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Jul, 2024;53 (7): 2777-2793.

The Best Predictor of Future Behavior May Be the Past: Exploring Behavior Change in Men Who Have Sex with Men Using Pre-exposure Prophylaxis in the Netherlands.

Daphne van Wees, Liza Coyer, Mark van den Elshout, Eline Op de Coul, Fleur van Aar
Author Information
  1. Daphne van Wees: Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), P.O Box 1, 3720 BA, Bilthoven, The Netherlands. daphne.van.wees@rivm.nl. ORCID
  2. Liza Coyer: Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, The Netherlands.
  3. Mark van den Elshout: Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, The Netherlands.
  4. Eline Op de Coul: Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), P.O Box 1, 3720 BA, Bilthoven, The Netherlands.
  5. Fleur van Aar: Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), P.O Box 1, 3720 BA, Bilthoven, The Netherlands.
PMID: 38709341 DOI: 10.1007/s10508-024-02863-z

Abstract

Pre-exposure prophylaxis (PrEP) use prevents HIV transmission, and may lead to changes in sexual behavior. We aimed to explore sexual behavior over time, and identify predictors of behavior change in men who have sex with men (MSM) using PrEP at sexual health centers (SHC) in the Netherlands. We used longitudinal data from the national STI surveillance database (January 2018-June 2021) of HIV-negative MSM who first initiated PrEP in the national PrEP pilot. We modelled behavior change after PrEP initiation, and identified predictors of behavior change using multi-state Markov models. The probability of stopping group sex, chemsex, use of poppers or erection stimulants, and having ≥ 10 partners in the past 6 months among included MSM (n = 4,349, n SHC visits = 21,820) was higher compared to the probability of starting with these behaviors after PrEP initiation. However, MSM who used condoms consistently during anal sex had a high probability of changing to inconsistent condom use (0.8) at the next visit, and inconsistent condom users mostly remained inconsistent (0.8). First visit, visiting the SHC more often (vs. regular), and STI diagnosis were predictors of starting or continuing with most of the behaviors associated with increased risk. Behavior change was less likely among older participants (> 34 compared to ≤ 34 years), and during COVID-19 lockdown and post-lockdown periods compared to pre-COVID-19. Although condom use decreased over time, transitions towards stopping with other behaviors associated with increased likelihood of acquiring an STI after PrEP initiation were common. This may suggest increased sexual empowerment, especially among younger MSM. Predictors of behavior change may help to identify MSM who are likely to start with or continue to engage in these behaviors in the near future and to provide suitable and timely counselling about behavior and PrEP adherence.

Keywords

Men who have sex with men Pre-exposure prophylaxis Sexual behavior Sexual orientation Sexually transmitted infections

