Perceptions, experiences and concerns with sexually transmitted infections among current and former PrEP users: a longitudinal qualitative study of gay, bisexual and queer men in Canada

Design and setting

Data were derived from the PrEP Implementation Project (PRIMP), a mixed-methods implementation science study. The study aimed to understand how to better deliver PrEP to GBQM in Canada’s two largest provinces with varying PrEP access. In BC, PrEP is free for most residents, including Canadian citizens, permanent residents, refugees, and Indigenous people, who have access to the province’s Medical Services Plan.¹³ Meanwhile, in Ontario, PrEP is free for specific groups (e.g. <25, 65+ years of age) and publicly funded but with co-payments for others. PrEP in Ontario costs around CAD250/month, with most insurance plans covering between 50 and 100% of out-of-pocket expenses.¹⁴ The PRIMP study involved in-depth longitudinal interviews with current and former PrEP and non-PrEP users to discuss their experiences and interest in PrEP. This study involved human participants and was approved by the University of Toronto Research Ethics Board (Ref. 11252), Unity Health Toronto Research Ethics Board (Ref. 1694), University of British Columbia Research Ethics Board, University of Victoria Research Ethics Board, and Island Health Research Ethics Board (Harmonised, Ref. H18-01525). Details of the study have been reported elsewhere.^15–18

Recruitment and participants

Participants were recruited from participating clinics and community partners. Eligible participants had to be at least 19 years old, HIV-negative, sexually active, and identify as GBQM. To ensure consistency across study sites, we recruited participants aged 19 years and over to align with the minimum age for accessing healthcare services in both provinces. Although Ontario allows minors aged 14 years and older to consent to care, BC requires patients to be 19 years of age.¹⁹ Individuals were eligible to participate regardless of PrEP experience (i.e. never used PrEP, former PrEP user, or current PrEP user). A recruitment website and poster were shared with potential participants over email and social media. These recruitment tools linked to an eligibility screener used to increase the diversity of participants, including GBQM with diverse PrEP use histories, balanced representation of racial and ethnic backgrounds, a range of ages, and inclusion of gender-diverse participants. All participants gave informed consent to participate in the study. A total of 38 participants who were current or former PrEP users were recruited in Ontario (n = 18) and BC (n = 20).

The first round of interviews in Ontario was conducted in March–July 2020 (T1), the second round in June–September 2021 (T2), and the third round in March–May 2022 (T3). Among the 18 participants, 15 completed three interviews, 2 completed two, and 1 was interviewed once. In BC, the first round of interviews was conducted in October–December 2020 (T1), the second round in September–November 2021 (T2), and the third round in November–December 2022 (T3). Nineteen participants completed three interviews, and one was interviewed twice. In both study sites, 34 individuals completed all three interviews.

Data collection and analysis

An interview guide was developed in consultation with a community advisory board comprising of partners from GBQM health organisations. Across the three time points, participants were asked questions about STI history, testing, and experience. All interviews were conducted online due to COVID-19 public health restrictions. Interviews lasted 30–90 min, were audio recorded, and transcribed verbatim. Participants received a CAD30 honorarium for the first interview, CAD50 for the second, and CAD70 for the third.

A total of 109 interviews were conducted. Data analysis included reflexive thematic coding and longitudinal recurrent cross-sectional analysis using NVivo Version 12 (QSR International; http://www.qsrinternational.com/nvivo). After each round of interviews, a reflexive thematic analysis was performed.^20,21 After the three rounds of interviews, a longitudinal analysis was conducted. Building on previous qualitative longitudinal research, each theme was organised chronologically, and differences and similarities between each time point were looked for.^22,23 Longitudinal analysis focused on tracing individual trajectories over time. It was then shared with the entire team for feedback. Pseudonyms are used throughout to trace narratives across the time points.

Lack of STI-related concerns due to treatment and prevention optimism

Throughout the interview time points, almost all participants perceived HIV as more severe because of its permanency, whereas STIs were considered minor inconveniences due to easy access to medications and frequent testing. For example, Omar said, ‘I wasn’t afraid of the other STIs because there’s treatments, like HIV is one that you’re kind of living with for the rest of your life’ (age 30s, BC, current user at T1). Despite some participants reporting an increase in CAS due to PrEP use and acknowledging heightened STI risks, many of them expressed a lack of STI-related concerns. As Rishi shared, ‘I stopped using condoms [and] took more risks with STIs […], but I know that they’re treatable’ (age 40s, Ontario, current user at T1). For these men, factors such as their partner’s HIV status or PrEP use did not significantly impact their apprehension about contracting STIs. For example, Zayn stated, ‘Because of my PrEP use, I don’t ask people about their HIV status’ (age 20s, Ontario, current user at T2).

