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


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.

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  • Abbas, U. L., Hood, G., Wetzel, A. W., & Mellors, J. W. (2011). Factors influencing the emergence and spread of HIV drug resistance arising from rollout of antiretroviral pre-exposure prophylaxis PrEP. PloS One, 6, e18165. doi:10.1371/journal.pone.0018165.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  • Anderson, P. L., Glidden, D. V., Liu, A., Buchbinder, S., Lama, J. R., Guanira, J. V., et al. (2012). Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Science translational medicine, 4(151), 151ra125.

  • Azar, M. M., Springer, S. A., Meyer, J. P., & Altice, F. L. (2010). A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization. Drug and Alcohol Dependence, 112, 178–193. doi:10.1016/j.drugalcdep.2010.06.014.

    Article  PubMed  PubMed Central  Google Scholar 

  • Azar, P., Wood, E., Nguyen, P., Luma, M., Montaner, J., Kerr, T., & Milloy, M. J. (2015). Drug use patterns associated with risk of non-adherence to antiretroviral therapy among HIV-positive illicit drug users in a Canadian setting: A longitudinal analysis. BMC Infectious Diseases, 15, 193. doi:10.1186/s12879-015-0913-0.

    Article  PubMed  PubMed Central  Google Scholar 

  • Baeten, J. M., Donnell, D., Ndase, P., Mugo, N. R., Campbell, J. D., Wangisi, J., et al. (2012). Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. New England Journal of Medicine, 367, 399–410. doi:10.1056/NEJMoa1108524.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  • Brooks, R. A., Kaplan, R. L., Lieber, E., Landovitz, R. J., Lee, S. J., & Leibowitz, A. A. (2011). Motivators, concerns, and barriers to adoption of preexposure prophylaxis for HIV prevention among gay and bisexual men in HIV-serodiscordant male relationships. AIDS Care, 23, 1136–1145. doi:10.1080/09540121.2011.554528.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brooks, R. A., Landovitz, R. J., Regan, R., Lee, S. J., & Allen Jr., V. C. (2015). Perceptions of and intentions to adopt HIV pre-exposure prophylaxis among black men who have sex with men in Los Angeles. International Journal of STD & AIDS, 26, 1040–1048. doi:10.1177/0956462415570159.

    Article  Google Scholar 

  • Carlo Hojilla, J., Koester, K. A., Cohen, S. E., Buchbinder, S., Ladzekpo, D., Matheson, T., & Liu, A. Y. (2016). Sexual behavior, risk compensation, and HIV prevention strategies among participants in the San Francisco PrEP Demonstration Project: A qualitative analysis of counseling notes. AIDS and Behavior, 20, 1461–1469. doi:10.1007/s10461-015-1055-5.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  • Cassell, M. M., Halperin, D. T., Shelton, J. D., & Stanton, D. (2006). Risk compensation: The Achilles’ heel of innovations in HIV prevention? BMJ (Clinical Research Ed.), 332, 605–607. doi:10.1136/bmj.332.7541.605.

    Article  Google Scholar 

  • Centers for Disease Control and Prevention. (2014). Preexposure prophylaxis for the prevention of HIV infection in the United States—2014. A Clinical Practice Guideline. Retrieved from

  • Centers for Disease Control and Prevention. (2016). HIV Surveillance Report, 2015 (vol. 27). Accessed [October, 2017]

  • Corbin, J., & Strauss, A. (2008). Basics of qualitative research (3rd ed.). Thousand Oaks: Sage.

    Google Scholar 

  • Dawson, D. A. (2011). Defining risk drinking. Alcohol Research and Health, 34, 144–156.

    PubMed  PubMed Central  Google Scholar 

  • de Wit, J., Murphy, D., Lal, L., Audsley, J., Roth, N., Moore, R., … Wright, E. (2015). O19. 2 Pre-exposure prophylaxis and risk compensation: Evidence of decreased condom use at three-month follow-up among predominantly gay male participants in the VicPrEP study. Sexually Transmitted Infections, 91, A68-A68.

  • Donnell, D., Baeten, J. M., Bumpus, N. N., Brantley, J., Bangsberg, D. R., Haberer, J. E., et al. (2014). HIV protective efficacy and correlates of tenofovir blood concentrations in a clinical trial of PrEP for HIV prevention. Journal of Acquired Immune Deficiencies Syndrome, 66, 340–348. doi:10.1097/QAI.0000000000000172.

    CAS  Article  Google Scholar 

  • Ellis, R. J., Childers, M. E., Cherner, M., Lazzaretto, D., Letendre, S., Grant, I., & Group, H. I. V. N. R. C. (2003). Increased human immunodeficiency virus loads in active methamphetamine users are explained by reduced effectiveness of antiretroviral therapy. Journal of Infectious Diseases, 188, 1820–1826. doi:10.1086/379894.

    Article  PubMed  Google Scholar 

  • Gibson, S., Crouch, P.-C., Hecht, J., Gagliano, J., Patriarca, T., Auerbach, J., … Hall, C. (2016). Eliminating barriers to increase uptake of PrEP in a community-based clinic in San Francisco. Paper presented at the International AIDS Conference, Durban, South Africa.

