在 PrEP 時代，同性戀社會和性規範正在發生變化
資料來源：Krishen Samuel / 2022 年 9 月 5 日 / aidsmap / 財團法人台灣紅絲帶基金會編譯
圖片：UfaBizPhoto/Shutterstock.com
雖然成本仍然是加拿大男同性戀和雙性戀男性獲得 PrEP 的最大障礙，但他們也感受到了服用 PrEP 和不使用保險套進行性行為的壓力，年輕男性往往對 HIV 傳播不感到那麼焦慮。根據最近的定性研究，這反映了 PrEP 和 U=U 時代社會和性規範的轉變。
雖然自 2016 年以來加拿大已批准 HIV 暴露前預防（PrEP），但實施受到成本挑戰的阻礙。某些省級健康保險計畫，包括不列顛哥倫比亞省的健康保險計畫，完全涵蓋符合指引的男同性戀和雙性戀男性的 PrEP。然而，在安大略省等其他省份情況並非如此，那裡的 PrEP 完全覆蓋到 25 歲、65 歲以上，以及那些接受殘疾補助金和社會援助的人。在加拿大各地，符合條件的原住民、武裝部隊成員和退伍軍人都可以使用 PrEP。
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研究
多倫多大學的 Mark Gaspar 博士旨在更好地了解 HIV 陰性男同性戀、雙性戀和酷兒男性的 PrEP 決策。他和同事利用PrEP 級聯 (PrEP Cascade)，從考慮 PrEP之準備狀況、尋找 PrEP 、以及到與醫療保健提供者討論PEP等層啟，他和同事在 2020 年 3 月至 2020 年 10 月期間對安大略省和不列顛哥倫比亞省的男性進行了 45 次深入的一對一訪談（除一位採Zoom方式外）。
40% 的男性年齡在 30-39 歲之間，而不到三分之一的男性年齡在 20-29 歲之間。較大多數男性被確定為順性別（91%）和同性戀（87%），而白人佔 38%，東亞裔佔 16%，黑人佔 13%。 45 名男性中有 37 人正在服用或已經服用 PrEP。 38% 的人居住在大多倫多地區，而 33% 的人居住在溫哥華。
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獲得 PrEP 的費用
PrEP 的成本是獲取上最大的障礙，尤其是在安大略省。一些參與者表示，他們認為 PrEP 「只適用於富人」，因為獲得 PrEP 通常取決於是否有一份擁有私人醫療保險的工作，並且能夠支付與 PrEP 相關的共同支付費用。對於參與「零工經濟」的男性或那些改變工作和保險計畫的男性來說，持續獲得 PrEP 是一項挑戰。
雖然許多參與者承認，如果他們想獲得 PrEP，他們可以這樣做，但他們意識到持續獲得 PrEP 所涉及的努力，包括交通費用和請假去就診。因此，除了將自己視為感染 HIV 的風險之外，他們還需要感覺到 PrEP 的價值超過了所有相關成本。對於一些男性來說，儘管他們認為自己處於感染 HIV 的高風險中並且需要獲得 PrEP，但成本卻是一個過於高昂的障礙。對於那些負擔得起 PrEP 的人來說，其他障礙被認為不那麼重要。
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與 PrEP 相關的健康問題
對服用 PrEP 猶豫不決的男性往往對副作用、感染其他性傳播感染和 PrEP 的有效性表示最強烈的擔憂。總的來說，參與者一致認為 PrEP 在預防 HIV 方面非常有效。一些參與者對 PrEP 含有抗 HIV 藥物及其對腎臟、骨骼和肝臟的影響表示擔憂，儘管受訪者自己都沒有遇到過這樣的問題：
「我不擔心[立即的、短期的]副作用。我只是還沒有看到它對身體有什麼作用。我們必須在五到十年或三年後看看它對身體的影響，你知道嗎」？
一位用戶分享說，由於擔心副作用，他經常會暫停他的 PrEP。然而，大多數男性認為副作用是暫時的，或者如果停止 PrEP 則很容易逆轉。
另一個與感染 HIV 以外的性傳播感染有關的問題；有人質疑 PrEP 的必要性是否可以簡單地使用保險套來預防所有 STI：
「是的，[我擔心]副作用以及.. . .如果我仍然需要戴保險套——那麼保險套應該可以預防愛滋病毒和其他性傳播感染。如果您服用 PrEP，它會保護您免受 HIV 感染，但不能保護其他一切。因此，服用 PrEP 並使用保險套，這卻是我認為過度使用的，所以只需使用保險套並結束它。這是我單純的想法。但我不喜歡保險套。所以這就是為什麼我最終會遇到不安全的性行為（在 PrEP 上）」。
