Reliability of Condom and Prep Again Hiv
AIDS Patient Care STDS. 2022 Jul 1; 29(vii): 408–417.
Attitudes Towards PrEP and Anticipated Condom Employ Amid Concordant HIV-Negative and HIV-Discordant Male Couples
Colleen C. Hoff, PhD, 
1 Deepalika Chakravarty, MS,one,, 2 Anja E. Bircher, MA,i Chadwick Grand. Campbell, MPH,1 Kirk Grisham, MPH,three Torsten B. Neilands, PhD,ii Patrick A. Wilson, PhD,3 and Shari Dworkin, PhD, MS4
Colleen C. Hoff
oneCenter for Inquiry and Teaching on Gender and Sexuality, San Francisco State University, San Francisco, California.
Deepalika Chakravarty
iMiddle for Inquiry and Instruction on Gender and Sexuality, San Francisco State University, San Francisco, California.
twoCentre for AIDS Prevention Studies, University of California at San Francisco, San Francisco, California.
Anja East. Bircher
1Center for Research and Instruction on Gender and Sexuality, San Francisco Country University, San Francisco, California.
Chadwick K. Campbell
aneCenter for Research and Teaching on Gender and Sexuality, San Francisco State Academy, San Francisco, California.
Kirk Grisham
threeColumbia University, Mailman School of Public Health, New York City, New York.
Torsten B. Neilands
twoCenter for AIDS Prevention Studies, University of California at San Francisco, San Francisco, California.
Patrick A. Wilson
3Columbia University, Mailman School of Public Health, New York City, New York.
Shari Dworkin
4Department of Social and Behavioral Sciences, Academy of California at San Francisco, San Francisco, California.
Abstruse
Since the July 2012 approval past the FDA of emtricitabine/ tenofovir disoproxil fumarate (Truvada) for use as pre-exposure prophylaxis (PrEP) against HIV, its feasibility and acceptability has been under study. HIV-discordant couples are likely targets for PrEP but piffling is known about how this new prevention tool impacts relationships. We examined, among gay male couples, the acceptability of individual and partner use of PrEP and intentions to use condoms with primary and exterior partners in the context of PrEP use. Data are from two independent samples of couples recruited in the San Francisco bay surface area and New York Metropolis—a qualitative one (N=48 couples) between March and November, 2011, and a quantitative one (N=171 couples) between June, 2012 and May, 2013. Data were categorized past couple HIV condition and general linear models; chi-square tests of independence were used to examine safety-use intentions with primary and outside partners, past sexual chance profile, and race. Nigh half of the HIV-negative couples felt PrEP was a skilful HIV prevention strategy for themselves and their partner. Over one-half reported that they would not change their current safe utilize if they or their partner were taking PrEP. However, approximately 30% of HIV-negative couples reported that they would stop using condoms or use them less with primary and outside partners if they were on PrEP or if their partner was on PrEP. A large percentage of couples view PrEP positively. Still, to ensure safety for both partners, future programing must consider those who intend not to use condoms while on PrEP.
Introduction
In July of 2012, emtricitabine/ tenofovir disoproxil fumarate (Truvada) became the first drug to be canonical by the U.s. Food and Drug Administration (FDA) for utilize as pre-exposure prophylaxis (PrEP) in combination with safer sexual activity practices to reduce the risk of sexually acquired HIV infection in adults at high risk. Further, in May 2014, the US Centers for Disease Control (CDC) released clinical practise guidelines for providers prescribing PrEP,1 and in July 2022 the Earth Wellness System (WHO) suggested that all men who have sexual practice with men (MSM) consider taking PrEP prophylactically in conjunction with other take a chance reduction strategies (due east.g., condoms).2
PrEP has been plant to be effective through trials conducted across the earth3,4 with different populations, including discordant heterosexual couplesfive and MSM.6 The iPREX trial showed a 44% reduction in HIV incidence in MSM and transgender women who used PrEP.half-dozen Reductions in incidence increased to 73% when medication adherence was greater than ninety%. Most recently, information technology was reported that no new infections occurred when blood spot testing indicated drug levels associated with using 4–half dozen tablets per calendar week.vii Studies examining the efficacy of PrEP in conjunction with adherence rates go on to be conducted; this is important because people taking PrEP outside of a large trial may accept dissimilar experiences than those participating in a trial where behaviors are monitored closely and regularly. However, the full general consensus of these large trials is that PrEP is a promising biological HIV prevention intervention for adherent high chance individuals.
