Keenan Withers BA, Khoa Tran MPH, James Huynh MA, MPH, Jeffrey Klausner MD, MPH, Steve Shoptaw PhD, Le Minh Giang MD, PhD
Factors that impact Pre-Exposure Prophylaxis (PrEP) adherence among men who have sex with men (MSM) who frequently use stimulants in Hanoi and Ho Chi Minh City (HCMC), Vietnam: An Applied Thematic Analysis
Purpose: In Vietnam, men who have sex with men (MSM) who frequently use amphetamine-type stimulants (ATS) (e.g. methamphetamine, amphetamine, ecstasy/MDMA) are one of the most at-risk groups for HIV. Pre-Exposure Prophylaxis (PrEP) could substantially reduce HIV transmission; however, the factors associated with PrEP adherence are relatively unknown in this population. The purpose of our study is to explore factors that impact PrEP adherence among HIV-uninfected Vietnamese MSM who use stimulants.
Methods: From November 2019 to May 2020, semi-structured in-depth interviews were conducted with 40 MSM using PrEP and self-reported stimulant use. All MSM was recruited by community-based organizations (CBO) /men’s sexual clinics that provide PrEP outreach and support services for clients who reside in Hanoi and Ho Chi Minh City. We screened participants for stimulant use using the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and ABON multi-drug urine dipstick. A semi-structured in-depth interview guide was developed with direct input from local community health staff which explored the following domains: (i) facilitators and barriers that impact PrEP uptake and adherence, (ii) impact of ATS and other substance use on PrEP adherence, and (iii) sexual practices when using ATS and other substances. Interviews were audio-recorded and conducted in Vietnamese, transcribed into Vietnamese and subsequently translated into English. A codebook was developed using an iterative process through a subjective assessment method. Data were analyzed with applied thematic analysis using a combined deductive and inductive approach to identify key categories and themes.
Results: The median age of participants (N=40) was 25 years (range: 18-36). Half (n=20) of participants completed vocational school or college/university, and while 72.5% (29/40) were currently employed. All participants reported frequent stimulant use on the ASSIST and 50% (20/40) of participants had a positive urine drug screen for methamphetamine, amphetamine, and/or ecstasy. Most (95%, 38/40) reported having used substances before or during sex with male partners in the prior three months, and 90% (36/40) reported having had condomless sex in the prior six months; 52.5% and 65% of MSM perceived themselves to be at moderate or high risk for HIV infection and other sexually transmitted infections respectively. Regarding PrEP adherence, 97.5% were currently using PrEP, 45% (18/40) were using PrEP for 6 months or more and 92.5% (37/40) reported that they use PrEP 4 or more days per week.
Salient themes include (i) Risk of HIV infection primarily from condomless sex while using simulants and the varying impacts on PrEP adherence. (ii) “Highfun” (Vietnamese term for sex while under the influence of stimulants), and PrEP taking behaviors. (iii) PrEP adherence facilitated by clinic accessibility, trust in community-based organizations and healthcare providers, support from friends, and PrEP as a sense of security from HIV. (iv) Substance use as a way to cope with psychosocial stressors and negative mental health symptoms (v) Non-substance use related barriers to adherence involving stigma, PrEP side effects, forgetting to take PrEP daily, and disparities in medical resources.
Conclusions: Findings suggest that stimulant use may play an important role in both sexual activities and coping with daily psychosocial stressors. Overall, most MSM view PrEP as a useful tool in Highfun and a protective factor against HIV infection. Despite the effects of stimulants, most MSM are motivated to use PrEP and report minimal challenges with PrEP adherence. This formative research can help guide the delivery of PrEP services and inform culturally specific interventions by promoting the integration of harm reduction and psychosocial support into current PrEP services for this marginalized, at-risk group for HIV.