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PrEP 對性的影響
參與者分享了關於 PrEP 對其性生活的影響的不同經驗。有幾個人有更多的性生活，使用的保險套更少。在某些關係中，PrEP 打開了探索非固定單一伴侶制的大門。然而，也有一些男性表示他們的性生活沒有改變，並質疑他們是否需要 PrEP。一位參與者說：「就像我在浪費它。就像我正在服用它，但我仍然沒有那麼 [性] 活躍，你知道嗎」？然而，一位參與者表示，他很高興自己繼續服用 PrEP，儘管他曾一度認為自己不需要它。這挑戰了固定風險的概念，顯示它會隨著時間的推移而波動，在某些時候 PrEP 比其他時候更需要。此外，一些男性開始 PrEP 並不是因為他們認為自己處於高風險之中，而是為了嘗試一下，看看它如何適應他們的性生活。
「以前，一名男子可能會因服用 PrEP 而被指控濫交，現在他被視為應對此負責」。
與此相關的是，許多 PrEP 使用者分享了他們如何在不同點停止、暫停和重新啟動 PrEP。男性談到基於事件使用的給藥或圍繞 PrEP 給藥計畫性行為，但表示很難找到有關偶爾使用 PrEP 的準確信息：
「我想即使有人問我，哦，你想發生性關係，我說是的，如果我當時沒有參加 PrEP，我通常會在一周後或多於一周，所以我有時間再次加強 PrEP」。
PrEP 有助於男性計畫他們近期和未來的性生活。一位參與者表示，他希望在 25 歲後保持長期的固定單一伴侶制關係，因為在那個年齡，安大略省的省級保險將不再涵蓋 PrEP：
「我想最終安定下來，和一個人在一起，而不必擔心勾搭之類的事情」。
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改變社會和性規範
男性表示，由於 PrEP，有關性行為的規範發生了變化，特別是關於保險套的使用和「安全性行為」的概念。
「有些人就是不想使用保險套，如果你想和他們發生性關係，那就好像是你將要無套」。
對於一些參與者來說，這具有明顯的種族因素，PrEP 被視為與白人男同性戀有關的東西。這種關聯意味著一些黑人男同性戀者不會接受它，除非他們認識的其他男性正在服用，否則他們可能會冒著被視為迎合白人男性的風險。
「如果我的黑人朋友不接受，那麼我顯然不會接受」。
參與者還描述了與 PrEP 相關的認知演變。以前，一個男人可能會因為服用它而被指控濫交（「舒發泰妓女」），但現在他被認為對此負有責任。
「我會讓人們說道，『不，謝謝，我不感興趣』，我會說，好吧；他們會說，『好吧，你正在接受 PrEP，我不想勾搭，因為你顯然是在一個橫衝直撞妓女』，這已經對我說過幾次了。然而現在就像，我和那些沒有參加 PrEP 的人交談，我想，『他媽的，你沒有參加 PrEP，你瘋了嗎』」？
然而，一些男性抵制了服用 PrEP 的壓力。對他們來說，這要麼被視為沒有必要確保性安全，要麼被視為製藥公司從男同性戀的性生活中獲利的一種方式。
雖然一些接受 PrEP 的男性對與無法檢測到病毒載量的男性發生性關係變得更有信心，並且承認這可以使披露狀態上更容易，但仍有一些人在 PrEP 時代對愛滋病毒感染者表示恥辱。
「我在 PrEP 上，是的，我覺得和無法檢測到病毒量的人交往很舒服」。
「如今，[HIV] 陽性的人甚至不覺得他們需要告訴你他們是陽性的。 [。 . .] 我就像，我不想這樣做 [與 HIV 陽性男性發生性關係]。這是我的身體，我可以為所欲為。這並不意味著我不了解所有事實」。
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不同世代之間差異
PrEP 觀念存在著明顯的代際差異。 80 年代和 90 年代性活躍的男性對這種行為的看法與年輕男性截然不同，後者往往對 HIV 傳播不感到那麼焦慮。
「我一直認為不使用安全套就等於愛滋病」。
「我 [40 多歲]。所以當我 20 歲的時候，就像沒有，你知道的，愛滋病毒仍然像是一種死刑判決。所以，這類事情 [如 PrEP] 是令人興奮的，但我想是的。 . .我不確定，我不知道我在想要完全接受或了解更多方面猶豫不決」。
「我對 [HIV] 傳播並沒有太多焦慮，我認為部分原因是因為這個。 . .我認為最近在治療愛滋病毒方面取得了更多的醫學進展」。
還有一種感覺是，隨著 PrEP 的出現，在行為介入方面取得的所有進展都將在年輕一代身上消失。
「所以現在說，喲，吃這個藥，別想了。我當時想，呃，操，所有這些年的行為改變工作都在一瞬間消失了」。
