Sex, PrEP, and Stigma: Experiences with HIV Pre-exposure Prophylaxis Among New York City MSM Participating in the HPTN 067/ADAPT Study

The HPTN 067/Alternative Dosing to Augment Pre-Exposure Prophylaxis Pill Taking (ADAPT) study evaluated daily and non-daily dosing schedules for oral pre-exposure prophylaxis (PrEP) to prevent HIV. A qualitative sub-study including focus groups and in-depth interviews was conducted among men who have sex with men participating in New York City to understand their experience with PrEP and study dosing schedules. The 37 sub-study participants were 68% black, 11% white, and 8% Asian; 27% were of Hispanic/Latino ethnicity. Mean age was 34 years. Themes resulting from qualitative analysis include: PrEP is a significant advance for HIV prevention; non-daily dosing of PrEP is congruent with HIV risk; and pervasive stigma connected to HIV and risk behavior is a barrier to PrEP adherence, especially for non-daily dosing schedules. The findings underscore how PrEP intersects with other HIV prevention practices and highlight the need to understand and address multidimensional stigma related to PrEP use.


Introduction
Oral emtricitabine/tenofovir disoproxil fumarate (FTC/ TDF) as pre-exposure prophylaxis (PrEP) to prevent HIV acquisition was approved by the FDA in 2012 [1] and has the potential to alter the trajectory of the US epidemic if used by those at substantial risk for HIV, including men who have sex with men (MSM) [2,3]. However, only about 4% of MSM surveyed in the 2014 National HIV Behavioral Surveillance had taken PrEP in the last 12 months, a much lower proportion than the 25% estimated to meet behavioral indications for PrEP [4]. Some potential barriers to 1 3 use of the currently approved daily PrEP regimen, such as the need for long-term adherence to a daily medication [5,6], users' concerns about medication toxicity [7][8][9][10], and cost [9][10][11], may be mitigated by nondaily PrEP regimens [12][13][14][15][16]. Contextual factors, notably users' perceptions and experiences of social attitudes about PrEP [17][18][19][20], can also influence its use. While perceived social norms concerning PrEP use and how PrEP fits into sexual practices have been explored hypothetically in qualitative research among people who would be potentially eligible to take PrEP [21][22][23][24], to date there is limited qualitative research exploring experiences using open-label PrEP [18,[25][26][27], particularly for non-daily dosing [19].
The current analysis presents findings from a qualitative sub-study conducted among New York City participants in HPTN 067/Alternative Dosing to Augment Pre-Exposure Prophylaxis Pill Taking (ADAPT), a Phase II, randomized, open-label clinical trial comparing the feasibility and acceptability of alternative PrEP dosing schedules of oral FTC/ TDF. The qualitative sub-study focused on understanding contextual factors influencing participants' use of PrEP, how participants fit PrEP into their established HIV prevention practices, and their preferences for dosing schedules.

Main Study Overview
Study methods and main results of HPTN 067/ADAPT have been described elsewhere [28][29][30]. In brief, the study assessed coverage of sexual intercourse events (defined as taking a pre-sex dose within 4 days prior to sex and taking a post-sex dose within 24 h following sex); the number of PrEP tablets required for coverage; and side effects (ClinicalTrials.gov NCT01327651). The study enrolled HIV-uninfected women in Cape Town, South Africa and HIV-uninfected MSM and transgender women (TGW) at sites in Harlem, New York City and Bangkok, Thailand. Recruitment methods varied by site. Harlem participants were recruited through a mix of community recruitment strategies, referrals from providers, word of mouth, and on-line advertising. Participants were randomly allocated 1:1:1 to one of three unblinded, open-label PrEP dosing schedules for 24 weeks of self-administered dosing: the current FDA-approved daily regimen (a single FTC/TDF tablet once a day); twice-weekly doses of a single FTC/TDF tablet with an additional tablet within 2 h after sexual intercourse (time-driven); or a single FTC/TDF tablet taken up to 48 h before sex and an additional tablet taken within 2 h after intercourse (event-driven). All participants received counseling on adherence to their assigned dosing schedule [31] and behavioral risk reduction, condoms and lubricant.
Separate qualitative sub-studies including focus groups (FG) and individual in-depth interviews (IDI) were conducted at each study site to explore the social and cultural dimensions that could affect PrEP use.

