Willingness to use and have sex with men taking HIV pre-exposure prophylaxis (PrEP): results of online surveys of Australian gay and bisexual men, 2011-2015

Predictors of Human Immunodeficiency Virus Pre-Exposure Prophylaxis (PrEP) Uptake in a Sexual Health Clinic With Rapid PrEP Initiation

Background

Improved pre-exposure prophylaxis (PrEP) uptake is essential for human immunodeficiency virus (HIV) prevention initiatives. Offering PrEP at the time of HIV and sexually transmitted infection (STI) testing can improve uptake. We offered rapid PrEP initiation in a sexual health clinic and assessed predictors of PrEP interest, initiation, linkage, and retention.

Methods

Between November 2018 and February 2020, PrEP-eligible individuals who presented to a sexual health clinic were offered a free 30-day supply of PrEP plus linkage to continued PrEP care. Univariable and multivariable analyses of demographic and HIV risk data were conducted to determine predictors of PrEP uptake.

Results

Of 1259 adults who were eligible for PrEP (99.7% male, 42.7% White, 36.2% Hispanic), 456 were interested in PrEP, 249 initiated PrEP, 209 were linked, and 67 were retained in care. Predictors of PrEP interest included younger age (P < .01), lower monthly income (P = .01), recreational drug use (P = .02), and a greater number of sexual partners (P < .01). Negative predictors of PrEP initiation included lower monthly income (P = .04), testing positive for chlamydia (P = .04), and exchanging money for sex (P = .01). Negative predictors of linkage included self-identifying as Black (P = .03) and testing positive for an STI (P < .01). Having health insurance positively predicted both linkage (P < .01) and retention (P < .03).

Conclusions

A minority of PrEP-eligible HIV and STI testers initiated PrEP when offered, suggesting that easy PrEP access in sexual health clinics alone may not improve uptake. Predictors of uptake included established HIV risk factors and markers of higher socioeconomic status, suggesting that those aware of their risk and with the means to utilize health services engaged best with this model.

Increasing awareness of HIV pre-exposure prophylaxis (PrEP) and willingness to use HIV PrEP among men who have sex with men: a systematic review and meta-analysis of global data

Introduction

Integrated knowledge regarding pre‐exposure prophylaxis (PrEP) awareness and willingness to use PrEP can be useful for HIV prevention in high incidence groups. This review summarizes the awareness of PrEP and willingness to use PrEP among men who have sex with men (MSM).

Methods

Online electronic databases were searched before 31 August 2021. A meta‐analysis was conducted to pool studies analysing PrEP awareness and willingness to use PrEP. LOESS regression and linear regression were applied to fit the trends over time for the proportion of MSM aware of PrEP and willing to use PrEP. Dose–response meta‐analysis (DRMA) was conducted by a restricted cubic spline model to explore the relationship between willingness to use PrEP and selected factors.

Results and Discussion

A total of 156 articles involving 228,403 MSM were included. The pooled proportions of MSM aware of PrEP and willing to use PrEP were 50.0 (95% CI: 44.8–55.2) and 58.6% (95% CI: 54.8–62.4), respectively. PrEP awareness varied among countries with different economic status and different WHO regions, among different publication and research years, PrEP types and support policies. PrEP willingness differed among countries with different economic status and groups with different risks of HIV. The awareness of PrEP increased from 2007 to 2019 with a slope of 0.040260 (p<0.0001), while the proportion of MSM willing to use PrEP decreased from 2007 to 2014 (slope = –0.03647, p = 0.00390) but increased after 2014 (slope = 0.04187, p = 0.03895). The main facilitators of willingness to use PrEP were PrEP awareness, condomless sexual behaviours, high perceived risk of HIV infection and influence of social network. The main barriers were doubts about the efficacy and side effects of PrEP. DRMA results indicated that MSM with more sexual partners and lower level of education were more willing to use PrEP. No publication bias was observed.

Conclusions

The proportions of PrEP awareness and willingness to use PrEP among MSM have increased since 2014, although the awareness was low and the willingness was moderate. Improving awareness of PrEP through increasing access to PrEP‐related health education and enhancing risk perceptions of HIV infection could have positive effects on the willingness to use PrEP among MSM.

