Prevention Science

, Volume 20, Issue 1, pp 168–177 | Cite as

Gay and Bisexual Men’s Strategies to Maintain Daily Adherence to Their HIV Pre-exposure Prophylaxis (PrEP) Medication: Results from a Qualitative Study

  • Christian GrovEmail author
  • Anthony W. P. Flynn
  • Alexa B. D’Angelo
  • Javier Lopez-Rios
  • David W. Pantalone
  • Ian W. Holloway
  • Jeffrey T. Parsons


Since FDA approval in 2012, HIV pre-exposure prophylaxis (PrEP) has been adopted by key populations, including gay and bisexual men (GBM), to reduce their HIV transmission risk. Given that PrEP is optimally effective when taken as prescribed, it is critical to understand the adherence strategies GBM use. We conducted one-on-one, semi-structured interviews with GBM taking PrEP in 2015–2016 (n = 103). Using thematic analysis, we identified six adherence strategies, with most participants (84.3%) utilizing multiple strategies to maintain adequate adherence: (1) integrating PrEP into part of a daily routine, (2) using a pillbox, (3) cognitive strategies/visual cues, (4) setting recurring smartphone alarms or reminders, (5) keeping medication on oneself at all times, and (6) partner or peer support for reminders and/or pill sharing. Overall, participants reported high PrEP adherence (M = 1.6 missed doses in the prior 30 days), though nearly all described missing at least one dose unintentionally in the past. Participants credited their high levels of adherence in part to the strategies they adopted. Providers working with GBM prescribed PrEP, especially patients reporting difficulties with adherence, might consider recommending any or all of the six strategies described in this study.


Pre-exposure prophylaxis (PrEP) Adherence Gay and bisexual men HIV Qualitative data 



The authors would like to acknowledge the contributions of other members of the PrEP & Me study team (Mark Pawson, Demetria Cain, Brian Salfas, Chloe Mirzayi, Juan Castiblanco, and Ruben Jimenez), and other staff from the Center for HIV/AIDS Educational Studies and Training (Chris Hietikko, Tina Koo, Desmond Dutcher, and Carlos Ponton). Finally, we thank Shoshana Kahana at NIDA and all of our participants who participated in PrEP & Me.


PrEP & Me was funded by the National Institute of Drug Abuse (R21- DA039019, PI: Grov).

Compliance with Ethical Standards

Conflicts of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH). NIDA/NIH had no role in the production of this manuscript nor necessarily endorses its findings.