References

  1. Achterbergh, R. C. A., Hoornenborg, E., Boyd, A., Coyer, L., Meuzelaar, S. J. A., Hogewoning, A. A., Davidovich, U., van Rooijen, M. S., Schim van der Loeff, M. F., Prins, M., & de Vries, H. J. C. (2020). Changes in mental health and drug use among men who have sex with men using daily and event-driven pre-exposure prophylaxis: Results from a prospective demonstration project in Amsterdam, the Netherlands. EClinicalMedicine, 26, 100505. https://doi.org/10.1016/j.eclinm.2020.100505 [DOI: 10.1016/j.eclinm.2020.100505]
  2. Andresen, S., Balakrishna, S., Mugglin, C., Schmidt, A. J., Braun, D. L., Marzel, A., Doco Lecompte, T., Darling, K. E., Roth, J. A., Schmid, P., Bernasconi, E., Günthard, H. F., Rauch, A., Kouyos, R. D., & Salazar-Vizcaya, L. (2022). Unsupervised machine learning predicts future sexual behaviour and sexually transmitted infections among HIV-positive men who have sex with men. PLoS Computational Biology, 18(10), e1010559. https://doi.org/10.1371/journal.pcbi.1010559 [DOI: 10.1371/journal.pcbi.1010559]
  3. Armstrong, H. L., Roth, E. A., Rich, A., Lachowsky, N. J., Cui, Z., Sereda, P., Card, K. G., Jollimore, J., Howard, T., Moore, D. M., & Hogg, R. S. (2018). Associations between sexual partner number and HIV risk behaviors: Implications for HIV prevention efforts in a treatment as prevention (TasP) environment. AIDS Care, 30(10), 1290–1297. https://doi.org/10.1080/09540121.2018.1454583 [DOI: 10.1080/09540121.2018.1454583]
  4. Basten, M. G. J., van Wees, D. A., Matser, A., Boyd, A., Rozhnova, G., den Daas, C., Kretzschmar, M. E. E., & Heijne, J. C. M. (2021). Time for change: Transitions between HIV risk levels and determinants of behavior change in men who have sex with men. PLoS ONE, 16(12), e0259913. https://doi.org/10.1371/journal.pone.0259913 [DOI: 10.1371/journal.pone.0259913]
  5. Biello, K. B., Edeza, A., Montgomery, M. C., Almonte, A., & Chan, P. A. (2019). Risk perception and interest in HIV pre-exposure prophylaxis among men who have sex with men with rectal gonorrhea and chlamydia infection. Archives of Sexual Behavior, 48(4), 1185–1190. https://doi.org/10.1007/s10508-018-1260-1 [DOI: 10.1007/s10508-018-1260-1]
  6. Bierman, W., Hoornenborg, E., & Nellen, J. (2022). Nederlandse multidisciplinaire richtlijn Pre-expositie profylaxe (PrEP) ter preventie van hiv (update 2022). https://www.soaaids.nl/files/2022-07/20220711-PrEP-richtlijn-Nederland-versie-3-update-2022.pdf
  7. Coyer, L., Prins, M., Davidovich, U., van Bilsen, W. P. H., Schim van der Loeff, M. F., Hoornenborg, E., Matser, A., & Boyd, A. (2022). Trends in sexual behavior and sexually transmitted infections after initiating human immunodeficiency virus pre-exposure prophylaxis in men who have sex with men from Amsterdam, the Netherlands: A longitudinal exposure-matched study. AIDS Patient Care and STDs, 36(6), 208–218. https://doi.org/10.1089/apc.2021.0219 [DOI: 10.1089/apc.2021.0219]
  8. Curley, C. M., Rosen, A. O., Mistler, C. B., & Eaton, L. A. (2022). Pleasure and PrEP: A systematic review of studies examining pleasure, sexual satisfaction, and PrEP. Journal of Sex Research, 59(7), 848–861. https://doi.org/10.1080/00224499.2021.2012638 [DOI: 10.1080/00224499.2021.2012638]
  9. Datta, J., Reid, D., Hughes, G., Mercer, C. H., Wayal, S., & Weatherburn, P. (2019). Awareness of and attitudes to sexually transmissible infections among gay men and other men who have sex with men in England: A qualitative study. Sexual Health, 16(1), 18–24. https://doi.org/10.1071/sh18025 [DOI: 10.1071/sh18025]
