Spanish researchers urge more awareness campaigns on PEP

Only a third of gay men and one in six heterosexual people who came forward for a rapid HIV community testing programme were aware of post-exposure prophylaxis (PEP), a Spanish study has found.

Post-exposure prophylaxis (PEP) needs to be distinguished from pre-exposure prophylaxis (PrEP): it involves starting a course of HIV therapy – usually a month’s worth – as soon as possible after a high-risk exposure to HIV in order to prevent an infection becoming established. Studies suggest PEP can prevent at least four out of five infections if started within 48 hours of exposure. The latest UK guidelines on administering PEP were published in 2011.

The findings of the study, which gathered data between June 2009 and July 2010, contrasts with 56% of gay men knowing about PEP in the UK Gay Men’s Sex Survey of 2007 (Hickson, which gathered data in 2006) and almost universal knowledge amongst gay men in Australia in 2005 (Grulich). This is despite PEP being freely available in hospital emergency departments in Spain since 1998 and the most recent Spanish guidelines being issued in 2008.

There are two reasons for lower awareness in the Spanish survey, which in fact matches the level of awareness in a study conducted in New York. Firstly, the surveys with the highest awareness tend to include HIV-positive participants, and the Spanish study excluded them; but secondly, there has been no public awareness campaign about PEP in Spain, in contrast to the UK and Australia, and people are only going to find out about it from a clinician when they go for an HIV test.

Another distinctive aspect of this study is that very few surveys have assessed knowledge of PEP amongst heterosexual people, even though in practice in Europe a higher number of heterosexual couples have requested it than gay men, sometimes inappropriately.

The Spanish survey assessed PEP knowledge as part of a programme of rapid HIV testing in the community, which also included the home-testing feasibility study reported recently on aidsmap.com.

The programme offered free rapid HIV tests in vans placed in various locations in Spain: in the middle of Madrid’s 'gay village'; in two suburban towns; and in cities in the Canary Islands and the south-east of Spain.

In total, 2545 people were tested, with roughly a third each gay and bisexual men (34%), heterosexual men (30%) and women (35%); 3% had ever injected drugs. Over a quarter came from outside Spain, mainly from Latin America. Slightly more than half, and a clear majority of women, were under 30.

Half of the participants had previously had an HIV test (three-quarters of gay men, 42% of heterosexual men and 36% of women). Nearly 60% of gay men had tested more than once but only one in four heterosexual men and one in six women.

Overall, 22% of participants had heard of PEP; 34% of gay men but only 16.5% of heterosexual men or women. Among the whole group, the 20% of people who were from Latin America were less likely to know about PEP than native Spaniards, though the small number of people (about 5%) from other European and developed countries were more likely to know about it.

Knowledge of PEP in heterosexual people was largely dependent on their having been tested for HIV, with people who had more than one HIV test being twice as likely to know about it than those who had never tested. Amongst gay men, knowledge of PEP was half as likely in the 23% of men who said they were “non-scene” and nearly twice as likely in university graduates. Men with more than ten partners in the last year were nearly three times as likely to know about PEP and men who largely met partners on the internet were 50% more likely.

Only 48 individuals in the survey (2%) had ever taken PEP: 23 gay men, 12 heterosexual men and 13 women.

Gay men were statistically no more likely to have taken PEP than heterosexuals, although numbers are so small as to make meaningful comparisons difficult; interestingly, a quarter of the gay men and 60% of the women who had taken PEP had done so for “non-sexual reasons”, possibly for occupational exposure. When PEP was taken for sexual exposure, it was largely prescribed appropriately; 70% had taken it for what the Spanish guidelines define as high-risk sex, and 58% for anal sex (one gay man took it for oral sex). Sixty per cent of people sought PEP because they had not used a condom and regretted it, rather than because of condom failure.

Pointing out that “there has been no structured effort to broadcast [PEP’s] existence among the population” in Spain, the researchers urge that: “Promotion of the availability of PEP, and of its value following unprotected sex or...condom breakage or slippage, should be made an important element of prevention programmes.”

• Another study in this series assessed the feasibility of home testing - see this report.