  1. Atreja, A., Bellam, N., & Levy, S. R. (2005). Strategies to enhance patient adherence: Making it simple. Medscape General Medicine, 7, 4.Google Scholar
  2. Boeni, F., Spinatsch, E., Suter, K., Hersberger, K. E., & Arnet, I. (2014). Effect of drug reminder packaging on medication adherence: a systematic review revealing research gaps. Systematic Reviews, 3, 29.Google Scholar
  3. Bosworth, H. B., Granger, B. B., Mendys, P., Brindis, R., Burkholder, R., Czajkowski, S. M., et al. (2011). Medication adherence: a call for action. American Heart Journal, 162, 412–424.Google Scholar
  4. Bush, S., Magnuson, D., Rawlings, K., Hawkins, T., McCallister, S., & Mera Giler, R. (2015). Racial Characteristics of FTC/TDF for pre-exposure prophylaxis (prep) users in the US Paper presented at the ASM Microbe 2016, Boston.Google Scholar
  5. Calabrese, S. K., & Underhill, K. (2015). How stigma surrounding the use of HIV preexposure prophylaxis undermines prevention and pleasure: A call to destigmatize “Truvada Whores”. American Journal of Public Health, 105, 1960–1964Google Scholar
  6. Chaiyachati, K. H., Ogbuoji, O., Price, M., Suthar, A. B., Negussie, E. K., & Barnighausen, T. (2014). Interventions to improve adherence to antiretroviral therapy: a rapid systematic review. AIDS, 28, S187–S204.Google Scholar
  7. Delaney, K. P., Sanchez, T., Bowles, K., Oraka, E., DiNenno, E., & Sullivan, P. (2016). Awareness and use of PrEP appear to be increasing among internet samples of US MSM. Paper presented at the Conference on Retroviruses and Opportunistic Infections, Boston.Google Scholar
  8. Dolder, C. R., Lacro, J. P., Leckband, S., & Jeste, D. V. (2003). Interventions to improve antipsychotic medication adherence: Review of recent literature. Journal of Clinical Psychopharmacology, 23, 389–399.Google Scholar
  9. Flash, C., Landovitz, R., Mera Giler, R., Ng, L., Magnuson, D., Bush Wooley, S., & Rawlings, K. (2014). Two years of Truvada for pre-exposure prophylaxis utilization in the US. Journal of the International AIDS Society, 17, 19730. Scholar
  10. Gilmore, H. J., Liu, A., Koester, K. A., Amico, K. R., McMahan, V., Goicochea, P., et al. (2013). Participant experiences and facilitators and barriers to pill use among men who have sex with men in the iPrEx Pre-Exposure Prophylaxis Trial in San Francisco. AIDS Patient Care and STDs, 27, 560–566.Google Scholar
  11. Glidden, D. V., Anderson, P. L., & Grant, R. M. (2016). Pharmacology supports “on-demand” PrEP. The lancet. HIV, 3, e405–e406.Google Scholar
  12. Golub, S. A., Gamarel, K. E., Rendina, H. J., Surace, A., & Lelutiu-Weinberger, C. L. (2013). From efficacy to effectiveness: Facilitators and barriers to PrEP acceptability and motivations for adherence among MSM and transgender women in New York City. AIDS Patient Care and STDs, 27, 248–254.Google Scholar
  13. Gonzalez, J. S., Penedo, F. J., Antoni, M. H., Duran, R. E., McPherson-Baker, S., Ironson, G., et al. (2004). Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDS. Health Psychology, 23, 413–418.Google Scholar
  14. Grant, R. M., Anderson, P. L., McMahan, V., Liu, A., Amico, K. R., Mehrotra, M., et al. (2014). Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. The Lancet Infectious Diseases, 14, 820–829.Google Scholar
  15. Haberer, J. E. (2016). Current concepts for PrEP adherence: in the PrEP revolution; from clinical trials to routine practice. Current Opinion in HIV and AIDS, 11, 10–17.Google Scholar
  16. Kibengo, F. M., Ruzagira, E., Katende, D., Bwanika, A. N., Bahemuka, U., Haberer, J. E., et al. (2013). Safety, adherence and acceptability of intermittent tenofovir/emtricitabine as HIV pre-exposure prophylaxis (PrEP) among HIV-uninfected Ugandan volunteers living in HIV-serodiscordant relationships: a randomized, clinical trial. PLoS One, 8, e74314.Google Scholar
  17. Krakower, D. S., Ware, N., Mitty, J. A., Maloney, K., & Mayer, K. H. (2014). HIV providers’ perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study. AIDS and Behavior, 18, 1712–1721.Google Scholar
  18. Krakower, D. S., Jain, S., & Mayer, K. H. (2015). Antiretrovirals for primary HIV prevention: the current status of pre- and post-exposure prophylaxis. Current HIV/AIDS Reports, 12, 127–138.Google Scholar
  19. Lally, P., Van Jaarsveld, C. H. M., Potts, H. W. W., & Wardle, J. (2010). How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology, 40, 998–1009.Google Scholar