Since the release of the results from these trials, and in anticipation of PrEP becoming more than widely available, several studies accept explored its feasibility and acceptability. A highly debated aspect of PrEP feasibility and acceptability is the possibility of risk bounty, that is, the increment in sexual take a chance beliefs due to a sense of security provided by PrEP. Notably, two PrEP trials indicated no testify of risk compensation, with participant run a risk behavior remaining stable or decreasing over the course of PrEP use.eight,ix Both trials reported decreased number of sexual partners during study participation and the iPREX trial participants reported increased condom apply.6 Studies of MSM attitudes toward PrEP, however, indicated that motivation to use PrEP was associated with an intention to increment risk beliefs and decrease condom use.10,11
Additionally, a study of HIV-negative MSM in HIV discordant relationships indicated that recent unprotected anal intercourse (UAI) and greater HIV knowledge were associated with the belief that a condom is no longer needed while taking PrEP.12 Risk compensation intentions were too reported based on the partner type. Specifically, among men who engage in UAI with their HIV-negative primary partner only, run a risk compensation intentions were highest amid those who feel pressure from their partner non to utilize condoms; amid men who engage in UAI with master and not-main partners believed to be HIV-negative, take a chance compensation intentions were highest among those who believe condoms interfere with intimacy; amongst men who report UAI with men whose HIV status is unknown, risk compensation intentions were highest amidst those who felt condoms interfere with sexual pleasure.13
Additional examinations of factors associated with the feasibility and acceptability of PrEP employ among MSM have been conducted. A randomized pilot written report14 demonstrated the feasibility of PrEP use among young MSM, merely self-reported adherence and plasma drug concentrations were low and the authors recommended that enhanced adherence counseling was needed. Some take identified non-white participants as more probable to be interested in PrEP,fifteen, 6 while others have not found race/ethnicity to exist predictive of interest in PrEP.17 Some other written report indicated that participants who were older, had recently engaged in UAI, and/or perceived themselves to be at heightened risk of HIV infection were more likely to be interested in PrEP.18 Other factors that have been found to increase involvement in PrEP include less knowledge about PrEP and antiretroviral therapy likewise as lower levels of education.19 Participants' HIV status and the condition of their partners have also been considered in assessing attitudes toward PrEP, with a study of Australian MSM indicating no deviation in attitudes between HIV-negative and HIV-positive participants,twenty while a study of Thai MSM indicated decreased interest in PrEP use due to having an HIV-negative partner.21
Few studies have focused on MSM couples. However, i that did suggested that behavioral interventions to improve utilization should exist targeted to sex-partner blazon, given that primary partners were viewed as a support for taking PrEP merely casual partners were associated with barriers to PrEP disclosure.22 One study of MSM couples found that participants' concerns near chance compensation may decrease their interest in PrEP,23 and some other study found that concerns about intermittent use was considered a bulwark to PrEP use.24 In contrast, higher HIV chance perception, intimacy motivations for condomless sex, recent condomless anal sex with outside partners, education, and age were each independently associated with PrEP adoption intentions. Nevertheless, when assessed in a multivariate model, just age, teaching, and intimacy motivations for condomless sex were significantly associated with PrEP adoption.25
Despite this increasing body of knowledge about PrEP acceptability, at that place are limited information on this topic from a dyadic perspective. For instance, questions remain about how beingness in a relationship and having a primary partner influences PrEP employ and subsequent condom utilise. Specifically, it is unclear how men feel nearly their partners' PrEP apply as well equally their own. Moreover, it is non clear if couple serostatus (i.eastward., concordant HIV-negative vs. HIV-discordant) influences either involvement or acceptability of taking PrEP for one or both partners or condom employ with primary and outside partners.
The present study of concordant HIV-negative and HIV-discordant male person couples attempts to contribute in a novel way to our understanding of PrEP uptake and intended sexual behaviors in the context of PrEP use by examining the acceptability of individual and partner apply of PrEP among male couples. In improver, we explored intentions to utilise condoms with primary and exterior partners among high- and low-chance couples if one or both partners were hypothetically on PrEP. Finally, nosotros explored past individual- and couple-race, the intentions to utilize condoms with primary and outside partners if one or both partners were hypothetically on PrEP.
Methods
The present report analyzes data from two contained samples of gay male person couples from two distinct phases—quantitative and qualitative—of a broader study investigating relationship ability, race, and HIV risk.
Recruitment and screening
Compatible recruitment and screening procedures were followed for both phases of data collection. Couples were recruited in the San Francisco and New York City metropolitan areas. Stratified, purposive sampling was used to recruit black, white, and interracial (black-white) couples of concordant HIV-negative and HIV-discordant serostatus. Using both active and passive recruitment strategies, participants were recruited from venues frequented past MSM. Staff placed recruitment cards, flyers, and posters, as well as conducted active recruitment in community-based venues, such equally bars, community centers, churches, and local businesses. Advertisements were placed in local print media and online, and the research team reached out to specific staff members at community-based organizations and clinics who were willing to refer clients, patients, and members of their social and professional networks to participate in the study. Social media platforms such as Facebook and Grindr were likewise used to reach couples who are active online.
Interested MSM were screened individually via phone. To be eligible, participants had to: identify as black or white as their primary racial identity, be at least 18 years one-time; take lived in the US since age 7 or younger; know their own and their partner's HIV status; and take been in their relationship for at least 6 months. Additionally, at least ane partner in the human relationship had to report engaging in anal sex inside the previous 3 months. Men who identified every bit transgender were not eligible nor were couples who provided discrepant reports of their partner's serostatus. Both partners had to individually satisfy the eligibility criteria to exist eligible for participation as a couple. Eligible couples were given appointments to visit the written report offices for participation. All report procedures were reviewed and approved past the IRB's at San Francisco State University, and Columbia University.
Study one—Qualitative Interviews
Between March and November, 2011, 48 male person couples were recruited across the two written report locations.
Process
Six Chief's-level research assistants were trained in qualitative research methods, interviewing skills, and the ethics of human subjects research over a ii-twenty-four hour period catamenia. Participants provided written informed consent prior to the beginning of the interview. Members of the couple were interviewed separately just simultaneously to ensure confidentiality and to elicit sensitive information that may not otherwise have been revealed in the presence of the partner. Interviews were guided by a semi-structured, qualitative interview guide with interviews lasting an average of 90 min. Interview questions are available from the corresponding author upon asking. The interviews included the following domains: sexual relationship(s) and agreements, rubber utilize decision-making, acceptability of PrEP, and sexual run a risk beliefs. Each partner was paid $40.00 every bit an incentive on completion.
