Changes in Sexual Behavior, PrEP Adherence, and Access to Sexual Health Services Because of the COVID-19 Pandemic Among a Cohort of PrEP-Using MSM in the South

Sanjana Pampati, MPH; Kayla Emrick, MPH; Aaron J. Siegler, PhD; Jeb Jones, PhD


J Acquir Immune Defic Syndr. 2021;87(1):639-643. 

In This Article

Abstract and Introduction


Background: The coronavirus disease 2019 (COVID-19) pandemic has had unforeseen consequences on the delivery of HIV and sexually transmitted disease (STD) prevention services. However, little is known about how the pandemic has impacted pre-exposure prophylaxis (PrEP)-using men who have sex with men (MSM).

Methods: Data come from an online cohort of PrEP-using MSM in the Southern United States from October 2019 to July 2020. Participants were administered 10 surveys in total, including 1 ad hoc survey specifically on COVID-19. We conducted a cross-sectional analysis of this ad hoc survey (n = 56) and present changes in sexual behaviors and utilization of and access to sexual health services. Using linear mixed-effect regression models, we also analyzed data from the larger cohort and document how sexual behaviors and PrEP use varied longitudinally across several months.

Results: A fifth of participants discontinued or changed how often they take PrEP because of COVID-19. A quarter of the cohort documented challenges when attempting to access PrEP, HIV testing, or STD testing. For all sexual behaviors examined longitudinally—number of male sexual partners, anal sex acts, condomless anal sex, and oral sex (all measured in the past 2 weeks)—there was a decrease from February to April followed by an increase from April to June.

Discussion: Our findings suggest reduced access to and utilization of STD and HIV services coupled with a continuation of behaviors which confer STD/HIV risk. Ensuring appropriate delivery of STD/HIV prevention services during this pandemic is imperative.


As of January 2021, there were more than 20 million confirmed coronavirus disease 2019 (COVID-19) cases and more than 370,000 deaths across the United States.[1] Efforts to control the pandemic have heavily relied on the implementation of social distancing guidelines[2] and stay-at-home orders[3] that intend to limit the number of social contacts and promote isolation at home. Such practices can have unforeseen consequences on the delivery of needed health services.

Evidence suggests the pandemic has already influenced access to and utilization of sexually transmitted disease (STD)/HIV services, including a decline in HIV postexposure prophylaxis prescriptions,[4] potential disruptions in the HIV care continuum,[5–7] and access to HIV/STD testing.[8] In the context of delivery of sexual health services, men who have sex with men (MSM) who use HIV pre-exposure prophylaxis (PrEP) in the South are a key population of interest because prescription guidelines for PrEP underscore the importance of routine health care visits and periodic HIV and STD testing for MSM at high risk of recurrent STDs.[9] Furthermore, the focus on PrEP users in the Southern United States is warranted; the burden of HIV and STDs is disproportionately concentrated in the South,[10,11] and many of the current COVID-19 hotspots are in the South.[1] Refills for PrEP are typically authorized at a check-up visit after negative HIV status is confirmed and prescriptions may require pick-up at a pharmacy. As a result, it is possible that access and adherence to PrEP may be affected by the COVID-19 pandemic, as well as compliance to routine HIV/STD testing.

Elucidating changes in sexual behaviors because of the pandemic is also important. In fact, reduced access to STD/HIV testing and PrEP discontinuation may be less concerning if coupled with a reduction in sexual risk. A nationwide study with MSM and a study with gay and bisexual men suggested reductions in sexual risk taking, including decreases in the number of sexual partners.[5,12] However, with the ongoing lifting of stay-at-home orders and declining compliance to social distancing guidelines,[13] it is not apparent if these decreases in sexual risk have persisted. For example, 1 recent study of gay, bisexual, and other MSM self-reported a mean increase of 2.3 sex partners during the COVID-19 pandemic.[14] There is a need to examine longitudinal trends in sexual behaviors in the context of the ongoing pandemic. Moreover, little is known about individuals' COVID-19 risk perceptions in the context of sexual behavior, and such data can help contextualize behavioral changes. Accordingly, we examine changes to access and utilization of sexual health services and changes in sexual behavior because of the COVID-19 pandemic, as well as COVID-19 risk perceptions among a cohort of PrEP-using MSM in the South.