This included prescribing 90-day refills of PrEP to reduce in-person interactions, making medication available through mail, or switching to telehealth communication to reduce in-person interactions (Nagendra, 2020).

The Integrated Behavioral Model

The Integrated Behavioral Model (IBM) was adapted from previous behavioral models (e.g. the Theory of Reasoned Action) that focused on the influences of attitudes, perceived norms, and self-efficacy on health behavior (Glanz, 2015). The IBM expands on these previous models by integrating constructs such as behavioral salience, environmental constraints, and habit (Glanz, 2015). Thus, the IBM accounts for individual level, and to some extent, contextual factors that impact individual health behavior. The IBM has been previously applied to explain HIV prevention behaviors, including PrEP use and condom use among MSM. One study identified skills and environmental constraints as having a direct impact on PrEP uptake. The skills observed were PrEP and HIV knowledge, while constraints included LGBTQ-friendly healthcare providers and lack of English proficiency (Dai, 2021). The IBM may be a particularly relevant framework to apply to understanding HIV prevention behaviors during the COVID-19 pandemic, because in addition to attitudes, norms, and personal agency, it accounts for the salience of a health behavior as well as environmental constraints, both of which may be impacted by the context of the pandemic.

Current Study

The current study examines sexual behavior and PrEP use using qualitative, in-depth interview data from a sample of PrEP-using young MSM (n=28) collected during the COVID-19 pandemic. Using the IBM framework to inform our thematic analysis, we explore factors related to PrEP use during the COVID-19 pandemic including changing pandemic conditions, sexual behavior, and salience of PrEP use during the pandemic.

Methods

Procedures and Recruitment

The present analysis consists of in-depth interview data from a mixed methods study, called Day2Day (D2D). D2D is an ongoing study examining patterns of PrEP use and adherence among young MSM. D2D participants were recruited from a large cohort study based in the Chicago metropolitan area, called RADAR (n=1,129). The methods for the RADAR cohort study are described in more detail elsewhere (Mustanski et al., 2019). RADAR participants were eligible for D2D if they met the following criteria: (1) age 18–29, (2) cisgender MSM or non-binary assigned male at birth, and (3) current PrEP user. Enrolled participants completed a quantitative 90-day diary study assessing PrEP use and related factors (n=111). A subset of participants (n=40) participated in an in-depth qualitative interview (IDI) upon completion of their daily diary that aimed to elucidate contextual factors associated with varying patterns of PrEP use. The current data (n=28) represent those participants who completed their 90-day diary between April and September 2020 and agreed to participate in a qualitative interview Because the data presented here are a subset of a larger sample of interviews, and participant numbers correspond to their parent study identifiers, some of the participant identifiers referenced herein are higher than 28.

The IDI instrument included questions assessing various topics to contextualize PrEP use among diverse young MSM, including assessing aspects of identity, experiences with healthcare, sexual behaviors, and experiences with PrEP use. Of particular relevance to the current analyses, we included questions evaluating participant reflections on how the onset of the COVID-19 pandemic affected their PrEP use. The IDIs included in this analytic sample were conducted over a secure video conferencing software and audio recorded. All qualitative interviews occurred during the COVID-19 pandemic and were held virtually as a result of the stay-at-home announcement issued on March 20^th, 2020 (Chicago News Tribune, 2021). The segments included in this analysis addressed experiences during the COVID-19 pandemic.

Analysis

Interviews were transcribed verbatim. A team of three coders developed a thematic codebook including both inductive and deductive themes (Bernard, 2016). In an initial assessment of coding in the first quarter of transcripts, the coders reached a pooled Kappa of 0.71 (lowest 0.62, highest 0.78) indicating good agreement (Cicchetti, 1994). The final codebook was applied to all transcripts. A final assessment of Kappa was applied after coding, which yielded Kappa scores >0.70 indicating good reliability (Cicchetti, 1994). Thematic analysis was used to interpret patterns within the data. We used the IBM to organize the analysis. We examined discussion of sexual behavior and PrEP use behavior during the early months of the COVID-19 pandemic. Final codes included in this analysis pertained to the impacts of the COVID-19 on the daily lives of participants, sexual behavior and dating during the COVID-19 pandemic (e.g. economic, social distancing, etc.), PrEP use during the COVID-19 pandemic, mental health (as a contextual factor), and healthcare access. Findings are summarized with representative quotes following constructs from the IBM.