Information assay
Interviews were digitally recorded and transcribed verbatim, so reviewed for accurateness and grammatical errors. Using a Grounded Theory arroyo,26,27 members of the study team read and summarized 50% percent of the transcripts for use in the code development procedure. One time the codebook was established, iv research staff members practical the codes to the remaining transcripts. Transana qualitative data analysis software was used to facilitate analysis.28 To ensure reliability and consistency in coding, decision trails were maintained. In addition, 1 quarter of the transcripts were coded past an additional coder and verified by a staff member.
Study 2—Quantitative surveys
Between June, 2012 and May, 2013, a 2d independent sample of 171 couples was recruited across the ii study locations to complete a survey in A-CASI (Sound Computer Assisted Self Interviews). The survey explored several domains including: sexual human relationship(s) and agreements, condom use controlling acceptability of PrEP, and sexual gamble behavior. Each partner was paid $forty.00 as an incentive on completion.
Measures
Participant characteristics recorded included HIV status, sexual understanding type, age, relationship length, race, didactics, employment, and income.
Sex behavior
Participants responded to detailed questions almost their sexual behavior in the by iii months. The questions asked about the number of episodes of anal sex they had with their chief partner also every bit with outside partners of HIV-positive, HIV-negative, and unknown serostatus. Further questions queried nearly insertive and receptive anal sex activity, with and without ejaculation, and with and without condoms. Using these responses about anal sex as well equally the participant'southward and his primary partner'southward serostatus, we created two carve up take chances variables: the counts of UAI with the primary partner (UAIPP) and the counts of UAI with any outside partner (UAIOUT). Further, each of these take chances variables was dichotomized into null episodes of UAI and at least one episode of UAI in the past 3 months.
PrEP
Participants were first provided a brief overview of PrEP—its purpose, how long it needs to be taken, and its documented concrete side effects. This was followed by a variety of questions regarding PrEP: whether he had heard of PrEP, what he idea of PrEP every bit an HIV prevention strategy for himself and his primary partner (response options ranged from 'an extremely skilful strategy' to 'an extremely bad strategy'), the likelihood of using PrEP for himself ("How probable would you be to use PreP if information technology were available to you lot?" with a v-point response 'Not at all' to 'Extremely'), how effective would PrEP demand to be in reducing the chance of contracting HIV for him to apply it (responses ranged from 20% to 100% in increments of xx). The participant was then asked almost his anticipated condom utilise behaviors in 3 unlike scenarios—if he himself were on PrEP, if his primary partner was on PrEP and if an outside partner was on PrEP (e.chiliad., "If y'all were on PreP, you would use condoms…" with responses ranging from 'A great deal more oftentimes' to 'A corking deal less often' and 'Non at all'). Finally, the participant was queried about his likelihood of disclosing broken agreements to his primary partner if he were on PrEP (responses ranged from 'A great deal more likely' to 'A bully deal less likely' and 'Would not disclose at all'), and whether the decision to use PrEP would exist an private or joint decision with his primary partner.
Data analyses
Ii participants declined to answer the PrEP questions and were excluded for these analyses. The sample therefore consists of 340 individuals from 171 couples. All analyses were conducted in SAS V9.4. First, we generated frequencies and measures of key tendency in order to describe the sample characteristics. Owing to the exploratory nature of the present analyses, we categorized the sample from Study two into 3 groups—men in seroconcordant negative relationships, HIV-negative men in serodiscordant relationships, and HIV-positive men in serodiscordant relationships. All analyses were conducted separately for these three groups.
The two primary topics explored in-depth were: stance about PrEP equally a prevention strategy, and predictable condom use behaviors if they were to use PrEP. General linear models (using PROC GENMOD) were used to compare the categorical responses to these questions by age and human relationship length. In these instances of multiple comparisons, adjusted p values were obtained by applying the Bonferroni adjustment.
Further, all models pertaining to the men in seroconcordant negative relationships employed correlated residuals via an exchangeable correlation structure to account for both members of the dyads beingness included. We generated the overall frequencies (using PROC FREQ) of respondents' perception of PrEP every bit a prevention strategy then further explored these using chi-square tests of independence in two ways—showtime, by accounting for the presence or absence of UAI with principal and exterior partners, and second, by accounting for individual and couple-race. For frequencies pertaining to men in seroconcordant negative relationships, the Rao-Scott chi-square (in PROC SURVEYFREQ) was used to business relationship for the clustering of individuals inside dyads. In all chi-square tests with low cell counts, Fisher'due south exact test was used. We similarly analyzed the responses to anticipated condom use behaviors—overall, by presence/absence of UAI, and by race categories.
Results
Of the 48 couples in the qualitative stage (Study 1), 26 (54%) were concordant HIV-negative and 22 (46%) were HIV-discordant (Table 1). In that location were 17 white, xvi black, and fifteen interracial (black-white) couples in the sample. Approximately half of the couples were from each study site. The median age was 30 years (range: 18–66 years), and median relationship length was one.6 years (range: 6 months to 36 years). Couple agreement types included both open (twoscore%) and closed (56%); additionally, one couple reported a discrepant agreement (where one partner reported having an open agreement and the other partner reported having a closed agreement) and i couple had no understanding. A bulk (75%) of participants reported having at least some college didactics. A majority (81%) of the participants earned less than $50,000 per year and 42% were unemployed.
Table 1.
