Gay men often not accessing PEP despite risk of HIV exposure

Gay men may not be accessing HIV post-exposure prophylaxis (PEP) in situations when its use would be warranted, a study published in the online edition of Sexually Transmitted Infections suggests.

Investigators in Brighton conducted interviews with 15 gay men who were currently taking, or had recently completed, a course of post-exposure prophylaxis after unprotected anal intercourse. They found that prior to accessing this treatment, the men generally had a poor understanding of what post-exposure prophylaxis involved.

The investigators also found that although the men described the sexual encounter leading to the accessing of post-exposure prophylaxis as unusual, they could almost all describe other circumstances where their risk behaviour was such that treatment with post-exposure prophylaxis would have been warranted. Furthermore, the interviews suggested that the men attempted to distance themselves from their risk behaviour, attributing it to the use of drugs and alcohol or in some way blaming their sexual partner.

Post-exposure prophylaxis (a short course of treatment with antiretroviral drugs after possible exposure to HIV) is becoming increasing available for individuals reporting sexual risk behaviour. The number of gay men presenting for such treatment has increased following targeted advertising campaigns and the publication of professional guidelines.

There is robust evidence that post-exposure prophylaxis can prevent infection with HIV. But there have been reports of HIV infection despite its use following possible sexual exposure to the virus. In many instances these infections can be attributed to ongoing sexual risk behaviour.

Investigators wished to gain a better understanding of the factors and rationale leading gay men to access post exposure prophylaxis. They were hopeful that the results of their study could lead to the development of health promotion campaigns targeting men who are not accessing this treatment after possible exposure to HIV.

Between January 2007 and January 2008 investigators in Brighton conducted semi-structured interviews with 15 gay men who were currently taking or had recently completed a course of post-exposure prophylaxis.

Generally, the men had a scanty knowledge of what this treatment involved before accessing it. They knew that such treatment was available and that it had the potential to prevent infection with HIV. However, it was only after accessing treatment that the men became aware that post-exposure prophylaxis needs to be started within 72 hours of possible HIV exposure to be effective; that it involved taking a combination of anti-HIV drugs; the duration of treatment; and the potential for treatment failure.

One participant told the investigators: “[I knew that] there was a treatment available. But yeah the actual mechanisms of it I wasn’t aware of.” Another described his shock at discovering the post-exposure prophylaxis involved therapy with antiretroviral drugs: “I got home and read through the leaflets and basically realised that it was a medication designed for people with HIV…It was a bit of a slap around the face reading that.”

Unprotected anal intercourse was the main behaviour leading to the accessing of post-exposure prophylaxis. The men generally described this behaviour as being “rare” or a “one-off” and mentioned it within the context of drug or alcohol use. Such risk behaviour was also described as being out of character and the men generally considered themselves as having a low risk of infection with HIV.

For example, one individual told the investigators: “I had just separated recently, so it [unprotected anal sex] was kind of a way of me trying to react, I don’t know, trying to just forget about it, just have fun, you know do drugs and get drunk.”

Another common theme was linking unusual risk behaviour with sexual partners who were in some way unusual or “other”. The men commonly attributed a number of risky characteristics to partners with whom they had had unprotected sex, such as sexually transmitted infections, promiscuity, “adventurous sex”, and a habit of having unprotected sex. Universally, the men did not believe that they also had such risky characteristics.

Use of certain venues was also associated with the subsequent accessing of post-exposure prophylaxis, generally saunas, certain bars, and cruising grounds. One individual told the investigators: “It was certainly kind of one-off I think…it was in a sauna, where I’d gone after being out drinking”. Another man described the venues associated with HIV risk thus: “regularly going to the Brighton cruising ground and not being that careful…going to one of Brighton’s saunas and not being careful. I don’t put myself at risk cruising around.”

Most of the men, however, were able to describe other circumstances when the use of post-exposure prophylaxis would have been warranted but was not sought. Generally, the sexual behaviour and partner was not perceived as being of sufficient risk. The investigators suggest that this is consistent with the “othering” of the incident and partner leading to the eventual accessing of treatment.

One participant described his decision to access treatment on this occasion but not others in these terms: “What was different? To be honest nothing apart from they didn’t tell me they had HIV, so they might as well have been positive and they just didn’t tell me.”

Unprotected anal sex with other partners was widely reported. However, the men reported that they “trusted” their partners or that it occurred within the context of a relationship. However, replies to the investigators' questions showed that the risk assessments leading to this behaviour were rarely founded upon mutual HIV testing.

The investigators are therefore concerned that gay men often fail to access post-exposure prophylaxis because they do not perceive a sexual encounter to have been high risk enough, despite the fact that it carried a high risk of HIV exposure.

In some other circumstances, men reported being reluctant to access post-exposure prophylaxis as they did not wish to “waste” the time of healthcare staff, or because they thought they had left it too late.

There was no indication that use of post-exposure prophylaxis increased sexual risk behaviour or that it was thought of as a replacement for other methods of HIV prevention. Indeed, the idea that such treatment was a kind of “morning after pill” was abhorrent. However, there was a willingness to attribute such beliefs to other gay men, which the investigators believe is further evidence of a willingness to “other” sexual risk behaviour.

In their discussion of their findings, investigators note that most of the men could identify occasions when the use of post-exposure prophylaxis would have been warranted but was not accessed because the sexual risk behaviour was not perceived as being sufficiently “unusual.” They write “this begs the question; how many other MSM are involved in similar exposure events and yet do not have the same triggers for presenting to clinic? Extra work needs to be targeted at [post-exposure prophylaxis] understanding among men who have sex with men and improving accuracy of subjective calculations.”

They also suggest that certain men with high-risk sexual behaviour should be provided with post-exposure prophylaxis information and treatment “starter packs”.