Acceptability of HIV pre-exposure prophylaxis in China: A systematic review and meta-analysis

Using pre-exposure prophylaxis (PrEP) for the prevention of HIV infection is a popular, contemporary research topic. We retrieved PubMed, Web of Science, MEDLINE, Wanfang, CNKI, and Sinomed databases, and related websites to identify studies both in Chinese and English, which reported the acceptability of PrEP in China. A total of 3203 citations were retrieved, of which 54 were included. We found that the acceptability varied widely across the country, ranging from 19.1% to 94.6%, and the pooled estimate was 66.8% (95% CI: 62.0%–71.3%). Higher acceptability of PrEP was associated with the following factors: individuals with a lower educational degree, higher income, non-discriminatory attitude towards AIDS or AIDS patients, self-perceived high HIV risk, feeling that PrEP should be promoted, familiarity with PrEP, history of HIV testing, history of anal intercourse, consistent condom use, higher number of sexual partners. The main reasons for not using PrEP are doubting its validity, fear of potential side effects and financial burden, and fear of stigma for using PrEP. This review found that the acceptance in China was moderate.

Changes in Sexual Behaviour Following PrEP Initiation Among Australian Gay and Bisexual Men in Relationships: Results from a Prospective Observational Study

Few studies have examined changes in sexual behaviour following HIV pre-exposure prophylaxis (PrEP) initiation among gay, bisexual and other men who have sex with men (GBM) in relationships. In a national, online, prospective study of GBM in Australia, we compared sexual behaviours prior to and after PrEP initiation among HIV-negative and unknown-HIV-status men (recruited 2014-2017) not taking PrEP at baseline and who completed at least one six-monthly follow-up by July 2018. Among men in relationships who did not initiate PrEP (n = 339), we compared their most recent survey to their prior one, while among men in relationships who initiated PrEP (n = 81), we compared follow-ups before and after PrEP initiation. Among the 81 PrEP-initiators who were in a relationship both before and after initiation, the proportion reporting their regular partner was on PrEP increased from 8.3 to 44.4% (p < 0.001) and the proportion reporting receptive CLAIC increased from 27.2 to 44.4% (p = 0.009). Overall, men who initiated PrEP were more likely to be in a relationship with a partner on PrEP, and it appeared they started PrEP around the same time. Receptive CLAIC also became more common.

Willingness, preferred ways and potential barriers to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in China

OBJECTIVE

To explore willingness and preferred ways to use HIV pre-exposure prophylaxis (PrEP), factors associated with willingness, and potential barriers to PrEP use among men who have sex with men (MSM) in Changsha, China.

DESIGN

A cross-sectional survey was conducted from 25 June to 31 August 2019. Two hundred and fifty-five MSM were recruited from three community-based organisations (CBOs) in Changsha City. Willingness and potential barriers to use PrEP were examined using researcher-created scales. Univariate and multivariate logistic regression was used to analyse the factors associated with willingness to use PrEP. P values <0.05 were considered significant.

SETTING

Three MSM inclusive CBOs in Changsha, Hunan Province, China.

PARTICIPANTS

255 HIV-negative MSM were recruited through their CBOs with snowball sampling.

RESULTS

Less than half of the participants (43.1%) had heard of PrEP and 15.3% were willing to use PrEP. The participants reported higher willingness to use event-driven PrEP (3.70±0.07) than daily PrEP (2.65±0.07). Higher self-rated risk and fear of contracting HIV (OR: 14.47, 95% CI 2.19 to 95.53), awareness of PrEP (OR: 4.20, 95% CI 1.64 to 10.73), sharing one's own sexual orientation with parents or siblings (OR: 2.52, 95% CI 1.54 to 7.20) and having a university education or above (OR:0.29, 95% CI 0.12 to 0.72) were associated with willingness to use PrEP. Only 12.2% of the sample was concerned about potential barriers to PrEP use.

CONCLUSION

Efforts to improve awareness and knowledge of PrEP, teach self-evaluation of HIV infection risk and provide social and emotional support for MSM are needed to scale up PrEP implementation in China.