Recruitment
Sub-study participants were recruited from the Harlem study sample of 179 participants. Potential participants were invited to participate in either FG or IDI after they had completed the 24 weeks of self-administered PrEP use and within 3 months of study completion. Separate FG comprised of participants from each arm were scheduled to include participants who enrolled at early and late intervals during the main study follow-up period. Similarly, IDI with participants from each arm were scheduled at early and late intervals during the main study follow-up period. Convenience sampling was used to recruit FG participants; purposeful sampling [32] was used for IDI to capture the range of experiences with self-administered PrEP, including difficulties adhering to the assigned dosing schedule or discontinuation of PrEP.

Data Collection
Following written informed consent, FG and IDI were conducted in English by an experienced qualitative researcher who was not involved in main study procedures, so as to limit social desirability and reporting biases. Semi-structured interview guides (Tables 1 and 2) developed by the main study investigators included open-ended, exploratory questions and optional follow-up probing questions that allowed participants to introduce topics relevant to their experience. Domains of inquiry included usual HIV prevention practices before study participation; changes in sexual practices while in the study; acceptability and perceived feasibility of assigned dosing schedule; hypothetical preferences among the three schedules; and facilitators and barriers to adherence. Demographic information was collected at the main study enrollment visit via interviewer-administered questionnaire and sexual risk behavior via computer-assisted self-interview at the main study randomization visit; data were abstracted for sub-study participants.

Qualitative Data Analysis
Recorded FG and IDI were professionally transcribed, de-identified and entered into Dedoose, a web application for qualitative data analysis [33]. Three co-authors (JF, YH-M, ASL) reviewed and coded a subset of transcripts using a preliminary set of deductive codes derived from the Probe for preventive misconception-that use of the study medication provided greater benefits than reasonably expected.

Social motivation/study connections [Just a couple of questions left.]
17. Did anyone close to you know about your participation in this trial?
Probe for partial disclosure of study procedures, e.g., did participants say that they were in a prep study but not that they were taking medication, or that they were on a specific dosing schedule.
18. What kinds of things influenced your decision to tell people or not to tell people that you were in this study and/or that you were taking the study medication?
19. What would you say about any support you got from people important to you, the study team members you worked with during your clinic visits, or other participants you met during visits or as a part of your involvement in the study? Did you get any support from others? What would be an example of that?
Recommendations 20. Last question-Are there any observations or recommendations for the research team that you would like to offer that have not been discussed? guides, with additional codes identified and applied through grounded theory techniques of open coding and comparative analysis [34]. The results were scrutinized to eliminate redundant or imprecise codes, clarify code definitions, and construct a coding schema used to code the entire set of transcripts [35]. The complete set of coded excerpts was reviewed by the larger team for inconsistencies and discrepancies, which were resolved through an iterative process of discussion and re-coding [36]. A chart generated by Dedoose showing the presence or absence of codes in each transcript was scrutinized for indications of systematic differences in coding of FG and IDI. No systematic differences were observed (data not shown). Thematic analysis was then conducted on a data set of coded excerpts from both FG and IDI to identify themes [37] that characterized perceptions, motivations, and experiences related to PrEP use.

Ethical Review and Participant Compensation
The main HPTN 067/ADAPT study and the sub-study were reviewed and approved by the Columbia University Medical Center Institutional Review Board. All participants provided written informed consent to participate in the main and substudies. FG and IDI participants were compensated 50 dollars and roundtrip public transportation fare.