  10. De Baetselier, I., Reyniers, T., Platteau, T., Wouters, K., Nöstlinger, C., Cuylaerts, V., Buyze, J., Laga, M., Kenyon, C., Crucitti, T., & Vuylsteke, B. (2021). Recurrent sexually transmitted infections among a cohort of men who have sex with men using pre-exposure prophylaxis in Belgium are highly associated with sexualized drug use. Sexually Transmitted Diseases, 48(10), 726–732. https://doi.org/10.1097/olq.0000000000001424 [DOI: 10.1097/olq.0000000000001424]
  11. Evers, Y. J., Op den Camp, K. P. L., Lenaers, M., Dukers-Muijrers, N., & Hoebe, C. (2023). Alcohol and drug use during sex and its association with sexually transmitted infections: A retrospective cohort study among young people aged under 25 years visiting Dutch STI clinics. Sexually Transmitted Infections, 99, 97–103. https://doi.org/10.1136/sextrans-2021-055355 [DOI: 10.1136/sextrans-2021-055355]
  12. Flores Anato, J. L., Panagiotoglou, D., Greenwald, Z. R., Blanchette, M., Trottier, C., Vaziri, M., Charest, L., Szabo, J., Thomas, R., & Maheu-Giroux, M. (2022). Chemsex and incidence of sexually transmitted infections among Canadian pre-exposure prophylaxis (PrEP) users in the l’Actuel PrEP Cohort (2013–2020). Sexually Transmitted Infections, 98, 549–556. https://doi.org/10.1136/sextrans-2021-055215 [DOI: 10.1136/sextrans-2021-055215]
  13. Grov, C., Rendina, H. J., Ventuneac, A., & Parsons, J. T. (2013). HIV risk in group sexual encounters: An event-level analysis from a national online survey of MSM in the US. Journal of Sexual Medicine, 10, 2285–2294. [DOI: 10.1111/jsm.12227]
  14. Hammoud, M. A., Maher, L., Holt, M., Degenhardt, L., Jin, F., Murphy, D., Bavinton, B., Grulich, A., Lea, T., & Haire, B. (2020). Physical distancing due to COVID-19 disrupts sexual behaviors among gay and bisexual men in Australia: Implications for trends in HIV and other sexually transmissible infections. Journal of Acquired Immune Deficiency Syndromes, 85(3), 309–315. https://doi.org/10.1097/QAI.0000000000002462 [DOI: 10.1097/QAI.0000000000002462]
  15. Hoornenborg, E., & Rijnders, B. (2019). HIV Pre-expositie profylaxe (PrEP) richtlijn Nederland. https://nvhb.nl/wp-content/uploads/2019/04/PrEP-richtlijn-Nederland-versie-2-dd-15-april-2019.pdf
  16. Hoornenborg, E., Achterbergh, R. C. A., Schim van der Loeff, M. F., Davidovich, U., van der Helm, J. J., Hogewoning, A., van Duijnhoven, Y. T. H. P., Sonder, G. J. B., de Vries, H. J. C., & Prins, M. (2018a). Men who have sex with men more often chose daily than event-driven use of pre-exposure prophylaxis: Baseline analysis of a demonstration study in Amsterdam. Journal of the International AIDS Society, 21(3), e25105. https://doi.org/10.1002/jia2.25105 [DOI: 10.1002/jia2.25105]
  17. Hoornenborg, E., Coyer, L., Achterbergh, R. C. A., Matser, A., Schim van der Loeff, M. F., Boyd, A., van Duijnhoven, Y. T. H. P., Bruisten, S., Oostvogel, P., & Davidovich, U. (2019). Sexual behaviour and incidence of HIV and sexually transmitted infections among men who have sex with men using daily and event-driven pre-exposure prophylaxis in AMPrEP: 2 year results from a demonstration study. Lancet HIV, 6(7), e447–e455. https://doi.org/10.1016/S2352-3018(19)30136-5 [DOI: 10.1016/S2352-3018(19)30136-5]
  18. Hoornenborg, E., Coyer, L., van Laarhoven, A., Achterbergh, R., de Vries, H., Prins, M., & Schim van der Loeff, M. (2018b). Change in sexual risk behaviour after 6 months of pre-exposure prophylaxis use: Results from the Amsterdam Pre-exposure Prophylaxis Demonstration Project. AIDS, 32(11), 1527–1532. https://doi.org/10.1097/QAD.0000000000001874 [DOI: 10.1097/QAD.0000000000001874]