Sample Characteristics
| Qualitative | Quantitative | |||
|---|---|---|---|---|
| n | % | north | % | |
| Couple characteristics | ||||
| Human relationship length (years) median (range) | 1.58 | (0.v–36) | 3 | (0.5–45) |
| Number at each site | ||||
| San Francisco Bay Area | 25 | (52.08) | 81 | (47.37) |
| New York City | 23 | (47.92) | 90 | (52.63) |
| Serostatus | ||||
| Concordant negative | 26 | (54.17) | 120 | (lxx.eighteen) |
| Serodiscordant | 22 | (45.83) | 51 | (29.82) |
| Race | ||||
| Blackness | 16 | (33.33) | 41 | (23.98) |
| White | 17 | (35.42) | 93 | (54.39) |
| Black-white | 15 | (31.25) | 37 | (21.64) |
| Sexual agreement blazon a | ||||
| Closed | 27 | (56.25) | 65 | (38.01) |
| Open up | 19 | (39.58) | 73 | (42.69) |
| Discrepant b | ane | (2.08) | 33 | (19.iii) |
| Private characteristics | ||||
| Age (years) median (range) | 30 | (18–66) | 36.24 | (19.39–71.39) |
| Education | ||||
| Completed high schoolhouse or less | 24 | (25) | 72 | (21.17) |
| Some college/Acquaintance degree/Available'southward caste | 55 | (57.29) | 104 | (30.59) |
| Graduate degree | 17 | (17.71) | 164 | (48.23) |
| Employment | ||||
| Employed (full-time/self-employed) | 41 | (42.71) | 188 | (55.3) |
| Employed office-time | 15 | (15.62) | sixty | (17.65) |
| Unemployed | 40 | (41.68) | 92 | (27.06) |
| Annual income | ||||
| Less than $20,000 | xl | (41.67) | 121 | (35.69) |
| $20,000–$49,999 | 37 | (38.54) | 111 | (32.74) |
| $50,000–$79,999 | 8 | (8.33) | 63 | (18.58) |
| $lxxx,000 and college | 11 | (11.46) | 44 | (12.98) |
Of the 171 couples in the quantitative phase (Written report 2), 120 (seventy%) were concordant HIV-negative and 51(30%) were serodiscordant (Table 1). There were 93 white, 41 black, and 37 interracial (black-white) couples in the sample. Approximately half of the couples were from each study site. The median age was 36.two years (range: 19–71 years) and the median relationship length was 3 years (range: six months to 45 years). Couple understanding types included open up (43%), airtight (38%) and discrepant (19%). A majority (79%) of participants reported having at least some college didactics. More than than half of the participants earned less than $50,000 per year and 27% were unemployed.
Written report 2: PrEP acceptability in the context of the primary relationship
Less than half the sample (46.2%) had always heard of PrEP before, and 9.half-dozen% of the sample reported having taken PrEP earlier (data non shown in tables). Among the HIV-negative men in serodiscordant relationships, over half (51%) said they were 'very much' or 'extremely' likely to use PrEP if it was available to them, while a much lower percentage (27%) of men in seroconcordant HIV-negative relationships said the same. A majority (over 70%) of men conveyed that they would be willing to take PrEP if it was at to the lowest degree fourscore% effective in reducing the chance of contracting HIV. Roughly fourscore% of the HIV-negative men would inform their principal partner if they started taking PrEP, and over 75% said that the decision to use PrEP would be made jointly with their primary partner. A bulk (fourscore%) of HIV-positive men said they would be supportive of their primary partner's decision to take PrEP. On the question of disclosure of cleaved agreements while on PrEP, the majority (63%) of HIV-negative participants said that existence on PrEP would not change their likelihood of disclosing a broken agreement to their primary partner, 6% would not disclose a cleaved agreement at all, 18% would be less likely, while 13% would exist more likely to disembalm a break.
In the following presentation of the findings, all quotes are from Study ane (qualitative phase), whereas all numbers (percentages, etc.) are from Study 2 (quantitative phase) unless otherwise stated.
Attitudes towards PrEP every bit an HIV prevention strategy for self and chief partner
Men in concordant HIV-negative relationships
Almost one-half of the men in concordant HIV-negative relationships felt that PrEP would be a good HIV prevention strategy for themselves and their partners (46% and 44%, respectively) (Table 2). Approximately twenty% each perceived PrEP to be a bad HIV prevention strategy for themselves and their primary partner. This sentiment is illustrated in the following quote:
Table ii.
Written report 2: Attitudes About PrEP equally an HIV Prevention Strategy
| Bad | Neither adept nor bad | Good | |||||
|---|---|---|---|---|---|---|---|
| PrEP as a prevention strategy… | N | n | (%) | northward | (%) | due north | (%) |
| Men in -/- relationships: | |||||||
| (…for self) | 239 | 47 | (nineteen.vii) | 82 | (34.3) | 110 | (46) |
| (…for main partner) | 236 | 52 | (22) | 81 | (34.three) | 103 | (43.6) |
| HIV-negative men in+/- relationships: | |||||||
| (…for self) | 51 | 5 | (9.8) | 17 | (33.3) | 29 | (56.9) |
| HIV-positive men in+/- relationships: | |||||||
| (…for primary partner) | 50 | vii | (14) | 10 | (twenty) | 33 | (66) |
"I guess for those that want to have unprotected sex I approximate it would be okay but I don't think it's a proficient idea, that'southward merely me" (Black, 43, HIV-).
Further, 34% each were ambivalent virtually PrEP equally a HIV prevention strategy both for themselves and their chief partner. For some couples, this ambivalence seemed to stem from their current relationship condition, also as a questioning of how well this novel strategy volition work. For example:
"If I was unmarried and not in a relationship, I don't know. I might consider taking information technology just I retrieve I would take information technology in combination with still practicing safe sex because you lot know things could always break, something could always happen then possibly the pill would be some extra insurance and then I might consider taking information technology in conjunction with practicing safe sex if I was out there single" (White, 43, HIV-).
