Intention and preference to use long-acting injectable PrEP among MSM in the Netherlands: a diffusion of innovation approach.

Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) is efficacious in preventing HIV among men-who-have-sex-with-men (MSM) and will be soon available in Europe. This study investigated the intention and preference to use LAI-PrEP among MSM in the Netherlands by employing a diffusion of innovation approach. This study had a cross-sectional design nested within a cohort study established in 2017 to understand oral PrEP use among MSM. 309 MSM completed the survey on their awareness, interest, intention, and preference for LAI-PrEP in June 2022. Among them, 83% showed high/very-high interest in, and 63% showed high/very-high intention to use LAI-PrEP. A repeated innovator effect from the early adopters to LAI-PrEP was not observed. Early adopters did not show increased intention to use LAI-PrEP compared to other MSM subgroups, but neither did PrEP-naïve nor PrEP-discontinued MSM. However, among the 218 current oral PrEP users, suboptimal adherence was associated with preference for LAI-PrEP but not with intention to use it. In conclusion, our findings indicated that an effective, available, and affordable LAI-PrEP would be welcomed in the Netherlands, but that its introduction may not significantly expand PrEP coverage. However, the introduction of LAI-PrEP in the Netherlands could prove beneficial to MSM with suboptimal adherence to oral PrEP.

Brief Report: Determinants of Potential Sexual Activity Reduction in the Face of the Mpox Epidemic.

BACKGROUND: The current mpox epidemic is most prevalent among men-who-have-sex-with-men (MSM). Vaccination programs are being rolled-out to curb the epidemic. Behavioural measures have been called for as well, for example, by the WHO and national public health authorities to reduce the number of sexual partners and sexual activity. We investigated intentions and determinants among Dutch MSM to follow such behavioural measures. METHODS: Early in July 2022, in the context of a dynamic ongoing epidemic, 394 MSM answered an online questionnaire investigating concepts such as perceived mpox risk, vaccination and behavioural change intentions and collecting socio-demographic and sexual behaviour information. RESULTS: The overall intentions to reduce number of partners and sexual activity were high, but only a minority had developed definite intentions. Determinant analysis revealed that dating/open relationship status was a positive predictor; vaccination intentions did not predict sexual behaviour change; those not on PrEP were more likely to change their sexual behaviour. Mpox infection concern was the main predictor for behaviour change intentions. CONCLUSIONS: Our results show that behavioural measures to avoid an mpox infection are present in majority of participants in our survey, but high intentions are held by a minority. Taking the historic complexity of behavioural change pleas among MSM into account sensitive, additional public health measures are necessary to reach and to inform MSM about potential benefits of sexual behaviour change.

Sexual Distancing During 5 Periods Around and During the COVID-19 Pandemic, Amsterdam, the Netherlands.

BACKGROUND: Social and sexual distancing (ie, abstaining from sex with persons outside one's household) was important in the control of the COVID-19 pandemic. Compliance to distancing measures can change over time. We assessed changes in compliance to the sexual distancing measures during five periods of the COVID-19 pandemic in the Netherlands. METHODS: Between November 2021 and March 2022, we used a structured questionnaire containing questions about sexual behavior and factors that could have influenced compliance with sexual distancing. Variables related to sexual behavior were measured for 5 periods, before and during the pandemic, delineated by imposement and relaxation of lockdown measures. RESULTS: Eight hundred seventy participants (predominantly MSM) completed the questionnaire. We found that compliance to the sexual distancing measures decreased over time. The number of casual partners was highest after the lockdown measures were relaxed for the second time (April 2021 to March 2022), and even higher than before the first lockdown. Factors positively associated with sexual distancing compliance were: having confidence in the information provided by the government and experiencing less or similar need for physical contact compared with before the pandemic. Factors that lowered compliance over time were: previously having had COVID-19, perceiving the lockdown measures as overstated, having sex with casual partners and similar drug use during the pandemic as before. CONCLUSIONS: Our findings suggest that sexual distancing measures are difficult to maintain for a long period. Other measures, such as confinement to a small network of known partners, might be more effective for longer pandemics in minimizing the spread of infectious diseases.

