While few gay men in England are currently aware of pre-exposure prophylaxis (PrEP), most men who are introduced to the idea support PrEP being made available. Half would consider taking it themselves, but most would prefer to take it on a daily basis, rather than before and after each time they have sex. These findings come from a snapshot survey of gay men in England, published by Sigma Research this week.
Pre-exposure prophylaxis (PrEP) involves HIV-negative people taking anti-HIV drugs in order to reduce their risk of infection. Results of the iPrEX study into the safety and effectiveness of PrEP in gay and other men who have sex with men showed that, overall, it reduced infections by 43%. Much higher levels of efficacy were seen in men with good adherence to PrEP.
Recent studies with American gay men have shown that while only a minority of men is aware of PrEP, a majority would consider using it. Most men say PrEP would not affect their own use of condoms, particularly if it is only partially effective.
To investigate the views of gay men in England, researchers put a series of questions to members of the Sigma Panel in June 2011. The panel is made up of approximately 1500 gay men, bisexual men and other men that have sex with men (MSM) who respond to monthly cross-sectional online surveys about HIV and sexual health. The surveys have a short turnaround for analysis and reporting to health workers.
Only men who do not have diagnosed HIV were asked about PrEP; 1259 responded.
Interest in taking PrEP
Prior awareness of PrEP was low. Only 17% of respondents said that they had already heard of the idea of taking a pill before sex in order to prevent HIV infection.
Having informed respondents about what PrEP is and how it might be prescribed, the researchers asked whether men would consider using PrEP, should they be offered it at a sexual health clinic.
Just over half (52%) said they would consider it, while 30% weren’t sure and 17% wouldn’t consider taking PrEP.
There were no differences in the proportion who would consider its use by age, education or sexual identity. Men who had casual partners were slightly more likely to consider its use. Men who had a regular sexual partner who was HIV-positive were no more likely to consider PrEP than others.
Men who would consider using PrEP were asked why. Generally they wished to avoid HIV infection and believed that PrEP could help reduce this risk. Many of these men saw PrEP as providing “additional protection”; this could help bring peace of mind. Some men who use condoms all the time expressed an interest in taking PrEP.
PrEP was perceived as useful by a number of men who were conscious that their behaviour carried a higher degree of risk. This included men who regularly had unprotected sex with multiple partners, or who did so when they were not in control, due to intoxication or submission. These men did not see PrEP as influencing their sexual behaviour but as reducing the risks and anxieties associated with sex they already had.
Other men did say that PrEP could help them have sex they want to have, but do not currently have because it seems too risky. This includes men who do not like using condoms.
As noted above, 17% of men wouldn’t consider using PrEP. They cited a number of reasons for this. While a number of men said that they preferred to use condoms (because of convenience, protection against STIs or perceived reliability), others didn’t think that they ever had unprotected sex with men with HIV. Moreover, some men saw taking PrEP as indicative of being an irresponsible person who uses it in order to take sexual risks. This was at odds with their own self-image as a responsible person.
The researchers note that men who are exposed to HIV - without being aware that they may be putting themselves at risk - are unlikely to use an intervention such as PrEP.
Men who didn’t want to use PrEP also cited other disadvantages, including its experimental and unlicensed nature, and discomfort with the idea of continually taking drugs (which may have side-effects) for preventative purposes.
Men who were unsure about whether they would use PrEP raised a number of similar concerns. When they were informed that PrEP would not give 100% protection against HIV, this often turned them against the idea of using it. The researchers note that many respondents overestimate the effectiveness of condoms and many men will judge PrEP against a benchmark of 99% effectiveness.
Men who didn’t think they would want to use PrEP themselves were asked if it should be made available to others. Just 7% of this group (3% of the whole sample) thought it should not be.
Dosing preferences
Respondents who would consider taking PrEP were asked which of two dosing regimens they would prefer, assuming they were of equivalent efficacy. They could choose between a daily dose or pills before and after sex (one pill 6 to 24 hours before and one pill 2 to 24 hours after).
Fifty five per cent would prefer a daily pill, 28% before and after sex, and 18% were not sure.
Men pointed out that sex is often spontaneous and they cannot predict when it will happen. A daily pill eliminates the dilemma of turning down an offer of sex or taking a risk without having taken PrEP. Moreover, a daily pill would become a habit, leading to better adherence.
Men who preferred the before-and-after regimen generally thought of themselves as having sex less frequently and with more planning and forewarning. Some men did not like the idea of taking pills all the time.
Overall, the researchers conclude: “Surface acceptability of PrEP among gay and bisexual men in England is high. There should be considerable community support for research and service developments addressing this treatment.”