Assessing the Role of Gay Community Attachment, Stigma, and PrEP Stereotypes on Young Men Who Have Sex with Men's PrEP Uptake

Negative stereotypes about pre-exposure prophylaxis (PrEP) hinder PrEP uptake among young men who have sex with men (YMSM). Prior research suggests community homophobia may be linked to negative PrEP attitudes. Conversely, individuals with high gay community attachments (GCA) may have more access to credible PrEP information/resources. Among 285 YMSM recruited online, we estimated structural equation models to test competing conceptual models that inform pathways from perceived stigmas, GCA, and negative PrEP stereotype endorsements to PrEP uptake. In Model A, perceived stigma was directly associated with PrEP uptake, partially mediated by stereotype endorsement (β =  - 0.05; 95% CI [- 0.09, - 0.01]) and GCA (β =  - 0.06; 95% CI [- 0.11, 0.02]). In Model B, perceived stigma was associated with PrEP uptake (β =  - 0.07; 95% CI [- 0.14, - 0.01]) through stereotype endorsement among high GCA YMSM. Complemented by anti-stigma initiatives, PrEP outreach for YMSM should utilize sex-positive messaging and disentangle negative PrEP stereotypes within gay-centric social spaces.

Access to Subsidized Health Care Affects HIV Pre-Exposure Prophylaxis (PrEP) Uptake Among Gay and Bisexual Men in Australia: Results of National Surveys 2013-2019

BACKGROUND

We assessed willingness to use HIV pre-exposure prophylaxis (PrEP) and current PrEP use among gay and bisexual men (GBM) in Australia.

METHODS

National, online cross-sectional surveys of GBM were conducted in 2013, 2015, 2017, and 2019. Willingness to use PrEP was measured on a previously validated scale. Trends and associations with key measures were analyzed using multivariate logistic regression.

RESULTS

During 2013-2019, 4908 surveys were completed. Among HIV-negative and untested men not currently using PrEP, willingness to use PrEP increased from 23.0% in 2013 to 36.5% in 2017 (P < 0.001) but then plateaued at 32% in 2019 (P = 0.13). The proportion of current PrEP users increased significantly from 2.5% in 2015 to 38.5% in 2019 (P < 0.001). In 2019, factors independently associated with being a current PrEP user (compared with non-PrEP users who were willing to use PrEP) included having subsidized health care (Medicare), knowing HIV-positive people, being recently diagnosed with an STI other than HIV, having higher numbers of recent male sexual partners, recent condomless sex with casual and regular partners, and frequent PrEP sorting.

CONCLUSION

Willingness to use PrEP has plateaued as its use has rapidly increased among GBM in Australia. PrEP use is concentrated among more sexually active men with access to subsidized health care. Free or low cost access schemes may facilitate broader access among GBM who want or need PrEP but lack access to subsidized health care.

Gay and Bisexual Men's Perceptions of Pre-exposure Prophylaxis (PrEP) in a Context of High Accessibility: An Australian Qualitative Study

We report on Australian gay and bisexual men's (GBM) perceptions of preexposure prophylaxis (PrEP). Drawing on an online longitudinal cohort study, 1,404 free-text responses from HIV-negative or untested Australian GBM were qualitatively analysed. The chi-square statistic was then used to assess differences regarding PrEP-perceptions by participants' demographic and behavioral characteristics. Positive views of PrEP were twice more common than negative. Those with positive views thought PrEP helped overcome HIV fear and anxiety, enhanced sexual pleasure, and was a 'socially responsible' course of action. Those with negative views believed that people without medical conditions did not need medication and expressed concern that PrEP was replacing condoms, representing 'dangerous' behavior. Descriptive statistics revealed differences in PrEP-perceptions relating to age, recency of HIV testing, and PrEP eligibility. This study is the first to use free-text data to examine the frequency of Australian GBM's PrEP-perceptions, highlighting the potential benefits and challenges to its promotion.

Interest in Taking HIV Pre-exposure Prophylaxis Is Associated with Behavioral Risk Indicators and Self-Perceived HIV Risk Among Men Who Have Sex with Men Attending HIV Testing Venues in Sweden

This study explored factors associated with interest in taking PrEP among men who have sex with men (MSM) attending HIV testing venues in Sweden. Data from 658 HIV-negative respondents, surveyed by a questionnaire at six sites, were analyzed descriptively and by univariable and multivariable logistic regression. A total of 453 (68.8%) of the respondents expressed interest in taking PrEP. Reporting self-perceived risk of HIV acquisition as moderate or high, reporting ≥ 5 partners for condomless anal intercourse during the past year, and reporting hard drug use during the past year were independently associated with interest in taking PrEP. However, an aggregated variable of self-reported rectal gonorrhea, rectal chlamydia, or syphilis infection during the past year was not associated with interest in taking PrEP. Overall, Swedish MSM were well-informed regarding PrEP, and interest in taking PrEP was positively associated with sexual risk indicators.

