The effect of pre-exposure prophylaxis (PrEP) on negotiating casual sex between gay men: disclosure, assumptions, and communication

Keywords: casual sex, communication, gay men, HIV disclosure, HIV prevention, HIV risk reduction, HIV status, PrEP.

Disclosure of HIV status and communication between sexual partners about the use of effective HIV risk reduction strategies such as condoms, pre-exposure prophylaxis (PrEP) and undetectable viral load (UVL) are important tools in the prevention of HIV transmission. With the rapid adoption of PrEP among gay and bisexual men (GBM) in Australia,¹ long-held assumptions about HIV risk reduction have shifted.² Both PrEP and UVL make sex without condoms safe from HIV. Furthermore, in-person discussions about HIV prevention among GBM may be supplanted by disclosures on online or mobile profiles.^3–5 However, it is less clear how PrEP is affecting understandings of ‘safe sex’ and HIV risk reduction among GBM and their expectations about disclosure to and from partners.^6,7

Understandings of HIV risk, the use of different risk reduction methods and experiences and expectations of stigma (negative reactions) influence the likelihood of HIV status disclosure.⁸ Before the rapid increase in PrEP uptake among GBM in Australia, expectations about disclosure differed: one study found that 76% of HIV-negative GBM expected HIV-positive partners to disclose their status but only expected 42% of HIV-negative partners to do so.⁹ People living with HIV often face negative reactions when disclosing their HIV status to sexual partners, and may moderate or avoid disclosure in some situations to reduce negative reactions.^10–12 The growing use of biomedical prevention methods such as PrEP and UVL was hoped to reduce these experiences of HIV stigma and make HIV disclosure easier.¹³ In recent years, Australian HIV-negative men have become as likely as HIV-positive men to disclose their HIV status to at least some of their casual partners,¹⁴ which may reflect higher levels of HIV testing and growing levels of PrEP use. Research conducted in Australia suggests that PrEP users have generally found it easy to disclose PrEP use to potential sex partners, and have not faced negative reactions.^15,16 Fewer than 1 in 10 GBM not using PrEP nominated fear of negative social reactions as an influence in their decision to not use PrEP.¹⁷ This contrasts with research from North America, which has found that early PrEP users reported negative or judgmental reactions from some peers about PrEP use and its perceived association with irresponsibility or promiscuity, before it became more commonly used.¹⁸ In Australia, the climate towards PrEP use has generally been supportive, with the majority of Australian GBM consistently indicating support for GBM using PrEP and reporting willingness to have sex with PrEP users.¹⁹

Since 2016, mobile phone apps have been the most popular way for GBM in Australia to meet sexual partners.³ Many GBM include their HIV, PrEP or UVL status in their personal profiles. They may assume that their partners have seen this information and made an assessment about the need for different prevention methods.²⁰ However, in one US study, only a minority of GBM disclosed their HIV status (38%) or PrEP status (19%) on apps.²¹ Despite HIV disclosure having become more common among GBM over time, it is not clear how status disclosure and negotiation has changed in the context of rising PrEP use and greater awareness of UVL.

This study explores the disclosure of PrEP use, HIV status and communication with sex partners by HIV-negative gay men in Sydney, Australia. We describe how the disclosure (or non-disclosure) of PrEP use and HIV-related information is conducted, participants’ rationales for these practices, and whether new norms and expectations about discussion and disclosure are emerging.

We conducted semi-structured interviews with gay men in Sydney, Australia from October 2017 to May 2018 to explore their HIV risk reduction and disclosure practices during sexual encounters in the biomedical prevention era. Ethical approval was obtained from the University of New South Wales (UNSW) Human Research Ethics Committee. Consenting participants were invited to be interviewed from the Following Lives Undergoing Change (Flux) cohort study, which investigated HIV prevention through the use of PrEP, sexual behaviours and drug use among GBM in Australia. The Flux study protocol has been previously published.²²

To be eligible to participate in these interviews, men had to be aged at least 16 years old, reside in New South Wales, and report previous incidents of condomless anal intercourse with casual partners (i.e. they had participated in events where there may have been a risk of HIV transmission). Eligible men were recruited via email invitations. Participants did not receive compensation for their participation.

