London gay men anticipate some pros and cons of different PrEP methods – but optimal efficacy is key to acceptability

When presented with a range of possible HIV prevention technologies – a daily pill, pills before and after sex, injections, or a rectal gel – gay men in London have a range of views about which methods they would prefer, but the biggest determining factor was a method’s efficacy. Men felt they might be willing to experience more inconvenience or greater discomfort if a particular method offered them greater protection against HIV than another.

These findings, based on in-depth, qualitative interviews, come from a doctoral thesis by Will Nutland at the London School of Hygiene and Tropical Medicine. This is the first study to compare the acceptability of different HIV prevention technologies in gay men in the UK.

Twenty gay men living in London took part in interviews. All were HIV negative and had had sex without a condom since their last HIV test – including seven who knew they’d had it with an HIV-positive man. Ages ranged from 21 to 45; the majority were white and university-educated.

The interviews were conducted in late 2012. At this stage there was relatively little public discussion or awareness of PrEP (pre-exposure prophylaxis) in London (the PROUD study results were released in February 2015). Interviewees were presented with the results of the iPrEx study of PrEP as a daily pill in men who have sex with men, the CAPRISA study of PrEP as a vaginal gel (microbicide) and an early safety study of an injectable antiretroviral.

As well as asking about the acceptability of daily pills, the researcher asked about pills taken before and after sex, an injection taken once a month, a long-acting implant, and a gel or foam that is inserted in the rectum before sex.

Individual views

In line with other studies, a daily pill to prevent HIV was broadly acceptable to the men interviewed. Roughly a third would definitely want to take it, a third would consider it and a third would not want to take it. When PrEP was personally unacceptable, it was generally because men thought their HIV risks to be too insignificant to justify using a daily pill, because they were concerned about the possible side-effects, or because they were uncomfortable using a pharmaceutical medicine to prevent HIV.

Several said that adherence to a daily medicine would not be an imposition. Many were already taking another medicine or vitamin pill each day. One man perceived a particular benefit to the routine.

“I think it’s easy to forget HIV sometimes… I think if that was a constant reminder every day – I have to take a pill, I have to take a pill – something in the back of your head might click in if you were getting in to a situation and you’d think ‘hang on a second: there’s a reason why I’m taking a pill’.”

Some felt that an injection had the advantage of not requiring daily adherence, but others were worried about the pain of an injection. While some were sure they would not want to self-inject, others had different views.

“The control about who is doing the injection is quite important actually – whether it’s them or me. I would feel less in control of my life if I had to go and get this injection. I would feel more positive about it if I could do it at home and looking after my own health.”

Interviewees worried that a long-acting implant just under the skin (similar to a contraceptive implant) might be visible and noticeable. Some reactions were particularly negative.

“I don’t like the idea of being physically marked. It’s almost like being branded in some way and it’s um … it feels like it is depersonalizing or dehumanizing me in some way.”  

Of note, there were two interviewees who were more interested in long-acting injections than the others. One was already taking daily PrEP pills (that he had imported from overseas) and another had tried to access PrEP from a sexual health clinic. This may suggest a PrEP acceptability continuum: once men have considered PrEP acceptable enough to take, they may be more ready to consider alternative, more convenient methods. Views are therefore likely to evolve.

An intermittent PrEP regimen (pills only needed before and after sex) was sometimes seen as preferable because it might have fewer side-effects.

“For me … the advantage of not taking a daily pill would be, you know, to give my body a rest. For me that would be like a, you know, not overdoing my liver or kidney.”

Some men could see the potential of intermittent PrEP for people who only occasionally take sexual risks, especially in relation to a holiday or a special occasion. However most of the participants used apps to find sexual partners and this was usually spontaneous. Roughly a third were concerned that the pre-planning and organisation that this method required would not work for them. 

“I’m not in a position when I can predict so well. It’s a nice idea if my life had that structure to it… it could work if I knew when I was having sex you know but… yeah… only if I knew so it’s a bit hit and miss.”

