Gay, bisexual, and queer men’s confidence in the Undetectable equals Untransmittable HIV prevention message: longitudinal qualitative analysis of the sexual decision-making of pre-exposure prophylaxis users over time
Daniel Grace
A * , Emerich Daroya A , Mark Gaspar A , Alex Wells B , Mark Hull C , Nathan Lachowsky B and Darrell H. S. Tan D
+ Author Affiliations
- Author Affiliations
A Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
B School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada.
C Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
D St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada.
Sexual Health - https://doi.org/10.1071/SH23015
Submitted: 25 January 2023 Accepted: 5 May 2023 Published online: 1 June 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Background: Our objective was to understand what gay, bisexual, and queer men (GBQM) who had experience using pre-exposure prophylaxis (PrEP) thought about the ‘Undetectable equals Untransmittable’ (U=U) message and how it informed their sexual decision-making over time.
Methods: We conducted annual longitudinal qualitative interviews (2020–22) with 17 current or former PrEP users as part of a mixed-methods implementation science study examining barriers and facilitators to PrEP awareness, access, and adherence. Over 3 years, 47 interviews were conducted with GBQM in Ontario, Canada. Interviews were transcribed verbatim and coded in NVivo following reflexive thematic analysis.
Results: Participants’ sexual health decision-making was informed by their confidence in biomedical HIV prevention and the person taking medication (i.e. themselves using PrEP versus a real/imagined person living with HIV (PLHIV)). Longitudinal narratives of U=U clustered around four overarching themes: (1) U=U confidence (i.e. increasing trust in U=U irrespective of their PrEP use); (2) PrEP confidence (i.e. accounts of self-reliance and PrEP as sufficient HIV protection); (3) combination confidence (i.e. trusting U=U and PrEP as a package); and (4) partner confidence (i.e. potential ‘distrust’ of U=U due to uncertainties about partners’ medication adherence). Overall, men described increased sex with PLHIV over time, including some participants who, during earlier interviews, said they would ‘never be comfortable’ with serodifferent sexual partners.
Conclusions: GBQM’s use of PrEP shaped how they thought about U=U and sex with PLHIV. Although many GBQM embraced treatment as prevention/U=U as significant to their sexual lives, longitudinal analysis revealed its varied and uneven adoption across participants and time.
Keywords: Canada, gay, bisexual, and queer men, HIV prevention, longitudinal, pre-exposure prophylaxis (PrEP), qualitative, sexual behaviours, sexual decision-making, ‘Undetectable equals Untransmittable’ (U=U).
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