Correlations Between Community-Level HIV Preexposure Prophylaxis Coverage and Individual-Level Sexual Behaviors among US Men Who Have Sex with Men

Background HIV preexposure prophylaxis (PrEP) has been associated with changes in sexual behavior after PrEP initiation. However, behavioral differences may also emerge among PrEP non-users in communities with high PrEP coverage. Methods We used demographic, behavioral, and sexual network data from ARTnet, a cross-sectional study of US men who have sex with men conducted during 2017–2019. Multivariable regression models with a Bayesian modeling framework in which individuals were nested within their residential geographic areas were used to estimate associations between area-level PrEP coverage and five sexual behavior outcomes (number of total, main, and casual male partners [network degree]; count of one-time partnerships; and consistent condom use in one-time partnerships), controlling for individual PrEP use. Results PrEP coverage ranged from 10.3% (Philadelphia) to 38.9% (San Francisco). Total degree was highest in Miami (1.35) and lowest in Denver (0.78), while the count of one-time partners was highest in San Francisco (11.7/year) and lowest in Detroit (1.5/year). Adjusting for individual PrEP use and demographics, community PrEP coverage was associated with higher total degree (adjusted incidence rate ratio [aIRR]=1.73; 95% CrI, 0.92–3.44), casual degree (aIRR=2.05; 95% CrI, 0.90–5.07), and count of one-time partnerships (aIRR=1.90; 95% CrI, 0.46–8.54). Without adjustment for individual PrEP use, these associations were amplified. There were weaker associations with main degree (aIRR=1.21; 95% CrI, 0.48–3.20) and consistent condom use in one-time partnerships (aIRR=1.68; 95% CrI, 0.86–3.35). Conclusions Most of the associations between community PrEP coverage and sexual behavior were explained by individual PrEP use. However, there were residual associations after controlling for individual PrEP use, suggesting that PrEP coverage may partially drive community-level changes in sexual behavior. ### Competing Interest Statement Julia Marcus has previously consulted for Kaiser Permanente Northern California on a research grant from Gilead Sciences unrelated to the submitted work. ### Funding Statement This work was supported by grants from the National Institutes of Health (R01AI138783, R21MH112449, P30AI050409, K01AI122853) and the MAC AIDS Fund. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Emory University Institutional Review Board approved the study. All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Model code and data are available at the indicated git repository.