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  IAS 2017: Conference on HIV Pathogenesis
Treatment and Prevention
Paris, France
July 23-26 2017
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Experiences and perceptions of PrEP among gay, MSM, and TGW in the PROUD study in England: 'Rules' of Sex, Psychological, Psychosocial Benefits
  PrEP in PROUD Rarely Replaces Sex "Rules," But It May Loosen Them
9th IAS Conference on HIV Science (IAS 2017), July 23-26, 2017, Paris
Mark Mascolini
Starting tenofovir/emtricitabine preexposure prophylaxis (PrEP) in England's PROUD trial did not lead participants to abandon self-imposed smart-sex rules about condoms, positioning, and serosorting [1]. Instead, using PrEP "slightly loosens the boundaries" men set for themselves when having sex with partners or pickups. PrEP also appeared to have psychosocial benefits not considered earlier.
These insights and others emerged from responses in semistructured interviews with 41 PROUD trial participants. PROUD randomized 544 HIV-negative men and transgender women who have sex with men to start daily PrEP immediately or after 12 months [2]. The randomized phase of the trial ended early when it became clear that immediate PrEP offered significantly greater protection against HIV (86% reduced risk).
As part of the trial, investigators interviewed some participants about their experience with and perceptions of PrEP in relation to other risk-reduction strategies. The 41 interviewed participants included 20 in the immediate PrEP arm (19 of whom used PrEP) and 21 in the deferred arm (14 of whom used PrEP). Median age of the interview group stood at 37.4. Thirty-four participants (83%) were white and 26 (63%) were born in the UK. Thirty-six participants (88%) had a job, 17 (41%) were in a relationship, 40 were cis-male, and 1 was transgender female.
Rules of sex involved condoms (for example, "if it was a one-night stand, it would be condoms"), strategic positioning (for example, "I don't generally bottom outside of a relationship"), sorting HIV-positive partners, sorting negative partners, ejaculation, and postexposure prophylaxis. PrEP did not generally make participants abandon these limits, but it loosened them.
PrEP had diverse impacts on sex behavior, leading one participant to stop using condoms with an HIV-positive steady partner, and encouraging one to have receptive anal sex more. But some respondents said using PrEP had not changed their sex habits ("having these pills doesn't give me an excuse to be more crazy than I already am.") Participants used similar descriptive similes to characterize PrEP, such as security blanket, safety net, protective bubble, and crash helmet.
Some participants saw psychosocial benefits in PrEP, saying for example that it "has replaced fear as the central focus of relationships," removes stress or worry, or permits sex "as I like it without having this horrible feeling of 'my god' after." PrEP made one respondent become more intimate with partners, gave another "peace of mind" through added control, and led another to credit PrEP with being "very good for my mental health (ADHD)."
A few participants saw PrEP as a time-limited strategy as their desire for steady sex or group sex wanes with age. "My aim," explained one participant, "would be to move to a position where I had dealt with my demons and was able to be safe, cast ironly safe, and at that stage I would be happy to not take the medication."
PROUD investigators believe their analysis of these interviews supports several conclusions. First, the biological protection PrEP affords offers psychosocial benefits. Second, PrEP gets added to but does not replace existing rules for smart sex. Third, PrEP offers "increased individual choice in the mitigation of risk during periods of higher risk activity." And fourth, PrEP implementation program should address the psychosocial and psychological aspects of risk.
1. Gafos M, Nutland W, Wayal S, et al. Experiences and perceptions of PrEP among gay and other men who sex with men (MSM) using PrEP in the PROUD study in England. 9th IAS Conference on HIV Science (IAS 2017), July 23-26, 2017, Paris. Abstract TUAC0105.
2. McCormack S, Dunn DT, Desai M, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet. 2016;387:53-60.


Background: There are concerns that PrEP could increase risk compensation, especially reducing condom use. The PROUD study (Nov12-Nov16) reported an 86% reduction in HIV and no increase in STIs. We explore PROUD participants'' experiences and perceptions of PrEP in relation to other risk reduction strategies.
Methods: We conducted semi-structured in-depth-interviews with 41 HIV-negative MSM, purposively selected based on self-reported high/low PrEP adherence and increased/same risk behaviour. Interviews were digitally recorded, transcribed and analysed using framework analysis.
Results: The majority of participants reported risk reduction strategies including occasional condom use, strategic positioning, or sero-sorting. Participants applied rules to their sexual behaviour, such as using condoms "if it was a one night stand", or not being receptive "outside of a relationship". Typically, PrEP was added to the existing set of ''rules''. For some participants, PrEP allowed a relaxing of the rules, for example about strategic positioning: "I have definitely experienced more as a bottom", or about condomless sex: "I have had more unprotected sex than before?it doesn''t mean that I only have unprotected sex". Other participants insisted PrEP had not changed their rules: "I haven''t changed the way I think because I am taking this pill". Participants described PrEP as a "security blanket", an added "defence mechanism" and used analogies such as wearing a "crash helmet? on my bicycle". PrEP was described as affording "more intimacy", "reassurance", and giving "added control". By using PrEP, many participants with HIV-positive partners sought to reduce their partner''s anxiety about the risk of transmission. The benefits of PrEP were described within the social context of risk environments in cities like London, the chemsex scene, and the digitization of sexual contact. PrEP use was viewed as time-limited: "clearly it is a period, a moment? it is not going to be a lifetime".
Conclusions: These data suggest that PrEP was added to a range of ''rules'' already used to mitigate risk, rather than replacing them. PrEP impacted on the boundaries of the rules for some people but not all. In social contexts of high-risk behaviour, PrEP offers added protection and psycho-social benefits that increase individual choice in the mitigation of risk.