“Sex without fear”
Introduction
Gay, bisexual, and other men who have sex with men (GBMSM) experience a higher global prevalence of psychosocial health problems including harmful substance use, intimate partner violence (IPV), and mental health issues such as depression and anxiety, compared to heterosexuals [1,2,3]. These disparities have been attributed to the higher stress levels experienced by sexual minorities due to internalised, anticipated and experienced prejudice and discrimination on the basis of their sexuality [4].
GBMSM are also disproportionately affected by HIV [5], and a psychosocial stressor that is heightened for GBMSM is HIV-related anxiety during sex. The Hunter Alliance for Research and Translation found across multiple studies that 25–39% of GBMSM say they think about HIV in the day-to-day either most or all the time, and 29–46% say they think about HIV most or all the time during sex [6]. Golub (2018) describes this as a “psychological tragedy” [7] burdening GBMSM since the 1980s emergence of HIV, where thoughts of risk and fear intrude during moments that should be focused on intimacy, pleasure, and fulfilment. While HIV-related anxiety may be omnipresent for many GBMSM, a heightened awareness of HIV risk does not always translate to consistent condom use [8]. There are other factors which can increase the likelihood of engaging in condomless sex, both positive – such as a desire for greater sexual pleasure, sense of intimacy, and emotional closeness with sexual partners – and negative – including psychosocial trauma and internalised stigma [8]. The presence of one or more of these factors may be sufficient to override HIV-related anxiety and facilitate engagement in condomless sex.
HIV Pre-exposure Prophylaxis (PrEP) offers effective HIV prevention for those who aren’t able to consistently use condoms. PrEP refers to the use of antiretroviral therapy (ART) by HIV-negative people before and during periods of exposure to HIV (for example, via condomless sex) to prevent acquisition of HIV. Tenofovir disoproxil fumarate combined with emtricitabine (TDF/FTC) was the first drug formulation approved as PrEP [9]. Until 2020, the World Health Organization only endorsed oral PrEP in the form of tablets taken daily or episodically; delivery methods now also include the dapivirine vaginal ring and long-acting injectable cabotegravir [10, 11].
The PROUD (PRe-exposure Option for reducing HIV in the UK: immediate or Deferred) trial demonstrated in 2015 that the inclusion of oral PrEP in the sexual health package offered to GBMSM and trans women in sexual health clinics in England reduced HIV acquisition by 86%, with no infections observed among participants taking PrEP at the likely time of exposure [12]. Baseline data from PROUD showed that the offer of oral PrEP attracted participants with a higher risk of HIV acquisition than the general population of GBMSM in England [13], and high rates of associated risk factors, including previous and incident STIs, previous use of PEP, drug use (particularly of chemsex-associated drugs), higher-risk sexual behaviours, depression, and intimate partner violence [13, 14]. More recent research has indicated that PrEP is contributing to a population-level reduction in HIV incidence among GBMSM in England and elsewhere [15,16,17].
Anecdotal evidence began to emerge as early as 2014 that PrEP was having an impact on GBMSM’s health and wellbeing in a manner that went far beyond its primary function of preventing HIV transmission [18]. Subsequently, PrEP use has been associated with a reduction in HIV-related anxiety and internalised homophobia, and an increased sense of sexual satisfaction, intimacy, and self-efficacy [19,20,21,22,23]. However, PrEP users may also face stigma from others who perceive PrEP as facilitating a deterioriation in sexual responsibility among GBMSM, typified by the derogatory term ‘Truvada whores’ [24, 25] (Truvada (Gilead Sciences, Foster City, CA, USA) is the branded name for TDF/FTC). Among GBMSM, the presence of these attitudes reflect not only internalised homophobia, but also the mindset of sexual prudence which replaced gay sexual liberation during the early days of the HIV epidemic. Consequently, condomless sex has become intertwined with problematic notions of uncleanliness, contamination, and ‘sluttiness’ [26].
Given the implications of these issues for uptake and continuation, understanding the psychosocial impact of PrEP use among is therefore important for maximising its individual and public health benefits. Thus far, there has been limited research considering the broader psychosocial impact of PrEP in the UK. A cross-sectional survey led by PrEPster and Public Health England asked PrEP users if PrEP had a positive or negative impact on their life, with open text responses indicating that experiences included reduced stress and anxiety, but this was not explored in detail [27].
‘Psychosocial’ factors can be understood as an intermediary (meso-level) bridge between macro-level social structures and the micro-level individual, such as support from social networks, control at work or in the home, security, and autonomy [28]. Martikinainen et al. (2002) describe a psychosocial explanation of health as one in which macro- and meso-level social processes lead to perceptions and psychological processes at the individual level, which in turn influence health through biological responses to stress or changes in behaviours and lifestyles [28].
In this paper, we utilise this understanding of psychosocial impact to explore how the use of oral PrEP influences the interactions between meso-level psychosocial factors and individual psychological factors, and in turn how these factors affect health through emotions and behaviour.
Conclusion
In summary, this analysis suggests that by removing HIV risk from sex, PrEP improves users’ wellbeing by reducing HIV-related anxiety and internalised stigma and increasing HIV prevention self-efficacy, sexual pleasure, and intimacy. In turn, these psychological changes may influence behaviour in the form of greater sexual freedom, reduced harmful drug use, and more protective sexual health behaviours. However, PrEP may create internal conflict for some gay men, due to its disruption of social norms around condom use and its perceived influence on their sexual behaviour leading to reduced condom use self-efficacy. Our findings support calls to consider the psychosocial impact of PrEP in prescribing guidelines. They also highlight the need for prescribers to be aware of the risk that some PrEP users may experience internal conflict and reduced self-efficacy around condom use, and to be able to offer psychosocial support as part of the PrEP service package. These findings provide a baseline of PrEP’s psychosocial impact amongst some of the first PrEP users in England and could potentially inform current and future PrEP provision and research in a range of populations and settings.