Reconciling intimacy and safety: a qualitative systematic review of HIV pre-exposure prophylaxis implementation among gay and bisexual men

Figures & data

Figure 1. Flow diagram of study identification and selection process.

Table 1. Characteristics of included studies (n = 24).

Author (year)	Location	Participants	Data [date]
Brooks et al. (2019)	USA	29 Hispanic/Latino men: 25 gay and 4 bisexual; mean age 29.8 years (SD 6.53); all currently on PrEP (mean 16.5 months); recruited via gay apps, events, and referrals	Semi-structured interviews [Jan–Oct 2017]
Brooks et al. (2020)	USA	26 Black men: 25 gay and 1 bisexual; mean age 31.5 years (range: 22–46); all currently on PrEP (mean 20.5 months); recruited via gay apps, events, and referrals	Semi-structured interviews [Jan–Oct 2017]
Collins, McMahan, and Stekler (2017)	USA	14 MSM: nearly 100% (13) cisgender and mostly (12) White; median age 40.5 years (range: 26–66); all currently on PrEP (median 3.5 months); recruited via PrEP providers	Semi-structured interviews [Jul–Aug 2014]
Devarajan et al. (2020)	USA	20 gay and cisgender men: 15 Black, 4 White, and 1 Asian; mean age 30.2 years (range: 22–47); 17 current and 3 former PrEP users; recruited via referrals and flyers posted in online and offline community spaces	Semi-structured interviews [Jun–Oct 2018]
Dubov et al. (2018)	USA	43 MSM: 25 White, 9 African American, 6 Hispanic, 2 Asian, and 1 other ethnicity; mean age 30.3 years (range: 22–53); all currently on PrEP (range: 2–24 months); recruited online as part of a larger study	Semi-structured interviews [Jun–Oct 2015]
Gafos et al. (2019)	UK	40 gay cisgender men; median age 37.4 years (IQR: 31.9–42.7); 33 had ever used PrEP (mean 14.3 months); recruited from the PROUD trial (an open-label wait-listed randomised control study: participants receive PrEP immediately or after 12 months)	Semi-structured in-depth interviews [Feb 2014–Jan 2016]
Grace et al. (2018)	Canada	16 gay men: 11 White, 1 Asian, 1 Black, 1 Indigenous, and 1 other ethnicity; mean age 37.6 years (SD 11.02); recruited from the PREPARATORY-5 demonstration project	Focus group and individual interviews [Nov 2014–Jun 2016]
Huang et al. (2019)	Taiwan	31 Taiwanese MSM; mean age 33 years; all had ever used PrEP (average 3 months); enrolled in the Taiwan PrEP Demonstration Project; recruited via online flyers, gay apps, medical institutions’ referrals, and snowballing	Semi-structured interviews [Nov 2016–August 2017]
Hughes et al. (2018)	USA	32 MSM: 13 White, 12 Hispanic/Latino, 5 African American, 1 Asian, and 1 mixed race; mean age 40 years (range: 24–66); recruited from the US PrEP Demonstration Project	Semi-structured interviews [May 2014–Aug 2015]
Hojilla et al. (2016)	USA	26 MSM: 16 White, 7 Hispanic, 2 African American, and 1 Asian; median age 37 years (range: 21–63); recruited from the US PrEP Demonstration Project with at least 24 weeks of follow-up (i.e. minimum 4 counselling sessions)	Counselling notes [Oct 2012–May 2013]
Kecojevic et al. (2021)	USA & UK	15 gay men: 10 White, 3 African American, and 1 Asian; their perspectives and experiences of taking PrEP elicited solely from the videos they posted on YouTube	Online videos [Apr 2012–Jan 2018]
Koester et al. (2017)	USA	61 MSM: 45% White, 37% African American, and 15% Latino; median age 34 years; all elected to take PrEP; recruited from the iPrEX open-label extension study	In-depth interviews [Apr–Aug 2012]
Mabire et al. (2019)	France	45 MSM; median age 35 years (range: 20–67); recruited from the ANRS-IPERGAY trial (a randomised, placebo-controlled double-blind study of on-demand PrEP efficacy)	Semi-structured collective interviews [2014]
Malone et al. (2018)	USA	40 MSM (20 couples): 32 White, 5 Black, and 3 other race; median age 33 years (IQR: 29–45); at least one partner having or getting PrEP prescription—17 couples and 27 men had ever used PrEP; recruited via an urban health centre and local community-based organisations	Dyadic interviews
Martinez-Lacabe (2019)	UK	15 gay men: 13 cisgender and 2 transgender; median age 41 years (range: 28–55); all had ever used PrEP; recruited by snowball sampling with seeds solicited via Facebook	Semi-structured oral history interviews
Orne and Gall (2019)	USA	22 gay, bisexual, and queer cisgender men: 42% White, 33% Black, 23% other ethnicity, primarily Latino; on PrEP for at least three months; recruited by respondent-driven sampling with seeds solicited via flyers and social media	In-depth interviews [Jun 2017–Oct 2018]
Parker et al. (2015)	USA	24 MSM: 18 White, 6 Hispanic/Latino, 1 Black, and 5 other ethnicity; mean age 33.2 years (SD 10.5); on PrEP for at least three months; recruited from one outpatient centre	In-depth interviews
Puppo et al. (2020)	France	68 MSM; median age 38.1 years (IQR: 31.5–46.6); recruited from the ANRS-Prévenir trial (a cohort study with a choice of daily or on-demand PrEP); 26 men were on daily PrEP intake schedule and 41 on-demand	Focus groups [Mar–Apr 2018]
Quinn et al. (2020)	USA	36 Black MSM: 25 gay, 5 bisexual, 6 other identity; mean age 25.9 years (range: 20–30); 27 current and 9 former PrEP users; recruited via community-based organisations	Focus groups [2018]
Rivierez et al. (2018)	France	23 MSM; median age 38.5 years [IQR: 30–43]; all had to have used PrEP informally at least twice in the past 12 months; recruited via community-based organisations	In-depth, semi-structured interviews [Mar 2015–Feb 2016]
Schwartz and Grimm (2019)	USA	38 MSM: 27 White, 7 Latino, 2 Middle Eastern or North African, and 2 Biracial; average age 35 years; all reported to be on PrEP; recruited via gay apps (Grindr and Scruff)	In-depth interviews [May–Dec 2016]
Storholm et al. (2017)	USA	30 MSM: 29 gay and 1 bisexual, and 12 White, 7 Latino, 6 Asian, and 5 African American; mean age 27.5 (range: 20–35); all currently on PrEP (average 10.7 months) and reported recent substance use and missed PrEP doses; recruited from MSM prescribed PrEP at a medical clinic	Semi-structured interviews
Sun et al. (2019)	USA	22 MSM: 20 cisgender, 1 queer, and 1 transgender man, and 73.9% White, 17.4% Latino, and 8.7% multiracial; mean age 39.9 (range: 21–67); all reported current or past PrEP use; recruited via community-based organisations	In-depth interviews
Yang et al. (2020)	USA	18 MSM: 15 Black/African American, 2 Caucasian, 1 Hispanic; average age 28 years; recruited by PrEP Peer Navigators from participants of Baltimore city health department clinics PrEP program	In-depth interviews [Mar–Nov 2017]

