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COVID Restraints Followed by More Condom-Free
Sex, Less PrEP, in Amsterdam MSM
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HIVR4P Virtual, January 27-28 and February 3-4, 2021
Mark Mascolini
Amsterdam men who have sex with men (MSM) in a preexposure prophylaxis (PrEP) demonstration project had more condom-free sex with known and unknown casual partners after Dutch COVID-related social restrictions started on March 15, 2020 [1]. Although overall sex with casual partners fell during the COVID era, PrEP use fell with unknown casual partners. An online unreviewed preprint details findings of this study [2].
The first case of COVID-19 appeared in the Netherlands on February 27, 2020. By March 15, the country instituted social restrictions aimed at controlling the pandemic. At the same time, Amsterdam's sexually transmitted infection (STI) clinic scaled down PrEP care and stopped routine HIV/STI testing. Health authorities gradually eased these PrEP and STI restrictions starting in May 2020 and appointments resumed.
Researchers at the Public Health Service of Amsterdam and collaborators at other centers conducted this study to assess changes in sex behavior, condom use, and PrEP use when COVID restrictions took effect. They gathered daily data prospectively from MSM via a cell phone application and analyzed findings from December 1, 2019 through June 30, 2020.
The study involved people enrolled in AMPrEP, a PrEP demonstration project for MSM and transgender persons at least 18 years old that began in 2015. Participants can chose between daily PrEP and PrEP timed to sexual encounters. Researchers defined three main outcomes: (1) proportion of days reporting anal sex before and after COVID restrictions by partner type: steady, known casual, and unknown casual, (2) proportion of anal sex acts covered by PrEP and/or condoms before and after COVID restrictions by partner type, and (3) evaluation of these changes over the same period in the year before COVID restrictions began. They analyzed the first outcome by multilevel logistic regression and the second by bivariate probit regression.
Among 302 active AMPrEP participants on December 1, 2019, 136 (45%), all of them MSM, recorded daily data via cell phone. Median follow-up since men began PrEP stood at 3.9 years. The proportion of days when men had anal sex with steady partners rose significantly when COVID restrictions took effect (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.10 to 1.44), but this increase proved transient. The rate returned to pre-COVID levels by June 2020. These changes were not visible over the same period in 2019.
Proportion of anal sex days with known casual partners dropped significantly with COVID restrictions (OR 0.73, 95% CI 0.64 to 0.82) and even more so with unknown casual partners (OR 0.54, 95% CI 0.48 to 0.61). Again, these changes were transient, rebounding to pre-COVID levels by the end of May 2020. These changes were not seen with known casual partners and were less apparent with unknown casual partners over the same period in 2019.
When COVID restrictions took effect, PrEP use during sex decreased with unknown casual partners (beta = -0.36, 95% CI -0.72 to 0.00) but did not change with steady partners or known casual partners. Condom use during sex fell with known casual partners (beta = -0.36, 95% CI -0.67 to -0.04) and unknown casual partners (beta = -0.24, 95% CI -0.46 to -0.03) but did not change with steady partners.
The Amsterdam team concluded that HIV-negative MSM had less anal sex with casual partners and more anal sex with steady partners when COVID social restriction took hold in the Netherlands on March 15, 2000, but these changed proved transient. Decreasing sex with casual partners paralleled a drop in PrEP use. Perhaps the most concerning finding was declining condom use with known and unknown casual partners when COVID rules began.
The researchers believe their findings "indicate the importance of continued sexual health services, including STI screening and PrEP care, during COVID-19 restrictions."
References
1. Coyer L, Jongen VW, Zimmermann HML et al. Transient changes in daily sexual behavior and pre-exposure prophylaxis use after the implementation of COVID-19 restrictions among men who have sex with men. HIVR4P (HIV Research for Prevention) Virtual, January 27-28 and February 3-4, 2021. Abstract OA11.05LB.
2. Jongen VW, Zimmermann HMI, Boyd A, et al. Transient changes in daily sexual behavior and pre-exposure prophylaxis use after the implementation of COVID-19 restrictions among men who have sex with men. Lancet preprint. Posted December 17, 2020.
https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3739803
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