'Less education' associated with PrEP and PEP use: only one in five gay men yet aware of PrEP

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Use of PrEP

A survey (Mansergh) of 454 HIV-negative gay men in four US cities (New York, Los Angeles, Chicago and San Francisco) has found that men with lower educational attainment (high school only) were more likely to use antiretrovirals informally for HIV prevention, either as pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP), than men who had had further education.

In a parallel survey of 557 HIV-positive gay men, men with lower educational attainment were, similarly, more likely to share their antiretroviral pills with HIV-negative partners to use as PrEP or PEP.

Taken together, 22% of the men in the two surveys were under 30, 35% in their 30s and 43% 40 or over. A third were black, 38% white and the rest Hispanic or of other ethnicity.

Roughly a third each of the sample had education only to high school level, to some college qualification, or to a university degree.


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.


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).

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

safer sex

Sex in which the risk of HIV and STI transmission is reduced or is minimal. Describing this as ‘safer’ rather than ‘safe’ sex reflects the fact that some safer sex practices do not completely eliminate transmission risks. In the past, ‘safer sex’ primarily referred to the use of condoms during penetrative sex, as well as being sexual in non-penetrative ways. Modern definitions should also include the use of PrEP and the HIV-positive partner having an undetectable viral load. However, some people do continue to use the term as a synonym for condom use.

The survey asked both groups if they had used PrEP or PEP or, in the case of the HIV-positive men, provided it to others, in the last six months.

Informal use of PrEP or PEP was still comparatively uncommon; only a few per cent of those surveyed overall had used ARVs as prevention or provided them in the previous six mnoths.

However men with high-school-only education were two to six times more likely to report using one of these strategies.

In the negative group, 5% of men with only high school education had used PrEP compared with 1% of others, and 8% had used PEP compared with 3% of others.

In the positive group, 6% of men with only high school education had provided PrEP compared with 1% of others and 8% had provided PEP compared with 2%. Men in their 30s and black men were also more likely to provide ARVs to partners for use as PrEP or PEP than other groups.

In multivariate analysis, lower educational level remained statistically significant in the case of PEP, but not with PrEP. HIV-negative men with high-school-only education were 3.5 times more likely to use PEP than others. HIV-positive men with high school-only education were 2.7 times more likely to provide PEP than men with some college education and 9.3 times more likely to provide it than men with university degrees.

This is a survey of informal (non-prescribed) use of ARVs as prevention and, while some of the PrEP/PEP use may reflect difficulties with safer sex, in may also reflect two other things: firstly, gay men and especially black gay men with lower socioeconomic status are more likely to have HIV and may therefore encounter partners with HIV more often or judge themselves to be at higher risk; and secondly gay men with better educations may be better at getting healthcare providers to prescribe PEP or PrEP.

Nonetheless, the authors say, "non-prescribed use of antiretroviral therapy for prophylaxis should be monitored".

Awareness of PrEP

Another survey (Al-Tayyib) of gay men in Denver found that only one in five gay men there had heard of PrEP.

This survey was part of the annual National HIV Behavioural Surveillance System (NHBSS) which uses a series of surveys to ask gay men, injecting drug users and high-risk heterosexual people about their sexual risk behaviour over the last year.

In the Denver survey of gay men, 462 men participated. Two-thirds were white, 27% Hispanic and 9% black or of other ethnicity. Forty-three per cent had had more than four partners in the past year and 17% more than ten.

The survey told participants: "In PrEP, people take a pill every day that contains the same medicine used to treat people with HIV. Scientists want to know if taking this medicine will prevent people exposed to HIV from becoming infected." Participants were asked if they were aware of this.

Only 22% of gay men had heard of PrEP. However, when it was described to them, nearly 60% said they would take PrEP if it was 75% effective and 44% said they would take it if it was only 50% effective.

Reasons for not considering PrEP (people could give more than one reason) included low perceived risk (48%); worry it would be expensive (48%); always using condoms (45%); worry they might forget to take it (38%); distrust of the scientists (17%); and worry about what others would think (10%).

More than 90% of the men said they didn't foresee changing the number of partners they had if they took PrEP, and 82% said it wouldn't change their use of condoms; 10% said they would use condoms less but 6% said they would use them more.

Presenter Alia Al-Tayyib told the Tenth AIDS Impact conference: “Understanding the attitudes and preferences of persons at risk for HIV infection is needed to help guide the development of prevention strategies that incorporate PrEP use.”


Mansergh G et al. ‘Less education’ is associated with use and sharing of antiretroviral medications for prophylaxis of HIV infection by US men who have sex with men. Sexually Transmitted Infections, early online publication; doi: 10.1136/sextrans-2011-050188, 2011.

Al-Tayyib A et al. Knowledge of and attitudes towards pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men in Denver, Colorado. Tenth AIDS Impact conference, Santa Fe, New Mexico, abstract 207, 2011.