Uneven PEP awareness amongst people living with HIV in France

A majority of HIV-positive immigrants in France are unaware of the availability of post-exposure prophylaxis (PEP), a study published in a supplement to the January 2^nd edition of AIDS has found. The study found that knowledge of PEP was not evenly distributed across a sample of HIV-positive individuals surveyed in 2003, and that gay men, and individuals who had casual partners had a better awareness of PEP, whereas immigrants, and individuals with a regular HIV-negative partner had significantly poorer PEP awareness.

In 1998, the French government issued recommendations for the use of PEP in non-occupational settings. These state that anyone who believes that they have been exposed to HIV can access PEP within 48 hours of this exposure at any hospital. An emergency physician assesses an individual’s risk and, if it is thought appropriate, a three-day starter kit of PEP is provided with a referral to a specialist HIV reference physician who decides whether treatment should be continued for a month. The French media mentioned the possibility of obtaining PEP at the time the guidelines were issued, and an opinion poll in 2001 showed that 15% of the general French population were aware of the existence of PEP. A study, also conducted in 2001, showed that almost two-thirds of HIV-positive individuals in the two French regions with the highest HIV prevalence were aware of the existence of PEP.

Information campaigns about PEP have been targeted at gay men and injecting drug users in France, and investigators from the VESPA study wished to evaluate the awareness of PEP amongst a nationally representative sample of HIV-positive individuals and to see if any factors could predict PEP awareness.

The study was conducted in 2003 and included 2932 patients receiving care at 102 HIV clinics across France. During face-to-face interviews, data were gathered from individuals about their HIV exposure group, country of origin and socioeconomic characteristics. To assess awareness of PEP, individuals were asked this question: “Have you heard about the existence of emergency treatment to prevent HIV infection that can be taken after unprotected sex?”

Individuals were also asked to provide details of their relationship status, and to say if they had had unprotected sex with either a regular of casual partner in the last year who was either HIV-negative or of unknown HIV status.

Finally, data were also gathered from the HIV clinic on patients’ disease stage, use of antiretroviral therapy and immunological and virological characteristics.

A total of 2280 individuals were sexually active and were included in the investigators’ analysis. The mean age was 41 years, 58% were employed, 74% were men, and 40% were gay men. In all, 80% of the sample were taking antiretroviral therapy and 66% had an undetectable viral load and 91% a CD4 cell count above 200 cells/mm³.

The investigators found that individuals were engaging in sexual activity which would merit the use of PEP. Almost 50% of the sample reported having a regular partner who was HIV-negative, with 34% saying that they had no regular partner and 17% an HIV-positive partner.

The investigators also established that 13% of individuals with a regular HIV-negative partner had had unprotected sex with this partner in the previous year. In addition, 47% of the sample said that they had had casual sex in the previous year, and 11% of these individuals said that they had had unprotected sex in these circumstances.

Despite these levels of risk activity, 30% of the sample reported that they had never heard of PEP. This lack of awareness was not distributed equally across the sample. In particular, 60% of immigrant men and women did not know that PEP was available. Statistical analysis showed that being older (p < 0.001), a lower level of education (p < 0.001), and being unemployed (p < 0.03) were significantly associated with poorer PEP awareness. By contrast gay men had a better awareness of PEP than both heterosexual men and women and injecting drug users.

When the investigators looked at the relationship between sexual risk behaviour and PEP awareness they found that there was no difference in knowledge of PEP between those who reported a regular relationship and those who did not. However, individuals who reported unprotected sex with a regular partner who was HIV-negative were less aware of PEP than those not reporting this high-risk activity (odds ratio, 1.7).

The investigators also found that individuals who reported casual partners had a better awareness of PEP than those who did not (odds ratio, 0.6), but there was no difference in PEP awareness between those reporting unprotected sex with casual partners and those who did not.

“The VESPA study reveals a dramatic lack of awareness about PEP among immigrants of both sexes who are living with HIV”, emphasise the investigators. They believe that this may be due to a lack of information in the mass media about PEP.

Concern is expressed by the investigators about their finding that 13% of individuals in a regular relationship with an HIV-negative partner had unprotected sex. They write, “the challenge for secondary prevention is…particularly important within serodiscordant couples, because regular partners have in recent years become a regular source of HIV infection, according to several studies among gay men.”

In conclusion, the investigators write, “physicians and healthcare workers must provide people living with HIV and their partners with better information about PEP as part of a broad-based strategy for managing the possibility of HIV transmission within a regular partnership.”