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Background: There are concerns that PrEP could increase risk compensation, especially reducing condom use. The PROUD study (Nov12-Nov16) reported an 86% reduction in HIV and no increase in STIs. We explore PROUD participants'' experiences and perceptions of PrEP in relation to other risk reduction strategies.
Methods: We conducted semi-structured in-depth-interviews with 41 HIV-negative MSM, purposively selected based on self-reported high/low PrEP adherence and increased/same risk behaviour. Interviews were digitally recorded, transcribed and analysed using framework analysis.
Results: The majority of participants reported risk reduction strategies including occasional condom use, strategic positioning, or sero-sorting. Participants applied rules to their sexual behaviour, such as using condoms “if it was a one night stand”, or not being receptive “outside of a relationship”. Typically, PrEP was added to the existing set of ''rules''. For some participants, PrEP allowed a relaxing of the rules, for example about strategic positioning: “I have definitely experienced more as a bottom”, or about condomless sex: “I have had more unprotected sex than before?it doesn''t mean that I only have unprotected sex”. Other participants insisted PrEP had not changed their rules: “I haven''t changed the way I think because I am taking this pill”. Participants described PrEP as a “security blanket”, an added “defence mechanism” and used analogies such as wearing a “crash helmet? on my bicycle”. PrEP was described as affording “more intimacy”, “reassurance”, and giving “added control”. By using PrEP, many participants with HIV-positive partners sought to reduce their partner''s anxiety about the risk of transmission. The benefits of PrEP were described within the social context of risk environments in cities like London, the chemsex scene, and the digitization of sexual contact. PrEP use was viewed as time-limited: “clearly it is a period, a moment? it is not going to be a lifetime”.
Conclusions: These data suggest that PrEP was added to a range of ''rules'' already used to mitigate risk, rather than replacing them. PrEP impacted on the boundaries of the rules for some people but not all. In social contexts of high-risk behaviour, PrEP offers added protection and psycho-social benefits that increase individual choice in the mitigation of risk.