Results

Sample Characteristics

Demographics were collected at baseline. Characteristics of the analytic sample are summarized in Table 1. The average length of the interview was ~53 minutes. As shown in table 1, the sample was racially diverse. All participants identified as cisgender men and were on a daily oral PrEP regimen at the beginning of the study.

Table 1:

Demographics of young MSM characterized as highly adherent to PrEP (n = 28)

	n		%
Race/Ethnicity
Asian or Pacific Islander	3		11
Black or African-American	7		25
Hispanic/Latinx	7		25
Non-Hispanic White	3		32
Multiracial	2		7
Sexual Orientation
Gay	25		89.3
Bisexual	3		10.7
Age	Mean	SD	Range
	25.6 years	1.9	23–30
Average Time Using PrEP		3.6 years
Relationship Status
Single (n, %)	21		75.0
Monogamous Relationship (n, %)	6		21.4
Non-monogamous Relationship (n, %)	1		3.6

SD: standard deviation.

Pandemic-related restrictions and the increased risk of contracting the COVID-19 virus impacted the context in which participants were taking PrEP. Many themes discussed in the IDIs aligned with constructs of the IBM, particularly the shifting salience of PrEP use in the context of the early COVID-19 pandemic, the environmental barriers to PrEP use, and the intent to use PrEP in the future. Figure 1 illustrates our application of the IBM to describe changes in PrEP use among a sample of young MSM during the COVID-19 pandemic.

Figure 1:

Constructs from the Integrated Behavioral Model Used to Describe Changes in PrEP Use During the COVID-19 Pandemic

PrEP use behavior in the time of the COVID-19 pandemic

Many of our participants expressed that their PrEP use was altered during the course of the COVID-19 pandemic. The most common reason for temporarily stopping PrEP was because of a reduction in casual sex. Of the total 28 participants, 13 indicated that they still continued to adhere to their PrEP regimens during the pandemic, while 8 participants explicitly stated that they were taking a PrEP break (5 participants did not explicitly say).

Environmental Constraints in the time of COVID

IBM describes environmental constraints as external barriers that impede on the given behavior, thus impacting the likely of engaging in the behavior. In this study, the COVID-19 pandemic created a rapid and dynamic shift of environmental constraints.

Healthcare Access.

Of the total 28 participants, 25% (n=7) described adjusting their dating habits (i.e., by reducing the number of casual partners and/or decreasing their amount of sex) to account for COVID-19 transmission risk, 25% (n=7) experienced reduced healthcare access, and 18% (n=5) discussed the use of telehealth. Few participants experienced difficulties with refills or adherence to PrEP during the pandemic. For these participants, many of these issues were related to difficulty navigating new clinic procedures and lapses in medication due to mail-in prescription issues. While these participants experienced adherence and access issues related to their PrEP use, they were also having limited sexual activity during the COVID-19 pandemic. As a result, they did not perceive themselves to be at increased risk for HIV acquisition despite lapses in adherence.

“I actually get my PrEP from Nurx, the online procurement app, and that’s just really tricky. I have just been unable, ever, to meet the actual time that I needed a refill for it, which did not matter because to be fully honest, I’m not really sleeping with anyone.–Participant 59, single, 2 years on PrEP

Of the participants who experienced adherence and access issues, they were all resolved by learning to navigate COVID-19 clinic procedures, troubleshooting mail-in prescription services or deciding not to take PrEP all together.

Telehealth as a Mitigator.