  20. Lam, W. Y., & Fresco, P. (2015). Medication adherence measures: an overview (pp. 12). BioMed Research International.
  21. Lewis, M. A., Uhrig, J. D., Bann, C. M., Harris, J. L., Furberg, R. D., Coomes, C., & Kuhns, L. M. (2013). Tailored text messaging intervention for HIV adherence: a proof-of-concept study. Health Psychology, 32, 248–253.Google Scholar
  22. Liu, A. Y., Hessol, N. A., Vittinghoff, E., Amico, K. R., Kroboth, E., Fuchs, J., et al. (2014). Medication adherence among men who have sex with men at risk for HIV infection in the United States: implications for pre-exposure prophylaxis implementation. AIDS Patient Care and STDs, 28, 622–627.Google Scholar
  23. McDonald, H. P., Garg, A. X., & Haynes, R. B. (2002). Interventions to enhance patient adherence to medication prescriptions: Scientific review. Journal of the American Medical Association, 288, 2868–2879.Google Scholar
  24. Mera Giler, R., Magnuson, D., Trevor, H., Bush, S., Rawlings, K., & McCallister, S. (2017). Changes in truvada (TVD) for HIV pre-exposure prophylaxis (PrEP) utilization in the United States: (2012-2016). Paper presented at the 9th International AIDS Society Conference on HIV Science, Paris, France.Google Scholar
  25. Miles, M. B., & Huberman, M. (1994). Qualitative data analysis: an expanded sourcebook. Thousand Oaks: Sage Publications.Google Scholar
  26. Molina, J.-M., Capitant, C., Spire, B., Pialoux, G., Cotte, L., Charreau, I., et al. (2015). On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. New England Journal of Medicine, 373, 2237–2246.Google Scholar
  27. Neuendorf, K. A. (2002). The content analysis guidebook. Thousand Oaks: Sage.Google Scholar
  28. Pantalone, D. W., Rood, B. A., Morris, B. W., & Simoni, J. M. (2014). A systematic review of the frequency and correlates of partner abuse in HIV-infected women and men who partner with men. Journal of the Association of Nurses in AIDS Care, 25, S15–S35.Google Scholar
  29. Parsons, J. T., Rendina, H. J., Grov, C., Ventuneac, A., & Mustanski, B. (2015). Accuracy of highly sexually active gay and bisexual men's predictions of their daily likelihood of anal sex and its relevance for intermittent event-driven HIV pre-exposure prophylaxis. Journal of Acquired Immune Deficiency Syndromes, 68, 449–455.Google Scholar
  30. Patel, R. R., Mena, L., Nunn, A., McBride, T., Harrison, L. C., Oldenburg, C. E., et al. (2017). Impact of insurance coverage on utilization of pre-exposure prophylaxis for HIV prevention. PLoS One, 12, e0178737.Google Scholar
  31. Patrick, R., Forrest, D., Cardenas, G., Opoku, J., Magnus, M., Phillips, G. I., et al. (2017). Awareness, willingness, and use of pre-exposure prophylaxis among men who have sex with men in Washington, DC and Miami-Dade County, FL: National HIV behavioral surveillance, 2011 and 2014. JAIDS Journal of Acquired Immune Deficiency Syndromes, 75, S375–S382.Google Scholar
  32. Patton, M. Q. (1990). Qualitative evaluation research (2nd ed.). Newbury Park: Sage Publications, Inc..Google Scholar
  33. Petersen, M. L., Wang, Y., van der Laan, M. J., Guzman, D., Riley, E., & Bangsberg, D. R. (2007). Pillbox organizers are associated with improved adherence to HIV antiretroviral therapy and viral suppression: a marginal structural model analysis. Clinical Infectious Diseases, 45, 908–915.Google Scholar
  34. Pop-Eleches, C., Thirumurthy, H., Habyarimana, J. P., Zivin, J. G., Goldstein, M. P., de Walque, D., et al. (2011). Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS, 25, 825–834.Google Scholar
  35. Remien, R. H., Mellins, C. A., Robbins, R. N., Kelsey, R., Rowe, J., Warne, P., et al. (2013). Masivukeni: Development of a multimedia based antiretroviral therapy adherence intervention for counselors and patients in South Africa. AIDS and Behavior, 17, 1979–1991.Google Scholar
  36. Robbins, R. N., Spector, A. Y., Mellins, C. A., & Remien, R. H. (2014). Optimizing ART adherence: Update for HIV treatment and prevention. Current HIV/AIDS Reports, 11, 423–433.Google Scholar
  37. Rodrigues, R., Shet, A., Antony, J., Sidney, K., Arumugam, K., Krishnamurthy, S., et al. (2012). Supporting adherence to antiretroviral therapy with mobile phone reminders: Results from a cohort in South India. PLoS One, 7, e40723.Google Scholar
  38. Ronis, D. L., Yates, J. F., & Kirscht, J. P. (1989). Attitudes, decisions, and habits as determinants of repeated behavior. In A. R. Pratkan, S. J. Breckler, & A. G. Greenwald (Eds.), Attitude structure and function (pp. 213–239). Hillsdale: Lawrence Erlbaum Associates, Publishers.Google Scholar
