PrEP use does not worsen mental health outcomes, finds Amsterdam study

A three-year study following gay and bisexual men and transgender women who use pre-exposure prophylaxis (PrEP) in Amsterdam finds no evidence to suggest it increases risky behaviours or leads to worsening mental health.

But the study did find high levels of pre-existing anxiety and depression among PrEP users, with around one in five reporting these conditions – around double that of Dutch men in the general population.

Previous research has shown that PrEP can lessen people’s concerns about getting HIV, leading to worries that it could increase casual, condomless sex and recreational drug use. But the relationship between PrEP use and mental health is less understood.

To examine this issue, researchers followed around 340 gay and bisexual men and two trans women in Amsterdam who were taking PrEP, either daily or before and after sex (known as ‘event-driven’), for around 2.5 years.

The majority were white (85%), university-educated (77%) and took daily PrEP (74%). In the past six months, all participants had experienced one or more of the following: condomless anal sex with casual partners, at least one sexually transmitted infection, use of post-exposure prophylaxis (PEP) after sex, or sex with an HIV-positive partner who had a detectable viral load.

Through yearly self-administered assessments, conducted between August 2015 and September 2018, researchers assessed the mental health conditions of anxiety, depression, sexual compulsivity, alcohol use disorder and drug use disorder.

Researchers observed a 13% reduction in the proportion of participants displaying sexual compulsivity (from 23% to 10%) and a 7% reduction in the proportion with a drug use disorder (from 38% to 31%). Researchers found no significant reduction in the proportion of people with alcohol use disorder.

There was no difference in changes to mental health between daily and event-driven PrEP users. But individuals on daily PrEP were more likely to have more sexual partners, engage in condomless anal sex and have an STI than event-driven users.

Overall, 6% of participants had experienced intimate partner violence in the past five years and 14% had had a non-consensual sexual experience.

The findings suggest certain mental health disorders are related to one another. For instance, those with anxiety or depression were less likely to recover from sexual compulsivity and more likely to develop drug use disorder.

Among those reporting a mental health problem only 18% sought professional help. This is lower than the general Dutch population, where 34% of people with a mental health issue seek help.

The mental health data used in this study was based on self-reporting and not diagnoses, which means the actual prevalence of mental health issues could differ to that which has been reported.

But the findings suggest that including mental health and drug-misuse services in PrEP programmes could be of benefit for many of those accessing it.