Sex Didn't Stop During the Pandemic; Neither Should HIV PrEP

Heather Boerner

April 19, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Nearly 1 in 10 Southern gay and bisexual men reported they'd discontinued use of HIV pre-exposure prophylaxis (PrEP) during the early months of the COVID-19 pandemic, according to data published online in the Journal of Acquired Immune Deficiency Syndrome.

This led lead author Sanjana Pampati, MPH, a PhD student at Emory University's Rollins School of Public Health, to suggest that now is the time to follow up with PrEP patients to assess their use, their access to testing for HIV and other sexually transmitted infections (STIs), and their sexual behavior as the pandemic continues into its second year.

"It's not reasonable to assume that for a year and a half people are going to continue to not engage in sexual behavior," said Pampati. "Now is the time to ensure service delivery, such as home HIV testing, telemedicine, or extending the prescription of PrEP to 90 days to make sure people are receiving these kinds of essential sexual health services."

The survey began life with another purpose: To track adherence to PrEP in a more nuanced way, said Pampati. With most medicines, adherence is a zero-sum game — either you take it every day or you don't. That makes sense when the medicine is for an existing condition like heart disease or HIV, where to stop taking triggers disease progression.

The CDC has approved Truvada and Descovy for PrEP as a daily oral dose only. But in practice, research shows that many people take the pills only around the times when they know they will be having sex. It's an approach called 2-1-1 dosing or on-demand PrEP and has been found to effectively prevent HIV. It's not yet approved in the US, but Pampati's adviser, Jeb Jones, assistant professor of epidemiology at Emory, wanted to find out whether PrEP adherence actually aligned with potential risk.

So Pampati and Jones designed a survey that queried participants about their sexual experiences, their experiences of STIs, how often and when they took their HIV prevention pills, and how often they received HIV and other STI tests. They administered a baseline survey in October 2019, and then followed up with an identical survey every 2 weeks thereafter.

"This is what makes the study a little bit different from a lot of other studies on PrEP use" during COVID-19, she said. "[Most] started after the pandemic and they asked people retrospectively, 'How did your behavior change?' We were actually doing the collecting before."

So when COVID did disrupt people's lives, the researchers added an ad hoc survey in July 2020 and invited the participants to fill it out. It included questions about how COVID-19 affected their access to and use of PrEP; how the pandemic affected their sexual lives, and therefore sexual risk; and what risk they thought different sexual behaviors carried for SARS-CoV-2 transmission. Then Pampati and team analyzed sexual behavior and PrEP use over the previous 8 months.

Seventy-eight participants who identified as cisgender gay or bisexual men, all between 18 and 34 years old and residents of the US South, comprised the overall study. Fewer than half of the participants in the main study were white, 27% were Black, 16% were Latino, and 91% identified as gay.

The 56 participants who responded to the COVID sub-study were less likely to be Black (from 20 participants to 10), less likely to be younger than 25 (from 35 to 22), and less likely to earn below $20,000 a year. This is notable for the epidemic, which right now has its most deleterious impact on young same-gender-loving Black men.

What they found was that 9% of participants had discontinued PrEP during the pandemic and only two (4%) switched to 2-1-1 PrEP dosing. Nearly half — 43% or 24 people — reported that they hadn't had an STI test during the pandemic. That was less true for HIV tests, but still, just 1 in 3 participants (32%) went without an HIV test — and getting those tests was more difficult during the pandemic, with 20% and 18%, respectively, reporting trouble getting an HIV or STI test.

Most participants reported a decrease in sexual activity early in the pandemic, with 79% reporting that their number of sexual partners had dropped, 68% reporting that they were having less anal sex, 64% reporting less frequent oral sex, and 67% reporting that they were practicing rimming less often.

Still, that same proportion — 79% — reporting having had sex since social distancing guidelines went into effect. Sexual-activity patterns were random before the pandemic, but they showed a clear arc during the pandemic. For instance, in February 2020, 31% reported having two or more sexual partners — a proportion that dropped to 8% by April. But by June, it was back up to 25%.

The good news is that gay and bisexual Southern men who stayed on PrEP through the early months of the COVID-19 pandemic continued to take the pills consistently. In December, participants reported missing only 1.2 pills over the prior 2 weeks. And they did that again in June. Interestingly, mean missed PrEP doses dropped in the initial months of the pandemic, to 0.7 missed in the previous 2 weeks.

"What this data shows is that early in the pandemic, we didn't see many major differences in PrEP use," Pampati told Medscape Medical News. But she said that that finding comes with a pretty big caveat: "It's a possibility that the study ended before we would see those sorts of changes. Maybe people had prescriptions that lasted long enough."

While the study was small and relied on self-report — a measurement often considered unreliable — the data conforms with other reported changes in sexual behavior by gay and bisexual men early in the pandemic, said Kenneth Mayer, MD, medical director of Fenway Health, an LGBTQ health center in Boston. He pointed to another Emory survey, published just as the pandemic was beginning, showing that by April 2020 access to PrEP and HIV testing had already dropped, especially for young people at high risk for HIV. That's the same group that fell out of Pampati's survey.

Last year, Mayer was involved in one of those retrospective cohort studies looking at PrEP access and use in the early days of the pandemic. That analysis, based on Fenway data and presented at the International AIDS Conference (AIDS 2020), showed that new prescriptions for PrEP plummeted by 72% between January and April 2020, and lapses in patients refilling their PrEP prescription rose by 278%. The total number of people taking PrEP shrunk by 17.9%. That paper also found a drop in HIV and STI testing, showing that test positivity rose for other STIs as people who may have had more symptoms were motivated to come in for a test.

And he said he suspects that the rebound Pampati's data began to see in June likely continued.

"Now, as people are becoming more optimistic and getting vaccinated and less worried about COVID-19, people revert to behaviors that might put themselves at risk," said Mayer, who was not involved in the Emory study.

That's not a problem if they're going through a period of celibacy or if they "have found the love of their lives," he said. But some PrEP users — before the pandemic and now — have a hard time predicting when they might have sex. So intermittent PrEP use or going off of PrEP for whatever reason during the pandemic, poses a real worry. Studies have found that people who have a history of prior PrEP use but who are no longer on it have an HIV acquisition rate closer to people who never started PrEP, he said.

"So it's really important for [the patient] and the clinician to think about what are the circumstances of stopping, and what would be a safe way to ensure you don't get surprised later," he said. "To me, that's some of the biggest tragedies — people who knew enough about PrEP to start it, had a perception of their risk to be on PrEP, but then didn't persist and became infected."

And this risk is even greater in the South, said Pampati, who highlighted that PrEP rollout has been slower in most Southern states than in Boston, where Mayer is, and especially slow among the people who stand to benefit most: young Latino and Black men who have sex with men (MSM).

"A really important next avenue of research is looking at how the service disruptions layer on to existing barriers to care that Black MSM and Hispanic MSM experience in relation to PrEP and HIV/AIDS prevention services," she said. "There's really a potential to sort of magnify disparities."

Heather Boerner is a science and medical reporter based in Pittsburgh, Pennsylvania, and can be found on Twitter at @HeatherBoerner. Her book, "Positively Negative: Love, Sex, and Science's Surprising Victory Over HIV," came out in 2014.

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