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


In our cohort study of PrEP-using MSM, we found the COVID-19 pandemic has impacted access to and utilization of numerous sexual health services: A quarter of the cohort reported challenges while attempting to access PrEP, HIV testing, or STD testing. Despite PrEP prescription guidelines indicating periodic HIV and STD testing for MSM at high risk of recurrent STIs,[9] our study found that many participants had not received an STD test or HIV test in the previous 3 months. However, it is not clear whether these findings relating to STD and HIV testing are unique to the pandemic because studies before the pandemic have also found imperfect compliance to STD and HIV testing guidelines for PrEP users.[15,16] Moreover, the pandemic's influence on PrEP use itself is inconclusive; a fifth of participants either indicated they discontinued PrEP use or changed how often they take PrEP because of COVID-19, but there were minimal changes in the number of missed PrEP doses among those who remained on PrEP across periods.

To contextualize these findings relating to delivery and utilization of services, we also examined changes in sexual behavior and found important variations by partner type and period. Most participants indicated a decrease in sexual activity with casual partners, but fewer reported decreases with main partners. Examining longitudinal trends, there seemed to be a consistent pattern—the cohort's mean level of sexual risk dropped from February to April and then increased from April to June. While looking at data from several months before the pandemic, we found inconsistent and random fluctuations in the cohort's mean level of sexual risk, which further affirms the stark changes we observed in the months of the pandemic are likely not just due to noise. Our findings corroborate a recent longitudinal assessment of a cohort of Latinx sexual minority men and transgender women comparing 2 timepoints (May 2020 vs. 8–18 months before the pandemic) that also found reductions in condomless sex.[17] We extend the findings from this study, as well as aforementioned cross-sectional studies which documented reductions in sexual risk among MSM and gay bisexual men,[5,12] by evaluating multiple time points after the pandemic and found that such reductions may be short-lived. The impact of these potential "rebounds" in sexual risk in the context of persistent disruption of clinical services can be far-reaching—1 modeling study projected hundreds of HIV cases and thousands of STI cases among MSM in Atlanta over the course of 5 years.[18] Although our study was unequipped to do so, examining how these service disruptions differentially affect populations is imperative because they may magnify existing disparities in communities of color and result in the emergence of new disparities in HIV.[19]

However, there did not seem to be meaningful variation in the number of missed PrEP doses by calendar month among participants who remained on PrEP. Although evidence of period effects for PrEP adherence was not apparent, it is important to note that a fifth of the cohort reported discontinuing PrEP use altogether or taking PrEP less frequently. Furthermore, as prescriptions typically need to be written every 3 months, it is possible that potential effects to PrEP adherence would not be captured because of our study's time frame.

Our study has limitations. Given limited sample size, we were unable to test for demographic and geographic differences in our findings. Furthermore, because participants are from several states in the South, we were unable to link our findings to specific state-level policies to control COVID-19. Our assessment of time since the last STD and HIV test is from the ad hoc COVID-19 survey, and we were unable to longitudinally examine how testing behaviors were impacted because of the pandemic. All data are self-reported and are subject to social desirability biases, and there is the potential for seasonal effects to influence our findings. All participants were eligible for the COVID-19 survey; yet, some participants did not complete this optional survey, potentially leading to selection bias. It is unclear what the potential direction of this bias would be. Findings may not be generalizable to other populations or settings. In particular, as all survey materials were administered in English only, the experiences of non–English-speaking populations may not be adequately reflected.

Our findings underscore the need to maintain STD and HIV prevention efforts during the COVID-19 pandemic as recent calls for action have stressed.[20,21] Finding unique ways to deliver these essential services is needed. Guidance from the US Centers for Disease Control and Prevention and other sources offer a host of options to ensure appropriate care during the pandemic,[22,23] including laboratory-only visits for indicated HIV/STD tests, at-home HIV/STD testing, self-testing for HIV through an oral swab-based test, extending the prescription of PrEP to a 90-day supply to decrease trips to the pharmacy, using telemedicine when possible, and finally referring patients elsewhere if needed services cannot be provided. Clinical anecdotes illustrate the challenges, as well as opportunities, in ensuring high-quality PrEP care during the pandemic.[24,25] Moreover, a critical component of PrEP check-up visits is risk reduction counseling and incorporating discussions of COVID-19 risk into these discussions may be needed. For all sexual activities examined, most participants rated the COVID-19 acquisition risk as moderate to high [ie, >50 on a scale of 0 (no risk) to 100 (highest risk)], aligning with a recent study of gay, bisexual, and other MSM.[14] However, for all sexual activities except kissing, there was substantial variability in the perceived level of COVID-19 acquisition risk, suggesting a need for clearer risk reduction messaging in clinical contexts[26]—and beyond. Public health messaging on COVID-19 risk and sex has largely been absent, although some local health departments have released guidance on safe sex during the pandemic.[27]

Continued monitoring of PrEP use, utilization of sexual health services, and sexual behaviors during the pandemic among PrEP-using MSM and other subpopulations is needed, including longitudinal studies powered to examine short- and long-term changes, qualitative investigations detailing specific barriers and facilitators to care, and analyses of pharmaceutical and medical claims data elucidating temporal changes in service utilization. Given our findings which suggest reduced access to and utilization of STD and HIV prevention services coupled with a continuation of behaviors which confer STD/HIV risk, ensuring appropriate delivery of these essential services and relevant risk-reduction messaging as this pandemic continues to unfold is critical.