A psychosocial network approach studying biomedical HIV prevention uptake between 2017 and 2019.

Biomedical HIV-prevention strategies (BmPS) among men who have sex with men (MSM), such as pre-exposure prophylaxis (PrEP) and viral load sorting (VLS), are essential but relatively new and their uptake gradual. Using an extension of the causal attitude network approach, we investigated which beliefs are related to uptake of PrEP and VLS at each time-point. We included 632 HIV-negative MSM from the Amsterdam Cohort Studies from four data-waves between 2017 and 2019. We estimated weighted, undirected networks for each time-point, where we included pairwise interactions of PrEP and VLS uptake and related beliefs. PrEP use increased from 10 to 31% (p < 0.001), while VLS was reported by 7-10% at each time-point. Uptake of both BmPS was directly related to the perceived positive impact of the strategy on one's quality of sex life and perceived supportive social norms. Overall network structure differed between time points, specifically in regard to PrEP. At earlier time points, perceptions of efficacy and affordability played an important role for PrEP uptake, while more recently social and health-related concerns became increasingly important.The network structure differed across data-waves, suggesting specific time changes in uptake motives. These findings may be used in communication to increase prevention uptake.

Mpox stigma among men who have sex with men in the Netherlands: Underlying beliefs and comparisons across other commonly stigmatized infections.

People with or at risk for mpox are likely to be stigmatized because of analogies to other sexually transmitted infections. Stigma is driven by beliefs about the perceived severity of the condition and perceived responsibility for acquiring the condition, both in broader society and individual responsibility. We explored these beliefs and compared them across mpox, human immunodeficiency virus (HIV), syphilis, gonorrhoea, and chlamydia in an online survey, conducted in July 2022, with 394 men-who-have-sex-with-men in the Netherlands. We compared mean scores between infections using repeated measures analysis of variance and conducted hierarchical regression analyses to identify determinants of both mpox perceived responsibility endpoints. Results showed that participants expected that mpox would be seen as a "gay disease" and will be used to blame gay men. Compared to other infections, mpox was considered less severe than HIV, but more severe than syphilis, gonorrhoea, and chlamydia. Perceived responsibility was comparable across infections, but, for each infection, participants perceived attributed responsibility to be higher in society than individual responsibility. Both perceived responsibility endpoints were highly correlated with each other and with other stigma beliefs. These results provide insight on the underlying determinants of mpox stigma and demonstrate that anticipated mpox stigma is present in the Netherlands.

Can we screen less frequently for STI among PrEP users? Assessing the effect of biannual STI screening on timing of diagnosis and transmission risk in the AMPrEP Study.

BACKGROUND: In many countries, HIV pre-exposure prophylaxis (PrEP) users are screened quarterly for STIs. We assessed the consequences of less frequent STI testing. We also assessed determinants of asymptomatic STI and potential for onward transmission. METHODS: Using data from the AMPrEP study, we assessed the proportion of syphilis, and genital, anal, and pharyngeal chlamydia and gonorrhoea diagnoses which would have been delayed with biannual versus quarterly screening. We assessed the potential for onward transmission by examining reported condomless anal sex (CAS) in periods after to-be-omitted visits when screening biannually. We assessed determinants of incident asymptomatic STIs using Poisson regression and calculated individual risk scores on the basis of the coefficients from this model. RESULTS: We included 366 participants. Median follow-up was 47 months (IQR 43-50). 1,183STIs were diagnosed, of which 932(79%) asymptomatic. With biannual screening, 483 asymptomatic STIs (52%) diagnoses would have been delayed at 364 study visits. Of these visits, 129 (35%), 240 (66%) and 265 (73%) were followed by periods of CAS with steady, known casual or unknown casual partners, respectively. Older participants had a lower risk of asymptomatic STI (incidence rate ratio (IRR) 0.86/10-year increase, 95% CI 0.80 to 0.92), while CAS with known (IRR 1.36, 95% CI 1.10 to 1.68) and unknown (IRR 1.86, 95% CI 1.48 to 2.34) casual partners and chemsex (IRR 1.51, 95% CI 1.28 to 1.78) increased the risk. The individual risk scores had limited predictive value (sensitivity=0.70 (95% CI 0.66 to 0.74), specificity=0.50 (95% CI 0.48 to 0.51)). CONCLUSION: Reducing the STI screening frequency to biannually among PrEP users will likely result in delayed diagnoses, potentially driving onward transmission. Although determinants for asymptomatic STIs were identified, predictive power was low.

