AIDS and Behavior (2019) 23:534–543 https://doi.org/10.1007/s10461-018-2214-2

ORIGINAL PAPER

Pre‑exposure Prophylaxis Among Men Who have Sex with Men: Dual Motivational Model of Intention to Use Pre‑exposure Prophylaxis

Yerina S. Ranjit1 · Alex Dubov2 · Maxim Polonsky3 · Liana Fraenkel4 · Adedotun Ogunbajo5 · Kenneth Mayer6 · Frederick L. Altice1

Published online: 6 July 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract Men who have sex with men (MSM) account for most new HIV infections in the United States. Despite representing a frac- tion of the population, MSM make up an estimated 65% of new infections. To address this epidemic, pre-exposure prophy- laxis (PrEP) is recommended to supplement use. Despite its efectiveness, PrEP uptake among MSM is low. Few studies have employed theoretical approaches to understand PrEP use intention. Incorporating factors like fatigue, expectation of better sexual experiences, and perceived risk are proposed in this dual motivational path model of PrEP use intention. This model hypothesized that PrEP use intention is infuenced by two key pathways: (1) protection motivation pathway, and (2) sexual expectancy pathway. Data were collected using social networking applications from 402 MSM. The model was tested using structural equation modeling. We elaborate the complex decision-making process proposed by this novel theoretical model and discuss its practical implications.

Keywords Men who have sex with men (MSM) · Pre-exposure prophylaxis (PrEP) · Dual motivational model · Safe sex fatigue, perceived risk

Introduction 2011, condom use among MSM declined by 20% [5, 6]. To address this expanding epidemic, national prevention guide- Men who have sex with men (MSM) account for most new lines recommend pre-exposure prophylaxis (PrEP) using HIV infections in the United States [1]. Despite represent- Truvada to supplement to condom use [7, 8]. A meta-anal- ing only 2–5% of the U.S. population, MSM comprise an ysis demonstrated that PrEP decreased the rate of serocon- estimated 65% of new HIV infections [2–4]. A contributing version in MSM by 92% when taken as prescribed [9]. PrEP factor of increased HIV incidence among MSM is associated has also been shown to efectively reduce HIV infections with increasingly prevalent condomless sex. From 2005 to among other key populations, including sex workers in India and Africa [10], people who inject drugs in Thailand [11], * Yerina S. Ranjit women in Africa [12], and transgender women in Brazil, [email protected] Ecuador, Peru, South Africa, Thailand, and the United States [13]. PrEP is approved for all women including pregnant 1 AIDS Program, Department of Internal Medicine, Yale women, sero-discordant couples and transgender women. University, 135 College Street, New Haven, CT, USA Although PrEP uptake among MSM is increasing in cer- 2 Loma Linda University School of Public Health, tain parts of the country, it remains relatively low and is une- Loma Linda, CA, USA ven, especially among young MSM of color [14–16]. With 3 Quinnipiac University School of Business, Hamden, CT, only 5% of MSM taking PrEP, a mathematical modeling USA study suggests that if coverage could increase by 40% in high 4 Section of Rheumatology, Yale University School risk MSM, one-third of HIV infections could be averted in of Medicine, New Haven, CT, USA the next decade [17]. Despite the evidence, low PrEP uptake 5 Department of Behavioral and Social Sciences, Brown in MSM is associated with lack of interest or awareness, low University School of Public Health, Providence, RI, USA previous experience with post-exposure prophylaxis (PEP), 6 Department of Global Health and Population, Harvard T.H. Chan, School of Public Health, Boston, MA, USA

