A survey of beliefs and opinions on HIV prevention options, conducted by NAM as part of a programme of European HIV prevention work, has found that respondents believed that using antiretroviral therapy (ART) is almost as effective in preventing HIV infections as using condoms.
HIV testing and condom provision remain the prevention resources that respondents believed need most prioritisation.
Respondents also tended to believe that HIV testing rates were low in their area – possibly lower than in actual fact. They tended to somewhat overestimate the effectiveness of consistent condom use in preventing HIV and were unsure of the efficacy of PrEP – which may reflect widely different efficacy reported in studies. As for antiretroviral therapy, while the majority believed it was highly effective in reducing the chances of someone passing on HIV, one in six believed it would be no more than 50% effective.
The results analysed in this news report are those in the English-language version. The survey was also available in French, Portuguese, Spanish and Russian and responses in these languages will be analysed in a later report.
The NAM prevention opinion and beliefs survey (NPOB) appeared on aidsmap.com and ran between 15 July and 4 October this year. It was targeted at people working in HIV prevention organisations in Europe, though anyone was free to participate, and was answered by 243 people, with 71% (173) answering in English.
In the entire multi-language survey, 46% of respondents came from outside the UK. In the English-language responses, 25% of respondents did; there were a number of English-language responses from Germany and Portugal and representation from countries ranging from Ireland to Ukraine.
Also in the entire survey, a bare majority (53%) worked for an HIV prevention or treatment organisation but a minority (46%) of people who answered the English-language survey did.
Those who did mainly worked in a paid position, with 25% in a leadership position such as director or chair, but 20% were volunteers. The majority of organisations represented (68%) were non-governmental or community-based organisations or charities, but 18% of respondents were healthcare providers.
Those who worked for an organisation were asked if they worked with particular groups. Of those who said yes to this, two-thirds said they worked with gay men, about 50% with people of African background, and 25% with other ethnic minorities and migrant groups. Other groups mentioned included people who inject drugs and young people (both about 15%) and sex workers, women and people with HIV (all about 12%). Other groups mentioned were prisoners and children (5% each) and disabled people, high-risk heterosexuals, couples, and family and carers (one mention each).
The vast majority (88%) said HIV testing was readily available in their area, but 70% said that making HIV testing even more widely available in their area was a priority, with a number specifically mentioning testing in primary and emergency care and in the community (“in ordinary places” said one); in contrast only two people mentioned home testing and were rather cautious about it (“because of lack of support for a positive result”). One person said that when they switched to providing testing using oral tests, they picked up on a number of new infections.
When asked to estimate what proportion of the populations they worked with had actually tested for HIV, the median answer was 37.5%.
This may be an underestimate: in the UK general population, the recent Natsal survey (Sonnenberg) found that 28% of women and 17% of men had tested for HIV in the last five years, but that this rose to 55% of people who had attended a sexually transmitted infection clinic, 52% of men who had had any sex with men and 45% of people of black African ethnic origin.
HIV prevention method effectiveness
Respondents were asked to give their estimates for the effectiveness of four different HIV prevention methods: consistent condom use, a person with HIV taking ART, or an HIV-negative person taking pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP). ‘Effectiveness’ was deliberately left undefined.
A majority of respondents (57%) thought condoms were at least 95% effective, and a slim majority (53%) thought ART was at least 90% effective, though only 39% thought it was 95% effective or more.
In contrast, over half of respondents (56%) thought PEP was no more than 80% effective and 57% thought PrEP was no more than 75% effective. A large minority of respondents – nearly 40% – thought PrEP was 50% effective or less. This may reflect widespread confusion about the contrast between the overall effectiveness of PrEP reported from randomised controlled studies (which ranged from zero to 72%) to the likely biological efficacy if it is taken every day (at least 96%). In the case of condoms, by contrast, the majority of respondents gave the efficacy in perfect use. Effectiveness in consistent use – i.e. where people attempt to use them 100% of the time – is more in the region of 80%; only 19% of respondents cited 80% or less as the effectiveness they estimated for condoms.
People were asked if they were confident that people who needed condoms, treatment specifically for prevention purposes, PEP or PrEP could get them in their area: the proportion who agreed they could was 88% for condoms, 57% for ART for prevention, 67% for PEP, but only 18% for PrEP. A large majority supported more widespread access to condoms and PEP and a slightly smaller majority (78%) to ART for prevention: respondents were generally supportive of access to PrEP, with 60% supporting wider access, and only one in eight (12.4%) opposed to it: but this left nearly 30% who were uncertain about it.
Prevention: barriers and priorities
People were asked to select from a list of reasons why they thought that at-risk people did not access a full range of HIV prevention options. The most frequently selected of twelve different options was that people did not think they were at risk (40%): the next most common reasons were HIV stigma (17%) and not understanding the risks of transmission (16%).
They were also asked what the biggest institutional barriers were to the provision of HIV prevention services: a large majority agreed that lack of priority or finances for HIV was the primary reason, rather than because people did not agree about prevention method effectiveness.
Finally, respondents were asked two questions. Firstly, they were asked to rank twelve different HIV prevention options, including, in addition to the four above, behaviour change programmes, wider HIV testing, counselling, needle exchange, the prevention of mother-to-child transmission, awareness-raising campaigns, and social and economic support, in terms of the amount of resources they thought were currently allocated to them in their area.
They were then asked what priority they thought each of these twelve options should be given.
In terms of what was currently prioritised, respondents thought the majority of resources went into HIV testing programmes, condom provision and distribution, the prevention of mother-to-child transmission, and awareness-raising campaigns. The four least resourced areas, they thought, were ART specifically for prevention, opiate substitution therapy, socioeconomic support and, at the bottom of the list, PrEP.
When asked if they wanted to reprioritise areas, testing and condom provision were given the same high priority. Prevention of mother-to-child transmission, however, slipped down the league table from number three to number six, while the provision of ART for prevention rose from ninth to fifth place, though one respondent said that, “this is only because mother-to-child transmission already has a lot of resources devoted to it”.
Respondents were also strikingly lukewarm about prevention for people who inject drugs, with needle exchange falling five points in the league table from sixth to eleventh place and opiate substitution therapy ending up at the bottom. Behaviour change programmes, socioeconomic support and PrEP rose by two places each, though in the latter two cases this only took them to positions nine and ten in terms of priority rather than the bottom two places. Several respondents, however, commented that ranking HIV prevention methods in order of priority was a really difficult exercise.
The survey also prompted a multitude of comments from respondents, which we will analyse in a further article.
Sonnenberg P et al. Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal) The Lancet 382(9907):1795-1806, 2013. See http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61947-9/fulltext – full text is free but requires login.