Stigma-related apprehensions

Acquiring STIs was concerning for some participants because of self-stigmatisation and the perceived stigma associated with these conditions.²⁵ Participants raised apprehensions regarding feeling ‘unclean’ and ‘embarrassed’ when contracting STIs. Additionally, they expressed worries about being stigmatised when disclosing an STI diagnosis to sexual partners. Over time, the trajectories of STI-related stigma concerns evolved as they better understood treatment options. For example, Jamal described experiencing self-stigma after his first gonorrhoea and chlamydia infections: ‘I felt self-degrading, and like, I’m not clean’ (age 20s, Ontario, current user at T1). However, upon receiving medications, Jamal realised that ‘it was such a basic treatment’ (T1). Later, Jamal did not discuss how STIs have generated feelings of shame. Instead, he articulated how he ‘[knew] how other STIs work, especially the bacterial ones’ (current user at T2). For Jamal, receiving medications for STIs and obtaining regular testing as part of PrEP care appeared to have helped in destigmatising STIs.

Harry also described experiencing self-stigmatisation and perceived stigma. He reported acquiring chlamydia and felt ‘really embarrassed’ about ‘having to explain to previous partners’ (age 30s, BC, current user at T1). During his 2022 interview, however, Harry did not discuss any STI-related stigma. Instead, Harry reported discontinuing PrEP because he ‘wasn’t having anonymous anal sex’ and perceived himself as low risk due to primarily engaging in oral sex (former user at T3).

Perceived risk among other PrEP users due to increased CAS

Some men expressed concerns about their risk of acquiring STIs due to perceived increased CAS among other PrEP users, which persisted throughout the study. Although Damien did not voice any apprehensions about STIs because ‘we can still treat them’, he described some anxiety about other PrEP users engaging in CAS (age 40s, BC, current user at T1). In 2021, Damien explained how other PrEP users ‘view PrEP as a panacea for all things’ (current user at T2). He also discussed how other PrEP users ‘are more willing to buy into the freedom that gives them to have sex without a condom’ (T2).

Similarly, Tyler discussed how ‘other STDs […] aren’t getting enough attention’ because he believed that ‘the focus was always so much on HIV’ (age 20s, Ontario, former user at T3). He continued, ‘The fact that condoms prevent other STDs has […] gone out of the window’ (T3). During Tyler’s first interview, he said that engaging in CAS was not a ‘regular practice’ he engaged in because of his previous experience with syphilis: ‘I know there’s other STIs that you can get’ (current user at T1). Later, however, Tyler discussed that he was ‘not a fan of [condoms]’ but acknowledged their utility (‘very much useful’) (former user at T3). By contrast, Damien described wearing condoms ‘most of the time’ (current user at T1, T3).

Perceived risk among non-PrEP users due to inconsistent testing

Some participants expressed concerns about acquiring STIs from individuals they believed were not undergoing regular STI testing, particularly non-PrEP users unaware of their HIV status. Some participants consistently expressed these views across the three time points. Although Aiden explained his low fears about STIs, he worried about other people ‘not getting tested […] [especially people] who don’t already know their status’ (age 30s, Ontario, current user at T1). He continued,

If you’re on PrEP, you’re getting tested regularly because it’s simply part of the process. But for people who are not, it’s not uncommon for me to hear stories of people not getting tested. (T1)

Aiden’s concerns regarding STIs did not change in 2022, and he discussed that he was ‘using condoms’ when ‘having sex with a new partner’ to avoid STI acquisition (current user at T3).

Although some participants’ STI-related concerns linked to inconsistent testing among non-PrEP users remained constant, others expressed anxieties only once during the 3-year study period. For example, Jack consistently expressed optimism about treatment and prevention throughout the study (T1 and T3). However, in 2021, he noted that the COVID-19 pandemic created barriers to testing, which may have hindered some GBQM from getting tested, potentially impacting the spread of STIs. As Jack said, ‘People can’t get their testing as regularly done, so you probably see pockets of that spiking and spreading’ (age 30s, BC, current user at T2).