A Survey on HIV/AIDS-Related Knowledge, Attitudes, Risk Behaviors, and Characteristics of Men Who Have Sex with Men among University Students in Guangxi, China

In recent years, the prevalence of human immunodeficiency virus (HIV) infection among Chinese university students has increased significantly, and HIV transmission among men who have sex with men (MSM) comprises more than half of the new cases. There is still a lack of research investigating the incidence of male-to-male sex, the attitudes towards MSM, and the awareness of HIV/AIDS among university students in Guangxi, one of the HIV high-risk areas in China. Therefore, we performed a cross-sectional investigation among 578 male students, recruited by stratified sampling, in universities in Nanning, Guangxi, between January 2016 and March 2017. Researcher-administered anonymous questionnaires were completed. Self-recognition as MSM was found in 8.48% of the subjects. Compared with non-MSM, university student MSM included more people over the age of 20 (OR = 4.95), had less migration from other districts of Guangxi (OR = 0.26), and the majority were nonmedical students (OR = 8.99). In total, 63.25% of the male student participants reported a lack of acceptance of MSM, while 35.47% acknowledged barriers between themselves and acquaintances who were MSM. Overall, 67.30% of the subjects correctly answered questions related to AIDS knowledge. The proportion of MSM subjects who answered the AIDS-related questions completely correctly was significantly lower than that of non-MSM subjects (42.86% vs. 69. 57%, respectively, OR: 0.33), but the self-recognition risk of MSM was significantly higher than that of non-MSM (OR = 2.59). Risky behaviors associated with HIV infections, including smoking, alcohol consumption, drug abuse, and inconsistent condom use, were significantly higher among the MSM participants. The percentages of student's willingness to accept MC and PrEP were 70.93% and 77.51%, respectively. These results raise the alarm that university student MSM in Guangxi, China, require urgent public attention and more effective health education, including the education on MC and PrEP.

Baseline characteristics of gay and bisexual men in a HIV pre-exposure prophylaxis demonstration project with equity quotas in Auckland, New Zealand

Background In New Zealand, pre-exposure prophylaxis (PrEP) should target gay and bisexual men (GBM), and equity is an important principle. Baseline characteristics of GBM offered PrEP in a demonstration project with an enrolment quota of 50% non-Europeans are described.

METHODS

An open-label, single-arm treatment evaluation study design ('NZPrEP') was used. The settings were four publicly funded sexual health clinics in Auckland in 2017. The study population was 150 GBM recruited from clinics, community sources and social media. Participants self-completed an online questionnaire about PrEP awareness, attitudes and sexual risk behaviour in the last 3 months. Baseline characteristics are described and examined to determine whether these were associated with PrEP initiation status (self-referral vs doctor/nurse recommendation).

RESULTS

In total, 150 GBM of whom half (52%) were non-European, including 21.3% Maori, 19.3% Asian and 8.7% Pacific, were enrolled into the study. Two-thirds (65.3%) self-referred for PrEP and one-third (34.7%) were recommended PrEP by the doctor/nurse. Participants reported a high number of male condomless receptive anal intercourse partners (MenAICLR) (median 3, range 0-50), with 10% reporting 10 or more MenAICLR and 45.3% reporting group sex. In the previous year, 65.3% had a sexually transmissible infection (STI); 18% had rectal chlamydia or gonorrhoea at enrolment. Almost half (47.7%) had recently used drugs with sex, including 8.1% who used methamphetamine. Participants recommended PrEP had lower education, lived less centrally and had a higher STI prevalence than PrEP self-referrers, but their risk behaviour was similar.

CONCLUSIONS

Early PrEP adopters in New Zealand have high HIV risk. Demonstration projects should consider equity mechanisms so that minorities can participate meaningfully.

