Gay men interested in taking PrEP already report high-risk behaviour

Surveys of gay men in the Netherlands and Australia suggest that some would use condoms less frequently if they were taking PrEP – but that these men are generally not using condoms consistently anyway. The data, presented to the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia, last week, suggest that PrEP may give men at higher risk of infection a way to protect their health, rather than undermining consistent condom use.

Researchers in the Netherlands and Australia conducted separate surveys of HIV-negative men, with around 500 men participating in each study. In addition, the Dutch researchers explored motivations and barriers to PrEP use during in-depth interviews with 20 of their participants. PrEP is not yet licensed in either country.

There was some awareness of PrEP among survey participants, but knowledge was limited. Few respondents rejected the idea of taking PrEP out of hand but the proportion with a strong interest was limited – 13% of Dutch respondents had a high intention of using PrEP. In Australia, 26% agreed and 11% strongly agreed that they would want to use PrEP as soon as it becomes available in the country.

Dutch men classified as having a high risk of HIV (more than five casual partners, unprotected sex with a casual partner or a sexually transmitted infection in the last six months) were four times more likely than other men to have a high intention of using PrEP. Australian men who reported unprotected anal intercourse with casual partners were 1.5 times more likely to want to use PrEP than other men.

The Australian men were asked if they would prefer to take PrEP so as not to need to use condoms. Whereas 38% of those who already practised unprotected anal intercourse with casual partners agreed with this statement, only 14% of consistent condom users did.

Broadly similar findings were reported in the Dutch study. Furthermore, during in-depth interviews one man commented, “Effectiveness of 44% is more than what I have now.” Another man explained his interest in PrEP:

“Because I always try to have sex as safe as possible, but yes, there are times that you just had too much to drink or the passion is just too strong that you forget… PrEP would offer me a bit more freedom and I would worry a bit less.”

The Dutch researchers also found that there was a greater interest in PrEP when men thought they would need to take it for a shorter period of time – supporting the idea of PrEP being appropriate for “seasons of risk” (periods during which an individual's sexual behaviour is riskier). Whereas 89% of those with a high intention to take PrEP would take it for three months, 74% would take it for a year and 52% for ten years.

The Dutch men were also concerned about financial costs – 55% would be willing to pay €50 a month, but only 3% would pay €1000 a month.

Based on their qualitative interviews, the Dutch researchers sum up their respondents’ motivations for using PrEP:

• PrEP has a high perceived efficacy as a prevention strategy.
• PrEP reduces anxiety for contracting HIV.
• PrEP improves quality of sex life (tactile, pleasure, spontaneity).
• PrEP makes partner choice easier.
• PrEP provides solidarity with an HIV-positive partner.

And the barriers:

• High costs of PrEP.
• Perceived insufficient efficacy of PrEP.
• Anticipated side-effects of PrEP.
• Anticipated high threshold for getting PrEP prescribed.
• Low perceived self-efficacy to adhere to daily PrEP.
• Ethical objections to taking pills to prevent HIV.

In terms of using PrEP intermittently, i.e. for three days before and after sex, this was thought to have some attraction as it entails less commitment, fewer side-effects and less cost. But few men pre-planned their sex life sufficiently to make the strategy seem practical.

The Australian researchers also presented a poster on the informal use of PrEP. These data come from a separate survey of 707 men who were recruited on the basis of their interest in the preventive role of antiretrovirals, so the findings that 4.7% had used PrEP in the past year and 13.2% had taken PEP are unlikely to be representative of the wider population. Almost three quarters who had taken PrEP had obtained the medications through a doctor or clinic; a third used drugs left over from previously taking PEP; with fewer men obtaining drugs from an HIV-positive partner or friend. Most informal users had taken PEP more than once and tested for HIV regularly.

The use of PrEP was limited to specific contexts or events, such as sex parties, when using crystal meth or during Mardi Gras. Only half the users knew that PrEP should be taken daily and only one in five did so. The researchers say that informal PrEP users had poor knowledge of PrEP and sometimes confused it with PEP – they recommend educating gay men about its correct use and making it available to individuals at high risk of infection.