Data date indicates the period during which participants’ discourses were produced or elicited. Where available, it is the reported date when interviews were conducted or interviewees were recruited. Otherwise, the date corresponds to the period of the PrEP trial or project that participants were enrolled in or the dates when the videos were posted (Kecojevic et al. 2021).

Brooks, R. A., O. Nieto, A. Landrian, and T. J. Donohoe. 2019. “Persistent Stigmatizing and Negative Perceptions of Pre-Exposure Prophylaxis (PrEP) Users: Implications for PrEP Adoption among Latino Men Who Have Sex with Men.” AIDS Care 31 (4): 427–435. https://doi.org/10.1080/09540121.2018.1499864

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Brooks, R. A., O. Nieto, A. Landrian, A. Fehrenbacher, and A. Cabral. 2020. “Experiences of Pre-Exposure Prophylaxis (PrEP)–Related Stigma among Black MSM PrEP Users in Los Angeles.” Journal of Urban Health 97 (5): 679–691. https://doi.org/10.1007/s11524-019-00371-3

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Collins, S. P., V. M. McMahan, and J. D. Stekler. 2017. “The Impact of HIV Pre-Exposure Prophylaxis (PrEP) Use on the Sexual Health of Men Who Have Sex with Men: A Qualitative Study in Seattle, WA.” International Journal of Sexual Health 29 (1): 55–68. https://doi.org/10.1080/19317611.2016.1206051

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Devarajan, S., J. M. Sales, M. Hunt, and D. L. Comeau. 2020. “PrEP and Sexual Well-Being: A Qualitative Study on PrEP, Sexuality of MSM, and Patient-Provider Relationships.” AIDS Care 32 (3): 386–393. https://doi.org/10.1080/09540121.2019.1695734

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Dubov, A., P. Galbo, F. L. Altice, and L. Fraenkel. 2018. “Stigma and Shame Experiences by MSM Who Take PrEP for HIV Prevention: A Qualitative Study.” American Journal of Men’s Health 12 (6): 1843–1854. https://doi.org/10.1177/1557988318797437

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Gafos, M., R. Horne, W. Nutland, G. Bell, C. Rae, S. Wayal, M. Rayment, A. Clarke, G. Schembri, R. Gilson, et al. 2019. “The Context of Sexual Risk Behaviour Among Men Who Have Sex with Men Seeking PrEP, and the Impact of PrEP on Sexual Behaviour.” AIDS and Behavior 23 (7): 1708–1720. https://doi.org/10.1007/s10461-018-2300-5

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Grace, D., J. Jollimore, P. MacPherson, M. J. Strang, and D. H. Tan. 2018. “The Pre-Exposure Prophylaxis-Stigma Paradox: Learning from Canada’s First Wave of PrEP Users.” AIDS Patient Care and STDs 32 (1): 24–30. https://doi.org/10.1089/apc.2017.0153

