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We mapped gay and bisexual men’s (GBM) patterns of using pre-exposure prophylaxis (PrEP) over time and explored sexual behavior as PrEP use changed. We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBM living in Australia who had changed their PrEP use since initiating. There was considerable diversity in patterns of discontinuation, suspension, and recommencement of PrEP. Reasons for changing PrEP use mostly centered on accurate perceived changes to HIV risk. Twelve participants reported condomless anal intercourse with casual or fuckbuddy partners after discontinuing PrEP. These sex events were unanticipated, condoms were not a preferred option, and other risk reduction strategies were applied inconsistently. Service delivery and health promotion can support safer sex among GBM when PrEP use fluctuates by promoting event-driven PrEP and/or non-condom-based risk reduction methods during periods off daily PrEP, and guiding GBM to better recognize changing circumstances of risk and when to recommence PrEP.

IntroductionStigma is a significant contributor to the HIV diagnosis disparities experienced among migrants who are gay and bisexual men (GBM) living in high-income countries.MethodsWe conducted interviews with 24 migrant GBM in Australia diagnosed with HIV from 2017 onwards, who since their diagnosis had become well-connected to sexual health services and participation in research. Interviews were conducted between October 2018 and December 2019. We aimed to identify how HIV and sexual identity stigmas were barriers to accessing HIV testing and prevention.ResultsThese stigmas were deeply embedded into social, cultural, and institutional settings in participants’ countries of origin, resulting in poor HIV literacy, reluctance to access HIV-related services, including HIV testing, and fears of being identified as gay/bisexual publicly. Underpinned by internalised stigma, these fears and poor outcomes often persisted after moving to Australia. Other barriers to accessing HIV-related services in Australia included apprehension about a potential HIV-positive result and the possibility of visa cancellation, concerns about confidentiality, and a lack of confidence and support in navigating the healthcare system, including how to access pre-exposure prophylaxis.ConclusionAddressing these multifaceted HIV testing and prevention barriers requires policies, systems, and interventions that increase health literacy about HIV testing, prevention, and treatment; build trust and confidence when navigating Australian health services; and reduce the impacts of HIV and sexual identity stigmas in migrants’ countries of origin on their experiences in Australia.

Many gay Australian serodiscordant couples are currently relying on an HIV-positive partner's undetectable viral load (UVL) to practice condomless sex. For these couples, preventing HIV is often considered a mutual responsibility, yet they lack a formally endorsed strategy that helps them navigate 'UVL for prevention' (UfP) as a couple. Drawing on interviews with 21 Australian gay men representing 15 serodiscordant couples, we explored 'the couple' within serodiscordant HIV prevention. In learning to rely on UfP, couples were initially apprehensive as they navigated unfamiliar territory, but their concerns faded over time. Confidence in UfP was facilitated by repeated condomless sex without transmission, consistent test results, and being in a couple framed by trust, commitment, and familiarity. Gay male serodiscordant couples should be encouraged to negotiate clear, spoken 'viral load agreements' (VLAs) if they choose to rely on UfP.