Trained interviewers (JK and SP) used a semi-structured interview guide to conduct interviews one-on-one with participants. Both interviewers identified as gay men, lived in Sydney and were involved in HIV research. The interviews generally lasted 1 h. The interview location was at the interviewee’s discretion and included UNSW campus in Sydney, a local community organisation, or at participants’ homes. All interviews were recorded, professionally transcribed, and reviewed for accuracy, with potentially identifiable information removed. Participants were assigned pseudonyms for this analysis. The transcripts were then coded and analysed for key themes using NVivo 12 software by JK and SP. The coding structure was a mixture of predetermined topics of interest and themes identified by actively reviewing transcripts. The approach to data collection was iterative and involved the interviewers discussing themes during the data collection period to refine the process.

Principles and techniques common to codebook thematic analysis were used to analyse the transcripts.^23–25 To ensure consistency with identified themes, codes were periodically compared. Conceptual saturation was considered to have been reached when most of the data were coded and no novel themes were found. This analysis focused on men’s accounts of discussions with sexual partners about PrEP and HIV status disclosure. We explored how men disclosed information about themselves when negotiating sex, and any consequences from disclosing or not disclosing PrEP use or non-use.

All procedures performed involving human participants were in accordance with the ethical standards of the Human Research Ethics Committee of UNSW Sydney and with the 1964 Helsinki declaration, its later amendments and comparable ethical standards.

All 26 participants interviewed in this study were gay-identified men, lived in Sydney, and were sexually active. Mean age was 45.8 years (range 22–70 years). Most participants reported being HIV-negative (n = 24) and two were HIV-positive. The majority of participants identified as white, Caucasian or Anglo-Australian (n = 24). At the time of interview, half the participants reported current daily PrEP use (n = 13). The majority had completed a university degree (n = 19) and were in full-time employment (n = 16). Eleven men reported being in a relationship with a regular partner.

Participants who were on PrEP described a variety of motivations for disclosing their use. Most participants who were on PrEP and discussed this with their partners said that this conversation was easier than their previous experiences of disclosing HIV status before PrEP. These conversations were described as easier because using PrEP was something active they had done to prevent HIV transmission rather than merely disclosing their HIV status, and PrEP use was believed to confirm one’s HIV-negative status:

People seem more readily willing to, to declare that they’re on PrEP, more so than they used to say they were HIV-negative or -positive. I guess because it’s more people see that as a solution. It’s not confronting. Being on PrEP is a declaration of safety more than ‘Oh, we better use condoms’. It’s easier to say that than to talk about a personal issue about being negative or being positive. (Calvin, HIV-negative, PrEP user, 60 years)

Several men described telling people directly about their PrEP status. For some, PrEP disclosure had given them greater confidence to talk about HIV prevention but had simultaneously supplanted previous expectations about discussing condoms. Also, what had previously been seen as a binary conversation about condoms or not having sex had become more nuanced after growing knowledge of and use of PrEP:

I think maybe PrEP is forcing a bit more of a conversation whereas previously there was an assumption that everyone would use condoms. So that’s not even a discussion. It was just, ‘This is what’s happening.’… I think that you could now want to use condoms or not use condoms, and that prompts a discussion whereas previously it was like, ‘Well, I’m not gonna have sex without a condom,’ so it’s either a yes or no. (Bill, HIV-negative, PrEP user, 39 years)

Bill conceptualised PrEP disclosure as a catalyst for further discussion about the kind of sex each partner wanted. Bill suggested that whereas previously condoms were the assumed norm with little discussion occurring, PrEP uptake had encouraged more discussion about whether or not to use condoms.

Some men saw PrEP use as a way to ‘fit in’ to the new sexual landscape. Tom felt that PrEP use and disclosure increased opportunities for more diverse and more frequent sexual encounters:

He was on PrEP and like he would only have sex if someone else was on PrEP. And I just found from my previous experience… it’s a selling tool now. Like the commodification of sex, it’s all about how can you make yourself more desirable. It’s not just about having pecs and nice abs these days, like being on this bloody medication… Because, if you are, you can engage in all this crazy sex. (Tom, HIV-negative, not on PrEP, 31 years)

In addition to being a selling point, Tom also described PrEP as an obligation, making it possible to do more things sexually but also something expected by partners.

