Large internet surveys of American gay men show that the proportion who have heard of pre-exposure prophylaxis (PrEP) jumped from 45% in 2012 to 68% in 2015, with around half of men willing to consider using PrEP – but that actual usage is far lower and remains concentrated in a few key urban areas where public health authorities have facilitated its uptake.
Kevin Delaney of the Centers for Disease Control and Prevention (CDC) presented the data at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2016) in Boston.
Data came from three large internet-based surveys of gay, bisexual and other men who have sex with men (MSM) living in the United States, with recruitment via dating apps and websites, social media and gay websites. Surveys were conducted in May to August 2012 (2794 participants), December 2013 to May 2014 (3096 participants) and October 2014 to March 2015 (8406 participants). The Food and Drug Administration (FDA) first approved Truvada for use as PrEP in July 2012.
Awareness of PrEP, willingness to use PrEP and actual use all increased from survey to survey. In 2012, 45% were aware of PrEP, 39% would consider using it and 0.5% had actually used it (in the previous 12 months).
In the most recent survey, completed in March 2015, 68% were aware of it, 50% would use it and 4.9% had actually used it.
“There remains a large gap between the number of MSM who report being willing to use PrEP and those who actually have done so,” comment the researchers.
Respondents living in different parts of the country reported very different levels of PrEP use in the most recent survey – 2% in people living in rural areas and around 3.5% in most urban areas, but 11% in Seattle, 12% in New York City, 16% in Washington DC and 17% in San Francisco. In addition, around 8% of residents of Boston, Philadelphia, Chicago and Los Angeles reported recent PrEP use.
This likely reflects the impact of public health programmes in those cities to raise awareness of PrEP among people who could benefit from it, to train and support healthcare providers, and to reduce bureaucratic and financial barriers to access. However, in many other parts of the country, such programmes have not been provided.
Although other studies have reported less engagement with PrEP among black men, the researchers found that when they made statistical adjustment for confounding factors such as income, education and sexual behaviour, black men in this sample had similar levels of awareness, willingness and use as white men.
Men with more education or a higher income were much more likely to have heard of PrEP, but no more likely to have used it.
When comparing men who had used PrEP with those who had not, the key factors relate to sexual behaviour – 6.7% of men with ten or more sexual partners in the past year had used PrEP (compared to 0.9% of men with fewer partners), 6.6% of men recruited through a geospatial dating app had used it (compared to 1.2% of men recruited elsewhere) and 9.8% of those with a recent sexually transmitted infection (STI) had used PrEP (compared to 1.5% of men with no STI). Also, 4.9% of those taking part in the most recent survey had used PrEP, compared to 0.5% of men in the first. All these differences were highly statistically significant.
Separate surveys of gay men in New York City confirmed these findings (according to these data, recent PrEP usage increased from 2.1% in 2013 to 14.8% in 2015), with men reporting more sexual risk behaviours being more likely to have used PrEP. Men who had recently used post-exposure prophylaxis (PEP) were especially likely to have used PrEP – perhaps because those healthcare providers with experience of providing PEP have proven to be 'early adopters' of PrEP.
Less encouragingly, the New York survey found that men who did not have health insurance were much less likely to use PrEP (3.3%) than those men who had it (7.9%).
The theme of financial barriers to PrEP use was also picked up in a poster from the Kaiser Permanente programme in northern California. Whereas 21% of people who had a co-pay of less than $50 a month began to use PrEP but later stopped, 31% of individuals with a higher co-pay discontinued PrEP.
Women also had far higher rates of discontinuation (61%) than men, as did people with drug or heavy alcohol use (43%).
Whereas this programme has not had any cases of HIV seroconversion in 972 individuals while they were using PrEP, they have seen two seroconversions in individuals who had stopped using PrEP. Given these cases, the researchers say that “there is a critical need for strategies to support continuation of PrEP throughout periods of HIV risk.”
Delaney KP et al. Awareness and Use of PrEP Appear to Be Increasing Among Internet Samples of US MSM. Conference on Retroviruses and Opportunistic Infections (CROI 2016), Boston. Abstract 889, 2016.
Scanlin KE et al. Increasing PrEP Use Among Men Who Have Sex With Men, New York City, 2013-2015. Conference on Retroviruses and Opportunistic Infections (CROI 2016), Boston. Abstract 888, 2016.
Marcus JL et al. HIV Pre-exposure Prophylaxis: Adherence and Discontinuation in Clinical Practice. Conference on Retroviruses and Opportunistic Infections (CROI 2016), Boston. Abstract 894, 2016.