Motives for choosing, switching and stopping daily or event‐driven pre‐exposure prophylaxis – a qualitative analysis

Abstract

Introduction In settings where both daily and event‐driven pre‐exposure prophylaxis (PrEP) are offered to men who have sex with men (MSM), a clear understanding of the motives to choose between the different dosing‐regimens can facilitate more effective PrEP implementation. We therefore studied the motives for choosing for, switching between, and stopping daily or event‐driven PrEP. Methods We used data (August 2015‐June 2017) from the prospective, longitudinal, open‐label Amsterdam PrEP demonstration study, in which daily (dPrEP) and event‐driven PrEP (edPrEP) were offered to 374 HIV‐negative MSM and two transgender persons. Participants self‐selected the preferred PrEP‐regimen at baseline and could switch regimens at three‐monthly follow‐up visits. We measured motives for choosing PrEP‐regimen at baseline and for switching and stopping PrEP at follow‐up visits. Open‐ and closed‐end items were combined and qualitatively analysed. Results Choices of PrEP‐regimens were determined by personal and contextual factors, involving the perceived self‐efficacy concerning adherence, the risk‐context, and the anticipated impact of PrEP on physical and sexual wellbeing. dPrEP was preferred because of the anticipated better adherence and the fear of side‐effects relating to edPrEP re‐initiations. Moreover, dPrEP was perceived to be more effective than edPrEP. Motives to choose edPrEP were the expected physical burden of dPrEP, anticipated side‐effects of dPrEP, and fear to forget daily doses. Regarding the risk‐context: dPrEP was preferred for unplanned and/or frequent sex, while edPrEP was chosen when risk was predictable and/or less frequent. While some chose for dPrEP to gain more sexual freedom, others chose for edPrEP to minimize sexual risk episodes. Changes in the above factors, such as changing risk patterns, changing relationships or changing physical conditions, resulted in switching regimens. Choices to stop PrEP were related to lower sexual risk, adherence issues and side‐effects. Conclusions The great diversity of motives illustrates the importance of offering a choice of PrEP‐regimens. In counselling of MSM starting PrEP, choices for PrEP‐regimens may be addressed as a continuum of flexible and changeable options over time. This may help individuals choose the PrEP‐regimen that best fits their current sexual context, priorities and personal capabilities and therefore will be more easily adhered to.

Barriers to using HIV pre-exposure prophylaxis (PrEP) and sexual behaviour after stopping PrEP: a cross-sectional study in Germany

“…In our sample, 49.1% of the former PrEP users indicated that a reduced need for PrEP was a reason for stopping it. This is in accordance with findings from other studies of former PrEP users, where about half of the participants indicated stopping PrEP due to a perceived lower HIV risk [ 33 – 35 ]. This has also been described as ‘seasons of risk’, which suggests that HIV risk can undergo periodic changes over time.…”

“…Other reasons for stopping PrEP identified modifiable barriers. Financial burden and lack of health insurance cover have been identified as reasons for stopping PrEP [ 33 – 35 ] and in our sample 26.1% of former participants indicated that PrEP had become unaffordable. Since September 2019, about 3 months after the data collection for this analysis stopped, the costs for PrEP were covered by statutory health insurance in Germany when prescribed by HIV specialists.…”

Understanding pre-exposure prophylaxis (PrEP) regimen use: Switching and discontinuing daily and event-driven PrEP among men who have sex with men

“…An individual's choice of regimen over time is also likely to fluctuate with changing sexual and social contexts [7] . To date, reasons for changing PrEP regimens can only be inferred from single studies assessing hypothetical preferences after initiating PrEP [8] or qualitative analysis [9] , while no long-term longitudinal study on this issue has been conducted.…”

Pre-exposure prophylaxis makes it possible to better live one’s sexuality and guide men who have sex with men towards a responsible approach to their health: a phenomenological qualitative study about primary motivations for PrEP

“…All participants were mindful of adverse events and concerned about potential harm. Both this fear, and that of resistance to PrEP [ 39 ] were potential barriers to PrEP initiation [ 14 , 16 ], and needs to be addressed by professionals [ 40 ], or improved sexual health promotion through new interventions such as dating apps and social media [ 41 , 42 ].…”