As PrEP use became more common in Sydney, discussions about it became easier and more common, and less likely to generate a negative reaction.

More people know about it. More people are on it. So people’s knowledge about it is greater. And I think people have got over it as being ‘Oh, you’re a whore!’ You know, it’s like, ‘Oh, so do you, you sluts that take that because …’ I think people have become more aware of the science and the benefits of it…, I think the campaigns and the information have helped. And also word-of-mouth. (Dan, HIV-negative, PrEP user, 51 years)

Dan explained that community-level campaigns and discussions among peers had helped challenge stigmatising views about PrEP users, making disclosure of PrEP easier. Lance also described how PrEP had made discussions about being HIV-positive less stigmatising.

They probably talk less about your status because it really doesn’t matter as much anymore … Which is, in a way, a good thing... There’s sort of less… Less of a stigma there … your status isn’t as important as what it was once upon a time. (Lance, HIV-negative, PrEP user, 61 years)

Many men reported using sexual networking apps to communicate their HIV, PrEP or UVL status, which some participants felt eliminated the need for conversations one-on-one, making disclosure easier. They sometimes expected their partners to have reviewed their details online, thereby negating the need for discussion in person. They would nonetheless respond to questions about HIV status or PrEP if they arose, but disclosure of HIV status or PrEP use was not always confirmed with the presumed recipient. Paul, for example, disclosed his PrEP use via the profile fields within apps. He assumed that potential partners had read that information when arranging sex:

Some of the fields that are available in hook-up apps where people can say that they’re on PrEP, on Scruff and, and on Grindr too… if guys are on PrEP, they’re saying it in their profile. It’s just there. And I mean I certainly assume that people have read my profile. (Paul, HIV-negative, PrEP user, 39 years)

Other participants also suggested that biomedical prevention negated the need to discuss HIV prevention online, but in different ways. Pete, who was using PrEP, assumed most HIV-negative men on certain apps and websites were on PrEP or had UVL and this eliminated any need for conversation.

There’s an assumption, particularly with the apps like BBRT [a site for men who enjoy barebacking sex]… you just assume that people are [HIV] positive or on PrEP. I don’t think to ask as much anymore because I think everything feels a lot safer with PrEP and the undetectable viral load sort of thing going hand in hand. It feels like it’s not a necessary question for me to ask anymore, which I’m probably wrong about and I sort of cringe every time I say that. (Pete, HIV-negative, PrEP user, 35 years)

Pete talked about formerly feeling obliged to check the status of his partners, which he no longer felt, in a setting in which he felt most of his potential partners would be using PrEP or had UVL.

In the context of PrEP use, or presumed use, some participants described conversations about HIV prevention coming after sex, often as an afterthought. There was a feeling among some that there was not any need to discuss the use of HIV risk reduction strategies or HIV status as they were on PrEP and knowing their partner’s status or strategy was unnecessary.

It happens afterwards - I’ve noticed - quite a bit. So I’ve hooked up with somebody and then we’d have sex and everything. It’s all over and then they’re like, ‘Oh, what’s your status by the way?’ And it becomes this joke. Like, ‘Oh yeah, isn’t it funny how we don’t think to ask that anymore?’ but I also, because I’m not making a decision off of what their answer is anymore so yeah, often it happens after, after the fact. (Pete, HIV-negative, PrEP user, 35 years)

For Pete, HIV disclosure was now relatively unimportant due to wider PrEP use and his own use of it, so when it occurred, he regarded it as ‘funny’. He felt he did not need to know about his partners HIV status to make a decision about sex because of his PrEP use. For Bill, HIV disclosure no longer occurred automatically, but the use of condoms might either encourage or foreclose such conversations.

For my own experience, there’s no real conversation around whether somebody’s using condoms or not; they will just be using them. And, if you see that they are picking up a condom, you’ll be thinking, ‘Oh okay, right. This person isn’t on PrEP,’ or they don’t, or they still want to use a condom. If somebody’s picked up a condom and they’re about to use it, then that’s what they wanna do. I don’t need to necessarily have a discussion with them about it right there and then. (Bill, HIV-negative, PrEP user, 39 years)

So, for some men, suggesting or using condoms appeared to be easier than having to disclose HIV status, PrEP use or UVL, because they were visible. However, the condoms could also foreclose further conversation about HIV status, as their use implied a lack of PrEP use or a preference for condoms.