  19. Jackson, C. H. (2011). Multi-state models for panel data: The MSM package for R. Journal of Statistical Software, 38, 1–28. [DOI: 10.18637/jss.v038.i08]
  20. Jongen, V. W., Hoornenborg, E., van den Elshout, M. A., Boyd, A., Zimmermann, H. M., Coyer, L., Davidovich, U., Anderson, P. L., de Vries, H. J., Prins, M., & Schim van der Loeff, M. F. (2021a). Adherence to event-driven HIV PrEP among men who have sex with men in Amsterdam, the Netherlands: Analysis based on online diary data, 3-monthly questionnaires and intracellular TFV-DP. Journal of the International AIDS Society, 24(5), e25708. https://doi.org/10.1002/jia2.25708 [DOI: 10.1002/jia2.25708]
  21. Jongen, V. W., Zimmermann, H. M. L., Boyd, A., Hoornenborg, E., van den Elshout, M. A. M., Davidovich, U., van Duijnhoven, Y., de Vries, H. J. C., Prins, M., Schim van der Loeff, M. F., & Coyer, L. (2021b). Transient changes in preexposure prophylaxis use and daily sexual behavior after the implementation of COVID-19 restrictions among men who have sex with men. Journal of Acquired Immune Deficiency Syndromes, 87(5), 1111–1118. https://doi.org/10.1097/qai.0000000000002697 [DOI: 10.1097/qai.0000000000002697]
  22. Kapland, D. (2008). An overview of Markov chain methods for the study of stage-sequential developmental processes. Developmental Psychology, 44(2), 457–467. https://doi.org/10.1037/0012-1649.44.2.457 [DOI: 10.1037/0012-1649.44.2.457]
  23. Knoops, L., Poll van de, S., & Albers, T. (2021). Slammen in Nederland. Amsterdam
  24. Knox, J., Boyd, A., Matser, A., Heijman, T., Sandfort, T., & Davidovich, U. (2020). Types of group sex and their association with different sexual risk behaviors among HIV-negative men who have sex with men. Archives of Sexual Behavior, 49(6), 1995–2003. https://doi.org/10.1007/s10508-020-01744-5 [DOI: 10.1007/s10508-020-01744-5]
  25. Kumar, S., Haderxhanaj, L. T., & Spicknall, I. H. (2021). Reviewing PrEP’s effect on STI incidence among men who have sex with men-balancing increased STI screening and potential behavioral sexual risk compensation. AIDS and Behavior, 25(6), 1810–1818. https://doi.org/10.1007/s10461-020-03110-x [DOI: 10.1007/s10461-020-03110-x]
  26. MacGregor, L., Speare, N., Nicholls, J., Harryman, L., Horwood, J., Kesten, J. M., Lorenc, A., Horner, P., Edelman, N. L., Muir, P., North, P., Gompels, M., & Turner, K. M. E. (2021). Evidence of changing sexual behaviours and clinical attendance patterns, alongside increasing diagnoses of STIs in MSM and TPSM. Sexually Transmitted Infections, 97(7), 507–513. https://doi.org/10.1136/sextrans-2020-054588 [DOI: 10.1136/sextrans-2020-054588]
  27. Maxwell, S., Shahmanesh, M., & Gafos, M. (2019). Chemsex behaviours among men who have sex with men: A systematic review of the literature. International Journal of Drug Policy, 63, 74–89. https://doi.org/10.1016/j.drugpo.2018.11.014 [DOI: 10.1016/j.drugpo.2018.11.014]
  28. Prestage, G. P., Hudson, J., Down, I., Bradley, J., Corrigan, N., Hurley, M., Grulich, A. E., & McInnes, D. (2009). Gay men who engage in group sex are at increased risk of HIV infection and onward transmission. AIDS and Behavior, 13, 724–7306. [DOI: 10.1007/s10461-008-9460-7]
  29. Prestage, G., Maher, L., Grulich, A., Bourne, A., Hammoud, M., Vaccher, S., Bavinton, B., Holt, M., & Jin, F. (2019). Brief report: Changes in behavior after PrEP initiation among Australian gay and bisexual men. Journal of Acquired Immune Deficiency Syndromes, 81(1), 52–56. https://doi.org/10.1097/QAI.0000000000001976 [DOI: 10.1097/QAI.0000000000001976]
  30. R Development Core Team. (2020). R: A language and environment for statistical computing. In (Version 4.2.0) R Foundation for Statistical Computing. https://www.r-project.org/
