PrEPped for COVID? The association between HIV-PrEP use and COVID-19 among men and gender diverse people who have sex with men: findings from three large online surveys in the United Kingdom

Oral tenofovir and emtricitabine taken as pre-exposure prophylaxis (HIV-PrEP) is highly effective at reducing Human Immunodeficiency Virus (HIV) acquisition. Nucleotide analogues have also been shown to inhibit Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) polymerase activity in vitro, raising the question as to whether tenofovir-based HIV-PrEP could be useful for the prevention and treatment of COVID-19. We sought to examine the association between HIV-PrEP use and self-reported COVID-19 testing outcomes and respiratory symptoms among men and gender diverse people who have sex with men in the UK. Participants completed online surveys deployed at three time points during the COVID-19 pandemic (Survey 1 (S1) 23/06/20 − 14/07/20; S2 23/11/20 − 12/12/20; S3 23/03/21 − 14/04/21), including men (cis/transgender), transwomen or gender-diverse people reporting sex with another man (cis/transgender) or non-binary person assigned male at birth. The outcome was self-reported COVID-19 testing and COVID-19 related respiratory symptoms including a new continuous cough, high temperature or loss of smell and/or taste during the most recent lookback period. All participants reporting taking HIV-PrEP in the past year were compared with those who did not. Analysis was performed using logistic regression, adjusting for sociodemographic and behavioural factors. Among 4,544 participants living without HIV across three surveys (89.7% of all survey respondents), 21.4% (n = 970) reported recently using HIV-PrEP, 564 (12.4%) participants reported respiratory symptoms and 160 (3.5%) reported a positive COVID-19 test. There was a slight, non-statistically significant positive association between HIV-PrEP use and a COVID-19 positive test in the first survey-period (P1) (adjusted Odds Ratio (aOR) = 1.11, CI = 0.51–3.98). This positive association significantly increased across survey periods (P2: aOR = 4.26, CI = 1.21–14.97, P3: aOR = 9.02, CI = 2.69–30.31). There was a positive association between HIV-PrEP use and respiratory symptoms in the first survey-period (aOR = 1.45, CI = 1.03–2.03). However, this positive association reversed in survey-period 2 and 3 (P2: aOR = 0.62, CI = 0.40–0.95, P3: aOR = 0.45, CI = 0.28–0.72). We found no evidence that HIV-PrEP use protected against COVID-19 among participants. Conversely, we identified a positive association between HIV-PrEP use and COVID-19 which may reflect uncaptured behaviours that increase COVID-19 exposure amongst those using HIV-PrEP. The decline in respiratory symptoms in HIV-PrEP users over time might reflect some immune protection following exposures to respiratory viruses through more social mixing or a direct impact of HIV-PrEP on symptom severity.