Navigating patterns of oral PrEP use: A qualitative longitudinal study of gay, bisexual, and queer men's dynamic practices of pausing, on-demand, and stopping PrEP in Canada

The Canadian HIV pre-exposure prophylaxis (PrEP) guidelines recommend both daily and on-demand dosing for gay, bisexual, and queer men (GBQM), meeting additional risk criteria. However, limited research explored how GBQM implement pausing, on-demand, discontinuation, and resumption of PrEP, including the contextual factors affecting decision-making. Using a relationally situated implementation science framework, we examined how GBQM tailor PrEP use to changing social and sexual circumstances. We conducted 109 longitudinal interviews with current and former PrEP users from Ontario (n = 18) and British Columbia (n = 20), Canada, at three time points between 2020 and 2022. We identified three dynamic PrEP use trajectories: pausing, on-demand, and stopping. Pausing involved brief breaks followed by a return to daily use during heightened sexual activity. Others followed the 2-1-1 on-demand schedule, while some stopped PrEP with plans to resume if social and sexual circumstances change. During the COVID-19 pandemic, participants paused PrEP when sexual activities decreased, restarting daily use when sexual engagements resumed. Others paused due to relationship changes or sexual inactivity, resuming PrEP in anticipation of sex. On-demand PrEP was adopted to manage side effects or save costs. Some stopped PrEP for sustained periods due to monogamy, private insurance loss, side effects, or low perceived HIV risk. Participants expressed concerns regarding lack of information on these strategies, relying on online sources or peers for guidance. Most participants obtained enough PrEP knowledge to adapt use appropriately. Comprehensive education campaigns on adaptable PrEP use effectiveness and strategies to discontinue and resume PrEP for clinicians and GBQM should be implemented.