Perceived Monkeypox Concern and Risk among Men Who Have Sex with Men: Evidence and Perspectives from The Netherlands.

The current monkeypox epidemic is most prevalent among men who have sex with men (MSM). PrEP users and MSM with HIV (MSMHIV) are considered at highest risk of monkeypox infection in The Netherlands, and are being targeted for monkeypox vaccination. Together with the epidemiological evidence, perceived concern and risk are also relevant for decision making about health behaviour, e.g., vaccination uptake. It is thus timely to examine which subpopulations among MSM consider themselves to be most at risk and are most concerned about monkeypox. This study aimed to help determine if the current measures to curb the epidemic are successfully targeted or not in The Netherlands. We conducted an online survey among 394 MSM living in The Netherlands. We first calculated the prevalence and standardised prevalence ratio (SPR) of high perceived monkeypox concern/risk by PrEP-use and HIV status. We then conducted two multivariable logistic regression analyses to investigate perceived monkeypox concern/risk and their potential socio-demographic/behavioural/health/psycho-social determinants. Among the included MSM, 52% showed high perceived concern about and 30% showed high perceived risk of monkeypox infection. PrEP users (SPR = 0.83) showed a significantly lower chance of perceived concern; in addition, MSMHIV (SPR = 2.09) were found to have a significantly higher chance of perceiving high risk of monkeypox infection. In the multivariable logistic analyses, non-PrEP users (aOR = 2.55) were more likely to perceive higher concern, while MSM who were retired (aOR = 0.23) and who had had chemsex recently (aOR = 0.63) were less likely to perceive higher concern. MSMHIV (aOR = 4.29) and MSM who had an unknown/undisclosed HIV status (aOR = 6.07), who had attended private sex parties (aOR = 2.10), and who knew people who have/had monkeypox (aOR = 2.10) were more likely to perceive a higher risk for monkeypox infection. We found that high perceived risk (aOR = 2.97) and high perceived concern (aOR = 3.13) were correlated with each other. In sum, only one-third of MSM living in The Netherlands considered themselves at high risk of monkeypox infection, and only half of them reported high concern. We identified a potential discrepancy between "actual risk" and perceived risk of and concern about monkeypox among MSM in this early stage of the monkeypox epidemic in The Netherlands, especially among PrEP users and MSMHIV. More refined public health communication strategies may be needed to improve the understanding and knowledge of the "actual risk" of monkeypox infections among MSM sub-populations, to facilitate health behaviour uptake.

Monkeypox self-diagnosis abilities, determinants of vaccination and self-isolation intention after diagnosis among MSM, the Netherlands, July 2022.

Monkeypox is a zoonotic disease and leads to a smallpox-like disease in humans. The current epidemic in European countries requires informed responses. We investigated the ability to self-diagnose a potential infection, and determinants of vaccination and self-isolation intention after diagnosis among 394 MSM in the Netherlands. We found that about half were able to self-diagnose monkeypox, that 70% had a high intention to get vaccinated and 44% to self-isolate after monkeypox diagnosis. Determinants went beyond mere risk behaviour criteria.

