Rapid rise in PrEP awareness in US gay men, but only 5% have used PrEP

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.

Glossary

Food and Drug Administration (FDA)

Regulatory agency that evaluates and approves medicines and medical devices for safety and efficacy in the United States. The FDA regulates over-the-counter and prescription drugs, including generic drugs. The European Medicines Agency performs a similar role in the European Union.

post-exposure prophylaxis (PEP)

A month-long course of antiretroviral medicines taken after exposure or possible exposure to HIV, to reduce the risk of acquiring HIV.

sample

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

statistical significance

Statistical tests are used to judge whether the results of a study could be due to chance and would not be confirmed if the study was repeated. If result is probably not due to chance, the results are ‘statistically significant’. 

seroconversion

The transition period from infection with HIV to the detectable presence of HIV antibodies in the blood. When seroconversion occurs (usually within a few weeks of infection), the result of an HIV antibody test changes from HIV negative to HIV positive. Seroconversion may be accompanied with flu-like symptoms.

 

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.

Local data

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.”

References

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.

View the abstract and e-poster on the conference website.

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.

View the abstract and e-poster on the conference website.

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.

View the abstract and e-poster on the conference website.