Trust and stigma affect gay couples’ choices on PrEP and PEP

Both relationship-specific and structural factors influence whether coupled gay men living in New York City choose to use pre- and post-exposure prophylaxis (PrEP/PEP) for HIV prevention. Some men – particularly those in monogamous relationships – felt that discussing PrEP and PEP in the context of a relationship could threaten the relationship by raising issues of trust, while others felt that it had the potential to enhance sexual health and satisfaction.

Stigma from the gay community and healthcare providers around promiscuity also presented barriers to PrEP uptake. This qualitative research was conducted by Stephen Bosco, Dr Tyrel Starks and colleagues at City University New York and published in the Journal of Homosexuality.

Gay and bisexual men accounted for 66% of all new HIV diagnoses in the US in 2017. It is estimated that 35 to 68% of these infections happen within the context of a long-term relationship. This indicates that coupled gay men have the potential to benefit significantly from biomedical prevention strategies, such as PrEP (taken on an ongoing basis) and PEP (taken shortly after a suspected infection). However, only 7% of the potential 1.1 million gay and bisexual men who could benefit from PrEP were prescribed it in 2016. Black and minority men in the US remain most at-risk for HIV infection, while also having the lowest rates of PrEP uptake.

While PrEP is recommended to men in serodiscordant relationships (where one partner is HIV positive and the other negative) and those in non-monogamous relationships, there is limited research looking at coupled men’s use of biomedical prevention strategies.

The study

Semi-structured interviews were conducted with ten gay male couples in New York City in 2017 regarding barriers and facilitators around PrEP and PEP use within the context of their relationships. Each couple was interviewed together.

As part of the recruitment criteria, all couples included at least one partner aged 18 to 29; at least one HIV-negative partner (in fact only one couple included a partner with diagnosed HIV); and at least one partner who reported recent drug use. Of the 20 participants, half were Latino and 20% were African American. Most participants (65%) were college educated.

Five interviewees were on PrEP at the time of the interview.

In terms of sexual agreements, 30% said they had a monogamous relationship, 30% a non-monogamous relationship, and 40% had an agreement that sex with outside partners was only permitted when both members of the couple were present. In nine of ten couples, both members agreed about whether they were monogamous or non-monogamous. The average duration of relationships was approximately two years.

Relationship-specific factors

Many couples discussed relationship-specific challenges that arose when considering the use of PrEP or PEP. Using biomedical prevention was often associated with mistrust and infidelity within a relationship, especially for those in monogamous relationships. Using PrEP could call a partner’s intentions into question and was usually associated with promiscuity or the desire to have many sexual partners. A need for PEP could reveal that infidelity had taken place or that they had had sex with someone who was HIV positive or with an unknown status, thereby violating the relationship agreement. This was observed from exchanges between different partners:

Partner 1: "Probably because their partner would think, ‘Oh you wanna go on PrEP so like—’ ". Partner 2: "You’re gonna have all this unsafe sex … they might think ‘Oh, like if we’re monogamous like why would you even need that.’" Partner 1: "Cheating". (Monogamous couple).

Partner 1: "I think PEP over PrEP also has the fear of, ‘oh no it’s also post exposure, so you also have to admit to this behaviour.’" Partner 2: "I also feel like, if you need to have a conversation with your partner that you took PEP, or that you need PEP, it might be outside of the relationship ground rules." (Non-monogamous couple).

"PrEP could provide peace of mind regarding sexual encounters that happened outside the relationship."

However, couples also pointed out the benefits of taking PrEP or PEP within the context of a relationship. The main benefits cited were that PrEP could act as an additional layer of protection; it could provide peace of mind regarding sexual encounters that happened outside the relationship; and it could add to sexual health and satisfaction for the couple as a whole. In this sense, biomedical prevention strategies were seen as sexually liberating.

Partner 1: "It’s [PrEP] very useful, you never know who is lying about their status, so it’s extra protection for yourself." Partner 2: "It’s also, you know the spontaneity risk where it may be on your mind, but you just don’t realize at the time what you’re doing. So, as long as you are being regular with your medication, your PrEP, then it’s very useful." (Non-monogamous couple).

The one serodiscordant couple also highlighted additional benefits:

"Well especially for our relationship, I think it’s good because we decided not to use condoms. I’m HIV positive. He’s negative. Even though I’m taking my medication, even though I’m undetectable, he feels like he’s taking his PrEP for me and I’m taking my medication for him. For him, he feels he’s doing something for himself too." (Non-monogamous relationship).

Structural factors

Apart from relationship-specific factors impacting upon couples’ decisions, structural factors also had a bearing on whether or not they would use PrEP or PEP. In addition to healthcare access and costs, stigma was a recurring theme.

Stigma came from two main sources: healthcare providers who were either seen as unknowledgeable regarding PrEP/PEP or were judgemental regarding their use, as well as from within the gay community. Biomedical prevention evoked notions of promiscuity and being irresponsible.

"I think it’s getting rid of that stigma … So, you’re at the ER [emergency room] asking for PEP and you’re wondering what’s this doctor thinking. For instance, one time I went to the health department and they ask you how many sexual partners you’ve had in the last 3 months and I gave the doctor a number, and they had a lot to say about the number that I gave them." (Non-monogamous relationship).

"I believe it is the stigma of ‘oh why are you on PrEP? Are you having sex outside of your relationship? You wanna be a hoe?’" (Non-monogamous relationship).

Couples related that a reduction in stigma related to biomedical prevention would be an important step in increasing uptake. This would include supportive and well-informed conversations in the relationship, as opposed to judgement and shaming.

Partner 1: "I guess like the benefits it would bring to a couple. Like how it can, help couples even if they’re not in an open relationship, as extra security, even if you are in a monogamous couple." Partner 2: "Trying to remove the stigma that is also on PrEP." (Non-monogamous couple).  

Conclusion

These findings highlight the unique challenges that couples may experience when contemplating the use of biomedical prevention strategies. Often biomedical prevention is associated with infidelity and is viewed negatively within the context of a relationship.

“Relationship-specific factors illustrate a potential for dissonance between the desire to adopt PrEP and PEP to reduce HIV risk at the couple-level, and concerns that doing so will diminish relationship functioning,” say the authors.

The authors conclude by emphasising the need for couple-specific interventions and stigma reduction in order to increase the uptake of biomedical intervention strategies: “PrEP and PEP messaging needs to be tailored toward gay men in relationships through addressing their potential risk of HIV transmission without attacking the quality of their relationship.”