Prevention Science

, Volume 18, Issue 6, pp 737–747 | Cite as

Risk Perception, Sexual Behaviors, and PrEP Adherence Among Substance-Using Men Who Have Sex with Men: a Qualitative Study

  • Erik D. Storholm
  • Jonathan E. Volk
  • Julia L. Marcus
  • Michael J. Silverberg
  • Derek D. Satre


The antiretroviral drug combination emtricitabine and tenofovir disoproxil fumarate (TDF/FTC) taken as pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection, yet it also requires adherence and potentially decreases condom use. This study sought to examine these issues among a key population at risk of HIV infection, substance-using men who have sex with men (MSM). We conducted semi-structured interviews with an ethnically diverse sample of 30 young (aged 20–35) MSM prescribed PrEP within a large integrated healthcare system in San Francisco, who had reported recent drug use or hazardous drinking and one or more missed doses of PrEP. We explored participants’ risk perception and sexual risk behavior, drug and alcohol use, and PrEP adherence in the context of substance use. Interviews were transcribed and coded using a directed content analysis approach to identify key categories and commonalities, and differences across participants. Salient subcategories included positive psychological effects of being on PrEP (e.g., decreased anxiety, feelings of empowerment), social effects (e.g., reduced HIV stigma), and reduction in overall perceptions of HIV risk. While overall reported use of condoms went down and many reported a brief period of increased condomless sex following PrEP initiation, others continued condom use with most of their sexual partners. Contextual factors influencing their decision to engage in condomless sex included how well they knew the partner and whether the partner was on PrEP or HIV antiretroviral treatment. Factors associated with poor adherence included disruptions in daily routine and use of alcohol and methamphetamine. PrEP-prescribing clinicians should support their patients in making informed decisions about condom use and identifying strategies to maximize adherence in the context of substance use.


Pre-exposure prophylaxis PrEP Adherence Risk perception Sexual behavior Alcohol Methamphetamine Substance use 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they no conflicts of interest.


The study received support with grant numbers P50DA009253, T32 DA007250, R03DA043402, U01AA021997, and K01AI122853.

Ethical Approval

All study protocols and procedures involving human subjects were approved by the Institutional Review Boards of both the University of California, San Francisco and Kaiser Permanente Division of Research and were performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed Consent

We obtained informed consent from all participants included in this study.


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Copyright information

© RAND Corporation 2017

Authors and Affiliations

  • Erik D. Storholm
    • 1
    • 2
    • 3
  • Jonathan E. Volk
    • 4
  • Julia L. Marcus
    • 2
  • Michael J. Silverberg
    • 2
  • Derek D. Satre
    • 2
    • 3
  1. 1.RAND CorporationSanta MonicaUSA
  2. 2.Kaiser Permanente Northern California, Division of ResearchOaklandUSA
  3. 3.Department of PsychiatryUniversity of CaliforniaSan FranciscoUSA
  4. 4.Kaiser Permanente Medical CenterSan FranciscoUSA

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