Findings
As shown in

PrEP is a Significant Advance for HIV Prevention
Reflecting on how they protected themselves from HIV before using PrEP, participants described a combination of tactics that for most included at least some condom use, but also relied on their own assessment of the potential for HIV exposure that a given sexual partner represented and their ability to modify their own behavior accordingly. Some described this assessment as knowing a partner's status, others as a nuanced evaluation of the risk represented by a potential partner. "I'm not a condom user so what I did was I just try to keep my same partners…. And I know my partners' status. So that was my safe sex. I knew their status." FG Time-Driven Arm "For me, if I was entertaining the thought of having sex with him, now comes the thing of getting to know your character and knowing your history to see if you're promiscuous or you're the cheating type, or the lying type." FG Event-Driven Arm Several participants reflected that their habitual approach to prevention before using PrEP was fallible, resting as it did on their ability to discern risk in their partners or resist the temptation to engage partners who might expose them to HIV.
"Everything that look good to you ain't good for you. Everything that glitters ain't gold." IDI Daily Arm "Sometimes I am not able to say no when I need to say no when I know it is the best thing for me to say no, sometimes." IDI Time-Driven Arm In comparison to their prior strategies, participants viewed PrEP as a groundbreaking advancement in HIV prevention and expressed deep appreciation for its potential to protect them from HIV. Words and phrases used to describe what PrEP meant to the participants ranged from scientific to popular culture references and even included a description of HIV as a childhood adversary. The descriptions served to emphasize that PrEP was a true departure from previous strategies for HIV prevention.
"The biggest discovery in the last century was antibiotics; man it's saved so many lives. This is just as big as that to me." FG Daily Arm When asked how taking PrEP influenced their HIV prevention practices, participants frequently described becoming more aware of the need for prevention and adopting other protective behaviors during their time in the study.
"I think it changed my thought process a little bit. Like I thought about it a little more than I normally would have, like, 'Am I really going to trust this pill to do this? Or should I just put this condom on, as well?'… Actually, I put more thought into it." FG Daily Arm "It made me reduce my partners by a huge amount…. Just taking the pills continually reminded me to protect myself from HIV. And one of the risks of having HIV is just having an excessive amount of sexual partners, and then having risky encounters." FG Event-Driven Arm Many participants explicitly rejected the notion that PrEP justified abandoning other prevention methods, and several emphasized the need to protect themselves against infections other than HIV.
"People just came up and asked me, like, 'Hey, are you on the pill? Oh, good, so we can just like…' -No, that's not how it works for me." FG Daily Arm "This pill can help you but in conjunction with safer practices…. Because if you just take this one thing and not everything else it's going to fall apart." FG Event-Driven Arm "It's like I was bulletproof against the big package but the little packages could still slide up in there." FG Time-Driven Arm In contrast, a minority of participants acknowledged engaging in situations that they might have avoided without PrEP. Some explicitly connected their amplified risk behavior to the use of drugs or alcohol.
"I kind of turned it up a little bit, because I was on the medication, but again, I'd go back to the fact that I was actively using drugs, so I wasn't in my right frame of mind, and of course, being on the medication made me think, "Hey, man, I'm protected." FG Event-Driven Arm One participant recalled reflecting on and correcting an initial willingness to forgo usual protective behaviors while taking PrEP.
"It made me practice safe sex less, a little bit less than I would normally…. I felt kind of impervious to it, to catching HIV, because of the pill. I really had to check myself about that, I really did." FG Time-Driven Arm

Non-daily Dosing of PrEP is Congruent with the Episodic Nature of HIV Risk
Participants across study arms generally expressed preferences for non-daily dosing schedules, both because nondaily dosing corresponded to patterns of sexual activity and because they believed side effects of the PrEP medication would be less with less frequent dosing. "I'd rather do it when I have sex…. Like when I put on a condom, or the person I'm having sex with is putting on a condom, that's something I have to do in that moment, and not every day." FG Event-Driven Arm "I know sometimes I'm just not going to have sex for a week or so, because I just really don't feel like it. And taking the pill when you know you're not going to have sex kind of sucks because you know that it can cause kidney damage and bone density troubles." IDI Daily Arm One participant who based his preference for dosing schedule on the demonstrated efficacy of daily PrEP acknowledged that a proven non-daily schedule would be preferable.
"I think if it will be like hundred percent proven, then the less the better, but until then, I will take it as much as they say." FG Time-Driven Arm Several participants reasoned that dosing frequency should be calibrated to the individual's level of sexual activity.
"If people are having unprotected sex, then I think that they should take it every day. People that are… not really sexually active, I really think that twice a week would be a better suggestion for people like that. But people that are in a relationship and constantly having sex and intercourse and stuff like that, I think that they should take it every day." IDI Time-Driven Arm Some participants described acting on this rationale and adjusting their dose according to what they perceived as their level of risk.
"I did change my regimen a little bit when I found myself just being with a single partner for a bit over a month, so I wasn't taking it nearly as much, because I didn't feel I needed the prevention at the time." FG Daily Arm Despite the expressed preference for non-daily dosing, participants in non-daily dosing arms agreed that intermittent dosing presented adherence challenges. Remembering regular non-daily doses was difficult on the time-driven schedule; in both time-driven and event-driven arms forecasting sex in order to plan for dosing around sex was a challenge. "I'm not going to lie, the whole remembering to take the pill thing, being as how I was set to take it twice a week, not like it was every day, it was a little hard to remember." FG Time-Driven Arm "You never really know, you might think that you're not going to have sex and then you have sex. I actually didn't have [any pills] on me because I wasn't thinking about sex and then it happened, and I was like so far away from home that I wouldn't have been able to achieve it right after sex, like I was supposed to." FG Time-Driven Arm Several participants observed that sex-dependent doses were challenging if sex was accompanied by drug or alcohol use.
"Only if I was like getting high I would probably forget to take my "before" pill. Then I would take my "after" pill, definitely." IDI Event-Driven Arm