Vol:.(1234567890)1 3 AIDS and Behavior (2019) 23:534–543 535 access to health insurance and cost, concerns about side connectivity and intimacy between consenting individuals efects and impact on overall health [14, 16, 18, 19]. as an important motivation for condomless sex [32–34]. The MSM were willing, however, to consider using PrEP if distinct lines of inquiry between these competing theories they perceived it to be efcacious and if they knew their therefore require further reconciliation. Hence, understand- partners were on PrEP [20, 21]. One study of high-risk, HIV- ing the decision-making process of PrEP use is important to uninfected MSM suggested that nearly 70% of participants develop successful prevention strategies that acknowledge were willing to use PrEP if they believed PrEP to be 80% and address issues related to perceived barriers posed by efective in preventing HIV [21]. while promoting facilitators that drive MSM’s While PrEP may be efective, one of the unintended con- interest in using PrEP. sequences of this prevention intervention is perhaps MSM’s interest in decreasing condom use. In a study conducted in Expectation of Better Sexual Experience New York city, half of the men interested in using PrEP and as Motivation to Use PrEP 30% of the HIV-negative members within a sero-discordant couple in San Francisco reported their intention to decrease Many factors including physical discomfort, perception of condom use while on PrEP [20, 21]. Qualitative evidence HIV as a manageable condition, optimism or complacency suggests that MSM on PrEP avoid condoms to improve their generated by perception of reduced severity of disease, and sexual experience by mitigating HIV risk while increasing issues related to condom negotiation and trust have been sexual pleasure, freedom, and intimacy [22, 23]. Collec- attributed to non-use of condoms among MSM [2, 3, 30, 35, tively, these data imply two potentially distinct motivational 36]. Studies show that condoms interfere with intimacy and pathways for PrEP use: (1) internal motivation to protect predict higher instances of condomless sex, and the moti- oneself from HIV, and (2) expectations of better sexual expe- vation for intimacy supports condomless sex and predicts riences through condomless sex [21]. Whether or not these PrEP use intention among MSM [34, 37, 38]. Motivation pathways operate independently or not, however, have not for intimacy in these studies was measured by the relational been explored. aspects of sex such as trust and connection. While condoms This interest in engaging in condomless sex while on provide the protection from HIV and other sexually trans- PrEP has often been attributed to the psychological phenom- mitted infections, MSM often perceive condoms as a major ena of behavioral disinhibition and risk compensation while hindrance to pleasure and intimacy of sexual experience. In on PrEP [21, 24–27]. The theory of behavioral disinhibition sum, MSM abandon condom use because it thwarts emo- argues that MSM will engage in risky behavior by relaxing tional gratifcation during sex, and PrEP may provide the self-imposed constraints because they perceive PrEP as a assurances that MSM need to feel safe from HIV, yet does substitute for behavioral control. The risk compensation the- not interfere with their desire for physical and emotional ory argues that MSM will engage in increased condomless gratifcation and intimacy. The literature, therefore, suggests sex and have higher numbers of partners on PrEP because that for some MSM, the intention to use PrEP is infuenced of reduced perceived risk of HIV transmission (e.g., when by the motivation to maintain afective and sexual pleasures their HIV + partners are virally suppressed or when they while still seeking protection from acquiring HIV. Hence, themselves are on PrEP) [28]. Collectively, these theories this study posits that the expectation of better sexual experi- assume that at least some MSM are risk-seekers who desire ence on PrEP will predict PrEP use intention. unrestrained sexual behavior and put oneself and others in harm’s way despite the knowledge of the risk involved. This Safe Sex Fatigue and Negative Attitude Toward assumption negatively labels MSM and does not adequately Condoms address the dilemma MSM may experience when deciding to engage in condomless sex, and elaborate the underlying An important barrier to condom use among MSM is related motives behind their unwillingness to use condoms in the to safe sex fatigue [39–42], which is often measured by state- presence of an alternative that promises protection. Addi- ments like “I fnd it difcult to maintain sexual safety” [39, tionally, the theory of risk compensation has not fully found 43]. Also known as “prevention burn-out”, safe sex fatigue strong support by the empirical evidence [29]. For exam- can be defned as a state where maintaining safe sex behavior ple, an HIV vaccine study with unsubstantiated efcacy is perceived as burdensome. Trying to be consistently safe showed an increase in sexual risk-taking among MSM who during sex, therefore, contributes towards people’s negative received the vaccine [30], yet one post-exposure prophylaxis attitude towards safe sex. And this perception of burden, (PEP) [31] and one PrEP [29] study showed a decrease or in turn, afects condom use. This cyclical condom-fatigue no change in risky behavior among MSM in the intervention and attitude relationship seems to adversely impact safe sex group, respectively. Rather, many sexual behavior studies behavior and increase the risk of becoming infected with have cited a strong appeal for sexual pleasure, emotional HIV. Hence, MSM experiencing higher levels of fatigue are