PrEP Use in Times of COVID-19 in the Netherlands: Men Who Have Sex With Men (MSM) on PrEP Test Less for HIV and Renal Functioning During a COVID-19 Related Lockdown.

As a result of the COVID-19 pandemic, HIV care and prevention efforts have been disrupted. We investigated pre-exposure prophylaxis (PrEP) use and testing behaviors among MSM in the Netherlands, and the factors that influenced testing behaviors during the COVID-19 pandemic. A cohort of 766 MSM, established in 2017, was asked in August 2020 to report on their experiences during the COVID-19 pandemic via an online survey. Participants (n = 319) reported increased PrEP use and, among PrEP users (n = 211), significantly lower rates of having tested in the last 3 months for HIV and renal functioning compared to before the pandemic. Daily PrEP use and a higher number of sexual partners during the pandemic was significantly associated with continued HIV testing. Continued renal functioning testing was associated with older age. Correcting for pandemic-related disruptions in PrEP use and care will require sustained effort to understand and address missed opportunities.

RéSUMé: Como resultado de la pandemia de COVID-19, los cuidados y esfuerzos de prevención de VIH han sido interrumpidos. Investigamos el uso de la profilaxis preexposición (PrEP) y el comportamiento de diagnóstico de HSH en los Países Bajos y los factores de influencia durante la pandemia. Una cohorte de 766 HSH, establecida en 2017, reportó en agosto 2020 sus experiencias mediante una encuesta en línea. Los participantes (n = 319) reportaron un incremento en el uso de PrEP y, entre los usuarios de PrEP (n = 211), tasas menores de pruebas de VIH y funcionamiento renal comparado con tasas pre-pandemia. El uso diario de PrEP y un número mayor de parejas sexuales en pandemia fue asociado con la solicitud continua de pruebas de VIH. La solicitud continua de pruebas de funcionamiento renal fue asociada al incremento de edad. Un esfuerzo constante será necesario para corregir las interrupciones del uso y cuidado asociado a la PrEP.

Barriers and Motives for Complying With "Sexual Distancing" Among Men Who Have Sex With Men During the First COVID-19 Pandemic Lockdown in Amsterdam: A Qualitative Study.

BACKGROUND: Between March 15 and May 31, 2020, the Dutch government imposed lockdown and health measures to curb the coronavirus disease 2019 (COVID-19) pandemic. As part of social distancing, sexual distancing was one of these measures. Sexual distancing implied refraining from sex with partners outside of one's household. We aimed to elucidate barriers and motives for complying with sexual distancing and related factors that could have led to (non)compliance among men who have sex with men. METHODS: In this exploratory qualitative study, we interviewed men who have sex with men who visited the center for sexual health in Amsterdam during the first COVID-19 lockdown using a semistructured interview guide from March to May 2020. We interviewed both men who complied and did not comply with sexual distancing. The interviews were transcribed verbatim and analyzed using an open-coding process in MAXQDA. RESULTS: We included 18 noncompliers and 4 compliers to COVID-19 sexual distancing. Barriers to compliance were the following: lack of information on, or understanding of, the need for sexual distancing; being single; having had an active sex life before COVID-19; a high perceived importance of the social aspect of sex; a strong urge for sex; using sex to cope with the negative impact of the pandemic; being under the influence of alcohol or drugs; and not perceiving COVID-19 as a serious health threat. Motives for compliance were the following: perceiving COVID-19 as a serious health threat, direct confrontation with critically ill COVID-19 patients, protecting someone dear from COVID-19, and being convinced of the importance of social and/or sexual distancing measures. CONCLUSIONS: Information on sexual distancing needs to be made more explicit, accessible, understandable, inclusive, customized to individual barriers, and relatable to the key populations. This may improve the effectiveness of measures and health recommendations in both the current COVID-19 pandemic and future respiratory outbreaks.

Factors Associated With the Intention to Use HIV Preexposure Prophylaxis for Young and Older Men Who Have Sex With Men.