Men in serodiscordant relationships
Our information suggest that MSM in serodiscordant relationships may be more in favor of PrEP as a prevention strategy than men in concordant HIV-negative relationships. Fifty-7 percent of HIV-negative men with HIV-positive partners thought that PrEP would exist a good prevention strategy for themselves versus 46% of those in HIV-negative relationships. Similarly, 66% of HIV-positive men with HIV-negative partners felt PrEP was a skillful prevention strategy for their partners versus 44% of those in HIV-negative relationships. This theme is represented in the following quotes from the two partners in 1 couple:
"I think information technology's a positive thing peculiarly for people that are at high gamble. [My partner] and I have discussed information technology—almost him possibly taking information technology—and have both kind of come up to the conclusion that, aye, if it was made bachelor it would be a wise thing for him to take considering he's at such a loftier risk being in a magnetic [discordant] couple" (White, 26, HIV+).
"I would still probably accept it just because I know that every time that I sleep with him I'm being exposed to HIV" (White, 26, HIV-).
Twenty percent of the HIV-positive men with HIV-negative partners felt that for their partner, PrEP was neither a practiced or bad HIV prevention strategy. Few men in serodiscordant relationships felt that PrEP was a bad HIV prevention strategy.
Attitudes towards PrEP as a HIV prevention strategy, by sexual risk behavior and race
In Study 2, when analyzing men's attitudes towards PrEP according to their sexual take chances behavior, we did not discover any statistically significant differences in attitudes by whether they reported UAI with primary and outside partners. Further, in analyzing men's attitudes towards PrEP past their own race (black/white) as well every bit couple-level race (black/white/blackness-white), we did not notice whatsoever significant statistical differences between the groups (data non shown in tables).
Relationship factors associated with PrEP as a HIV prevention strategy
Relationship length was associated with attitudes towards PrEP as an HIV prevention strategy just amongst HIV-positive men in serodiscordant relationships—those reporting an ambivalent mental attitude toward PrEP had a significantly (adjusted p-value: 0.048) longer relationship length (hateful: 12.2 years) compared to those who consider it a good strategy (mean: 6.5 years). Historic period was not significantly associated with attitudes towards PrEP in any of the subgroups studied (data not shown in tables).
Anticipated safety employ while on PrEP
The majority of participants reported that if they were on PrEP, they would use condoms at almost the same rate equally the present, regardless of their own and their partner's serostatus and also whether they engaged in UAI with their primary partner or an outside partner.
Men in concordant HIV-negative relationships
Over half (56%) of the men in HIV-negative couples reported that if they were taking PrEP they would use condoms at the same rate as they are currently using condoms (Table iii, rows which contain 'Due north=' in the second cavalcade). For example, one participant stated that:
Table iii.
Report 2. Predictable Condom Apply in the Presence of PrEP, Categorized by Serostatus, Blazon of Partner, and the Presence/Absence of UAI
| Not at all | Less oft | Same every bit at present | More often | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| How ofttimes would you use condoms if ( __ ) was on PrEP? | northward | % | north | % | due north | % | due north | % | p Value a | |
| Men in -/- relationships: | ||||||||||
| (Yourself) | Due north=237 | 23 | (9.7) | 47 | (19.8) | 132 | (55.vii) | 35 | (14.8) | |
| UAIOUT? | No | 17 | (eight.iii) | twoscore | (19.4) | 118 | (57.3) | 31 | (15.1) | NS |
| Aye | vi | (19.4) | 7 | (22.vi) | xiv | (45.2) | 4 | (12.9) | ||
| UAIPP? | No | 2 | (5.3) | eight | (21.1) | 24 | (63.2) | 4 | (x.5) | NS |
| Aye | 21 | (10.6) | 39 | (19.6) | 108 | (54.3) | 31 | (xv.6) | ||
| (Your primary partner) | N=236 | 20 | (8.5) | 27 | (11.4) | 147 | (62.3) | 42 | (17.8) | |
| UAIOUT? | No | 13 | (6.iii) | 25 | (12.2) | 129 | (62.9) | 38 | (18.five) | 0.022 |
| Yeah | 7 | (22.half-dozen) | two | (vi.five) | 18 | (58.ane) | iv | (12.9) | ||
| UAIPP? | No | 0 | (0) | 7 | (xviii.4) | 24 | (63.2) | seven | (18.4) | NS |
| Yep | 20 | (ten.one) | xx | (10.ane) | 123 | (62.1) | 35 | (17.seven) | ||
| (The outside partner) | N=236 | 14 | (5.9) | 24 | (10.2) | 134 | (56.8) | 64 | (27.i) | |
| UAIOUT? | No | 8 | (three.ix) | 20 | (nine.8) | 119 | (58.1) | 58 | (28.3) | 0.008 |
| Yep | 6 | (19.4) | 4 | (12.ix) | xv | (48.4) | 6 | (19.four) | ||
| UAIPP? | No | 2 | (5.3) | 5 | (xiii.two) | 22 | (57.9) | ix | (23.vii) | NS |
| Yep | 12 | (6.1) | 19 | (9.6) | 112 | (56.six) | 55 | (27.8) | ||
| HIV-negative men in+/- relationships: | ||||||||||
| (Yourself) | Due north=50 | 4 | (8) | 7 | (14) | 29 | (58) | 10 | (twenty) | |
| UAIOUT? | No | two | (v.three) | half-dozen | (15.8) | 22 | (57.ix) | 8 | (21.i) | NS |
| Yes | 2 | (sixteen.7) | one | (8.3) | seven | (58.3) | two | (16.7) | ||
| UAIPP? | No | 0 | (0) | 3 | (15) | xiv | (70) | three | (15) | NS |
| Yep | 4 | (thirteen.3) | four | (13.3) | fifteen | (50) | 7 | (23.3) | ||
| HIV-positive men in+/- relationships: | ||||||||||
| (Your primary partner) | N=49 | 6 | (12.2) | 3 | (six.1) | 36 | (73.5) | 4 | (8.ii) | |
| UAIOUT? | No | two | (5.nine) | ane | (two.9) | 28 | (82.iv) | 3 | (8.viii) | NS |
| Yes | four | (26.7) | 2 | (13.three) | 8 | (53.3) | 1 | (half dozen.7) | ||
| UAIPP? | No | 1 | (5) | 0 | (0) | 19 | (95) | 0 | (0) | 0.034 |
| Yes | 5 | (17.2) | 3 | (10.3) | 17 | (58.half-dozen) | 4 | (13.viii) | ||
"I wouldn't suddenly stop wearing condoms…It would help…It would let me to experience much more relaxed and at ease with it but I would empathise that it wouldn't mean that I would be any—that I withal would be putting myself at risk. It would just allow me to have lesser of a chance of getting contracted with HIV. That would make me feel ameliorate" (White, 24, HIV-).
