PrEP Eases Gay and Bisexual Men’s Worries About HIV
PrEP can reduce patients’ worries about the risk of HIV, but anxiety can also keep them from seeking PrEP.
Men who have sex with men (MSM) are still at a high risk for the human immunodeficiency virus (HIV), as are cisgender women and transgender women who have HIV-positive male sex partners.1. This risk increases with sexual risk behavior, such as condomless sex. Fortunately, these individuals at risk for exposure to HIV can now take medication that nearly eliminates their risk of acquiring HIV. This medication is called pre-exposure prophylaxis (PrEP). When used as directed, PrEP decreases a MSM’s risk of acquiring HIV through sex by about 99%.2-6 Since PrEP was approved, researchers have asked many questions about PrEP.
PrEP decreases a MSM’s risk of acquiring HIV through sex by about 99%.2-6
How do MSM feel about taking PrEP? Do they find the idea of PrEP acceptable? Are they willing to start taking it? How many of them have access to it? How consistently are they taking it?7 Researchers are asking how PrEP affects how MSM feel about sex. For example, the One Thousand Strong study showed that PrEP improved MSM’s psychological well-being by reducing their sexual anxiety and their fear of HIV.7
For many people, anxiety is a barrier preventing them from SEEKING CARE.7
PrEP HELPS TO EASE CONCERNS
ABOUT THE RISK OF ACQUIRING HIV.7
The One Thousand Strong Study
The One Thousand Strong study is a longitudinal study of 1071 gay and bisexual men (GBM) who were HIV negative at baseline.7 This cohort was selected to reflect the US Census data on the diversity and distribution of GBM throughout the United States.8 The men were asked to fill out surveys at baseline, 12 months, and 24 months, as well as an optional survey at 18 months. Whitfield and coworkers analyzed the changes in the scores on the Multidimensional Sexual Self-Concept Questionnaire9 reported among men who started taking PrEP after the baseline survey. The men who started taking PrEP were mainly White and well-educated, and nearly half had a long-term partner. As expected, the men who had started taking PrEP reported having less anxiety about sex. However, the researchers found no changes in sexual satisfaction or sexual esteem after the men started taking PrEP.7
Three small, qualitative studies had already suggested that MSM have less anxiety and fear about acquiring HIV while they are taking PrEP.10-12 The One Thousand Strong study supports this conclusion with quantitative data. The relationship between PrEP use and reduced anxiety remained, even after the researchers adjusted for demographic differences, the effects of time, and the number of recent high-risk sex acts.
The results of the One Thousand Strong study were echoed by those of the Following Lives Undergoing Change (Flux) study, which was a longitudinal study of 1547 GBM in Australia. The Flux study found that PrEP use was independently associated with lower levels of anxiety about HIV.13 In contrast, a Dutch study of MSM who were given 1 of 2 different PrEP regimens did not find any changes in anxiety or alcohol use disorder after men started using PrEP. However, the study did document decreases in sexual compulsivity and drug use disorder.14
Psychological Benefits of PrEP
PrEP provides medical benefits by reducing MSM’s risk of acquiring HIV through sex by about 99%.2-6 The One Thousand Strong study showed that PrEP can also produce psychological benefits by reducing GBM’s anxiety about acquiring HIV. This effect may be important because MSM may seek out PrEP because they are feeling worried. The psychological benefits of PrEP could even extend to other people. An HIV-positive man may be less worried about sex with an HIV-negative partner if he knows that his partner is taking PrEP.11 If an HIV-positive man takes antiretroviral treatment, his viral load can drop to undetectable levels. As long as his viral levels stay that low, he runs almost no risk of transmitting the virus to his partner.15-17 Nevertheless, some HIV-positive men with undetectable viral loads still want their partners to take PrEP, as an extra safety measure.18 Likewise, the HIV-negative partner may wish to take PrEP. Because the HIV-negative partner is the one bearing the risk from the sexual encounters, he may wish to be the one in control of protection.18
Because the HIV-negative partner is the one bearing the risk from the sexual encounters, he may wish to be the one in control of protection.18
Anxiety and PrEP? It’s Complicated!
The One Thousand Strong study does have some important limitations. MSM can have many different reasons for starting PrEP, and not all of these reasons would have been captured by the surveys. The study did not measure how risky the participants thought their sex lives were before and after they started using PrEP. However, men who started taking PrEP probably did so because they were experiencing at least some anxiety about HIV. The results of the One Thousand Strong study confirmed that PrEP use helps to reduce this anxiety. Yet, anxiety does not always lead MSM to take PrEP. In some cases, anxiety could be a barrier to starting PrEP.19
The relationships among anxiety, depression, and PrEP initiation are complicated
Miller and coworkers did a scoping review of the effects that anxiety and depression might have on the PrEP care continuum in the United States.19 A scoping review is a broad overview of the available evidence about a topic, from studies of various designs.20 The aim is to provide guidance to researchers and policymakers, as well as healthcare providers. Miller and coworkers found that the relationships among anxiety, depression, and PrEP initiation are complicated. Among people at high risk for HIV, the people with anxiety and depression were no less likely to be aware of PrEP and no less willing to take it.19 However, anxious and depressed people might be less likely to seek HIV testing or have access to care, and thus less likely to get a prescription for PrEP. Even if they get a prescription and get it filled, they might be less likely to adhere to their PrEP prescription. However, if anxious patients do get and take PrEP, the protection that PrEP provides against HIV may help to ease their worries about HIV, especially if they engage in condomless sex.19
The vicious circle of anxiety
Anxiety can lead to avoidance of care, which leads to more anxiety. But if patients get and take PrEP, they may be less worried about HIV.19
PrEP for Sexual Health
In 1975, a group of experts from the World Health Organization described sexual health as “the integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love.”21 By reducing the transmission of HIV, PrEP makes an important contribution to sexual health for MSM and for women whose sexual partners are HIV positive. By relieving concerns about transmission of HIV, PrEP can also be beneficial to emotional well-being. Some experts even feel that PrEP should be made available through the mental health system.22
Anxiety plays a complicated role in HIV prevention. Thus, healthcare providers should screen patients for mental health concerns, so that patients who need PrEP can also be directed to appropriate mental health care.
People with serious mental health diagnoses, such as schizophrenia and bipolar disorder, have a high prevalence of HIV because of sexual behaviors, injection drug use, and social factors. They also face structural discrimination that limits their access to all types of preventive health services. For this reason, Sudler and coworkers suggest that community mental health clinics should consider providing PrEP.22
HVUWCNT220009 August 2022