  31. Rijksoverheid. (2021). Dashboard Coronavirus. https://coronadashboard.rijksoverheid.nl/landelijk/maatregelen
  32. Rogers, B. G., Tao, J., Darveau, S. C., Maynard, M., Almonte, A., Napoleon, S., Murphy, M., & Chan, P. A. (2022). The impact of COVID-19 on sexual behavior and psychosocial functioning in a clinical sample of men who have sex with men using HIV pre-exposure prophylaxis. AIDS and Behavior, 26(1), 69–75. https://doi.org/10.1007/s10461-021-03334-5 [DOI: 10.1007/s10461-021-03334-5]
  33. Rozhnova, G., Heijne, J. C. M., Bezemer, D., van Sighem, A., Presanis, A., De Angelis, D., & Kretzschmar, M. E. E. (2018). Elimination prospects of the Dutch HIV epidemic among men who have sex with men in the era of pre-exposure prophylaxis. AIDS, 32(17), 2615–2623. https://doi.org/10.1097/QAD.0000000000002050 [DOI: 10.1097/QAD.0000000000002050]
  34. Sarno, E. L., Macapagal, K., & Newcomb, M. E. (2021). “The main concern is HIV, everything else is fixable”: Indifference toward sexually transmitted infections in the era of biomedical HIV prevention. AIDS and Behavior, 25(8), 2657–2660. https://doi.org/10.1007/s10461-021-03226-8 [DOI: 10.1007/s10461-021-03226-8]
  35. Saxton, P. J. W., Azariah, S., Cavadino, A., Forster, R. F., Jenkins, R., Werder, S. F., Southey, K., & Rich, J. G. (2022). Adherence, sexual behavior and sexually transmitted infections in a New Zealand prospective PrEP cohort: 12 months follow-up and ethnic disparities. AIDS and Behavior, 26(8), 2723–2737. https://doi.org/10.1007/s10461-022-03617-5 [DOI: 10.1007/s10461-022-03617-5]
  36. Sewell, J., Miltz, A., Lampe, F. C., Cambiano, V., Speakman, A., Phillips, A. N., Stuart, D., Gilson, R., Asboe, D., Nwokolo, N., Clarke, A., Collins, S., Hart, G., Elford, J., & Rodger, A. J. (2017). Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics. International Journal on Drug Policy, 43, 33–43. https://doi.org/10.1016/j.drugpo.2017.01.001 [DOI: 10.1016/j.drugpo.2017.01.001]
  37. Slurink, I. A. L., van Benthem, B. H. B., van Rooijen, M. S., Achterbergh, R. C. A., & van Aar, F. (2020). Latent classes of sexual risk and corresponding STI and HIV positivity among MSM attending centres for sexual health in the Netherlands. Sexually Transmitted Infections, 96(1), 33–39. https://doi.org/10.1136/sextrans-2019-053977 [DOI: 10.1136/sextrans-2019-053977]
  38. Smith, D. K., Pals, S. L., Herbst, J. H., Shinde, S., & Carey, J. W. (2012). Development of a clinical screening index predictive of incident HIV infection among men who have sex with men in the United States. Journal of Acquired Immune Deficiency Syndromes, 60, 421–427. [DOI: 10.1097/QAI.0b013e318256b2f6]
  39. Starks, T. J., Adebayo, T., Kyre, K. D., Millar, B. M., Stratton, M. J., Jr., Gandhi, M., & Ingersoll, K. S. (2022). Pilot randomized controlled trial of motivational interviewing with sexual minority male couples to reduce drug use and sexual risk: The Couples Health Project. AIDS and Behavior, 26, 310–327. https://doi.org/10.1007/s10461-021-03384-9 [DOI: 10.1007/s10461-021-03384-9]
  40. Statistics Netherlands (CBS). (2022). New classification of population by origin: Replacing classification based on migration background and the concepts western/non-western. Retrieved from https://www.cbs.nl/en-gb/longread/statistische-trends/2022/new-classification-of-population-by-origin