  • Golub, S. A., Kowalczyk, W., Weinberger, C. L., & Parsons, J. T. (2010). Preexposure prophylaxis and predicted condom use among high-risk men who have sex with men. Journal of Acquired Immune Deficiencies Syndrome, 54(5), 548–555. doi:10.1097/QAI.0b013e3181e19a54.

    Article  Google Scholar 

  • Grant, R. M., Anderson, P. L., McMahan, V., Liu, A., Amico, K. R., Mehrotra, M., et al. (2014). Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: A cohort study. The Lancet. Infectious Diseases, 14(9), 820–829. doi:10.1016/S1473-3099(14)70847-3.

    Article  PubMed  Google Scholar 

  • Grant, R. M., & Koester, K. A. (2016). What people want from sex and preexposure prophylaxis. Current Opinion in HIV and AIDS, 11(1), 3–9. doi:10.1097/COH.0000000000000216.

    Article  PubMed  Google Scholar 

  • Grant, R. M., Lama, J. R., Anderson, P. L., McMahan, V., Liu, A. Y., Vargas, L., … iPrEx Study, T (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 363(27), 2587–2599. doi:

  • Haberer, J. E., Bangsberg, D. R., Baeten, J. M., Curran, K., Koechlin, F., Amico, K. R., et al. (2015). Defining success with HIV pre-exposure prophylaxis: A prevention-effective adherence paradigm. AIDS, 29, 1277–1285. doi:10.1097/QAD.0000000000000647.

    Article  PubMed  PubMed Central  Google Scholar 

  • Halkitis, P. N., Moeller, R. W., Siconolfi, D. E., Storholm, E. D., Solomon, T. M., & Bub, K. L. (2013). Measurement model exploring a syndemic in emerging adult gay and bisexual men. AIDS and Behavior, 17, 662–673. doi:10.1007/s10461-012-0273-3.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hendershot, C. S., Stoner, S. A., Pantalone, D. W., & Simoni, J. M. (2009). Alcohol use and antiretroviral adherence: Review and meta-analysis. Journal of Acquired Immune Deficiencies Syndrome, 52, 180–202. doi:10.1097/QAI.0b013e3181b18b6e.

    Article  Google Scholar 

  • Hinkin, C. H., Barclay, T. R., Castellon, S. A., Levine, A. J., Durvasula, R. S., Marion, S. D., et al. (2007). Drug use and medication adherence among HIV-1 infected individuals. AIDS and Behavior, 11, 185–194. doi:10.1007/s10461-006-9152-0.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hogben, M., & Liddon, N. (2008). Disinhibition and risk compensation: Scope, definitions, and perspective. Sexually Transmitted Diseases, 35, 1009–1010. doi:10.1097/OLQ.0b013e31818eb752.

    Article  PubMed  Google Scholar 

  • Humeniuk, R., Henry-Edwards, S., Ali, R., Poznyak, V., & Monteiro, M. G. (2010). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Manual for use in primary care. Retrieved from Geneva, Switzerland:

  • Landovitz, R. J., Kofron, R., & McCauley, M. (2016). The promise and pitfalls of long-acting injectable agents for HIV prevention. Current Opinion in HIV and AIDS, 11(1), 122–128.

  • Liu, A. Y., Cohen, S. E., Vittinghoff, E., Anderson, P. L., Doblecki-Lewis, S., Bacon, O., et al. (2016). Preexposure prophylaxis for HIV infection integrated with municipal- and community-based sexual health services. JAMA Internal Medicine, 176, 75–84. doi:10.1001/jamainternmed.2015.4683.

    Article  PubMed  PubMed Central  Google Scholar 

  • Liu, A. Y., Vittinghoff, E., Chillag, K., Mayer, K., Thompson, M., Grohskopf, L., et al. (2013). Sexual risk behavior among HIV-uninfected men who have sex with men participating in a tenofovir preexposure prophylaxis randomized trial in the United States. Journal of Acquired Immune Deficiencies Syndrome, 64, 87–94. doi:10.1097/QAI.0b013e31828f097a.

    CAS  Article  Google Scholar 

  • Marcus, J. L., Glidden, D. V., Mayer, K. H., Liu, A. Y., Buchbinder, S. P., Amico, K. R., … Grant, R. M. (2013). No evidence of sexual risk compensation in the iPrEx trial of daily oral HIV preexposure prophylaxis. PLoS One, 8, e81997. doi:10.1371/journal.pone.0081997

  • McCormack, S., Dunn, D. T., Desai, M., Dolling, D. I., Gafos, M., Gilson, R., et al. (2016). Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): Effectiveness results from the pilot phase of a pragmatic open-label randomised trial. The Lancet, 387, 53–60. doi:10.1016/S0140-6736(15)00056-2.

    Article  Google Scholar 

  • Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. doi:10.1037/0033-2909.129.5.674.

    Article  PubMed  PubMed Central  Google Scholar 

  • Molina, J. M., Capitant, C., Spire, B., Pialoux, G., Cotte, L., Charreau, I., et al., Group, A. I. S. (2015). On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. New England Journal of Medicine, 373, 2237–2246. doi:10.1056/NEJMoa1506273.