Some participants on PrEP decided not to disclose their PrEP use or HIV status because they viewed it as a personal choice and an act of personal responsibility that did not necessarily need to be shared. They felt no need to discuss their HIV status or PrEP use with partners, regardless of whether they had disclosed online. Knowing that they had protected themselves and others by taking PrEP was sufficient for these participants:

In terms of like people being on PrEP, I don’t know. I think I don’t disclose or it doesn’t occur to me maybe because I think that there is the sexual health is a shared responsibility and I know that I’m taking responsibility for my own sexual health. (Paul, HIV-negative, PrEP user, 39 years)

Paul described disclosure not being front of mind as he knew he was protecting himself from HIV thereby making a conversation about HIV redundant. The responsibility for maintaining sexual health had been met, in his view. Paul’s idea of ‘shared responsibility’ did not require that his partners knew about or agreed to his HIV prevention strategy.

Some participants believed the reduced risk and fear of HIV, due to the increased use of PrEP and UVL, had also reduced the expectation to disclose:

I feel like there’s probably less pressures to disclose because I feel like the risk is … people aren’t fearing that the Grim Reaper is gonna bowl them down like in that eighties ad anymore so they’re not assessing, they’re not having to assess the risk as much, so I feel like there’s less pressure for people to have to disclose. (Pete, HIV-negative, PrEP user, 35 years)

Pete referenced HIV prevention campaigns from earlier periods that promoted awareness (and fear) about HIV/AIDS in the public,²⁶ accompanied by an assumed requirement to assess and discuss risk. For others, improved treatments and preventative methods had changed the way gay men thought about discussing HIV:

I never ask them, actually. Often, they’ll volunteer that information [PrEP status] but it’s not something I ask…I don’t find that anybody really asks. But I generally volunteer that information. And I have it on my profile anyway so it’s, I just generally, if they’ve read the profile, it’s there straight away. (John, HIV-negative, PrEP user, 33 years)

John reported little expectation to disclose PrEP use or HIV status. He expected that few partners would ask this of him, nor did he ask for this information. He believed he had engaged in sufficient disclosure via the information he shared through apps.

In this study, conducted during the early phase of PrEP rollout in Sydney, we found widely varying views among gay men about what they felt they should tell partners about HIV status and PrEP use, and what they did in practice. For some participants, PrEP had negated the need for discussion with partners about HIV. Many assumed that their partners would see information about their HIV status or PrEP use on their online profiles or that their partners would ask, if necessary. Others felt that disclosure of HIV status was not important anymore, given growing use of PrEP and greater understanding of HIV treatment as prevention. Some participants believed that previous expectations to disclose HIV status, assess HIV risk, or consider condom use, had been lessened or removed by the introduction of PrEP. Most PrEP users saw these changes as unproblematic because they believed they were protected from HIV and posed no risk to their partners. While we conducted our research during the early years of PrEP rollout, we believe these results remain pertinent, as there is no published evidence suggesting that levels of PrEP discussion or disclosure have changed or increased since we conducted our interviews. This means that GBM need to be aware that discussion or disclosure of PrEP use and HIV prevention may be situational and need to be initiated, particularly by GBM who are not using PrEP.

Before the availability of biomedical forms of HIV prevention, HIV status disclosure before sex was relatively commonplace.^9,27 Disclosure or discussion may remain necessary for HIV-negative GBM who do not use PrEP and do not use condoms consistently, in order to negotiate safe sexual encounters appropriate to their own circumstances. However, the changed sexual field described by participants, after PrEP, may be less conducive to these discussions, as has been noted in other Australian research.¹⁵

Many men used apps and online profiles to share information about their HIV status, PrEP use or sexual health. The physical separation between sexual partners when communicating online may make disclosure and discussion feel easier or safer, as others have previously noted.²⁸ However, this separation could also facilitate non-disclosure, implied disclosure, and assumptions about what others knew, especially when people were uncomfortable about such conversations or saw them as unnecessary.

