Concerns about efficacy, cost and side-effects possible barriers to PrEP uptake in groups with high HIV risk

Concerns about cost, efficacy, and side-effects are possible barriers to the acceptability of pre-exposure prophylaxis (PrEP) in key at-risk groups, a study conducted in Peru and published in the International Journal of STD and AIDS shows.

“Important barriers to PrEP…included high out-of-pocket cost, partial efficacy and fear of side-effects,” comment the investigators, “these potential barriers will require careful attention when planning for PrEP dissemination.”

PrEP involves HIV-negative individuals taking antiretroviral drugs to prevent their infection with HIV.

There is considerable interest in this biomedical method of HIV prevention. There are already data suggesting that PrEP reduces the risk of infection, and a number of other studies into its efficacy are currently underway.

However, little is known about the attitudes towards PrEP in groups with a high risk of HIV.

Therefore investigators in Peru recruited female sex workers, male-to-female transgendered individuals, and men who have sex with men to focus groups.

In a session lasting two hours, the individuals’ knowledge and awareness of PrEP was explored, as were their expectations of the technology. Concerns about PrEP were also discussed, and participants were asked to consider whether the introduction of PrEP would lead to behavioural changes.

A separate analysis was also conducted to assess the acceptability of seven possible PrEP scenarios. These included factors such as cost, efficacy, dosing frequency, and duration of use.

“With hope and scientific data mounting, it is essential to prepare for the possible roll-out of PrEP should it be shown to be efficacious,” comment the investigators.

A total of 45 people were recruited to the study, and they were divided into seven focus groups, each of which included between four and eight individuals.

There was little knowledge of PrEP. Nevertheless, all three populations were generally supportive of the concept.

However, there were reservations about the need to take daily therapy, especially during periods of sexual abstinence.

Side-effects were a concern for female sex workers and transgendered individuals. Some MSM suggested that alcohol and drug use could interfere with adherence, and there was also a reluctance to disclose PrEP use to family members due to a fear of being labelled “promiscuous.”

Both transgendered individuals and female sex workers thought that PrEP should be free. However, MSM expressed the opinion that there should be cost attached. MSM were prepared to consider life-time therapy, whereas sex workers favoured focused, shorter-term use of the treatment.

All three groups desired 100% efficacy.

One MSM summed up the opinions of all three populations: “I think that everyone would demand 100%.”

Female sex workers were prepared to take PrEP daily. “Yes, everyday,” said one sex worker in a focus group. However, both transgendered individuals and MSM considered this dosing schedule as impractical or incompatible with their lifestyles.

There were different opinions in the study populations about the impact of PrEP on sexual risk behaviour. Female sex workers suggested that as the technology was only protective against HIV, they would still continue to use condoms. However, both MSM and transgendered individuals agreed that effective PrEP would make condom use less likely.

One MSM stated “If you tell someone, ‘Look, take these pills and it will prevent you from getting HIV,’ I can assure you that the next day, that person won’t take condoms anymore.”

PrEP was most likely to be acceptable if it had a cost of US$10 per month, was 95% effective, had no side-effects, was taken for ten years, was dosed before sex, and was dispensed in an HIV clinic by a nurse or doctor.

The three factors most associated with acceptability were lower cost (US$10 vs US$250 per month; p < 0.001); efficacy (95% vs 75%; p < 0.001); and side effects (no side-effects vs dizziness and nausea (p < 0.001).

“Our study demonstrated that clear differences were observed between groups, particularly the female sex workers versus the transgenered and MSM, pointing to the necessity of much deeper exploration of the intended target groups in each environment…where PrEP is introduced,” conclude the authors.

Galea JT et al. Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations. International Journal of STD and AIDS 22: 256-62, 2011.