BACKGROUND: The uptake of preexposure prophylaxis (PrEP) against HIV is low among young men who have sex with men (MSM) in the Netherlands. Studying the intention to use PrEP among non-PrEP using young and older MSM can guide health authorities in developing new prevention campaigns to optimize PrEP uptake. METHODS: We investigated the sociodemographic, behavioral, and psychosocial factors associated with a high PrEP use intention in the coming 6 months among 93 young MSM (aged ≤25 years), participating in an online survey, and 290 older MSM (aged ≥26 years), participating in an open, prospective cohort in 2019 to 2020. RESULTS: Perceiving PrEP as an important prevention tool was associated with a high PrEP use intention among young and older MSM. Among young MSM, a high level of PrEP knowledge and believing that PrEP users take good care of themselves and others were associated with a high PrEP use intention. Among older MSM, 2 or more anal sex partners, chemsex, high HIV risk perception, and believing PrEP increases sexual pleasure were associated with a high PrEP use intention. Believing PrEP leads to adverse effects was associated with a low intention to use PrEP among older MSM. CONCLUSIONS: To conclude, we showed that both behavioral and psychosocial factors were associated with a high PrEP use intention among young and older MSM. In addition to focusing on sexual behavior and HIV risk, future prevention campaigns and counseling on PrEP could incorporate education, endorsing positive beliefs, and disarming negative beliefs to improve the uptake of PrEP in young and older MSM.

Transient Changes in Preexposure Prophylaxis Use and Daily Sexual Behavior After the Implementation of COVID-19 Restrictions Among Men Who Have Sex With Men.

BACKGROUND: We assessed how the Dutch restrictions imposed on March 15, 2020, affected sexual behavior, preexposure prophylaxis (PrEP), and condom use among PrEP users in Amsterdam. METHODS: We used data on (1) PrEP use, (2) anal sex acts, and (3) condom use, per partner type [steady partners (SPs), known casual partners (KCPs), and unknown casual partners (UCPs)], collected daily through a mobile application used between December 1, 2019, and June 30, 2020. We compared the period before versus after March 15, 2020, regarding average proportion of days per week at which each end point was reported and average proportion of anal sex acts covered by PrEP and/or condoms. RESULTS: We included data from 136 men who have sex with men. After March 15, 2020, the proportion of days with anal sex increased with SPs [odds ratio (OR) = 1.26; 95% confidence interval (CI) = 1.10 to 1.44) and decreased with KCPs (OR = 0.73; 95% CI = 0.64 to 0.82) and UCPs (OR = 0.54; 95% CI = 0.48 to 0.61). Shifts in partner types were most profound immediately after March 15, 2020, whereas returning to prerestriction levels mid-May 2020. The proportion of days with PrEP use decreased from 74% before to 58% after March 15, 2020 (P < 0.001). After March 15, 2020, PrEP use during sex decreased with UCPs (ß = -0.36; 95% CI = -0.72 to 0.00) but not with SPs and KCPs. Condom use during sex decreased with KCPs (ß = -0.36; 95% CI = -0.67 to 0.04) and UCPs (ß = -0.24; 95% CI = -0.46 to 0.03) but not with SPs. CONCLUSIONS: MSM decreased sex with casual partners and increased sex with SP, but changes were transient. Decreases in sex acts with casual partners paralleled decreases in PrEP use. However, condom use during sex with casual partners decreased, indicating the importance of continued sexual health services, including sexually transmitted infections screening and PrEP care, during COVID-19 restrictions.

Factors Associated with Never Testing for HIV: Directions for Targeted Testing Interventions Among Men Who Have Sex with Men.