GBM who do not use condoms, PrEP or UVL remain at elevated risk of HIV transmission and may require additional resources to better enable communication.²⁹ Information about the changing norms concerning disclosure could highlight that PrEP users may not disclose their HIV status or PrEP use in person, although some may do so on apps, or have a discussion with a partner if asked. Not all men are equally well prepared and protected against HIV and some partners, such as men not using PrEP, may need to have a better understanding of others’ prevention practices and play a more active role in communication about ‘safe sex’.

Our results suggest that after a few years of PrEP rollout in Australia, it was unclear whether men felt an obligation to inform their partners whether they were on PrEP or not, as others have also observed.¹⁵ There was also no clear expectation as to whether men should disclose their use or non-use of PrEP or check on their partners’ HIV status or use of prevention methods such as PrEP or UVL. In contrast with research conducted overseas, our participants did not describe avoiding the disclosure of PrEP use for fear of negative reactions.¹⁸ Instead, some men who were taking PrEP felt that no communication with a partner was necessary, because they felt protected from HIV and that they were no risk to their partners. Nor did our participants report PrEP as an identity affecting disclosure. Despite the lack of discussion, and potentially unequal knowledge in the sexual encounter, this practice could still be perceived as ‘shared responsibility’ because participants believed that they posed no risk of HIV transmission to their partners. However, it departs from earlier understandings of shared responsibility in which both partners were expected to know about and agree on an HIV prevention strategy, or when condoms were a visual signifier of responsibility and care.^30,31 Other research has found that GBM may feel different obligations to disclose to and care for relationship partners and casual partners, prioritising relationship partners.³² This differentiation was not expressed by our participants. Aligning with what some men described in our study, other research exploring personal versus collective responsibility in relation to PrEP suggests that what looks like personal responsibility by PrEP users may still involve care for others.^15,33

This study has some limitations. Only two HIV-positive men were included in this sample, which limited our coverage of their experiences. The sample was composed entirely of gay men and was mainly white and Anglo-Australian, limiting our ability to describe the experiences of GBM from diverse racial backgrounds. The ethnicity of the sample was similar to other samples of PrEP users in 2018, which were predominantly white gay men.¹ If this research was to be repeated today, it would be important for overseas-born GBM to be interviewed because since our study was conducted, overseas born GBM in NSW and Australia have become over-represented in new HIV diagnoses.^34,35 Overseas-born (particularly Asian-born) GBM may face additional challenges in negotiating PrEP use and HIV prevention due to a lack of knowledge about HIV, racism, and lack of access to Medicare (Australia’s subsidised health insurance system).^36–38 Further research may be warranted to understand how disclosure and discussion of PrEP use, and the use of other HIV risk reduction strategies, evolves as PrEP use increases and the COVID-19 pandemic impacts on sexual behaviour among GBM.

Our research on experiences of PrEP disclosure and discussion found no clear expectations of what participants should tell their partners or what they expected in return. However, most gay men with whom we spoke to were still invested in behaving ‘responsibly’, which included protecting themselves and posing no risk to others. Many gay men expected their partners to inform themselves by referring to online profiles or asking about HIV prevention, if they were interested or concerned. Building a stronger, shared understanding among GBM that disclosure and discussion no longer automatically occur before sexual encounters may be useful. Although expectations of negotiation have been transformed in the biomedical prevention era, the sense of care and responsibility that GBM express could be built upon to update collective understandings of how ‘safe sex’ is practised, and to ensure that more GBM are effectively protected from HIV.

Participants did not consent to raw data being made available.

The authors have no relevant financial or non-financial interests to disclose.

This study was funded by a NHMRC Partnership Grant (Grant #1092852), the NSW Ministry of Health and UNSW Sydney. The Kirby Institute and the Centre for Social Research in health are funded by the Australian Government Department of Health. The Kirby Institute is affiliated with the Faculty of Medicine, UNSW, Sydney. The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of any of the institutions mentioned above.

The authors were involved in the following research activities: study design and methodology (all), data collection/interviewing (JK, SP), conceptualising the analysis (JK, SP, GP, MH), data analysis (JK, SP, GP, MH), writing/drafting the article (JK, GP, MH), commenting on drafts (all).