  39. Saldaña, J. (2013). The coding manual for qualitative research (2nd ed.). Thousand Oaks: Sage.Google Scholar
  40. Scanlon, M. L., & Vreeman, R. C. (2013). Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings. HIV AIDS (Auckl), 5, 1–17.Google Scholar
  41. Schwartz, J., & Grimm, J. (2017). PrEP on Twitter: Information, barriers, and stigma. Health Communication, 32, 509–516.Google Scholar
  42. Shet, A., Costa, A. D., Kumarasamy, N., Rodrigues, R., Rewari, B. B., Ashorn, P., et al. (2014). Effect of mobile telephone reminders on treatment outcome in HIV: Evidence from a randomised controlled trial in India. BMJ [British Medical Journal], 349, g5978.Google Scholar
  43. Simoni, J. M., Pearson, C. R., Pantalone, D. W., Crepaz, N., & Marks, G. (2006). Efficacy of highly active antiretroviral therapy interventions in improving adherence and HIV-1 RNA viral load: a meta-analytic review of randomized controlled trials. Journal of Acquired Immune Deficiency Syndromes, 43, 523–535.Google Scholar
  44. Simoni, J. M., Pantalone, D. W., Plummer, M. D., & Huang, B. (2007). A randomized controlled trial of a peer support intervention targeting antiretroviral medication adherence and depressive symptomatology in HIV-positive men and women. Health Psychology, 26, 488.Google Scholar
  45. Simoni, J. M., Nelson, K. M., Franks, J. C., Yard, S. S., & Lehavot, K. (2011). Are peer interventions for HIV efficacious? A systematic review. AIDS and Behavior, 15, 1589–1595.Google Scholar
  46. Snowden, J. M., Chen, Y. H., McFarland, W., & Raymond, H. F. (2017). Prevalence and characteristics of users of pre-exposure prophylaxis (PrEP) among men who have sex with men, San Francisco, 2014 in a cross-sectional survey: Implications for disparities. Sexually Transmitted Infections, 93, 52–55.Google Scholar
  47. Stawarz, K., Cox, A. L., & Blandford, A. (2015). Beyond self-tracking and reminders: designing smartphone apps that support habit formation. Paper presented at the Proceedings of the 33rd annual ACM conference on human factors in computing systems.Google Scholar
  48. Sudore, R. L., & Schillinger, D. (2009). Interventions to improve care for patients with limited health literacy. Journal of clinical outcomes management: JCOM, 16, 20.Google Scholar
  49. Tangmunkongvorakul, A., Chariyalertsak, S., Amico, K. R., Saokhieo, P., Wannalak, V., Sangangamsakun, T., et al. (2013). Facilitators and barriers to medication adherence in an HIV prevention study among men who have sex with men in the iPrEx study in Chiang Mai, Thailand. AIDS Care, 25, 961–967. Scholar
  50. Taylor, S. W., Psaros, C., Pantalone, D. W., Tinsley, J., Elsesser, S. A., Mayer, K. H., & Safren, S. A. (2017). “Life-Steps” for PrEP adherence: Demonstration of a CBT-based intervention to increase adherence to preexposure prophylaxis (PrEP) medication among sexual-minority men at high risk for HIV acquisition. Cognitive and Behavioral Practice, 24, 38–49.Google Scholar
  51. Van der Elst, E. M., Mbogua, J., Operario, D., Mutua, G., Kuo, C., Mugo, P., et al. (2013). High acceptability of HIV pre-exposure prophylaxis but challenges in adherence and use: Qualitative insights from a phase I trial of intermittent and daily PrEP in at-risk populations in Kenya. AIDS and Behavior, 17, 2162–2172.Google Scholar
  52. Watters, J. K., & Biernacki, P. (1989). Targeted sampling: Options for the study of hidden populations. Social Problems, 36, 416–430.Google Scholar

Copyright information

© Society for Prevention Research 2019

Authors and Affiliations

  • Christian Grov
    • 1
    • 2
    Email author
  • Anthony W. P. Flynn
    • 3
  • Alexa B. D’Angelo
    • 1
    • 2
  • Javier Lopez-Rios
    • 1
  • David W. Pantalone
    • 4
  • Ian W. Holloway
    • 5
  • Jeffrey T. Parsons
    • 6
  1. 1.Department of Community Health and Social SciencesCUNY Graduate School of Public Health and Health PolicyNew YorkUSA
  2. 2.CUNY Institute for Implementation Science in Population Health (ISPH)New YorkUSA
  3. 3.Department of Counseling PsychologyUniversity of Wisconsin MadisonMadisonUSA
  4. 4.University of Massachusetts BostonBostonUSA
  5. 5.Department of Social WelfareUniversity of California Los AngelesLos AngelesUSA
  6. 6.Hunter College of CUNY, The Center for HIV/AIDS Educational Studies and Training (CHEST)The Graduate Center of CUNYNew YorkUSA

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