A Behavioral Economic Examination of Sexual Behaviors in the Era of Pre-exposure Prophylaxis via Explanatory Sequential Mixed Methods

Nioud Mulugeta Gebru; Tyler G James; Seungjun Ahn; JeeWon Cheong; Meredith S Berry; Robert L Cook; Robert F Leeman

doi:10.1007/s10508-024-02822-8

A Behavioral Economic Examination of Sexual Behaviors in the Era of Pre-exposure Prophylaxis via Explanatory Sequential Mixed Methods

Arch Sex Behav. 2024 Apr;53(4):1541-1559. doi: 10.1007/s10508-024-02822-8. Epub 2024 Mar 12.

Authors

Nioud Mulugeta Gebru^{1

2

3}, Tyler G James⁴, Seungjun Ahn⁵, JeeWon Cheong⁶, Meredith S Berry^{6

7}, Robert L Cook^{8

9}, Robert F Leeman^{6

10}

Affiliations

¹ Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 S. Main St., Box G-S121-3, Providence, RI, 02912, USA. neo_gebru@brown.edu.
² Department of Health Education and Behavior, University of Florida, Gainesville, FL, USA. neo_gebru@brown.edu.
³ Southern HIV and Alcohol Research Consortium (SHARC), University of Florida, Gainesville, FL, USA. neo_gebru@brown.edu.
⁴ Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
⁵ Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
⁶ Department of Health Education and Behavior, University of Florida, Gainesville, FL, USA.
⁷ Department of Psychology, University of Florida, Gainesville, FL, USA.
⁸ Southern HIV and Alcohol Research Consortium (SHARC), University of Florida, Gainesville, FL, USA.
⁹ Department of Epidemiology, University of Florida, Gainesville, FL, USA.
¹⁰ Department of Health Sciences, Northeastern University, Boston, MA, USA.

Abstract

Pre-exposure prophylaxis (PrEP) use may be associated with condom use decisions. The current investigation examined sexual decision-making in the context of PrEP among young adult men who have sex with men (MSM) between 18 and 30 years old, using an explanatory sequential mixed methods design. For the quantitative aim, 99 MSM currently taking PrEP (i.e., PrEP-experienced) and 140 MSM not currently taking PrEP (i.e., PrEP-naive) completed an online survey, including the Sexual Delay Discounting Task (SDDT), which captures likelihood of condom use. For the qualitative aim, 15 people from each group were interviewed about their (1) conceptualizations of risky sex and (2) ways they manage their sexual risk. Participants were, on average, 25.69 years old (SD = 3.07) and 64% White. Results from the quantitative aim revealed, controlling for covariates, PrEP-experienced participants exhibited significantly lower likelihood of (1) using an immediately available condom and (2) waiting for a delayed condom (i.e., sexual delay discounting) compared to PrEP-naive participants. Qualitative themes explaining what young adult MSM consider to be risky sex included: (1) any sex as risky sex, (2) risky sex as "sex without a conversation," and (3) risky sex as sex with risk for physical harm. Themes on ways young adult MSM manage sexual risk were classified as proactive, reactive, and passive. Results suggest that PrEP use is related to condom use decisions. Taken together, quantitative differences in sexual delay discounting, but qualitatively similar conceptualizations and management of risky sex, suggest that the SDDT may be a useful tool in sex research to capture processes (i.e., delay discounting) underlying sexual decision-making that may be missed by traditional self-reports. Implications of results, including potentially providing (good quality) condoms with every PrEP prescription, and future research topics are discussed.

Keywords: Condom use; Men who have sex with men; PrEP; Risk compensation; Sexual Delay Discounting Task; Sexual orientation.

MeSH terms

Adolescent
Adult
Condoms
Economics, Behavioral
HIV Infections* / prevention & control
Homosexuality, Male
Humans
Male
Pre-Exposure Prophylaxis* / methods
Sexual Behavior
Sexual and Gender Minorities*
Young Adult

Abstract

MeSH terms

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