1 3 536 AIDS and Behavior (2019) 23:534–543 more likely to seek and be open to trying safer alternatives male and female drug users used the Information-Motiva- such as PrEP compared to those less fatigued. Addition- tion-Behavioral Skills (IMB) model to explain PrEP use ally, higher number of sexual partners (considered a risk intention [47]. The four items used in the composite moti- behavior) is associated with PrEP uptake [15]. Although the vation variable included three questions regarding general association between the two has not been fully explained or motivation to keep oneself and others safe from HIV, and elaborated in the literature, it can be assumed that MSM with one question about not being concerned of side efects [52]. greater number of sexual partners want to be safe because The IMB model, however, did not incorporate any ques- of their greater risk of acquiring HIV, and therefore, have a tions related to sexual (or drug use) expectations and risk higher intention and/or use of PrEP, compared to low-risk compensation while on PrEP. MSM. Using PrEP, or intending to do so, may be supported Given the complexity of the decision-making process by (a) their need to avoid risk, and (b) the need to avoid regarding safe sex among MSM, the current study proposes negative experiences when using condoms, including safe a novel theoretical model that examines the interrelationship sex fatigue, which they experience at a greater level than between motivating factors for PrEP use among MSM. The those who have fewer partners. Hence, this study posits that model (Fig. 1) posits that a higher number of sexual part- the number of partner will infuence safe sex fatigue directly ners infuence perception of risk and safe sex fatigue. Safe and PrEP use intention indirectly. sex fatigue, in turn, infuences negative attitudes about con- doms, which infuences the expectation of improved sexual Perception of Risk as Motivation for PrEP Use pleasure on PrEP. Both perception of risk and the sexual Intention expectancy on PrEP are expected to infuence the intention to use PrEP. In sum, the proposed model hypothesizes a Interest in PrEP among MSM has increased since its dual pathway to explain PrEP use intention: one driven by approval in 2012, which provides evidence of motivation to the intention to protect self and the other by the motivation protect oneself and others from HIV and other STIs [21, 37, to have enhanced sexual experience on PrEP. 42, 44, 45]. When MSM perceive themselves to be at risk, their intention to use PrEP is stronger [37]. The perception of risk is shown to increase with higher instances of con- Methods domless sex and with increased number of sexual partners [18, 37, 46–50]. Hence, the motivation behind using PrEP Using social (and sexual) networking applications (Apps) arises also from the need to protect oneself as well as from commonly used by MSM (Grindr, Hornet, Scruff, and maintaining the benefts or pleasures of condomless sex, Growlr), we gathered data from a convenience sample of 402 such as skin-to-skin contact, increased intimacy, and stress- participants in the U.S. Participants were recruited between free situations devoid of the need to inquire about partner May to August 2015 by randomly selecting app users. Their HIV status and condom negotiation [37, 49, 50]. profles are displayed on a grid of four photos in each row. Thus, this study aims to explore the complex relationship We used a randomization number chart displaying numbers between attitudes toward condom use and safe sex fatigue, from one to four to match the App’s display. A standard- expectation of better sexual experiences on PrEP, and per- ized script was used to message 800 selected App users. ceived risk on PrEP use intention among MSM. Understand- Interested participants received a link directing users to the ing this decision-making process is extremely important to survey, where eligibility was assessed and included: self- develop successful preventative strategies that acknowledge identifying as MSM, 21 years of age or older, self-reported and address issues related to perceived barriers posed by HIV negative status, and no previous history of using Tru- condoms while promoting facilitators that drive MSM’s vada for PrEP. Eligible participants used ‘click to consent’ interest in using PrEP. procedure. Participants were not fnancially compensated and the study was approved by the institutional review at Model of PrEP Use Intention Yale University.