However, 30% reported that they would not use condoms or would use condoms less if they themselves were taking PrEP. For instance:
"If I were using information technology I would assume that I wouldn't take to use a condom" (Blackness, xix, HIV-).
Sixty-two percent reported that they would use condoms at their current rate if their partner was taking PrEP, while approximately xx% reported they would apply condoms less or not at all. Fifty-seven percent said they would use condoms at the current rate if their outside partner was taking PrEP. Only xvi% reported they would use condoms less or not at all with an outside partner taking PrEP. Interestingly, between xv% and 27% reported that that they would use condoms more if they themselves were on PrEP (15%), if their partner was on PrEP (18%), or if an outside partner was on PrEP (27%).
Men in serodiscordant relationships
Discordant couples reported similar intentions to use condoms in the presence of PrEP apply. 50-eight pct of HIV-negative men with HIV-positive partners reported that they would use condoms at the electric current rate if they themselves were taking PrEP. The majority of HIV-positive men with HIV–negative partners (74%) also reported they would use condoms at the current rate if their HIV-negative partner was taking PrEP. In the qualitative interviews, many reported that STI's were an on-going concern. For example:
"Nosotros'd still apply condoms, yes, there's a lot more stuff out there besides HIV" (Black, 24, HIV+).
Xx percent of HIV-negative partners in a discordant couple reported they would use condoms less or non at all if they themselves were taking PrEP versus eighteen% of HIV-positive partners if their HIV-negative partner was taking PrEP. For case,
"I think that it would you know give usa an selection in terms if we wanted to not employ a prophylactic then that may exist a possibility for us" (Black, 33, HIV-).
Among the men in serodiscordant relationships, a fifth of the HIV-negative men reported that they would use condoms more than if they themselves were on PrEP and eight% of the HIV-positive men would increase their condom use if their primary partner was on PrEP.
Predictable safe use while on PrEP, past sexual risk behavior
In Written report 2, in analyzing men's anticipated condom apply while on PrEP by their sexual chance behavior, we institute some statistically meaning differences by whether they reported UAI with primary and outside partners (Table 3).
Men in concordant HIV-negative relationships
Among men in concordant negative relationships, sexual chance behavior with an outside partner was associated with the men'due south anticipated condom use if the primary partner, or the outside partner were to be on PrEP—a greater percentage of those who reported UAIOUT said they would finish using condoms if their primary partner or their outside partner was on PrEP, compared to those who did not report UAIOUT. Simply a similar association was not noted in the case of the men themselves being on PrEP. Farther, the presence or absenteeism of UAI with primary partner was not associated with anticipated condom employ in the cases of self, primary partner or outside partner being on PrEP.
Men in serodiscordant relationships
Among HIV-positive men in serodiscordant relationships who reported having UAI with their main partner, in that location was a significant shift towards lesser- or no-use of condoms if their master partner were to use PrEP. Among HIV-negative men in serodiscordant relationships, the presence of UAI with neither primary nor exterior partners was associated with their anticipated prophylactic apply if they themselves were to use PrEP.
Anticipated condom use while on PrEP, by race
On the topic of race, akin to the findings pertaining to sexual hazard behavior, HIV-negative men'southward intentions to apply condoms if they were themselves on PrEP, did non vary by their own or the couple-race or past whether their primary partner was seroconcordant or serodiscordant (Table four). For men in concordant negative relationships, race—both individual- and couple-level—was significantly related to anticipated safety use if their main partner were to be on PrEP. For the aforementioned group however, if an outside partner were to be on PrEP, just couple-race showed a relationship to anticipated condom use, and not one's own race.
Tabular array 4.
