Challenges of recommencing HIV pre-exposure prophylaxis (PrEP) use during the COVID-19 pandemic


BACKGROUND: The use of HIV pre-exposure prophylaxis (PrEP) among gay and bisexual men (GBM) in Australia rapidly increased until 2019, however many men suspended PrEP in 2020 during COVID-19 restrictions. As Australia mostly avoided large-scale COVID-19 infections, from June 2020 restrictions in most states eased, with many men increasing their sexual activity. However, little attention has been given to how men planned/anticipated these increases in sexual activity and how they recommenced PrEP.
METHODS: From an existing cohort study, 705 GBM consented to participate in a study comprising weekly surveys about their experiences of COVID-19 restrictions, including sexual practices and drug consumption. Weekly surveys contained a small number of open-ended questions, including about sex and relationships every four weeks, which provided real-time reflections on anticipated and actual sexual practices during COVID-19 restrictions. We undertook a thematic analysis of responses from 631 non-HIV positive GBM collected during a 36-week period of surveys (3-May-2020 ' 10-Jan-2021) that focused on anticipated and actual recommencement of PrEP.
RESULTS: 384 men provided responses to open-ended questions. 29 men highlighted PrEP across 48 entries, with ten men providing multiple entries. Three themes emerged from these responses. (1) Anticipation of future sexual encounters. Anticipation was central to men's considerations of recommencing PrEP. Men provided accounts of planning and recommencing PrEP over time, as well as re-suspending PrEP due to fluctuating local restrictions. Some men described unanticipated sexual encounters with casual partners where neither PrEP nor condoms were used. (2) Choice of PrEP strategy. Suspension of PrEP during the pandemic allowed for speculation about the most appropriate strategy upon recommencement (i.e., daily or on-demand dosing). Anticipating sexual encounters was noted as a challenge to adopting on-demand dosing. (3) Clinical procedures. Recommencing PrEP was also often articulated in relation to the steps required to obtain it (e.g., clinical consultations, sexual-health testing, or refilling prescriptions).
CONCLUSIONS: These findings highlight the fluctuating nature of PrEP during the COVID-19 pandemic and some challenges GBM face when recommencing PrEP as restrictions ease and sexual activity increases. Guidance should be provided to GBM on the effective use of non-daily PrEP dosing and periods of fluctuating PrEP use.