Many factors like motivation to maintain intimacy with con- domless sex, safe sex fatigue, lack of awareness, education, Measures cost, side efects, negotiating capabilities, perceived risk, self-efcacy, etc., have been cited as factors that infuence Number of sexual partners was measured using a single PrEP use intention [14, 37, 38, 46, 51]. Few studies, how- item, “How many sexual partners did you have in the past ever, have used theoretical models to understand the process 6 months?” (1 = One partner to 5 = 10 + partners). by which these predictors interact and infuence each other Negative attitude towards condoms was measured to afect the decision to use PrEP. A study among high risk using six items on 4-point Likert scale. The items were:

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Fig. 1 Hypothesized dual motivational model of PrEP use intention. of better sexual experience on PrEP and the protection motivation The hypothesized model proposes dual pathways to PrEP use inten- pathway, driven by perceived risk to self of acquiring HIV tion. The expectancy motivation pathway, driven by the expectation

“I believe that using condoms interferes with sexual PrEP use intention was measured using one item meas- pleasure”; “I believe that stopping to put on a condom ured on a numeric rating scale: 1 = I am certain I DO NOT ruins the moment”; “I believe that using condoms makes WANT to start PrEP to 10 = I am certain I DO WANT to me less sexually desirable”; “Using condoms during sex start PrEP [21]. ruins the mood”; “Using condom will feel unnatural”; and “My partner(s) will not be sexually satisfed if we use a condom”. The Cronbach alpha of this scale in the current Analysis study was α = .90 [53]. Safe sex fatigue was measured using three items on the To test the hypothetical model, we used structural equation same 4-point Likert scale. The items were: “It takes a lot of modeling (SEM). Unlike linear regression or correlation, efort for me to keep my sexual behavior safe”; “I feel tired SEM is a statistical technique that provides fexibility to of always having to monitor my sexual behavior”; and “I examine the interrelationships among dependent variables fnd it difcult to maintain my commitment to safer sex”. and independent variables. It also allowed us to examine The Cronbach alpha of the scale in the current study was the direct as well as indirect efects of each of the variables α = .84 [41, 54]. on the dependent variable [57, 58]. We used AMOS 24 to Sexual expectancy on PrEP was measured using eight conduct the SEM analyses [59, 60]. Relationships that were items on a 5-point Likert scale adapted from sex-related weak (less than 0.1) and not signifcant at p < 0.05 were alcohol expectancies scale [55]. The items, reverse coded removed. We also used the modifcation indices to examine stemmed from one anchor statement: “When on PrEP”: “I the missing links not hypothesized in the model. If those may be less likely to inquire about my partner’s HIV status missing associations improved the overall goodness of ft before having sex”; “I may be less likely to ask for/discuss/ of the model, we included those paths in the fnal model use condoms”; “I may be more likely have more adventurous [57]. We tested for indirect efects among variables by using sex”; “I think my sexual performance will be enhanced”; “I AMOS bootstrapping procedure with 4000 bootstrap sam- may feel more relaxed during sex”; “I think it will be easier ples and bias-corrected accelerated confdence intervals. to express my sexual needs or desires”; “I think sex will probably be more loving”; and “I may think about sex more often”. The Cronbach alpha of this scale was α = .84. Results Perceived risk was measured using two items on a 4-point Likert scale. The items were: “It is unlikely that I Descriptive Results will get HIV in the next year” and “It is unlikely that I will get sexually transmitted infections (STI) other than HIV in The sample (n = 402), on an average, were their early forties the next year” [56]. (M = 41.6 years, SD = 11.31), mostly white (87.6%), 7.2%

1 3 538 AIDS and Behavior (2019) 23:534–543 identifed as Black or African American and 12.7% identi- reported their as homosexual, 5.5% as fed themselves as Hispanic or Latino. Ninety-three percent bisexual, 0.2% as heterosexual, and 0.5% as transsexual. More than half of the population had received some col- lege education (57.8%). Majority of the population (95.3%) Table 1 Key characteristics of participants reported to have heard about PrEP (See Table 1). Characteristic Total (n = 402), No. (%) or Mean ± SD Dual Motivational Model of PrEP Use Intention

Age M = 41.58, SD = 11.33 Results from the SEM analysis for the hypothesized model Race/ethnicity shown in Fig. 2 had a poor ft χ2 = 48.73, df = 0, p = .00 with Latino or hispanic 51 (12.7) root mean square error of approximation (RMSEA) of 0.11. Non-hispanic 351 (87.3) Thus, a series of post hoc analyses were conducted to fnd White 353 (87.6) the best ftting model. Missing paths suggested by modifed African American/black 28 (7.2) indices based on the correlations were added to the model Asian 13 (3.2) (See Table 2 for the correlation matrix). Additionally, age American Indian/Alaska Native 7 (1.7) was correlated with PrEP use intention (r = − .13, p < .05), Native Hawaiian or Pacifc Islander 1 (0.2) therefore it was controlled for by adding to the model. Education The fnal expanded model obtained a close ft to the data < College 24 (6.0) χ2 = 18.55, df = 12, p = .10. The fnal model shown in Fig. 3 College 232 (57.7) also explained 20% of the variance in PrEP use intention and > College 146 (36.3) produced a comparative ft index (CFI) of .98, with RMSEA Heard of PrEP before the study of .04 (PCLOSE = .72). These model ft indices suggest our Yes 383 (95.3) model was a good ft for the data. No 19 (4.7) Sexual orientation Direct Efects Homosexual 374 (93) Bisexual 22 (5.5) A greater number of sexual partners in the past six months Heterosexual 1 (0.2) was associated with a higher perception of safe sex fatigue Transsexual 2 (0.5) (ρ = .20, p < .01), and greater perceived risk (ρ = .24, Other 3 (0.7) p < .01). Higher perception of safe sex fatigue was directly M mean, SD standard deviation, PrEP pre-exposure prophylaxis associated with higher negative attitude towards condoms