Written report 2: Anticipated Condom Utilise in the Presence of PrEP, Categorized by Serostatus, Type of Partner and Individual- and Couple-Race
| Not at all | Less ofttimes | Same as at present | More oft | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| How often would you apply condoms if ( __ ) was on PrEP? | due north | % | n | % | n | % | n | % | p Value a | |
| Men in -/- relationships: | ||||||||||
| (Yourself) | Due north=237 | 23 | (9.7) | 47 | (nineteen.8) | 132 | (55.7) | 35 | (14.8) | |
| Individual race | Blackness | 7 | (9.3) | 17 | (22.vii) | 35 | (46.7) | sixteen | (21.3) | NS |
| White | xvi | (9.9) | 30 | (18.5) | 97 | (59.9) | nineteen | (11.seven) | ||
| Couple race | Black | 5 | (10) | 14 | (28) | 21 | (42) | 10 | (20) | NS |
| White | thirteen | (nine.5) | nineteen | (thirteen.9) | 86 | (62.8) | 19 | (13.9) | ||
| Black-white | 5 | (ten) | fourteen | (28) | 25 | (l) | 6 | (12) | ||
| (Your primary partner) | N=236 | 20 | (8.5) | 27 | (11.4) | 147 | (62.three) | 42 | (17.8) | |
| Individual race | Black | 5 | (6.7) | 14 | (18.7) | 37 | (49.iii) | xix | (25.3) | 0.008 |
| White | xv | (9.iii) | 13 | (8.one) | 110 | (68.3) | 23 | (14.3) | ||
| Couple race | Black | four | (8) | thirteen | (26) | 21 | (42) | 12 | (24) | 0.004 |
| White | 12 | (eight.8) | 9 | (6.6) | 96 | (70.1) | twenty | (14.6) | ||
| Black-white | four | (8.two) | 5 | (ten.2) | 30 | (61.2) | 10 | (20.four) | ||
| (The outside partner) | N=236 | 14 | (5.9) | 24 | (10.ii) | 134 | (56.8) | 64 | (27.1) | |
| Individual race | Black | iv | (five.3) | 11 | (14.seven) | 38 | (50.seven) | 22 | (29.3) | NS |
| White | 10 | (6.two) | 13 | (viii.one) | 96 | (59.six) | 42 | (26.1) | ||
| Couple race | Blackness | iv | (8) | x | (20) | 20 | (40) | 16 | (32) | 0.032 |
| White | 7 | (v.i) | 9 | (6.half dozen) | 81 | (59.1) | twoscore | (29.2) | ||
| Black-white | 3 | (6.1) | 5 | (x.ii) | 33 | (67.four) | 8 | (16.3) | ||
| HIV-negative men in+/- relationships: | ||||||||||
| (Yourself) | N=l | iv | (8) | 7 | (fourteen) | 29 | (58) | 10 | (20) | |
| Individual race | Black | 3 | (sixteen.7) | 3 | (sixteen.7) | eight | (44.iv) | four | (22.two) | NS |
| White | 1 | (iii.1) | iv | (12.5) | 21 | (65.half-dozen) | 6 | (18.8) | ||
| Couple race | Black | 2 | (14.3) | 3 | (21.iv) | 6 | (42.9) | 3 | (21.four) | NS |
| White | 0 | (0) | 4 | (16.7) | 17 | (70.8) | 3 | (12.5) | ||
| Blackness-white | two | (16.7) | 0 | (0) | six | (fifty) | 4 | (33.iii) | ||
| HIV-positive men in+/- relationships: | ||||||||||
| (Your principal partner) | Due north=49 | vi | (12.2) | 3 | (six.1) | 36 | (73.5) | 4 | (viii.ii) | |
| Individual race | Black | two | (9.five) | two | (nine.five) | xiv | (66.7) | iii | (xiv.iii) | NS |
| White | 4 | (xiv.3) | 1 | (three.vi) | 22 | (78.six) | 1 | (3.half-dozen) | ||
| Couple race | Black | 2 | (14.iii) | 1 | (7.1) | ix | (64.3) | 2 | (14.3) | NS |
| White | 2 | (8.3) | 1 | (4.ii) | 20 | (83.3) | ane | (4.2) | ||
| Black-white | two | (18.2) | ane | (9.one) | 7 | (63.6) | 1 | (9.1) | ||
Predictable condom utilize while on PrEP, by age
Age was associated with anticipated prophylactic utilise simply for HIV-negative men in seroconcordant relationships for the case of the exterior partner being on PrEP—those who reported that they would completely stop using condoms if the outside partner were on PrEP, were significantly older (hateful: 48.1 years) than those who said they would use condoms 'less ofttimes' (mean: 36 years, p=0.002), 'the aforementioned as now' (hateful: 34.8 years, p=0.001) and 'more oft' (mean: 36.ix years, p=0.006). Relationship length was not significantly associated with intended condom utilise in any of the subgroups studied (data not shown).
Word
The present study investigated gay male couples' views of PrEP as an HIV prevention strategy and whether they intended to change their use of condoms every bit a result of PrEP utilize. Overall, we plant that in all the subgroups analyzed, the greatest number of men felt that PrEP was a good prevention strategy for themselves and their primary partners. The substantial proportion of couples positively endorsing PrEP every bit a proficient prevention strategy bodes well for the national priorities of reducing new HIV infections and HIV related health disparities among gay men.29 HIV-negative couples and serodiscordant couples were similar in their overall endorsement of PrEP as a prevention strategy. Nevertheless, HIV-positive partners in serodiscordant relationships were particularly accepting of the strategy for their HIV-negative partners. Having partner support for taking PrEP likely has important implications for overall acceptability and could potentially help with adherence by keeping regular pill taking routines,xxx–32 especially if the HIV-positive partner also takes medications and the couple takes their medications together.22
Despite this broad acceptance, many couples expressed ambivalence towards PrEP as a prevention strategy and a few felt that it was a bad prevention strategy. The relatively loftier number of men who reported ambiguity toward PrEP warrants further exploration. One possible explanation for ambiguity in the present study could be that the study was conducted earlier PrEP became widely available and before the initial CDC clinical practise guidelines were released in May, 2014.1 Many men did non know near PrEP and may have been expressing initial skepticism to something with which they were unfamiliar.33 Moreover, some gay men in relationships, particularly those with monogamous agreements, do non view themselves equally existence at chance for HIV,34 and many exercise not trust a "magic bullet" type of drug when they have been successfully relying on condoms or other rubber sex strategies for many years. These ambivalent couples may non perceive a articulate benefit in taking PrEP, especially if they are in fact at low take a chance. It is important to factor in a couple'due south sexual agreement type, current level of sexual risk, and whether at that place is partner support, when assessing the virtually effective course of action regarding PrEP uptake. Consideration of PrEP use for all MSM, equally suggested past the WHO,2 should include these factors and then every bit not to unnecessarily brunt health systems with loftier costs and unnecessarily brunt couples with fears of contagion.
