Recreational drug use is associated with the non-prescription use of HIV pre-exposure prophylaxis (PrEP) among gay men in Australia, according to research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The overall level of PrEP use was low, but the investigators believe that this will increase and that guidelines and education campaigns about its use are needed.
Gay men remain one of the groups most affected by HIV. Condoms are a mainstay of HIV prevention for this group, but new prevention interventions are urgently needed.
PrEP is a promising new prevention technology. It involves an HIV-negative person taking antiretroviral (ARV) therapy to reduce their risk of infection with the virus. In 2010, the results of the iPrEx study involving gay men at high risk of infection showed that PrEP treatment with Truvada (tenofovir and FTC) reduced the risk of infection with HIV by 44%. The benefits of PrEP were highest among men who took all or nearly all of their doses.
Truvada has been licenced for use as PrEP in the US and interim guidelines to try and ensure that it is used appropriately have been published.
However, Truvada can be bought over the internet or may be obtained from HIV-positive friends, meaning that there is clear potential for its non-prescription or informal use.
Investigators in Australia therefore wanted to determine the proportion of gay men who had used PrEP without a prescription and the factors associated with this behaviour.
They conducted a study involving 3677 gay men who reported recent anal sex. As part of a general survey into HIV risk, the men were asked: “In the last 6 months, have you taken any anti-HIV medication to prevent infection with HIV; before anal sex without a condom, and after anal sex without a condom (e.g. PEP).”
The research was undertaken in 2011. There are currently no guidelines in Australia about the use of PrEP.
Overall, 92 men (2.5%) reported using PrEP and 61 (66%) of these individuals also said they had taken antiretrovirals after unprotected sex.
Men reporting unprotected insertive anal sex (AOR = 2.71; 95% CI, 1.44-5.07) and both unprotected receptive and insertive anal sex (AOR = 2.36; 95% CI, 1.24-4.48) were significantly more likely to report the use of PrEP than men who did not report unprotected sex.
Use of PrEP was associated with certain drug use practices. These included regularly injecting drugs (AOR = 2.56; 95% CI, 1.03-6.36); using “party” drugs to enhance sexual pleasure either occasionally (AOR = 2.23; 95% CI, 1.33-3.73) or regularly (AOR = 5.34; 95% 2.99-9.56); and using drugs within the context of group sex (occasionally, AOR = 2.42; 95% CI, 1.29-4.52; regularly, 5.31; 95% CI, 2.62-10.76).
“Current use of ARVs before unprotected anal intercourse is likely limited to specific groups or networks of homosexual men who engage in high-risk practices,” suggest the authors.
Use of PrEP was more likely with partners of an unknown HIV status (5% vs 2% known HIV-positive vs 2% thought HIV-negative; p = 0.004).
PrEP use was also more common within the context of relationships of between twelve and 24 months (5%) duration compared to relationships of shorter (4%) or longer (1%) duration.
The authors acknowledge that the level of PrEP use revealed in their study was low. However, they believe that men using non-prescription PrEP were unlikely to have taken their therapy correctly and therefore would not have received “optimum levels of protection.”
They conclude, “the use of…PrEP by men with high HIV risk behaviour is currently at low levels, bit it may indicate early and budding prevention optimism…it is important to develop clinical and public health guidelines for PrEP use, train health practitioners and educate gay communities about the appropriate and effective use of PrEP.
Zablotska IB et al. The informal use of antiretroviral medications for pre-exposure prophylaxis (PrEP) of HIV among gay men in Australia. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0b013e31827e854a, 2012.