Fig. 2 Hypothesized dual motivational model of PrEP use inten- explained 16% of the variance in the outcome variable PrEP use tion. The hypothesized dual motivational model of PrEP use inten- intention. Overall model ft: χ2 = 48.733, df = 9, p = .01; CFI = .98; tion among MSM (N = 402) resulted in a poor ft. The fnal model RMSEA = .105; PCLOSE = .001

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Table 2 Correlations among the variables used in the path analysis 1 2 3 4 5 6 7 Mean SD

1 Age 1.0 41.58 11.31 2 Number of partners 0.03 1.0 2.96 1.34 3 Safe sex fatigue 0.11* 0.20** 1.0 2.25 0.82 4 Negative attitude towards condoms 0.14** 0.13** 0.67** 1.0 2.29 0.72 5 Sexual expectancy on PrEP 0.059 0.14** 0.48** 0.51** 1.0 3.00 0.81 6 Perceived risk − 0.00 0.29** 0.28** 0.18** 0.19** 1.0 1.78 0.69 7 PrEP use intention − 0.13* 0.17** 0.28** 0.27** 0.39** 0.24** 1.0 6.41 2.73

*Correlation is signifcant at the 0.05 level (2-tailed) **Correlation is signifcant at the 0.01 level (2-tailed)

Fig. 3 Revised dual motivational model of PrEP use intention. The added later based on modifed indices. The fnal model explained revised dual motivational model of PrEP use intention among MSM 20% of variance in the outcome variable PrEP use intention. Overall (N = 402). All paths are signifcant at p < .01. Indirect efects for model ft: χ2 = 18.558, df = 12, p = .100; CFI = 0.98; RMSEA = 0.04; tested AMOS bootstrapping procedure with 4000 bootstrap samples PCLOSE = 0.72 and bias-corrected confdence intervals. The dotted lines are paths

(ρ = .67, p < .00). The modifed indices suggested two Indirect Efects new direct mediating paths previously not hypothesized: paths from higher perception of safe sex fatigue to higher We found that the number of sexual partners in the past sexual expectancy on PrEP (ρ = .24, p < .01), and to higher 6 months had an indirect positive efect on PrEP use inten- perceived risk (ρ = 0.23, p < .00). Having higher negative tion (ρ = 0.08, p < .01), mediated by four variables: (1) safe attitude towards condoms also had a direct and positive sex fatigue, (2) negative attitude towards condoms, (3) infuence on higher sexual expectancy on PrEP (ρ = .35, sexual expectancies while on PrEP, and (4) perceived risk. p < .01). Having higher sexual expectancy on PrEP was These mediated relationships suggested two independent directly related to PrEP use intention (ρ = .36, p < .01). paths to PrEP use intention. The relationship between the Perceived risk also directly infuenced PrEP use intention selected variables are presented in Table 3. (ρ = .17, p < .05). Finally, age was controlled for and it was Specifcally, a higher number of sexual partners had an added to the model. It was negatively related to PrEP use indirect efect on PrEP use intention via safe sex fatigue, intention (ρ = − .15, p < .00). negative attitude towards condoms and expectation of better

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Table 3 Direct, indirect and total efects among variables included in the model assessing PrEP use intention Variables Direct ­efectsa Indirect efects Total efects Predictor Criterion B(SE) Beta B(SE) Beta B(SE) Beta

Number of partners Safe sex fatigue 0.21 (0.03) 0.2 – – 0.12 (0.03) 0.19* Negative attitude towards condoms – – 0.07 (0.02) 0.13* 0.07 (0.02) 0.13* Sexual expectancy on PrEP 0.13 (0.03) 0.24 0.06 (0.02) 0.09* 0.15 (0.02) 0.09* Perceived risk – – 0.02 (0.01) 0.05* 0.06 (0.03) 0.29* PrEP use intention – – 0.17 (0.01) 0.08* 0.17 (0.04) 0.08* Safe sex fatigue Negative attitude towards condoms 0.60 (0.24) 0.67 – – 0.6 (0.04) 0.67* Sexual expectancy on PrEP 0.24 (0.06) 0.24 0.24 (0.04) 0.24* 0.48 (0.05) 0.46* Perceived risk 0.23 (0.04) 0.23 – – 0.19 (0.04) 0.23* PrEP use intention – – 0.71 (0.09) 0.21* 0.71 (0.09) 0.21* Negative attitude towards condoms Sexual expectancy on PrEP 0.40 (0.06) 0.35 – – 0.4 (0.07) 0.36* PrEP use intention – – 0.49 (0.11) 0.13* 0.49 (0.01) 0.13* Sexual expectancy on PrEP PrEP use intention 1.23 (0.15) 0.36 – – 1.23 (0.15) 0.17* Perceived risk PrEP use intention 0.65 (0.19) 0.17 – – 0.65 (0.19) 0.36* Age PrEP use intention – – − 0.04 (0.01) − 0.15*