As COVID-19 restrictions changed, some participants mentioned accessing healthcare through telemedicine appointments and online prescription programs. Having the option to schedule a telehealth appointment was essential for maintaining PrEP regimens for some of our participants.

“No, my healthcare hasn’t been impacted. Howard Brown [Health Clinic] set up a telehealth interview. So I’ve been pretty good with healthcare.”-Participant 14, single, 3 years on PrEP

Telehealth options served as a facilitator for those participants who experienced challenges with in-person clinic visits but wanted to continue PrEP use during the COVID-19 pandemic.

“So I’ve had to gone to the pharmacy once or twice, but then they started the new mail prescription thing, it’s been fantastic, so that anxiety is gone from the prescription side.”-Participant 57, single, 4 years on PrEP

This participant described overcoming an access barrier by utilizing mail-in prescription services. Many participants experiencing access issues were able to overcome these issues by utilizing telehealth and alternative prescription methods, such as mail-in services.

Environmental Constraints on Dating and Sex

About one third of participants mentioned the risk of COVID-19 created hesitancy around dating. Most described caution with meeting new partners based on fear of contracting the COVID-19 virus. To mitigate fear, many participants took precautions such as asking new partners about their possible COVID-19 exposure risk during the pandemic.

“Dating has obviously been fewer and far between. ‘Then it’s like on top of the normal questions that you ask people, if they’ve been tested, if they’re taking any PrEP, it’s also like, “Have you been in any large crowds? Are you wearing a mask? Are you social distancing?”–Participant 14, single, 3 years on PrEP.

Few participants continued to have casual sex with new partners during the COVID-19 pandemic (n=2). Of these two, one described using a physical barrier during sex and the other described screening new partners for their COVID-19 risk behavior.

Salience of PrEP in the context of reduced sex

According to IBM, the salience of a behavior describes how prominent the behavior is within its surroundings. Within our study, sex behavior and its relation to HIV risk was discussed as a major factor in the relative salience of PrEP use in the context of the COVID-19 pandemic. The vast majority of participants described decreased sex. This reduction in casual sex was associated with the salience of PrEP use to participants. Thus, these participants noted that they made rational decisions about deprioritizing PrEP adherence in their lives as a result of decreased sex. Though uncommon, a few participants experienced increased sexual activity or no changes.

Participants were asked how the pandemic affected their dating and sexual experiences. To analyze the changes in sex behavior during the COVID-19 pandemic, participants were stratified by relationship status, because sexual risk factors can be different for those in monogamous relationships versus those who are in non-monogamous relationships or who are single. Monogamous relationships were defined as exclusive and intimate relationships with only one partner (n = 6). Non-monogamous relationship status was defined as having a serious partner in addition to partners outside of the relationship (n = 1). Single relationship status was defined as having casual sex with multiple partners (n = 21).

Explanations for decreased sex varied by relationship status, but all experienced reductions in HIV risk. Among single people, HIV risk was reduced because participants were not having as much casual sex with multiple partners who may have unknown HIV statues. For example, participant 18 emphasized their reluctance to meet new partners was because of the respiratory nature of COVID-19:

“When COVID first happened, everything went not in-person. And also, I was very intentional about, “If this is a respiratory thing, I should not be having that close contact with people.” So partners just went down to zero, almost immediately, and continuing to now.” –participant 18, single, 4 years on PrEP

One person in a monogamous relationship talked about social isolation forcing them to think creatively about the time they spent with their partner outside of physical intimacy, which decreased the amount of sex they were having. Other participants in relationships described social isolation as anxiety provoking which inherently decreased sex drive. For example, one participant describes their non-monogamous relationship transitioning to a monogamous relationship in efforts to minimize their COVID risk.

“I’m not seeing anyone outside of my boyfriend in a dating or sexual capacity, and so, it’s just us.”-participant 65, transitioned from open to monogamous relationship during pandemic, 1 year on PrEP

While the transition to a monogamous relationship was only described by one participant in our sample, it still aligns with the pattern of reducing COVID-19 risk by not meeting new partners.