Applying a rectal gel (microbicide) could be even more problematic.

“I would guess that if you were going out that night that would put you at work doing it in the toilets. That would be a hassle. Kind of annoying I think.”

Participants were more likely to find a gel acceptable if it could be used spontaneously – for example also serving as a lubricant – rather than having to apply it in advance. But around half the interviewees felt that the practicalities of preparing and applying a rectal gel made it unappealing.

“What a faff! You know, it’s not easy to get something up your ass and for it to stay there. It’s not like you can just have a gel packet that you can squirt up your ass. You would need an applicator and it doesn’t fold like a packet of lube in your pocket. Hmmm … not sure about that one.”

Men who had a cleaning or douching routine to prepare themselves for anal sex were especially likely to foresee problems. Others were concerned that the gel might leak, creating a mess and causing embarrassment. If this happened, they might also worry that they would no longer have enough gel to protect themselves.

Others were concerned that when applying the gel in the first place, it would be hard to know that they had applied enough gel to be protective.

“I think my initial thoughts are, I’m wondering, have I done it right? Have I done enough? Have I got it in at the right time?”

A quarter raised concerns about the smell, taste or feel of the gel – and the impact it might have on oral sex or rimming.

“The mess! You know, it’s bad enough when you’ve got lube in your arse! Someone starts fingering you and you’re full of gel – that’s not going to be an attractive look is it? It’s really not! No! It’s going to leak and that.” 

Efficacy and effectiveness

Despite all of these issues, the bottom line for most men was that a method that offered the greatest protection would have benefits that outweighed its drawbacks.

For example, this man saw practical problems with a long-acting injection but speculated that if it were as efficacious as a vaccine, it would be worth it.

“Only if the results were to be vaccine-like protection. If you tell me it is zero and I can go and become a cum whore then sure! [Laughs] But otherwise it would have to be … there’s a much higher level of commitment to go to a clinic and get injected than to take a pill. It really boils down to risk. If this reduces the risk to zero or close to, then we are talking.”

Another interviewee said:

“I don’t particularly think that the way that [PrEP] is given is not necessarily … I mean it wouldn’t be the deciding factor for me. I would take the most effective … I’d prefer the most effective format rather than the one that gave me the most comfort, if you like.”

Some men took into account the possibility that the way in which they used a product might mean that the product provided more or less protection. This man thought he might forget to take pills but that a long-acting injection would be more reliable.

“That would be awesome actually because I know that taking the pill is something that not everyone does. How many pregnant women are wondering around thinking they wish they hadn’t forgotten to take the pill? But if you… then went to the clinic once a month to get an injection, that would be amazing. Yeah it really would. Definitely preferable.”

For this man, problems applying a gel or individual physiological differences could undermine the protection that a gel might provide. Will Nutland notes that his interviewee is describing the difference between efficacy (protection under ideal conditions) and effectiveness (protection in real world conditions).

“If the pill gave a 60% greater chance of not becoming infected and the gel gave a 95% chance then it would warrant more because this gel [would then be] almost fool proof. But doing it in advance – I assume there has to be a certain amount of absorption – you can’t just suddenly start fucking like with a lube. It won’t be in the right place and it depends on the people. You know, some guys have greater anal mucus therefore absorption… it’s certainly not cut and dry and certainly not as swallowing a pill.”

In other words, a method with high efficacy would become less acceptable if an individual’s use of it made it less effective. When comparing daily pills, intermittent pills, injections, and gels, their efficacy and effectiveness were the most important factors influencing acceptability.

Will Nutland concludes that research into alternative PrEP methods needs to continue. “No single method of PrEP was ideally suited to every man. Whilst daily oral PrEP was the most acceptable method, other PrEP technologies need to be developed that offer at risk populations a range of technologies that meet the complex and differing needs of MSM.”