Pervasive HIV-Related Stigma Directed at PrEP Use is a Barrier to Adherence
In contrast to the positive effects that PrEP had on sexual experiences and the generally heightened awareness of prevention that participants gained while in the study, experiencing or anticipating stigmatizing attitudes surrounding PrEP use was reported across study arms.
"Some people saw the pills I was taking and they thought I was sick. Oh he got HIV, because he taking Truvada." IDI Daily Arm.
A few participants described contesting stigmatizing attitudes about PrEP in conversations with family and friends.
"[My mom] was like, "What does this mean? Are you trying to tell me that you have HIV?" And I said, "No, I'll send an article -a news article -about what this is all about." FG Daily Arm However, the association with HIV infection was generally difficult to counter with facts about PrEP, as the following exchange among FG participants suggests.
"You say, 'Yo, I'm on a PrEP regimen, dah-dah-dah.' You can explain it. You can give them documents in front of them like this -" "It's not going to work." "-It's not going to work. You know why? Because the only thing in their mind is AIDS." "Stigma." FG Event-Driven Arm Another type of stigma attached to PrEP related to the presumed promiscuity of PrEP users.
"One of my partners was like, 'Whoa, whoa. What does this mean? What are you doing?' In other words, indicating that just by taking the pill this means that I'm willy-nilly having unprotected sex." FG Daily Arm "When I was talking to guys online, there were a few of them that were just like -doesn't matter if you're on PrEP, I'd rather not have sex with you because I don't know if PrEP works or you're probably just like a big whore." FG Time-Driven Arm Some participants themselves acknowledged holding stigmatizing attitudes about PrEP use.
"For me, if someone just said so-and-so's using PrEP and I knew what PrEP was at that time, I would question what is their HIV status….
[Or] they could just be very -really promiscuous." FG Time-Driven Arm One participant vividly imagined gossip spreading through his social circle and extending to the workplace, ultimately impacting his job.

3
"You could tell somebody [that you are taking PrEP] and no more than 10 minutes later… the whole neighborhood is saying, 'Bob said he is taking them sex pills!' His friend then told Tom and Tom done told Mary. Now look, when you get to work Monday they are telling you need a physical… and you saying, 'What, boss? I just had a physical.' The rumors started in Manhattan and you work in the Bronx. How do they get there?" FG Event-Driven Arm To avoid negative reactions, participants were wary of disclosing their PrEP use to others.
"I confided in myself. I didn't tell nobody, because I know people judge you; taking pills they think you're sick, something wrong with you, so I just kept it to myself" FG Event-Driven Arm In addition to stigmatizing reactions from family and friends about PrEP use, participants also described anticipating or experiencing stigma when taking PrEP tablets after a sexual encounter. Some participants assigned to non-daily dosing arms developed strategies to hide postsex doses from their partner. One participant described hiding PrEP tablets in a mint box that he kept nearby during sexual encounters. "I didn't want to have them with me where the other person would find it because it was uncomfortable. Somebody did find them and I had to do some explaining, or it would have gotten into a big ugly fiasco." FG Event-Driven Arm "When I was having sex, I would take the pills and my partners would be like, 'Why are you taking those pills?'… Sometimes it would never get to the intercourse part. It would just stop the night. They would be mad and leave." IDI Time-Driven Arm Similarly, some participants who were assigned to the daily dosing schedule saw the appeal of taking PrEP in conjunction with sex but anticipated that it would be difficult to disclose pill-taking to sexual partners.
"I really like the before sex [schedule]. I mean, but then again, it would have been awkward if the guy sees me taking my pill and he's like -oh, what are you taking? And then I have to go and explain the pill and I don't want to do that." FG Daily Arm