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Huang, P., H.-J. Wu, C. Strong, F.-M. Jan, L.-W. Mao, N.-Y. Ko, C.-W. Li, C.-Y. Cheng, and S. W.-W. Ku. 2019. “Unspeakable PrEP: A Qualitative Study of Sexual Communication, Problematic Integration, and Uncertainty Management among Men Who Have Sex with Men in Taiwan.” Journal of Applied Communication Research 47 (6): 611–627. https://doi.org/10.1080/00909882.2019.1693608

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Hughes, S. D., N. Sheon, E. V. W. Andrew, S. E. Cohen, S. Doblecki-Lewis, and A. Y. Liu. 2018. “Body/Selves and Beyond: Men’s Narratives of Sexual Behavior on PrEP.” Medical Anthropology 37 (5): 387–400. https://doi.org/10.1080/01459740.2017.1416608

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Hojilla, J. C., K. A. Koester, S. E. Cohen, S. Buchbinder, D. Ladzekpo, T. Matheson, and A. Y. Liu. 2016. “Sexual Behavior, Risk Compensation, and HIV Prevention Strategies Among Participants in the San Francisco PrEP Demonstration Project: A Qualitative Analysis of Counseling Notes.” AIDS and Behavior 20 (7): 1461–1469. https://doi.org/10.1007/s10461-015-1055-5

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Kecojevic, A., Z. C. Meleo-Erwin, C. H. Basch, and M. Hammouda. 2021. “A Thematic Analysis of Pre-Exposure Prophylaxis (PrEP) YouTube Videos.” Journal of Homosexuality 68 (11): 1877–1898. https://doi.org/10.1080/00918369.2020.1712142

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Koester, K., R. K. Amico, H. Gilmore, A. Liu, V. McMahan, K. Mayer, S. Hosek, and R. Grant. 2017. “Risk, Safety and Sex among Male PrEP Users: Time for a New Understanding.” Culture, Health & Sexuality 19 (12): 1301–1313. https://doi.org/10.1080/13691058.2017.1310927

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Mabire, X., C. Puppo, S. Morel, M. Mora, D. Rojas Castro, J. Chas, E. Cua, C. Pintado, M. Suzan-Monti, B. Spire, et al. 2019. “Pleasure and PrEP: Pleasure-Seeking Plays a Role in Prevention Choices and Could Lead to PrEP Initiation.” American Journal of Men’s Health 13 (1): 1557988319827396. https://doi.org/10.1177/1557988319827396

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Malone, J., J. L. Syvertsen, B. E. Johnson, M. J. Mimiaga, K. H. Mayer, and A. R. Bazzi. 2018. “Negotiating Sexual Safety in the Era of Biomedical HIV Prevention: Relationship Dynamics among Male Couples Using Pre-Exposure Prophylaxis.” Culture, Health & Sexuality 20 (6): 658–672. https://doi.org/10.1080/13691058.2017.1368711

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Martinez-Lacabe, A. 2019. “The Non-Positive Antiretroviral Gay Body: The Biomedicalisation of Gay Sex in England.” Culture, Health & Sexuality 21 (10): 1117–1130. https://doi.org/10.1080/13691058.2018.1539772

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Orne, J., and J. Gall. 2019. “Converting, Monitoring, and Policing PrEP Citizenship: Biosexual Citizenship and the PrEP Surveillance Regime.” Surveillance & Society 17 (5): 641–661. https://doi.org/10.24908/ss.v17i5.12945

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Parker, S., P. A. Chan, C. E. Oldenburg, M. Hoffmann, J. Poceta, J. Harvey, E. K. Santamaria, R. Patel, K. I. Sabatino, and A. Nunn. 2015. “Patient Experiences of Men Who Have Sex with Men Using Pre-Exposure Prophylaxis to Prevent HIV Infection.” AIDS Patient Care and STDs 29 (12): 639–642. https://doi.org/10.1089/apc.2015.0186

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Quinn, K. G., E. Christenson, M. T. Sawkin, E. Hacker, and J. L. Walsh. 2020. “The Unanticipated Benefits of PrEP for Young Black Gay, Bisexual, and Other Men Who Have Sex with Men.” AIDS and Behavior 24 (5): 1376–1388. https://doi.org/10.1007/s10461-019-02747-7

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Rivierez, I., G. Quatremere, B. Spire, J. Ghosn, and D. Rojas Castro. 2018. “Lessons Learned from the Experiences of Informal PrEP Users in France: Results from the ANRS-PrEPage Study.” AIDS Care 30 (sup2): 48–53. https://doi.org/10.1080/09540121.2018.1468014

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Schwartz, J., and J. Grimm. 2019. “Stigma Communication Surrounding PrEP: The Experiences of A Sample of Men Who Have Sex With Men.” Health Communication 34 (1): 84–90. https://doi.org/10.1080/10410236.2017.1384430

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Storholm, E. D., J. E. Volk, J. L. Marcus, M. J. Silverberg, and D. D. Satre. 2017. “Risk Perception, Sexual Behaviors, and PrEP Adherence Among Substance-Using Men Who Have Sex with Men: A Qualitative Study.” Prevention Science 18 (6): 737–747. https://doi.org/10.1007/s11121-017-0799-8

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