Australian gay men cautious about PrEP; most in need are the most interested

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Only just over one in four Australian gay men in a recent scientific survey described themselves as ‘willing’ to use pre-exposure prophylaxis (PrEP) against HIV. The others, about two-thirds of the sample, were largely neutral about PrEP; only 3.4% said they would be unwilling to use it.

Those who were willing to use PrEP were significantly more likely to have had unprotected anal sex with casual partners in the previous six months; to have had more than ten partners during that time; to have ever taken post-exposure prophylaxis; and to perceive themselves as likely to become HIV positive in the future.

The paper also found that nearly half of the sample used condoms inconsistently with casual partners and less than 30% used them consistently with regular partner. This is consistent with other recent Australian surveys. It also found that although three-quarters of the group were confident in discussing condoms only 10% described using condoms as ‘a positive experience’ with the majority neutral or negative about condoms.

The study

The study was conducted by researchers from the University of New South Wales with researchers also involved from Goldsmith’s College in London and Utrecht in the Netherlands. It was part of the PrEPARE Project, a larger study of attitudes to PrEP in Australian gay men and Men who have Sex with Men (MSM).

Glossary

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).

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.

multivariate analysis

An extension of multivariable analysis that is used to model two or more outcomes at the same time.

exclusion criteria

Defines who cannot take part in a research study. Eligibility criteria may include disease type and stage, other medical conditions, previous treatment history, age, and gender. For example, many trials exclude women who are pregnant, to avoid any possible danger to a baby, or people who are taking a drug that might interact with the treatment being studied.

Participants were given a definition of PrEP thus:

“PrEP is when HIV-negative people take anti-HIV drugs before sex to try to reduce the chance of infection. Although there have been some promising trial results, PrEP is still being tested and is currently not available in Australia.”

Importantly, it did not give participants specific information about the trial results. It then asked nine questions about PrEP (two on concerns and seven on attitudes, examples being “I would be willing to take PrEP to prevent HIV” and “I am worried about the side effects of PrEP drugs”) and asked participants to score their answer on a five-point scale. The composite score from the seven questions on attitudes were then used to indicate willingness/neutrality/unwillingness to use PrEP, which was the study’s primary outcome measure.

It also measured attitudes towards condoms (nine questions, examples being “condoms are uncomfortable” and “condoms make sex more exciting”), about ease of discussing condoms with partners, about attitudes to medicines and about participants’ perception of the likelihood of becoming HIV positive in the future.

Results

The online survey was completed by 1283 men, but 122 (9.5%) said they already had HIV and were excluded, leaving 1161 for analysis. Of these 1161, 52% had a regular male partner, but nearly 67% had had two or more partners (casual or regular) in the previous six month (and 25% more than ten). Of the 600 men who had a regular partner, 47 individuals (8%) had a regular partner who had HIV and 70 (12%)

The average age of participants was 32. Eighty per cent had ever tested for HIV and 60% in the last month. Fifty-six per cent reported using condoms consistently with casual partners but only 29% with regular partners.

Twenty-eight per cent (327 individuals) reported positive attitudes towards using PrEP; 68.5% had neutral attitudes towards PrEP; and 3.4% (39 individuals) had negative attitudes towards it. [NB some of these figures were not published in the paper but were obtained by Aidsmap directly from the researchers.]

In univariate analysis, having positive attitudes towards PrEP was associated with youth, having more than ten partners, not being monogamous, unprotected sex with casual partners, the perceived risk of HIV, and also whether participants had even taken post-exposure prophylaxis. In the latter case 18.3% of those willing to take PrEP had taken PEP versus 13% of those neutral or unwilling to take PrEP.

In multivariate analysis, those willing to take PrEP were 4.7 times more likely to view themselves as ‘likely to become HIV positive and 2.8 times more likely to have unprotected sex than people who had no casual sex at all (they were 1.5 times more likely to be willing to take PreP if they had any casual sex, protected or otherwise). People were 20% less likely to be interested in taking PrEP per every ten years older.

The researchers also wanted to know if people contemplating PrEP would be less likely to use condoms. The vast majority (92%) said they were ‘likely to maintain their current level of condom use’, but given that 40% of this group had unprotected sex in the last six months with casual partners and 50% with regular partners if they had one, this still indicates that PrEP might be useful for this group. The eight per cent who said they were likely to decrease their level of condom use were 2.8 times more likely to have had unprotected casual sex and were 4.7 times more likely to regard themselves as likely to become HIV positive in the future.

The researchers comment that this indicates that interest in PrEP is highest amongst those most likely to benefit from it, but that potential for harm also exists if this group were to access PrEP but take it inconsistently.

“Overall,” they comment, “there is a relatively small group of gay and bisexual men in Australia who would be willing to use PrEP [but] they represent an appropriate target group.”

References

Holt M et al. Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected anal intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual men. Sexually Transmitted Infections doi:10.1136/sextrans-2011-050312. Early online edition, January 2012.