The study also revealed that the majority of couples would not change their current condom use if they or their partner were taking PrEP. This was true for both concordant HIV-negative couples and discordant couples. Even so, some couples reported that they would stop using condoms or use them less with primary and outside partners if they were on PrEP or if their partner was on PrEP. Thus far, research has non addressed the dyadic nature of condom decision-making in the presence of PrEP to assess the influence partners accept on each other. This is key to understanding the total potential of risk bounty. Risk bounty has been discussed in recent literature where results from big PrEP written report trials suggest very little risk compensation,six,8,9 while studies investigating intentions to use condoms in the presence of PrEP propose a high likelihood for reduced condom apply.x,11 Equally PrEP is made more widely available, it will be of import for providers to assess risk for HIV and other STIs with both partners and encourage continued condom utilize every bit appropriate. The initial FDA approval for PrEP and the CDC guidelines for prescribing PrEP stipulate that it should be taken in conjunction with safer sex practices. In practice, thorough risk assessments and safer sex activity counseling may exist difficult to achieve in busy medical practices. As PrEP continues to be scaled up, community-based prevention efforts volition be needed to reinforce the importance of practicing safer sex in conjunction with taking PrEP.
Although some early studies suggested that those virtually willing to accept PrEP were at highest risk, information technology remained a question as to whether in keeping with a higher risk profile, couples who engage in riskier behaviors would forgo condoms while using PrEP. This was not truthful in the nowadays study where intentions to apply condoms while taking PrEP did not vary significantly whether a couple had engaged in UAI or not. Most men, regardless of whether they engaged in UAI, felt that they would continue to apply condoms at the current amount.
Relationship length was a cistron for some couples (HIV-positive men in serodiscordant relationships) where longer term couples seemed more ambivalent about PrEP than shorter term couples. Given that in that location is a tendency for some couples to forgo condoms later on high levels of trust and intimacy in the relationship have formed, involvement in PrEP is more likely driven by perceptions of run a risk, as well equally, comfort from the added safe cyberspace that PrEP provides couples.
Differences in individual- and couple-level race were not associated with the acceptability of PrEP, which is counter to earlier studies reporting greater interest in PrEP among Black participants.15,16 However, individual- and couple-race was associated with anticipated rubber use. Among men in seroconcordant HIV-negative relationships, trends suggest that compared to White couples and bi-racial couples, Black couples would use condoms less if their partner were taking PrEP. Couple and individual differences past race are critical to explore especially given the loftier incidence of HIV among Black MSM.35 Earlier assay from the qualitative sample (Study 1) suggested that condoms were the default behavior and used more consistently among Blackness couples compared to White couples and biracial couples.36 Data from the present report suggest PrEP use and its promise of protection could substantially alter how couples view condom use.
The findings should be interpreted and utilized in light of the limitations of this study. Consequently, circumspection is warranted in generalizing to the larger MSM community. In improver, HIV status was self-reported. The qualitative phase, which made up the smaller of the two samples, was conducted prior to PrEP being approved by the FDA, and before the CDC guidelines were released. Because that many participants had not heard of PrEP earlier, our findings may underestimate men's knowledge of, and interest in taking PrEP. Intentions to use condoms while taking PrEP were compared based on sexual risk profiles (i.e., between men who reported condomless anal sexual practice and those who did not). Future studies in couples should also compare condom-utilise intentions of partners who are taking PrEP with the intentions of those who are not. Finally, our study does not examine actual changes in rubber use and asks hypothetical questions about what individuals conceptualize doing if they themselves or their sexual partners were to start using PrEP. Nonetheless, this is one of the few studies to clarify both quantitative and qualitative data from both partners of seroconcordant and serodiscordant, Blackness, White, and bi-racial couples allowing us to examine and present attitudes towards PrEP utilise and intended condom use from a unique and important perspective.
Effective and safe HIV prevention strategies are still urgently needed both domestically and worldwide. PrEP is a promising option for those who are at high risk and who take admission to it. Serodiscordant male couples have been identified equally strong candidates for PrEP uptake, given the inherent risk of a serodiscordant sexual human relationship. The present study found that the majority of serodiscordant couples view PrEP positively. HIV-positive partners are particularly enthusiastic given the on-going fright they endure of infecting their HIV-negative partner. HIV-negative couples are similar in their acceptability of PrEP and intentions for connected condom apply. Futurity enquiry examining actual versus intended sexual beliefs associated with PrEP use is critical and so that providers and other frontline professionals can support couples with the necessary behavioral skills that are needed for PrEP to be constructive.
Acknowledgments
The authors extend their thanks to the participants for their time and effort and to Research Assistants Carla Garcia, Sean Arayasirikul, H. Lenn Keller, Pamela Valera, Anthony Morgan, Allison Hamburg, Jonathan Ocampo, Darrell McElvane, Corey Drew, Alicia Ayala, Kalvin Leveille, Rej Joo, Sara Finlayson, Stephanie Arteaga, Jaih Craddock, and Terry Dyer for their work recruiting, scheduling, and interviewing participants. This enquiry was supported past grant RO1 #MH089276 from the National Institute of Mental Health.
Author Disclosure Statement
No conflicting financial interests exist.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504342/
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