「我作為一個酷兒的身份，一個酷兒男人，與迫在眉睫的愛滋病毒威脅是如此相互關聯，以至於無論我是否意識到這一點，我早期對這些其他選擇（如 PrEP）的沉默和懷疑幾乎可以與那個例子相提並論，一個老人會說，「哦，好吧，我要長大還真的很難，而這些 [年輕] 混蛋太容易了」。「我們都應該輕鬆一點，對嗎？所以是的，我想，我們都應該擺脫這種[對愛滋病毒的恐懼] 」。
結論
「除了實用障礙和生物醫學問題外，PrEP 還具有重大的社會意涵，它的採用會以多種且複雜的方式改變性行為和性方面上的事情」，作者總結道。 「醫療保健提供者和健康促進專家越能了解這些性行為的變化，他們就越有能力進行教育、徵求問題並完善他們向顧客傳達的信息，以確保同性戀、雙性戀和酷兒男性在有關有效降低風險的 PrEP上做出明智的選擇」。
參考文獻：
Gaspar M 等人。 「我還能做出哪些其他選擇」？：性少數男性、PrEP 級聯和 HIV 風險主觀思維上的轉變。定性健康研究， 32：1315-1327、2022（開放獲取）。https://doi.org/10.1177%2F10497323221092701
Gay social and sexual norms are shifting in the PrEP era
Krishen Samuel / 5 September 2022 / aidsmap
UfaBizPhoto/Shutterstock.com
While cost remains the biggest barrier to accessing PrEP for gay and bisexual men in Canada, they also felt pressure to take PrEP and have sex without condoms, with younger men tending to feel less anxious about HIV transmission. This reflects shifting social and sexual norms in the era of PrEP and U=U, according to recent qualitative research.
While pre-exposure prophylaxis for HIV (PrEP) has been approved in Canada since 2016, implementation has been impeded by cost challenges. Certain provincial health insurance plans, including British Columbia’s, fully cover PrEP for gay and bisexual men who meet the guidelines. However, this is not the case in other provinces, such as Ontario, where PrEP is fully covered until the age of 25, over the age of 65, and for those receiving disability grants and social assistance. Across Canada, eligible Indigenous people, members of the armed forces and military veterans can access PrEP.
The study
Dr Mark Gaspar from the University of Toronto aimed to better understand PrEP-decision making among HIV-negative gay, bisexual and queer men. Drawing on the PrEP Cascade, which considers readiness for PrEP, seeking PrEP out and discussing it with a healthcare provider, he and colleagues conducted 45 in-depth one-on-one interviews between March and October 2020 (all but one were over Zoom) with men in Ontario and British Columbia.
