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Vulnerable Periods

Characterizing Patterns of Sexual Risk and Substance Use During Lapses in Adherence to HIV Pre-exposure Prophylaxis Among Men Who Have Sex With Men

Wray, Tyler B. PhD*; Chan, Philip A. MD; Kahler, Christopher W. PhD*; Simpanen, Erik M. BS*; Liu, Tao PhD; Mayer, Kenneth H. MD§

JAIDS Journal of Acquired Immune Deficiency Syndromes: March 1, 2019 - Volume 80 - Issue 3 - p 276–283
doi: 10.1097/QAI.0000000000001914
Prevention Research

Background: Pre-exposure prophylaxis (PrEP) is highly efficacious, but some groups of men who have sex with men may have difficulty adhering to daily dosing. Prevention-effective adherence suggests that PrEP's efficacy depends on adherence at the time of HIV exposure; yet, few studies have examined how exposures (ie, high-risk sex) overlap with periods of consecutive missed PrEP doses. Substance use may also play a role in these vulnerable periods.

Methods: We used digital pill bottles to monitor the daily adherence of 40 PrEP-experienced patients recruited from an outpatient clinic in the Northeastern US over a six-month period. Participants also completed detailed online diaries every 2 weeks during this time that surveyed their sexual behavior and substance use each day.

Results: Daily adherence was high overall (M = 83.9%, SD = 18.0%), but 53% (N = 21) had a lapse of > 3 consecutive daily PrEP doses over 6 months. Participants' rate of engaging in high-risk condomless anal sex (CAS) did not differ across lapse days versus continuously adherent days. Alcohol use was not associated with engaging in CAS during a PrEP lapse. However, participants reported engaging in CAS significantly more often during a PrEP adherence lapse on days when they also used stimulant drugs.

Conclusions: Men who have sex with men may have periodic difficulty adhering to PrEP at the specific times when they are at risk. Stimulant drug use could play an important role in increasing HIV risk specifically during adherence lapses.

*Center for Alcohol and Addictions Studies, Brown University School of Public Health, Providence, RI

Department of Medicine, Alpert Medical School of Brown University, Providence, RI;

Department of Biostatistics, Center for Statistical Sciences, School of Public Health, Brown University, Providence, RI

§Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

Correspondence to: Tyler B. Wray, PhD, Center for Alcohol and Addictions Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912 (e-mail:

Supported by P01AA019072 (to P.A.C.) and L30AA023336 (to T.B.W.) from the National Institute on Alcohol Abuse and Alcoholism and P30AI042853 from the National Institute of Allergy and Infectious Diseases.

Informed consent was obtained from all individual participants included in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

K.H.M. has received unrestricted research grants from Gilead Sciences and ViiV. The remaining authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received August 02, 2018

Accepted October 29, 2018

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