PrEP pre-exposure prophylaxis *p < .01 for indirect and total efects a All direct efects are signifcant at p < .01 sexual experience on PrEP. Negative attitudes toward con- risk. These two pathways provide a basis for how PrEP doms infuenced PrEP use via sexual expectancy on PrEP expansion might be targeted. One path is associated with (ρ = 0.13, p < .01). Using a more conventional way of test- sexual expectations (expectancy driven motivation) and the ing mediation, when PrEP use intention was regressed on other associated with protection (prevention driven motiva- negative attitude towards condoms, the independent vari- tion). For both pathways, the number of sexual partners is able signifcantly predicted the dependent variable (β = 0.26, central to the proposed pathways. On one hand, higher num- p = .01), however the relationship disappeared (β = 0.09, ber of sexual partners, condom attitude and safe sex fatigue p = .08) when sexual expectancy (β = 0.34, p < .01) was were driving forces sexual expectancy on PrEP. On the other, entered into the model [61]. Perceived risk also mediated higher number of sexual partners and safe sex fatigue was the relationship between higher number of partners and PrEP found to infuence perceived risk (discussed in detail below). use intention. The direct and indirect paths are presented in In doing so, we established a unique dual model of motiva- Table 3. tion for PrEP use intention (See Fig. 3). Examining each of Based on these findings, the final SEM favored two these relationships separately provides us an explanation of diverging pathways infuencing PrEP use intention. One that how MSM making decision about using PrEP. is driven by the motivation to have better sexual experience, hence labeled as Expectancy Motivation Pathway, and the Expectancy Driven Motivation to PrEP Use Intention other that is driven by the need to protect oneself from infec- tions, labeled as Protection Motivation Pathway. In the expectancy driven motivational pathway to PrEP use intention, we see that sexual expectancy on PrEP was directly infuenced by negative attitude towards condoms and Discussion safe sex fatigue, and indirectly infuenced by higher number of partners. Here, sexual expectancy on PrEP is constructed The primary goal of this study was to better understand the by factors such as physical and emotional intimacy, condom determinants of intention to use PrEP among MSM. Numer- negotiations and spontaneity. This path illustrates that those ous individual (e.g., age, education and risky behavior such MSM who are tired of using condoms for safe sex and have as condomless sex), medication (e.g., side efects, efcacy) stronger dislike for condoms are likely to consider using and structural (e.g., free availability of PrEP) [14, 47] factors PrEP. Our fnding suggest that it is not merely the negative have been associated with PrEP use intention. In this study, attitude about condoms, but the promise of better sexual however, as hypothesized we found two paths to PrEP use experiences without condoms that motivates MSM to use intention: (1) sexual expectancy on PrEP, and (2) perceived PrEP, expanding the process by which dislike for condoms

1 3 AIDS and Behavior (2019) 23:534–543 541 may trigger PrEP use intention. Consistent with previous mostly geared towards promoting condoms. But because fndings, these results demonstrate the association between of increasing incidence of condomless sex, it is important PrEP use intention and perceived barriers of condoms like to target those MSM, who perceive themselves to be at intimacy, arousal and pleasure during sex [20, 21, 37]. This elevated risk, and address the underlying concerns of safe fnding also highlights MSM’s desire to have “normal sex” sex fatigue and the negative attitude towards condoms in as expressed by a blogger, “When have sex with- all HIV communication at individual level as well as by out a condom it is demonized as “barebacking”. But when health campaigns, without downplaying the preventative straight people do this, it is just “having sex”. Many straight power of condoms against STIs [2, 19, 34, 41, 42]. men have told me that their default setting is to have sex Finally, in this study, age was negatively related to without a condom and that they will only wear one at the PrEP use intention, which means younger people are more insistence of the female partner.” [23] Future studies can likely to be interested in using PrEP. Alternatively, how- examine which of the factors within sexual expectancies— ever, public health programs may also need to focus on namely physical pleasure, condom negotiation, or relational older population of MSM who may be experiencing higher intimacy, is most infuential in predicting PrEP use intention. level of fatigue, either because they have been practicing Additionally, safe sex fatigue, which is associated with sex with condoms longer or they simply dislike condoms decreased condom use, shows a direct infuence on negative for the reasons discussed above. It is also noteworthy that attitude towards condoms [32, 39, 43, 44, 54, 62]. Although most MSM who participated in this study were racially distinctly diferent constructs, safe sex fatigue and negative white and more than 90% in this sample were college or attitudes toward condoms were found to be highly correlated more educated. This representation may be refective a in this study, suggesting that fatigue is still associated with similar ethnic gap in access to HIV care [63] and of the continued use of condoms in some instances. Further, there digital divide [64] among diferent ethnic groups since was a direct association between higher number of sexual this study was advertised through Internet based social partners and safe sex fatigue and higher perceived risk. This networking apps used by MSM. suggests that MSM with higher number of sexual partners The fndings of this study are compelling and could have experienced a higher level of safe sex fatigue. Additionally, several practical implications for public health programs. having multiple partners indirectly infuenced PrEP use There are, however, noteworthy shortcomings. We can intention. These fndings demonstrate that people who are only draw associations among variables, and not causality engaging with many sex partners are more likely to use PrEP because this was a cross-sectional data. Future studies should because they perceive using condoms as highly burdensome. test the dual motivational model using longitudinal data. The study also measured intention and not the actual uptake of Protection Driven Motivation to PrEP Use Intention PrEP. Additionally, the data from this sample, did not have sufcient granularity to disentangle risk compensation. Aligned with previous studies, the results show that per- ceived rather than actual risk directly and positively infu- ences PrEP use intention [14, 52]. What is interesting and confirms previous findings is that perception of risk is Conclusion directly infuenced by both the number of sexual partners [14] and by safe sex fatigue [62]. This fnding supports the This study presents a new theoretical model of understand- notion that men, who engage in condomless sex despite the ing PrEP use intention among MSM: The Dual Motivational knowledge of risk to self, experience a state of cognitive Model of PrEP use intention. While it is important to con- dissonance and internal confict [22, 23]. A study of MSM tinue promoting condoms, especially with their benefts to who engaged in condomless sex found a signifcant number preventing other treatable STIs, it is crucial to acknowledge of them expressed concerns about their risk of acquiring safe sex fatigue among MSM who disproportionate expe- HIV, and were open to protecting oneself [45]. Hence, safe rience excess burden of HIV transmission. The proposed sex fatigued MSM who engage in condomless sex for the model suggests two important path that infuence PrEP use reasons of intimacy and sexual pleasure, may be more recep- intention: (1) Expectancy Motivation Pathway (the expec- tive to using PrEP to mitigate this internal confict [34, 45]. tation to have better sexual experience on PrEP) and (2) In sum, this study highlights the complexity of deci- Protection Motivation Pathway (the expectation to protect sion-making about PrEP among MSM, while providing oneself from HIV). Evidence from this study suggests that insights into strategies for effective intervention. The HIV campaigns need to be position and market PrEP as an fndings also provide an alternative explanation for con- additional protective strategy to supplement condom use, domless sex or increased risk behavior presented by risk and as a safety net for times when there are gaps in condom compensation theory. Public health programs today are use.