Forty percent of the men were aged 30-39, while just under a third were between 20-29. Most men identified as cisgender (91%), and gay (87%), while 38% were White, 16% East Asian and 13% Black. Thirty-seven of the 45 men were taking or had taken PrEP. Thirty-eight percent lived in the greater Toronto area, while 33% resided in Vancouver.
The costs of accessing PrEP
The cost of PrEP presented the biggest access barrier, particularly in Ontario. Some participants said they felt PrEP was “only for rich people” as access to PrEP often depended on having a job with private health insurance and being able to paying the co-pay associated with PrEP. For men participating in the ‘gig economy’ or for those changing jobs and insurance plans, consistent access to PrEP presented a challenge.
While many participants acknowledged that if they wanted to access PrEP, they could do so, they were aware of the effort involved in getting PrEP consistently, including transportation costs and taking time off work to go to medical appointments. Thus, in addition to viewing themselves as at risk for HIV, they also needed to feel that PrEP’s value outweighed all associated costs. For some men, despite seeing themselves as being at a high risk for HIV and needing to access PrEP, cost presented too prohibitive a barrier. For those who could afford PrEP, other barriers were seen as less significant.
Health concerns related to PrEP
Men who were hesitant about taking PrEP tended to voice the strongest concerns about side effects, contracting other STIs and the effectiveness of PrEP. In general, participants agreed that PrEP was highly effective at preventing HIV. Some participants expressed concerns regarding the fact that PrEP contains anti-HIV drugs, and its effects on their kidneys, bones and liver, although none of the interviewees had themselves experienced such problems:
“I don’t have a concern with [immediate, short-term] side-effects. I just haven’t seen what it does to the body. We have to see what it does to the body after five to ten years, or three years, you know?”
One user shared that he would often pause his PrEP due to concern over side effects. However, most men viewed side effects as temporary, or easily reversible if PrEP was stopped.
Another concern related to contracting STIs other than HIV; the necessity of PrEP was questioned if one could simply use condoms to prevent all STIs:
“Yes, [I am concerned with] side effects and also what’s the . . . if I still need to wear a condom—so a condom is supposed to prevent HIV and other STIs. If you take PrEP it’s going to protect you against HIV but not everything else. So then taking PrEP and using a condom I think is overdoing it. So just use a condom and get it over with. That’s my simple-minded thinking. And I don’t like condoms. So that’s why I would end up with the unsafe sex situation [on PrEP].”
PrEP’s impact on sex
Participants shared varied experiences regarding the effects PrEP had had on their sex lives. Several had more sex and used condoms less. In some relationships, PrEP opened the door to exploring non-monogamy. However, there were some men who stated that their sex life had remained unchanged and questioned whether they needed PrEP. According to one participant: “Like I’m wasting it. Like I’m taking it but I’m still not that [sexually] active, you know?” However, one participant stated that he was glad that he kept taking PrEP, despite not thinking that he needed it at one point. This challenges the notion of risk as fixed and instead indicates that it fluctuates over time, with PrEP being more necessary at some points than at others. Additionally, some men start PrEP not because they see themselves as being at high risk, but rather to try it out and see how it fits in with their sex lives.
“Previously a man could be accused of being promiscuous for taking PrEP, now he was viewed as responsible for doing so.”
Linked to this, many PrEP users shared how they stopped, paused and restarted PrEP at different points. Men spoke about using event-based dosing or planning sex around PrEP dosing, but stated that it was difficult to find accurate information on using PrEP episodically:
“I guess even if someone asks me, oh do you want to have sex and I say yes, if I’m not on PrEP at that time I’ll usually kind of set a date with them a week from now or more than a week so I have time to ramp up the PrEP again.”
PrEP contributed to how men planned both their immediate and future sex lives. One participant stated that he hoped to be in a long-term monogamous relationship once he turned 25, as PrEP would no longer be covered by provincial insurance in Ontario at that age:
“I want to finally settle down, and be with someone exclusively and not have to worry about hooking up and stuff.”