Another participant in a monogamous relationship described having decreased sex because he and his partner were not able to go out and instead had to be more creative about how they spent their time together during the pandemic.

“Yes. It has definitely made it difficult especially with not having much to do. Me and my partner have had to have been creative with how we spend our time. Recently sex has decreased. Before, it pretty much stayed the same even though I was with one partner. Pretty much the same.” –participant #9, transitioned from causal dating to monogamous relationship during the pandemic, 2 years on PrEP

This speaks to the desire to find new ways of spending time together, outside of sexual activity, especially since accessing local bars and other outdoor activities were limited.

PrEP Intentions

In the IBM, behavioral intentions are described as a plan to carry out a certain behavior. As the pandemic impacted the sex lives of our participants, their PrEP use was also impacted. Nearly half of the participants mentioned either taking a PrEP break during the pandemic or considering one. Those who considered a PrEP break explained that the uncertainty of the pandemic and when they would have sex with new partners again was a reason to temporarily discontinue PrEP. Of those who stopped taking PrEP, many were also not having casual sex and therefore conceptualized their HIV risk as low. Participant 1 described considering a PrEP break because they were not meeting new casual partners during the COVID-19 pandemic.

“I think I might stop PrEP soon. Considering what’s going on, I really slowed down my sex life. Yeah. Ever since COVID hit, the whole isolation thing happened, I’ve had to limit my connection with people to avoid any infection with COVID.” –Participant 1, single, 5 years on PrEP

Participants who decreased the amount of casual sex during the pandemic conceptualized themselves as low risk for contracting HIV, which ultimately led to their decision to temporarily discontinue PrEP. While these participants described PrEP breaks during the pandemic, the majority of them also expressed a desire to restart PrEP as they gathered new information about when it was safe to meet new partners again. This illustrates how the salience of PrEP use and the intention to use PrEP were closely linked as participants described a desire to restart PrEP once their sex behavior realigns with that of a higher HIV risk profile. None of the participants described taking a PrEP break while simultaneously experiencing increased sex or while simultaneously maintaining a typical amount of sexual activity during the pandemic.

PrEP as Habit

In the IBM, habit is described as a behavior that becomes second nature. Our study centered habit as continuing PrEP because it was integrated into a daily routine, despite low HIV risk. Almost half of participants described no changes in their PrEP adherence and refills. Of those, some participants expressed not having any issues maintaining PrEP regimens during the pandemic because taking daily PrEP was built into their daily routines. Regardless of a low HIV risk, these participants continued to take PrEP during the pandemic out of habit.

Other Constructs

The IMB model includes two elements that were not reported by the participants in our sample: attitudes and perceived norms. Attitudes toward PrEP and perceived norms about PrEP use were generally not discussed in relation to COVID-19. Perceived control was not explicitly discussed; however, participants demonstrated a degree of perceived control in discussing their decisions to maintain the PrEP regimen or to take a temporary break. Very few participants described feeling that their PrEP use was outside their control.

Discussion

This analysis presents reasons for changes in PrEP use among young MSM during the onset of the COVID-19 pandemic. This study is important because its qualitative nature helped to contextualize the reasons why young MSM made decisions about PrEP use. Utilizing the IBM to understand factors that contribute to shifts in PrEP use emphasizes the COVID-19 pandemic as an environmental constraint. The current findings have implications for the way healthcare providers have conversations about “seasons of risk” and reinitiation of PrEP (Elsesser, 2016). While existing data observed similar findings of temporary PrEP discontinuation, few studies used qualitative approaches. These findings discovered that young MSM used reasoned decision making around temporary PrEP discontinuation based on their perceived low HIV risk.

More than half of the participants attributed their decreased sexual activity to their trying to minimize COVID-19 risk. This phenomena was consistent with existing quantitative literature (Pampati et al., 2021). Additionally, our participants described using online dating apps for chatting and self-pleasure but did not express the desire to meet in-person.