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Funding Research reported in this publication was supported by the 11. Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA, National Institute of Arthritis and Musculoskeletal and Skin Dis- Leethochawalit M, et al. Antiretroviral prophylaxis for HIV infec- eases, part of the National Institutes of Health, under Award Number tion in injecting drug users in Bangkok, Thailand (the Bangkok AR060231-06 (Fraenkel). The content is solely the responsibility of Tenofovir Study): a randomised, double-blind, placebo-controlled the authors and does not necessarily represent the ofcial views of the phase 3 trial. Lancet. 2013;381(9883):2083–90. National Institutes of Health. The authors do not have any conficts of 12. Hanscom B, Janes HE, Guarino PD, Huang Y, Brown ER, Chen interest related to the content of this manuscript. YQ, et al. Brief report: preventing HIV-1 infection in women using oral preexposure prophylaxis: a meta-analysis of current Compliance with Ethical Standards evidence. J Acquir Immune Defc Syndr. 2016;73(5):606–8. 13. Deutsch MB, Glidden DV, Sevelius J, Keatley J, McMahan V, Guanira J, et al. HIV pre-exposure prophylaxis in transgender Conflict of interest Yerina S. Ranjit, Alex Dubov, Maxim Polonksy, women: a subgroup analysis of the iPrEx trial. Lancet HIV. Liana Fraenkel, Adedotun Ogunbajo, Kenneth Mayer, and Frederick 2015;2(12):e512–9. L. Altice declare that they have no confict of interest. 14. Krakower DS, Mimiaga MJ, Rosenberger JG, Novak DS, Mitty JA, White JM, et al. Limited awareness and low immediate Ethical Approval All procedures performed in studies involving human uptake of pre-exposure prophylaxis among men who have sex participants were in accordance with the ethical standards of the insti- with men using an internet social networking site. PLoS ONE. tutional and/or national research committee and with the 1964 Helsinki 2012;7(3):e33119. declaration and its later amendments or comparable ethical standards. 15. Hood JE, Buskin SE, Dombrowski JC, Kern DA, Barash EA, Katzi DA, et al. Dramatic increase in preexposure prophylaxis Informed Consent Informed consent was obtained from all individual use among MSM in Washington state. AIDS. 2016;30(3):515–9. participants included in the study. 16. Holloway I, Dougherty R, Gildner J, Beougher SC, Pulsipher C, Montoya JA, et al. PrEP Uptake, adherence, and discontinuation among California YMSM using geosocial networking applica- tions. J Acquir Immune Defc Syndr (1999). 2017;74(1):15–20. 17. Gomez GB, Borquez A, Caceres CF, Segura ER, Grant RM, Gar- References nett GP, et al. The potential impact of pre-exposure prophylaxis for HIV prevention among men who have sex with men and Trans- women in Lima, Peru: a mathematical modelling study. PLoS 1. Linley L, An Q, Song R, Valverde E, Oster AM, Qian X, et al. Med. 2012;9(10):e1001323. HIV testing experience before HIV diagnosis among men who 18. Mayer KH, Oldenburg CE, Novak DS, Elsesser SA, Krakower DS, have sex with men—21 Jurisdictions, United States, 2007-2013. Mimiaga MJ. Early adopters: correlates of HIV chemoprophylaxis MMWR Morb Mortal Wkly Rep. 2016;65(37):999–1003. use in recent online samples of US men who have sex with men. 2. Wolitski RJ, Valdiserri RO, Denning PH, Levine WC. Are we AIDS Behav. 2016;20(7):1489–98. headed for a resurgence of the HIV epidemic among men who 19. Golub SA, Gamarel KE, Rendina HJ, Surace A, Lelutiu-Wein- have sex with men? Am J of Public Health. 2001;91(6):883–8. berger CL. From efcacy to efectiveness: facilitators and barriers 3. Kalichman SC. Post-exposure prophylaxis for HIV infection in to PrEP acceptability and motivations for adherence among MSM gay and bisexual men: implications for the future of HIV preven- and transgender women in New York City. AIDS Patient Care tion. Am J Prev Med. 1998;15(2):120–7. STDS. 2013;27(4):248–54. 4. Chesney MA, Chambers DB, Kahn JO. Risk behavior for HIV 20. Hof CC, Chakravarty D, Bircher AE, Campbell CK, Grisham infection in participants in preventive HIV vaccine trials: a cau- K, Neilands TB, et al. Attitudes towards PrEP and anticipated tionary note. J Acquir Immune Defc Syndr Hum Retrovirol. condom use among concordant HIV-negative and HIV-discordant 1997;16(4):266–71. male couples. AIDS Patient Care STDS. 2015;29(7):408–17. 5. CDC. HIV testing and risk behaviors among gay, bisexual, and 21. Golub SA, Kowalczyk W, Weinberger CL, Parsons JT. Preexpo- other men who have sex with men—United States. MMWR Morb sure prophylaxis and predicted condom use among high-risk men Mortal Wkly Rep. 2013;62(47):958–62. who have sex with men. J Acquir Immune Defc Syndr. (1999). 6. Paz-Bailey G, Mendoza MCB, Finlayson T, Wejnert C, Le B, 2010;54(5):548–55. Rose C, et al. Trends in condom use among MSM in the United 22. Carlo Hojilla J, Koester KA, Cohen SE, Buchbinder S, Ladzekpo States: the role of antiretroviral therapy and seroadaptive strate- D, Matheson T, et al. Sexual behavior, risk compensation, and gies. AIDS. 2016;30(12):1985–90. HIV prevention strategies among participants in the San Francisco 7. Smith DK, Grant RM, Weidle PJ, Lansky A, Mermin J, Fenton PrEP demonstration project: a qualitative analysis of counseling KA. Interim guidance: pre-exposure prophylaxis for the preven- notes. AIDS Behav. 2016;20(7):1461–9. tion of HIV infection in men who have sex with men. CDC, 2011. 23. Cain M. Sex without fear: my experience with the HIV-prevention 8. Donnell D, Baeten JM, Bumpus NN, Brantley J, Bangsberg drug PrEP. The Guardian. 2017 June 22. DR, Haberer JE, et al. HIV protective efcacy and correlates 24. Hogben M, Liddon N. Disinhibition and risk compensation: scope, of tenofovir blood concentrations in a clinical trial of PrEP for defnitions, and perspective. Sex Transm Dis. 2008;35(12):1009. HIV prevention. J Acquir Immune Defc Syndr Hum Retrovirol. 25. Rudy BJ, Kapogiannis BG, Lally MA, Gray GE, Bekker LG, 2014;66(3):340–8. Krogstad P, et al. Youth-specifc considerations in the devel- 9. Spinner CD, Boesecke C, Zink A, Jessen H, Stellbrink HJ, Rock- opment of preexposure prophylaxis, microbicide, and vaccine stroh JK, et al. HIV pre-exposure prophylaxis (PrEP): a review of research trials. J Acquir Immune Defc Syndr. 2010;54(Suppl current knowledge of oral systemic HIV PrEP in humans. Infec- 1):S31–42. tion. 2016;44(2):151–8. 26. Guest G, Shattuck D, Johnson L, Akumatey B, Clarke EE, Chen 10. Vissers DCJ, Voeten HACM, Nagelkerke NJD, Habbema JDF, de PL, et al. Changes in sexual risk behavior among participants in a Vlas SJ. The impact of pre-exposure prophylaxis (PrEP) on HIV PrEP HIV prevention trial. Sex Transm Dis. 2008;35(12):1002–8. epidemics in Africa and India: a simulation study. PLoS ONE. 27. Eaton LA, Kalichman SC. Risk compensation in HIV pre- 2008;3(5):e2077. vention: implications for vaccines, microbicides, and other