  41. Traeger, M. W., Schroeder, S. E., Wright, E. J., Hellard, M. E., Cornelisse, V. J., Doyle, J. S., & Stoové, M. A. (2018). Effects of pre-exposure prophylaxis for the prevention of human immunodeficiency virus infection on sexual risk behavior in men who have sex with men: A systematic review and meta-analysis. Clinical Infectious Diseases, 67(5), 676–686. https://doi.org/10.1093/cid/ciy182 [DOI: 10.1093/cid/ciy182]
  42. van Bilsen, W. P. H., Boyd, A., van der Loeff, M. F. S., Davidovich, U., Hogewoning, A., van der Hoek, L., Prins, M., & Matser, A. (2020). Diverging trends in incidence of HIV versus other sexually transmitted infections in HIV-negative MSM in Amsterdam. AIDS, 34(2), 301–309. https://doi.org/10.1097/QAD.0000000000002417 [DOI: 10.1097/QAD.0000000000002417]
  43. van Bilsen, W. P. H., Zimmermann, H. M. L., Boyd, A., Coyer, L., van der Hoek, L., Kootstra, N. A., Hoornenborg, E., Prins, M., Davidovich, U., & Matser, A. (2021). Sexual behavior and its determinants during COVID-19 restrictions among men who have sex with men in Amsterdam. Journal of Acquired Immune Deficiency Syndromes, 86(3), 288–296. https://doi.org/10.1097/QAI.0000000000002581 [DOI: 10.1097/QAI.0000000000002581]
  44. van den Elshout, M. A., Hoornenborg, E., Coyer, L., Anderson, P. L., Davidovich, U., de Vries, H. J., Prins, M., & Schim van der Loeff, M. F. (2023). Determinants of adherence to daily PrEP measured as intracellular tenofovir diphosphate concentrations over 24 months of follow-up among men who have sex with men. Sexually Transmitted Infections, 99(5), 303–310. https://doi.org/10.1136/sextrans-2022-055499 [DOI: 10.1136/sextrans-2022-055499]
  45. van Wees, D. A., Drissen, M. C. M., den Daas, C., Heijman, T., Kretzschmar, M. E. E., & Heijne, J. C. M. (2020). The impact of STI test results and face-to-face consultations on subsequent behaviour and psychological characteristics. Preventive Medicine, 139, 106200. https://doi.org/10.1016/j.ypmed.2020.106200 [DOI: 10.1016/j.ypmed.2020.106200]
  46. van Wees, D. A., Visser, M., van Aar, F., Op de Coul, E. L. M., Staritsky, L. E., Sarink, D., Willemstein, I. J. M., de Vries, A., Kusters, J. M. A., den Boogert, E., Alexiou, Z. W., Götz, H. M., Jansen, T., van Sighem, A. I., & Heijne, J. C. M. (2022). Sexually transmitted infections in the Netherlands in 2021. https://www.rivm.nl/publicaties/sexually-transmitted-infections-in-netherlands-in-2021
  47. Vosburgh, H. W., Mansergh, G., Sullivan, P. S., & Purcell, D. W. (2012). A review of the literature on event-level substance use and sexual risk behavior among men who have sex with men. AIDS and Behavior, 16, 1394–1410. [DOI: 10.1007/s10461-011-0131-8]
  48. Walker, M. L., Stiasny, D., Guy, R. J., Law, M. G., Holt, M., Mao, L., Donovan, B., Grulich, A. E., Gray, R. T., & Regan, D. G. (2022). Assessing the impact of HIV preexposure prophylaxis scale-up on gonorrhea incidence among gay and bisexual men in sydney: a mathematical modeling study. Sexually Transmitted Diseases, 49(8), 534–540. https://doi.org/10.1097/olq.0000000000001649 [DOI: 10.1097/olq.0000000000001649]
  49. Zimmermann, H. M. L., Postma, L. R., Achterbergh, R. C. A., Reyniers, T., Schim van der Loeff, M. F., Prins, M., de Vries, H. J. C., Hoornenborg, E., & Davidovich, U. (2021). The impact of pre-exposure prophylaxis on sexual well-being among men who have sex with men. Archives of Sexual Behavior, 50, 1829–1841. https://doi.org/10.1007/s10508-020-01833-5 [DOI: 10.1007/s10508-020-01833-5]

MeSH Term

Humans
Male
Pre-Exposure Prophylaxis
Homosexuality, Male
Adult
Netherlands
Sexual Behavior
HIV Infections
Middle Aged
COVID-19
Condoms
Sexual Partners
Risk-Taking
Young Adult
Journal Article
Article has an altmetric score of 1

Word Cloud

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