Men who have sex with men (MSM) and who are unaware of their HIV infection contribute to onward HIV transmission and are more likely to progress to severe illness. We therefore assessed determinants of never testing for HIV among MSM living in the Netherlands. Between April and July 2019, 950 HIV-negative and 122 never-tested MSM completed a cross-sectional survey on sociodemographics, HIV testing behavior, and sexual risk taking, which was distributed through gay networking sites/apps. In never-tested MSM, median age was 37 (interquartile range = 22-51) years and 37 (30%) reported recent sexual risk behavior. Never testing was associated with younger age [adjusted odds ratio (aOR) per year increase = 0.98, 95% confidence interval (CI) = 0.97-1.00, p = 0.015], having sex with men and women (aOR = 2.85, 95% CI = 1.57-5.62, p = 0.001), and not knowing others living with HIV (aOR = 3.85, 95% CI = 2.35-6.32, p < 0.001) in multi-variable logistic regression analysis. A significant interaction effect between education level and residential area was observed (p = 0.001). Among higher-educated MSM, those living outside a large urban area had higher odds of never testing compared to those living in an urban area (aOR = 6.26, 95% CI = 2.42-16.24, p < 0.001). Lower-educated MSM had higher odds of never testing irrespective of residential area (large urban area: aOR = 12.06, 95% CI = 4.00-36.38; outside large urban area: aOR 9.29, 95% CI = 3.64-23.76; p < 0.001 for both). Among MSM recently exposed to sexual risk, never testing was associated with having sex with men and women (aOR = 2.80, 95% CI = 1.09-7.18, p = 0.032) and not knowing others with HIV (aOR = 4.91, 95% CI = 1.97-12.24, p = 0.001). To conclude, testing interventions for those never tested should be tailored to residential area and education level, and inclusive of bisexuality.

The Burden of Living With HIV is Mostly Overestimated by HIV-Negative and Never-Tested Men Who Have Sex With Men.

To assess whether HIV-negative men who have sex with men (MSM) have realistic views of the current implications of living with HIV, we compared data of 950 tested HIV-negative and 122 never-tested MSM on anticipated consequences of an HIV-infection to the actual experiences of 438 MSM living with HIV. Data were collected with a self-reported, web-based survey conducted between May-June 2019 in the Netherlands. Results indicated that, compared to HIV-positive MSM, HIV-negative MSM significantly overestimated 95% (37/39) of items assessing HIV-related burden. Never-tested participants overestimated 85% (33/39) of items. Overestimation in never-tested MSM was modified with increasing age and having HIV-positive friends/relatives. The high level of overestimation suggests the ongoing need to correct for misperceptions, as this could help reduce stigma towards those living with HIV and diminish fear of an HIV-diagnosis. The latter might be important to improve testing uptake in older never-tested MSM with outdated views on HIV.

The social meanings of PrEP use - A mixed-method study of PrEP use disclosure in Antwerp and Amsterdam.

Pre-Exposure Prophylaxis (PrEP) is a novel HIV prevention tool. PrEP stigma is a frequently reported barrier, while social disclosure of PrEP use may be an important facilitator. We explored how PrEP users managed PrEP use disclosure using a symbolic interactionist approach. We interviewed 32 participants from two PrEP demonstration projects (Be-PrEP-ared, Antwerp; AMPrEP, Amsterdam). We validated qualitative findings through Be-PrEP-ared questionnaire data. A minority of participants had received negative reactions on PrEP. The way PrEP use was disclosed was highly dependent on the social situation. In a sexual context among MSM, PrEP use was associated with condomless sex. Friends endorsed PrEP use as a healthy choice, but also related it to carelessness and promiscuity. It was seldom disclosed to colleagues and family, which is mostly related to social norms dictating when it is acceptable to talk about sex. The study findings reveal that PrEP stigma experiences were not frequent in this population, and that PrEP users actively manage disclosure of their PrEP user status. Frequent disclosure and increased use may have helped PrEP becoming normalised in these MSM communities. To increase uptake, peer communication, community activism and framing PrEP as health promotion rather than a risk-reduction intervention may be crucial.