1 3 AIDS and Behavior (2019) 23:534–543 543

biomedical HIV prevention technologies. Current HIV/AIDS Rep. among MSM in London: a community survey. Sex Transm Infect. 2007;4(4):165–72. 2013;89(3):207–11. 28. Kalichman SC, Rompa D. Sexual sensation seeking and Sexual 47. Mimiaga MJ, Case P, Johnson CV, Safren SA, Mayer KH. Pre- Compulsivity Scales: reliability, validity, and predicting HIV risk exposure antiretroviral prophylaxis attitudes in high-risk Boston behavior. J Pers Assess. 1995;65(3):586–601. area men who report having sex with men: limited knowledge and 29. Marcus JL, Glidden DV, Mayer KH, Liu AY, Buchbinder SP, experience but potential for increased utilization after education. Amico KR, et al. No evidence of sexual risk compensation in the J Acquir Immune Defc Syndr. 2009;50(1):77–83. iPrEx trial of daily oral HIV preexposure prophylaxis. PLoS ONE. 48. Grov C, Rendina HJ, Jimenez R, Parsons JT. Using online settings 2013;8(12):e81997. to identify gay and bisexual men willing to take or with experience 30. Chesney MA, Chambers DB, Kahn JO. Risk behavior for HIV taking PrEP: implications for researchers and providers. AIDS infection in participants in preventive HIV vaccine trials: a cau- Educ Prev. 2016;28(5):378–92. tionary note. J Acquir Immune Defc Syndr. 1997;16(4):266–71. 49. Wade Taylor S, Mayer KH, Elsesser SM, Mimiaga MJ, O’Cleirigh 31. Martin JN, Roland ME, Neilands TB, Krone MR, Bamberger JD, C, Safren SA. Optimizing content for pre-exposure prophylaxis Kohn RP, et al. Use of postexposure prophylaxis against HIV (PrEP) counseling for men who have sex with men: perspec- infection following sexual exposure does not lead to increases in tives of PrEP users and high-risk PrEP Naïve men. AIDS Behav. high-risk behavior. AIDS. 2004;18(5):787–92. 2014;18(5):871–9. 32. Ostergren JE, Rosser BRS, Horvath KJ. Reasons for non-use of 50. Rendina HJ, Whitfeld THF, Grov C, Starks TJ, Parsons JT. Dis- condoms among men-who-have-sex-with-men: a comparison of tinguishing hypothetical willingness from behavioral intentions receptive and insertive role-in-sex and online and ofine meeting to initiate HIV pre-exposure prophylaxis (PrEP): fndings from venue. Cult Health Sex. 2011;13(2):123–40. a large cohort of gay and bisexual men in the U.S. Soc Sci Med. 33. Sarkar NN. Barriers to condom use. Eur J Contracept Reprod 2017;172:115–23. Health Care. 2008;13(2):114–22. 51. Jackson T, Huang A, Chen H, Gao X, Zhong X, Zhang Y. Cogni- 34. Carballo-Diéguez A, Dolezal C. HIV risk behaviors and obstacles tive, psychosocial, and sociodemographic predictors of willing- to condom use among Puerto Rican men in New York City who ness to use HIV pre-exposure prophylaxis among Chinese men have sex with men. Am J Public Health. 1996;86(11):1619–22. who have sex with men. AIDS Behav. 2012;16(7):1853–61. 35. Ho DD. Therapy of HIV infections: problems and prospects. Bull 52. Shrestha R, Altice FL, Huedo-Medina TB, Karki P, Copenhaver N Y Acad Med. 1996;73(1):37–45. M. Willingness to use pre-exposure prophylaxis (PrEP): an empir- 36. Wolitski RJ. The emergence of barebacking Among Gay and ical test of the information-motivation-behavioral skills (IMB) bisexual men in the United States: a public health perspective. J model among high-risk drug users in treatment. AIDS Behav. Gay Lesbian Psychother. 2005;9(3/4):9–34. 2017;21(5):1299–308. 37. Gamarel K, Golub S. Intimacy motivations and pre-exposure 53. Helweg-Larsen M, Collins BE. The UCLA multidimensional prophylaxis (PrEP) adoption intentions among HIV-negative men condom attitudes scale: documenting the complex determi- who have sex with men (MSM) in romantic relationships. Ann nants of condom use in college students. Health Psychol. Behav Med. 2015;49(2):177–86. 1994;13(3):224–37. 38. Golub SA, Starks TJ, Payton G, Parsons JT. The critical role of 54. Ostrow DE, Fox KJ, Chmiel JS, Silvestre A, Visscher BR, Vanable intimacy in the sexual risk behaviors of gay and bisexual men. PA, et al. Attitudes towards highly active antiretroviral therapy AIDS Behav. 2012;16(3):626–32. are associated with sexual risk taking among HIV-infected and 39. Rowniak S. Safe sex fatigue, treatment optimism, and serosorting: uninfected homosexual men. AIDS. 2002;16(5):775. new challenges to HIV prevention among men who have sex with 55. Dermen KH, Cooper ML. Sex-related alcohol expectancies men. J Assoc Nurses AIDS Care. 2009;20(1):31–8. among adolescents: I. Scale development. Psychol Addict Behav. 40. Blackwell CW. Men who have sex with men and recruit bareback 1994;8(3):152–60. sex partners on the internet: implications for STI and HIV preven- 56. Napper L, Fisher D, Reynolds G. Development of the perceived tion and client education. Am J Mens Health. 2008;2(4):306–13. risk of HIV Scale. AIDS Behav. 2012;16(4):1075–83. 41. Stolte IG, de Wit JBF, Kolader M, Fennema H, Coutinho RA, 57. Chin WW. Commentary: issues and opinion on structural equation Dukers NHTM. Association between ‘safer sex fatigue’ and modeling. MIS Q. 1998;22(1):vii–xvi. rectal gonorrhea is mediated by unsafe sex with casual part- 58. Bollen KA, Long JS. Tests for structural equation models: intro- ners among HIV-positive homosexual men. Sex Transm Dis. duction. Sociol Methods Res. 1992;21(2):123–31. 2006;33(4):201–8. 59. Arbuckle JL. Amos. 24th ed. Chicago: IBM; 2014. 42. Kellogg AP. ‘Safe sex fatigue’ grows among gay students. Chroni- 60. Barrett P. Structural equation modelling: adjudging model ft. Pers cle High Educ. 2002;48(19):A37. Individ Dif. 2007;42(5):815–24. 43. Ostrow DG, Silverberg MJ, Cook RL, Chmiel JS, Johnson L, Li X, 61. Fairchild A, MacKinnon D. A general model for testing mediation et al. Prospective study of attitudinal and relationship predictors and moderation efects. Prev Sci. 2009;10(2):87–99. of sexual risk in the multicenter AIDS cohort study. AIDS Behav. 62. Adam BD, Husbands W, Murray J, Maxwell J. AIDS optimism, 2007;12(1):127. condom fatigue, or self-esteem? Explaining unsafe sex among gay 44. Coleman CL, Ball K. Determinants of perceived barriers to con- and bisexual men. J Sex Res. 2005;42(3):238–48. dom use among HIV-infected middle-aged and older African- 63. Hall HI, Frazier EL, Rhodes P, Holtgrave DR, Furlow-Parmley C, American men. J Adv Nurs. 2007;60(4):368–76. Tang T, et al. Diferences in human immunodefciency virus care 45. Balán IC, Carballo-Diéguez A, Ventuneac A, Remien RH, Dolezal and treatment among subpopulations in the United States. JAMA C, Ford J. HIV-negative men-who-have-sex-with-men who bare- Intern Med. 2013;173(14):1337–44. back are concerned about HIV infection: implications for HIV risk 64. Brodie M, Flournoy RE, Altman DE, Blendon RJ, Benson JM, reduction interventions. Arch Sex Behav. 2013;42(2):279–89. Rosenbaum MD. Health information, the internet, and the digital 46. Aghaizu A, Mercey D, Copas A, Johnson AM, Hart G, Nardone divide. Health Af. 2000;19(6):255–65. A. Who would use PrEP? Factors associated with intention to use

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