An online survey in the US has found that although gay and bisexual men who used PrEP(Pre Exposure Prophylaxis) had significantly more condomless sex with non-primary partners than men who didn’t use PrEP, they were less likely to be anxious. A relationship seen in previous studies between higher rates of condomless sex and more anxiety did not seem to operate for PrEP users.
The survey
The survey was conducted by Dr Robert Moeller and colleagues from Middlebury College in Vermont. It recruited participants via a gay dating site and was only ‘live’ on a single weekend in 2016. Its findings therefore are already three years out of date, especially as there are now considerably more PrEP users in the US.
The researchers asked demographic questions about use of PrEP and about sexual behaviour. They asked participants to complete three different validated questionnaires that are commonly used to measure depression, anxiety and internalised homophobia (self-stigma). The PHQ-9 and GAD-7 questionnaires (you can try them yourself by clicking the links) measure depression and anxiety respectively by asking respondents how many times in the last week they have experienced symptoms indicating either condition.
The IHP questionnaire for internalised homophobia asks people to what extent they agree with statements such as “I often feel it best to avoid personal or social involvement with other gay/bisexual men” and “I have tried to become more sexually attracted to women”.
The researchers divided the 2406 men who answered the survey into four categories: HIV-negative PrEP users, comprising 11% of respondents; HIV-negative men who did not use PrEP (66%); HIV-positive men (11%); and men who did not know their HIV status (12%). The average age of participants was 34; HIV-positive men (average age 39) and PrEP users (average age 37) were older, and men of unknown status younger (average age 29).
The Results
PrEP use was strongly tied to income. Only 5.5% of those earning under $20,000 a year were using PrEP versus 26% of all those earning over $100,000 a year, and 32% of the HIV-negative ones. Not knowing your HIV status was inversely tied to income, with 20% of those earning under $20,000 a year not knowing if they had HIV versus 5% of those earning over $100,000. Having tested HIV positive was not strongly associated with income.
Similarly, educational status was also linked to PrEP use. Only 6.5% of those with a high school diploma or less were using PrEP, compared with 17% of those with a postgraduate degree.
Perhaps surprisingly, 19% of men defining themselves as married took PrEP, versus 14% of those saying they were dating and 9.5% of those who were single. However, this was largely explained by PrEP use being concentrated among the 31% of married men and 36% of men who were dating who also said they were non-monogamous – and by the fact that not all single men were sexually active. The number of condomless anal sex casual partners during the last three months ranged from zero to 90, with an average number of 2.6.
There was a strong dichotomy in the number of casual condomless sex partners in the last three months between, on the one hand, PrEP users and HIV-positive men (average number respectively 5.5 and 5.2 partners) and, on the other hand, men who did not know their status and HIV-negative men not on PrEP (respectively 1.9 and 1.6 partners).
The Discussion
This was a relatively small survey and the difference in mental health scores between PrEP users and others, though consistent, were not especially large. The researchers note that a five-point decrease on the PHQ-9 and GAD-7 scales is regarded as a clinically significant improvement. Across a population, however, it may be important: for instance, the difference between men and women in such scales, despite mental ill-health being a strongly gendered condition, is generally in the region of one point.
Even though the differences were not large, the researchers emphasise the finding on anxiety: “While having a higher number of condomless-anal-intercourse partners is associated with increased anxiety among participants who are not on PrEP, whether HIV positive or HIV-negative, the use of PrEP seems to moderate this difference.”
They note that a number of other studies have found that depression, anxiety and internalised homophobia are all associated with greater HIV risk via condomless sex in gay men.
“These mental health burdens are frequently co-occurring and often function synergistically, as a syndemic,” they note, “[yet] our results indicate lower levels of mental health burden among PrEP users are related to significantly higher rates of condomless anal intercourse.”
“Syndemic” is a term that has been used to describe the way that pre-existing trauma, anxiety and depression, condomless and casual sex, chemsex and other drug use, the stigma of HIV itself, and societal disadvantage may all combine to greatly amplify the risk of HIV infection for certain members of already at-risk populations.
The syndemic idea explains why certain members of certain populations may be much more likely to risk and catch HIV than others. However, it also implies that it may be very difficult to break the vicious circle that may lead to HIV infection (or to other problems such as addiction).
*Originally written by Gus Cairns
