Sexual risk behaviors and PrEP use among Men who have Sex with Men: an Italian cross-sectional study

Introduction

MSM (Men who have Sex with Men) represent a high-risk group for HIV and STIs (Sexual Transmitted Infections). PrEP (Pre-Exposure Prophylaxis) is a recommended preventive strategy, yet concerns persist regarding risk compensation behaviors, with limited evidence in the Italian context. This study aimed to describe sexual behaviors among MSM in Italy, comparing PrEP users and non-users.

Methods

Cross-sectional study among 244 MSM (≥18 years) in Italy, recruited via anonymous online questionnaire disseminated through social media and LGBTQIA+ networks. The survey covered socio-demographic characteristics, sexual behaviors, HIV/STI risk perception and PrEP use. Our primary outcomes were unprotected anal intercourse and unprotected sexual risk behaviors. Associations were explored using descriptive and multivariable logistic regression analyses.

Results

Median age was 36.3 years (SD = 10.2). 43% used PrEP in the past year. 73.8% and 51.2% had unprotected anal intercourse and sexual risk behaviors, respectively. A higher risk of unprotected anal intercourse was found among MSM who had come out (OR = 7.2; p = 0.001) and had used PrEP in the past year (OR = 5.27; p < 0.001), while higher perceived STI risk was protective (OR = 0.27; p < 0.001). Regarding unprotected sexual risk behaviors, associations were observed with higher perceived STI risk (OR = 0.32; p < 0.001) and PrEP use (OR = 11.6; p < 0.001). All associations were confirmed in multivariable analyses. Age, education level, health status and HIV knowledge and risk perception were examined but yielded no statistically significant association with either outcome.

Conclusions

PrEP use was independently associated with increased risk of unprotected intercourse, likely reflecting risk compensation due to misconceptions regarding residual STI risk. Greater STI risk awareness demonstrated a protective effect. These findings underscore the need for more comprehensive and targeted sexual health literacy campaigns across Europe

Key messages

• PrEP reduces HIV risk but may promote a false sense of protection against STIs, highlighting the need for comprehensive prevention strategies.

• STI risk perception protects against unsafe sexual behaviors. Public health efforts should prioritize awareness campaigns targeting MSM communities.