Changing social and sexual norms
Men stated that norms around sex had changed because of PrEP, especially regarding condom use and notions of ‘safe sex’.
“There are some people that just don’t want to use condoms and if you want to have sex with them, that’s kind of where you’re gonna be.”
For some participants, this had a distinct racial element to it, with PrEP being seen as something associated with White gay men. This association meant that some Black gay men would not take it unless other men they knew were taking it, or they could risk being seen to cater to the whims of White men.
“If my Black friends aren’t taking it then I’m obviously not going to take it.”
Participants also described an evolution of perceptions related to PrEP. Whereas previously a man could be accused of being promiscuous for taking it (“Truvada whores”), he was now viewed as responsible for doing so.
“I would get guys saying, ‘no thanks, I’m not interested’ and I’d be like oh ok, and they’d be like, ‘well you’re on PrEP and I don’t want to hook up because you’re obviously on a whore rampage.’ That’s been said to me a few times. Now it’s like, I talk to guys who aren’t on PrEP and I’m like, ‘what the fuck, you’re not on PrEP, are you crazy?’”
However, some men resisted the pressure to take PrEP. For them, it was either not seen as necessary to ensure sexual safety, or it was viewed as a way for pharmaceutical companies to make a profit from the sex lives of gay men.
While some men on PrEP had become more confident in having sex with men with an undetectable viral load, and there was an acknowledgement that it could make disclosure easier, there were some who still expressed stigma towards those living with HIV in the era of PrEP.
“I’m on PrEP, yeah I feel comfortable hooking up with undetectable people.”
“Nowadays, guys who are [HIV-] positive don’t even feel like they need to tell you that they’re positive. [. . .] I’m just like, I don’t want to do it [have sex with HIV-positive men]. It’s my body I can do whatever the hell I want. It doesn’t mean I don’t understand all the facts.”
Generational differences
There were distinct generational differences in PrEP perceptions. Men who were sexually active in the 80s and 90s viewed it very differently to younger men, who tended to feel less anxious regarding HIV transmission.
“I always assumed that not using a condom equated to AIDS.”
“I’m [in my 40s]. So when I was like 20, like there wasn’t, you know, HIV was still like a death sentence kind of a thing. So, these kinds of things [like PrEP] are exciting, but I guess I yeah . . . I’m not sure, I don’t know what my hesitation is in terms of wanting to take it fully or know more about it.”
“I’ve not had a lot of anxiety around [HIV] transmission, I think part of that was because of that . . . I think more recent medical advancements in the treatment of HIV.”
There was also a sense that all the progress made regarding behavioural interventions would be lost on the younger generation with the advent of PrEP.
“So now to say, yo, take this pill and don’t even think about it. I was like, ugh, fuck, all of those years of behaviour change work sort of scuttled out in one moment.”
“My identity as a queer person, a queer man, was so interlinked with the looming threat of HIV that whether I was conscious of it or not, my early reticence and scepticism around these other options [like PrEP] was almost comparable to that example of an old person going, ‘oh well, I grew up it was really hard and these [younger] motherfuckers have it too easy.’ Well we all should have it a little bit easier, right? And so yeah, I was like, we should all be free of this [fear of HIV].”
Conclusion
“In addition to pragmatic barriers and biomedical concerns, PrEP has significant social implications with its uptake altering sexual practices and sexuality in diverse and complex ways,” the authors conclude. “The more healthcare providers and health promotion experts are able to understand these shifts in sexuality, the better equipped they will be at producing education, soliciting questions, and refining their messages to clients to ensure that gay, bisexual and queer men are making informed choices about PrEP that effectively reduce their risks.”
References
Gaspar M et al. “What other choices might I have made?”: Sexual Minority Men, the PrEP Cascade and the Shifting Subjective Dimensions of HIV Risk. Qualitative Health Research 32: 1315-1327, 2022 (open access).
https://doi.org/10.1177%2F10497323221092701