Discussion
The mainly black MSM participants in the Harlem HPTN067/ADAPT qualitative sub-study saw PrEP as a valuable addition to their existing HIV prevention strategies, which were based in part on their ability to discern risk in their partners and adjust their behavior accordingly. Participants commonly described a heightened awareness of prevention while taking PrEP and adopting additional protective behaviors, perhaps in part due to the regular counseling and HIV testing they received as part of study participation. At the same time, a minority of participants reported increased willingness to engage in sexual encounters that might put them at risk for HIV, similar to the reductions in condom use among some PrEP patients that has been noted in clinical practice settings [38]. The experience of recognizing and correcting increased risk behavior while on PrEP has been identified in other qualitative studies of PrEP use [39], highlighting that individual prevention practices are responsive to both perceptions of situation-specific risk and the internalization of support for practicing prevention behaviors [40,41].
In keeping with a situation-specific perspective on risk for HIV, Harlem sub-study participants frequently conceptualized adherence to PrEP as situational. They related the need to take PrEP to periods of condomless sex, number of current sexual partners, and other factors contributing to HIV risk such as substance use during sexual encounters. This perspective on taking PrEP is consistent with the emergent paradigm of 'prevention-effective' adherence to PrEP, in which the success of PrEP rests on accurately recognizing the potential for exposure to HIV and utilizing other prevention tools appropriately, in addition to achieving adequate adherence to PrEP medication [42]. The findings presented here suggest that dynamic approaches to PrEP aligned with levels of exposure to HIV, including non-daily dosing schedules, would be acceptable to potential users. However, Harlem participants noted challenges to such approaches, including establishing routines for intermittent pill taking, forecasting sexual encounters, having medication available proximate to sex, and managing sexual partners' attitudes about PrEP. Strategies for helping PrEP users recognize patterns of situational risk and adopt appropriate prevention practices such as limiting the number of sexual partners and ensuring that condoms are available may be a valuable addition to counseling on adherence to PrEP [42]; further implementation research on the optimal components of support for PrEP is needed. The most vividly-described challenges that participants reported experiencing with sex-dependent dosing involved hiding PrEP use from sexual partners and dealing with partners' negative response if participants disclosed PrEP use. Paradoxically, even as participants became more aware of their need for prevention and strengthened their preventionrelated practices, they reported experiencing or anticipating stigmatizing attitudes from family, friends and sexual partners who interpreted the use of a recognized anti-HIV medication as an indication of being HIV-infected or associated PrEP use with promiscuity and exceptionally high risk for HIV.
Stigma related to both HIV and sexual promiscuity is a recognized barrier to PrEP uptake and use [17,23,43,44]. Research into attitudes on PrEP use among the general population in the US documents that stigma regarding PrEP is influenced by existing frameworks of stigma, so that PrEP use among stigmatized groups, notably black MSM, is viewed more negatively than PrEP use among the general population [45]. Our study adds a layer of complexity to our understanding of how stigma impacts on PrEP use, highlighting the challenge stigma may present for sexdependent PrEP dosing. This finding is relevant to efforts to extend the findings of the ANRS IPERGAY study, in which a dosing strategy of two tablets of FTC/TDF two to 24 h before sexual intercourse and a third and fourth tablet at 24-and 48-h intervals after the first dose demonstrated 86% relative reduction in risk of HIV infection among MSM and TGW in a placebo controlled trial [16] and 97% relative risk reduction in the follow-on open-label. Further exploration of how stigma related to promiscuity and HIV treatment intersects with HIV prevention strategies and how it can be mitigated at the social and interpersonal level is critical [43,44,46,47].

Limitations
These findings are subject to several limitations. The substudy enrolled a convenience and purposive sample of mostly black MSM in New York City that is not generalizable to other populations in other areas. Although staff endeavored to reach study participants who had missed study visits to invite them to participate in the qualitative study, sub-study participants were significantly more likely to be retained in study follow-up visits than were other main study participants. Participants who were able to be reached and willing to participate in qualitative FG and IDI may be different than those who could not be reached or were unwilling to participate in the qualitative research. The group setting may have inhibited FG participants from voicing some opinions or sharing some experiences. Finally, the sub-study recruitment procedures were not designed to ensure participation by TGW participants in the main study and the sub-study sample included no TGW. TGW are disproportionately impacted by HIV and evidence suggests that they may experience elevated challenges adhering to PrEP [48]; more research into the experience of this highly vulnerable group is crucial.

Strengths
Our sub-study engaged mostly black MSM, a group highly impacted by HIV in the US [49]. They lived in an area with high HIV prevalence and were largely unemployed, a factor associated with likelihood of HIV infection among black MSM [50]. Thus, they represent a group likely to benefit from the successful implementation of PrEP in the US [51]. Unlike most qualitative studies conducted outside of PrEP efficacy trials, participants had completed several months of open label PrEP and the data reflect that experience rather than anticipated or hypothetical perceptions, preferences, barriers and facilitators.

Conclusions
As PrEP uptake in the US grows, the need for interventions to support its effective use becomes ever more urgent. The qualitative data presented here highlight critical areas of needed support, including integrating PrEP into other prevention strategies, adherence interventions for dosing schedules that are congruent with patterns of sexual activity and intensifying efforts to counter PrEP-related stigma. The findings are particularly relevant in characterizing PrEP-using experiences of Black MSM-a crucial population for HIV prevention efforts in the US.