Surveys of gay men in the Netherlands and Australia suggest
that some would use condoms less frequently if they were taking PrEP – but that
these men are generally not using condoms consistently anyway. The data,
presented to the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia,
last week, suggest that PrEP may give men at higher risk of infection a way to
protect their health, rather than undermining consistent condom use.
Researchers in the Netherlands and Australia conducted
separate surveys of HIV-negative men, with around 500 men participating in each
study. In addition, the Dutch researchers explored motivations and barriers to
PrEP use during in-depth interviews with 20 of their participants. PrEP is not
yet licensed in either country.
There was some awareness of PrEP among survey participants, but
knowledge was limited. Few respondents rejected the idea of taking PrEP out of
hand but the proportion with a strong interest was limited – 13% of Dutch
respondents had a high intention of using PrEP. In Australia, 26% agreed and
11% strongly agreed that they would want to use PrEP as soon as it becomes
available in the country.
Dutch men classified as having a high risk of HIV (more than
five casual partners, unprotected sex with a casual partner or a sexually transmitted infection in the
last six months) were four times more likely than other men to have a high
intention of using PrEP. Australian men who reported unprotected anal intercourse with casual partners were 1.5 times more
likely to want to use PrEP than other
The Australian men were asked if they would prefer to take
PrEP so as not to need to use condoms. Whereas 38% of those who already
practised unprotected anal intercourse with casual partners agreed with this
statement, only 14% of consistent condom users did.
Broadly similar findings were reported in the Dutch study.
Furthermore, during in-depth interviews one man commented, “Effectiveness of 44% is more than what I have now.” Another man
explained his interest in PrEP:
“Because I always try
to have sex as safe as possible, but yes, there are times that you just had too
much to drink or the passion is just too strong that you forget… PrEP would
offer me a bit more freedom and I would worry a bit less.”
The Dutch researchers also found that there was a greater
interest in PrEP when men thought they would need to take it for a shorter
period of time – supporting the idea of PrEP being appropriate for “seasons of
risk” (periods during which an individual's sexual behaviour is riskier). Whereas 89% of those
with a high intention to take PrEP would take it for three months, 74% would take it for a
year and 52% for ten years.
The Dutch men were also concerned about financial costs –
55% would be willing to pay €50 a month, but only 3% would pay €1000 a month.
Based on their qualitative interviews, the Dutch researchers sum up their
respondents’ motivations for using PrEP:
- PrEP has a high perceived efficacy as a prevention strategy.
- PrEP reduces anxiety for contracting HIV.
- PrEP improves quality of sex life (tactile, pleasure,
- PrEP makes partner choice easier.
- PrEP provides solidarity with an HIV-positive partner.
And the barriers:
- High costs of PrEP.
- Perceived insufficient efficacy of PrEP.
- Anticipated side-effects of PrEP.
- Anticipated high threshold for getting PrEP prescribed.
- Low perceived self-efficacy to adhere to daily PrEP.
- Ethical objections to taking pills to prevent HIV.
In terms of using PrEP intermittently, i.e. for three days
before and after sex, this was thought to have some attraction as it entails
less commitment, fewer side-effects and less cost. But few men pre-planned
their sex life sufficiently to make the strategy seem practical.
The Australian researchers also presented a poster on the
informal use of PrEP. These data come from a separate survey of 707 men who
were recruited on the basis of their interest in the preventive role of
antiretrovirals, so the findings that 4.7% had used PrEP in the past year and
13.2% had taken PEP are unlikely to be representative of the wider population.
Almost three quarters who had taken PrEP had obtained the medications through a
doctor or clinic; a third used drugs left over from previously taking PEP; with
fewer men obtaining drugs from an HIV-positive partner or friend. Most informal
users had taken PEP more than once and tested for HIV regularly.
The use of PrEP was limited to specific contexts or events,
such as sex parties, when using crystal meth or during Mardi Gras. Only half
the users knew that PrEP should be taken daily and only one in five did so. The
researchers say that informal PrEP users had poor knowledge of PrEP and
sometimes confused it with PEP – they recommend educating gay men about its
correct use and making it available to individuals at high risk of infection.