New Potentials for Old Pleasures: The Role of PrEP in Facilitating Sexual Well-being among Gay and Bisexual Men

Antiretroviral preexposure prophylaxis (PrEP; emtricitabine and tenofovir disoproxil fumarate [Truvada]) prevents HIV without penalizing sexual pleasure, and may even enhance pleasure (e.g., by reducing HIV-related anxiety). However, concern about sexual risk behavior increasing with PrEP use (risk compensation) and corresponding stereotypes of promiscuity may undermine PrEP's preventive potential. In this commentary, we review literature on sexual behavior change accompanying PrEP use, discuss risk compensation concerns and the "Truvada whore" stereotype as PrEP barriers, question the appropriateness of restricting PrEP access because of risk compensation, and consider sexual pleasure as a benefit of PrEP, an acceptable motive for seeking PrEP, and a core element of health. It is essential for science to trump stereotypes and sex-negative messaging in guiding decision-making affecting PrEP access and uptake.

We derived an estimate of male condom effectiveness during anal sex among men who have sex with men (MSM) because the most widely used estimate of condom effectiveness (80%) was based on studies of persons during heterosexual sex with an HIV-positive partner. Assessed male condom effectiveness during anal sex between MSM in 2 prospective cohort studies of HIV incidence by self-reported consistency of use. Analyzed data combined from US participants in the EXPLORE trial (1999-2001) public use data set and in the VAX 004 trial (1998-1999) data set. Initially, HIV-uninfected MSM enrolled in these trials completed baseline and semiannual interviews about their sexual behaviors with male partners and underwent HIV testing. Using a time-to-event model, effectiveness of consistent condom use in preventing HIV infection was estimated among men reporting receptive and/or insertive anal sex with an HIV-positive partner and consistency of condom use. Among MSM reporting any anal sex with an HIV-positive male partner, we found 70% effectiveness with reported consistent condom use (compared with never use) and no significant protection when comparing sometimes use to never use. This point estimate for MSM was less than the 80% effectiveness estimate reported for heterosexuals in HIV-discordant couples reporting consistent condom use. However, the point estimates in the 2 populations are not statistically different. Only 16% of MSM reported consistent condom use during anal sex with male partners of any HIV status over the entire observation period. These estimates are useful for counseling efforts and for modeling the impact and comparative effectiveness of condoms and other prevention methods used by MSM.

This study assessed unprotected anal and oral sex behaviors of HIV-positive gay and bisexual men in New York City and San Francisco with their main and non-main sexual partners. Here we focus on the use of three harm reduction strategies (serosorting, strategic positioning, and withdrawal before ejaculation) in order to decrease transmission risk. The data from a baseline assessment of 1168 HIV-positive gay and bisexual men in the two cities were utilized. Men were recruited from a variety of community-based venues, through advertising and other techniques. City differences were identified, with more men in San Francisco reporting sexual risk behaviors across all partner types compared with men in New York City. Serosorting was identified, with men reporting significantly more oral and anal sex acts with other HIV-positive partners than with HIV-negative partners. However, men also reported more unprotected sex with partners of unknown status compared with their other partners. Some evidence of strategic positioning was identified, although differences were noted across cities and across different types of partners. Men in both cities reported more acts of oral sex without ejaculation than with ejaculation, but the use of withdrawal as a harm reduction strategy for anal sex was more common among men from San Francisco. Overall, evidence for harm reduction was identified; however, significant differences across the two cities were found. The complicated nature of the sexual practices of gay and bisexual men are discussed, and the findings have important implications for prevention efforts and future research studies.