  • Moore, D. J., Blackstone, K., Woods, S. P., Ellis, R. J., Atkinson, J. H., Heaton, R. K., et al., The Tmarc, G. (2012). Methamphetamine use and neuropsychiatric factors are associated with antiretroviral non-adherence. AIDS Care, 24, 1504–1513. doi:10.1080/09540121.2012.672718.

  • Mugwanya, K. K., Donnell, D., Celum, C., Thomas, K. K., Ndase, P., Mugo, N., et al. (2013). Sexual behaviour of heterosexual men and women receiving antiretroviral pre-exposure prophylaxis for HIV prevention: A longitudinal analysis. The Lancet. Infectious Diseases, 13, 1021–1028. doi:10.1016/S1473-3099(13)70226-3.

    Article  PubMed  PubMed Central  Google Scholar 

  • National Institute on Drug Abuse. NIDA Quick Screen V1.0 and Questions 1–8 of the NIDA-Modified ASSIST V2.0. Retrieved from

  • Newcomb, M. E., Mongrella, M. C., Weis, B., McMillen, S. J., & Mustanski, B. (2016). Partner disclosure of PrEP use and undetectable viral load on geosocial networking apps: frequency of disclosure and decisions about condomless sex. JAIDS Journal of Acquired Immune Deficiency Syndromes, 71(2), 200–206.

  • Parker, S., Chan, P. A., Oldenburg, C. E., Hoffmann, M., Poceta, J., Harvey, J., et al. (2015). Patient experiences of men who have sex with men using pre-exposure prophylaxis to prevent HIV infection. AIDS Patient Care and STDs, 29, 639–642.

    Article  PubMed  PubMed Central  Google Scholar 

  • Perez-Figueroa, R. E., Kapadia, F., Barton, S. C., Eddy, J. A., & Halkitis, P. N. (2015). Acceptability of PrEP uptake among racially/ethnically diverse young men who have sex with men: The P18 study. AIDS Education and Prevention, 27, 112–125. doi:10.1521/aeap.2015.27.2.112.

    Article  PubMed  PubMed Central  Google Scholar 

  • Pines, H. A., Gorbach, P. M., Weiss, R. E., Shoptaw, S., Landovitz, R. J., Javanbakht, M., et al. (2014). Sexual risk trajectories among MSM in the United States: Implications for pre-exposure prophylaxis delivery. Journal of Acquired Immune Deficiencies Syndrome, 65, 579–586. doi:10.1097/QAI.0000000000000101.

    Article  Google Scholar 

  • Potter, W. J., & Levine-Donnerstein, D. (1999). Rethinking validity and reliability in content analysis. Journal of Applied Communication Research, 27(3), 258–284. doi:10.1080/00909889909365539.

  • Reback, C. J., Fletcher, J. B., Shoptaw, S., & Grella, C. E. (2013). Methamphetamine and other substance use trends among street-recruited men who have sex with men, from 2008 to 2011. Drug and Alcohol Dependence, 133, 262–265. doi:10.1016/j.drugalcdep.2013.06.007.

    Article  PubMed  PubMed Central  Google Scholar 

  • Shoptaw, S., & Reback, C. J. (2006). Associations between methamphetamine use and HIV among men who have sex with men: a model for guiding public policy. Journal of Urban Health, 83(6), 1151–1157.

  • Smith, D. K., Van Handel, M., Wolitski, R. J., Stryker, J. E., Hall, H. I., Prejean, J., et al. (2015). Vital signs: Estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV acquisition—United States, 2015. MMWR Morbidity and Mortality Weekly Report, 64, 1291–1295. doi:10.15585/mmwr.mm6446a4.

    Article  PubMed  Google Scholar 

  • Storholm, E. D., Satre, D. D., Kapadia, F., & Halkitis, P. N. (2015). Depression, compulsive sexual behavior, and sexual risk-taking among urban young gay and bisexual men: The P18 Cohort Study [published online August 27, 2015]. Archives of Sexual Behavior. doi:10.1007/s10508-015-0566-5

  • U.S. Census Bureau. (2010). Bay Area Census: San Francisco City and County. Retrieved from February 2, 2017, from

  • Volk, J. E., Marcus, J. L., Phengrasamy, T., Blechinger, D., Nguyen, D. P., Follansbee, S., & Hare, C. B. (2015). No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clinical and Infectious Diseases, 61, 1601–1603. doi:10.1093/cid/civ778.

    Article  Google Scholar 

  • 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(6), 1394–1410. 

  • Woolf, S. E., & Maisto, S. A. (2009). Alcohol use and risk of HIV infection among men who have sex with men. AIDS and Behavior, 13(4), 757–782.

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Correspondence to Erik D. Storholm.

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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.

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

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Storholm, E.D., Volk, J.E., Marcus, J.L. et al. Risk Perception, Sexual Behaviors, and PrEP Adherence Among Substance-Using Men Who Have Sex with Men: a Qualitative Study. Prev Sci 18, 737–747 (2017).

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