The Impact of Pre-exposure Prophylaxis on Sexual Well-Being Among Men Who Have Sex with Men.

Pre-exposure prophylaxis (PrEP) is a promising strategy to reduce HIV incidence among men who have sex with men (MSM). How and when PrEP is used could in part be influenced by its impact on the sexual well-being of its users. Yet, the impact of PrEP on sexual well-being has received little attention in current literature and is not well-understood. We conducted 43 in-depth interviews (June 2017-June 2018) with HIV-negative MSM who started PrEP within the Amsterdam PrEP study. We used purposive sampling to select participants who (1) reported changes on well-being indicators; (2) switched between PrEP-dosing regimens; (3) neither changed regimens nor changed on well-being indicators. Transcribed interviews were qualitatively analyzed by means of an open-coding process. Results showed that PrEP minimized HIV-related fear, increased self-esteem, and reduced stigma and shame about having condomless anal sex. The psychological relief provided by PrEP also enabled relaxation which reduced pain during anal sex. PrEP use increased the diversity of partner choices and improved the perceived quality of sexual relationships and the ability to develop relationships. Along with this positive impact, almost half of interviewees reported concurrent negative experiences. In some cases, PrEP triggered more extreme sexual behaviors and/or problematic increases in preoccupation with sex and drug use. These were perceived as having a negative impact on sexual relationships, sexual well-being, PrEP adherence, and general health. In conclusion, our findings suggest that PrEP contributes to improvements in sexual well-being that go beyond protection from HIV. Counseling strategies should be devised to help PrEP users mitigate possible co-existing negative consequences of PrEP use.

Sexual Behavior and Its Determinants During COVID-19 Restrictions Among Men Who Have Sex With Men in Amsterdam.

OBJECTIVE: To investigate the impact of Dutch COVID-19 restrictions on sexual behavior and HIV/sexually transmitted infection (STI) acquisition among men who have sex with men (MSM) participating in the Amsterdam Cohort Studies (ACS) on HIV in Amsterdam. METHODS: ACS participants complete a questionnaire on sexual behavior and are tested for HIV/STI biannually. They may also be tested at the STI clinic in-between study visits. On May 29, 2020, ACS participants were invited to complete an online questionnaire on health, COVID-19 risk perceptions, and sexual behavior. Determinants of reporting casual sex partners (CSP) during COVID-19 restrictions were examined using logistic regression. RESULTS: Of 683 MSM, 353 (52%; median age, 47 years; interquartile range, 38-53 years) completed the questionnaire. Since COVID-19, 73% reported a reduction in the number of CSP. CSP during COVID-19 restrictions were reported by 133 MSM (38%) and, in multivariable analysis, was associated with not having a college/university degree, being single, lower perceived importance of avoiding COVID-19, number of CSP before COVID-19, and current preexposure prophylaxis use (P < 0.05 for all). During COVID-19 restrictions, no HIV infections were diagnosed, and the STI positivity rate was 8%. CONCLUSION: Since COVID-19, the number of CSP decreased among MSM, and there may have been a temporary reduction in HIV/STI transmission. Some MSM were not fully compliant to social distancing regulations and reported CSP, which was related to prior sexual behavior and low perceived importance of avoiding COVID-19. For these men, it is important to maintain accessible HIV/STI-related testing and care during times of lockdown.

Decision-making regarding condom use among daily and event-driven users of preexposure prophylaxis in the Netherlands.