More than half of the participants discontinued PrEP use during COVID-19 pandemic because they were no longer meeting new casual partners, had reduced sex, and/or transitioned into a monogamous relationship. While the majority of the existing literature focused on issues of healthcare access, most of what we found around issues of access were in fact overcome and not perceived by our participants to be a primary reason for PrEP discontinuation. Many described healthcare facilities transitioning to virtual appointments in order to refill PrEP prescriptions. Additionally, some participants utilized online services to receive PrEP in the mail. The use of telehealth services was a leading reason for PrEP persistence among those who decided to maintain PrEP. Telehealth allowed participants to receive their medication on time, especially those who faced challenges getting in-person appointments. If these strategies continue to be used in the future, it could substantially improve access to PrEP for those who do not live near a PrEP provider.

Almost half of the participants in our study continued their PrEP regimens throughout the duration of the COVID-19 pandemic. The reasons for maintaining their PrEP use varied greatly. Reasons for continued PrEP use included ease of maintaining PrEP with daily routines, convenience of not having to restart if discontinued use and being protected for spontaneous sexual activity. These findings suggest that incorporating PrEP into daily routines can encourage optimal adherence during times of risk. Providers can introduce patients to the habitual nature of taking PrEP alongside a marker in one’s daily routine to ensure adherence.

This study used the IBM to understand the mechanisms at work for changes in sexual behavior and PrEP use as it related to the COVID-19 pandemic. The interconnectedness of these constructs created a scenario where participants contemplated the role of PrEP in their lives (behavior). As the stay-at-home orders were set (environmental constraints), many participants found themselves isolated and in turn having less sex (factor impacting the salience of behavior). This forced them to think deeply about their HIV risk and consequently their necessity to maintain PrEP use. On the other hand, the habitual nature that encouraged almost half our sample to continue PrEP use indicates that incorporating PrEP into daily routines was a mindless way to optimize adherence.

Findings from this study support the value of emphasizing that PrEP use is most beneficial during a person’s “season of HIV risk”. Thus, healthcare providers cannot expect that PrEP users will persist in their use indefinitely. Instead, it is critical to give young MSM the information and skills they need in order to make informed decisions about PrEP discontinuation and when to reinitiate. Further research may consider observing the current era of the COVID-19 pandemic to understand how people are planning to reinitiate PrEP use in the future and how this may be similar or different than reinitiating outside the pandemic.

Within our study, having the option for telehealth services was a necessary condition for PrEP users to continue their regimens during the COVID-19 pandemic. As structural barriers continue to be reasons from PrEP lapses, the use of telehealth can mitigate refill issues that PrEP users experiences. Online procurement services and virtual appointments encourage PrEP users to maintain adherence by providing options to receive PrEP outside of traditional, in-person clinic visits. Telehealth can also be pivotal in enhancing PrEP adherence in areas generally without PrEP providers (i.e., rural towns, “healthcare desserts,” etc.).

This study is one of the first to contextualize COVID-19 specific issues related to PrEP and sexual behavior using a qualitative approach. This study design helps to gain a better understanding of quantitative data that exists in the current literature about PrEP use and sexual behavior during the COVID-19 pandemic. There are some limitations to be considered when interpreting this data. The majority of the sample participants were highly adherent prior to the COVID-19 pandemic so, study findings may look different from more variant adherence profiles of participants. Additionally, the data collection was during a specific period in the COVID-19 pandemic where there was a spike in COVID-19 cases and before vaccines were available. Finally, we did not sample based on relationship status, so we do not have many examples of young MSM in open relationships to understand their PrEP use. Given this information, it may be interesting to explore sexual behavior and PrEP during later periods of the COVID-19 pandemic. The dynamism of the COVID-19 pandemic may suggest that sexual behavior and PrEP use will change based on perceived risk.