OBJECTIVE: To explore the frequency of and reasons for using condoms among men who have sex with men (MSM) on preexposure prophylaxis (PrEP). DESIGN: We analyzed quantitative app-based diary data on daily sexual practices (August 2015-February 2019) and qualitative in-depth interviews among MSM using daily PrEP and event-driven PrEP (edPrEP) in the Amsterdam PrEP demonstration project. METHODS: Participants could report daily about sex acts, PrEP use and condom use per partner type (steady and casual partners). We examined four strategies of PrEP and condom use: PrEP only, PrEP and condoms, condoms only, and neither strategy. We compared the proportions of sex acts per strategy between PrEP regimens. In 43 in-depth interviews, we explored motives for implementing each strategy. RESULTS: Three hundred and fifty-two participants reported 48 949 anal sex acts. PrEP only was the most common strategy employed with any partner type (81%, n = 39 650/48 949) and was motivated by anticipating more pleasurable sex, sexually transmitted infection's perceived curability, and habituation to condomless sex. Combining PrEP and condoms was more often chosen for sex acts with casual partners (18%, n = 6829/37 317) than with steady partners (5%, n = 614/11 632) and was linked to, for example, higher perceived vulnerability for sexually transmitted infections or HIV and avoidance of PrEP disclosure. Condoms only was uncommon but occurred particularly among edPrEP users (4%, n = 379/8695). Applying neither strategy was common among edPrEP users with steady partners (25%, n = 538/2122) and was motivated by low perceived HIV risk. CONCLUSION: Condoms remain a viable option for PrEP users in certain settings. Condoms were applied in higher risk settings, to avoid PrEP disclosure, or as substitute for PrEP, especially among edPrEP users.

Burden of living with HIV among men who have sex with men: a mixed-methods study.

BACKGROUND: With biomedical developments in treatment and prevention of HIV, the implications of living with HIV are considerably more manageable. Within this context, we aimed to describe and quantify the present-day burden of living with HIV among men who have sex with men (MSM) in the Netherlands. METHODS: In this mixed-methods study, we did in-depth interviews on HIV-related burden with MSM diagnosed with HIV between 2014 and 2018. Interviewees were recruited at three HIV treatment centres and the Public Health Service of Amsterdam in the Netherlands. Using the transcripts from all interviewees, the qualitative analysis was done by two independent researchers applying an open-coding process. Results were used to generate a questionnaire measuring HIV-related burden, which was distributed via gay dating apps or sites and social media. MSM diagnosed with HIV before 2019 who completed the questionnaire were included in the quantitative analyses. Descriptive analyses were used to report burden prevalence and to explore differences in burden among MSM diagnosed at different antiretroviral therapy periods. Sociodemographic determinants of burden were explored using multinomial logistic regression. FINDINGS: Between May, 2018, and March, 2019, 18 of 25 MSM who consented for further contact were interviewed, after which thematic saturation was reached. The interviewees revealed that aspects related to medicalisation and emotional consequences were burdensome temporarily after diagnosis, whereas aspects related to HIV status disclosure, stigma, and the sexual and social life were mentioned to be burdensome more persistently. Between April and July, 2019, 613 MSM with HIV started the quantitative survey, of whom 438 (71%) completed the questionnaire and were included in the analyses. These 438 MSM were diagnosed with HIV between 1984 and 2018. The median time since HIV diagnosis was 8 years (IQR 4-13). In total, 135 (31%) of 438 online respondents reported that living with HIV was generally experienced as burdensome and 361 (82%) would be relieved if HIV could be cured. Compared with a low level of burden, a moderate level of burden was associated with having another chronic condition (p=0·0030), and a high level of burden was associated with a more recent diagnosis (p=0·0060) and not knowing other individuals with HIV (p=0·0020). Disclosure dilemmas were reported to be the most burdensome, resulting in difficulties initiating sex (122 [32%] of 378 respondents) and establishing relationships (85 [41%] of 207 respondents). The most prevalent emotional consequences were shame (112 [26%] of 438 respondents) and stress (80 [18%] of 438 respondents). Disclosure and taking antiretroviral therapy in the presence of others were experienced as more burdensome among those diagnosed after 2005 than among those diagnosed in or before 2005. INTERPRETATION: Our findings highlight that despite medical advancements, further stigma reduction programmes and adapted psychosocial support for specific profiles of MSM living with HIV are needed. FUNDING: HIV Transmission Elimination Amsterdam Initiative.