HIV Nonoccupational Postexposure Prophylaxis Among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis of Global Data

HIV nonoccupational postexposure prophylaxis (nPEP) has been prescribed to men who have sex with men (MSM) for decades, but the global situation of nPEP implementation among this population remains unclear. To understand nPEP awareness, uptake, and factors associated with uptake among MSM, we searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science for studies reporting nPEP implementation among MSM published before May 19, 2019. We estimated pooled rates and their 95% confidence intervals (CIs) of awareness, uptake using a random-effects model. We identified 74 studies: 3 studies (4.1%) from upper-middle-income regions and 71 (95.9%) from high-income regions. The pooled rate of nPEP awareness and uptake was 51.6% (95% CI 40.6-62.5%) and 6.0% (5.0-7.1%), respectively. Pooled uptake rate was higher in upper-middle-income regions [8.9% (7.8-10.0%)] than in high-income regions [5.8% (4.8-6.9%)]. Unprotected anal sex was the most common exposure (range: 55.0-98.6%, median: 62.9%). Pooled completion of nPEP was 86.9% (79.5-92.8%). Of 19,546 MSM prescribed nPEP, 500 HIV seroconversions (2.6%) were observed. Having risky sexual behaviors and history of sexually transmitted infections were associated with higher nPEP uptake, whereas insufficient knowledge, underestimated risk of exposure to HIV, lack of accessibility, and social stigma might hinder nPEP uptake. Awareness and uptake of nPEP among MSM worldwide are low. Further efforts are needed to combat barriers to access nPEP, including improving accessibility and reducing stigma. Seroconversions post-nPEP uptake suggest that joint prevention precautions aside from nPEP are needed for high-risk MSM. More evidence from low-income and middle-income regions is needed.

How Male Sex Workers and Their Clients Shifted from Reluctance About HIV Pre-exposure Prophylaxis to Advocating for Its Use: A Longitudinal Mixed Methods Study

We assessed individual and collective responses to HIV pre-exposure prophylaxis ('PrEP') among a network of male sex workers and clients. From 2011 to May 2017, keyword searches on an online discussion forum identified 668 posts that referenced PrEP. We conducted four analyses: (i) discourse analysis identifying reactions to PrEP, (ii) thematic analysis constructing rhetorical strategies, (iii) content analysis comparing discursive positions and rhetorical strategies, and (iv) longitudinal analyses assessing trends over time. Forum posts adopted one of three discursive positions (reluctance, interest, advocacy), drawing upon four non-exclusive strategies (deference to experts and evidence, acknowledging personal and shared experiences, establishing philosophical arguments, engaging in speculation). Posts from sex workers were more likely than clients to be supportive of PrEP (96% vs. 42%; χ² = 18.46, p < 0.001) while over time this network moved from being predominantly reluctant about PrEP (61% of posts in 2012) to advocating for its use (65% of posts in 2017; Z = 5.01, p < 0.001).

Congruence between Hypothetical Willingness to Use Pre-Exposure Prophylaxis (PrEP) and Eligibility: An Online Survey among Belgian Men Having Sex with Men

Men who have sex with men (MSM) are at high risk for acquiring HIV in Belgium. This study explores MSMs’ hypothetical willingness to use pre-exposure prophylaxis (PrEP), assesses it against formal PrEP eligibility criteria, and identifies factors associated with incongruence between eligibility and willingness. We used data from an online survey of n = 1444 self-reported HIV-negative MSM. Participants were recruited through social media of MSM organizations and dating apps. Univariate analysis described PrEP willingness and eligibility; bivariate analyses examined how specific co-variates (socio-demographic, knowledge-related, and attitudinal and behavioral factors) were associated with eligibility and willingness. About 44% were eligible for PrEP and about 70% were willing to use it. Those who were eligible were significantly more likely be willing to take PrEP (p < 0.001). Two incongruent groups emerged: 16% of eligible participants were unwilling and 58% of ineligible participants were willing to use PrEP. Factors associated with this incongruence were sexual risk behavior, HIV risk perception, partner status, PrEP knowledge, and attitudinal factors. Because the two groups differ in terms of profiles, it is important to tailor HIV prevention and sexual health promotion to their needs. Among those at risk but not willing to take PrEP, misconceptions about PrEP, and adequate risk perception should be addressed.

The PrEP You Want: A Web-Based Survey of Online Cross-Border Shopping for HIV Prophylaxis Medications

Background

In response to the high cost of HIV pre-exposure prophylaxis (PrEP) medications in Canada, community organizations have created internet-based guides detailing how to legally order generic medications online and travel to collect them in the United States. However, little is known about the patients following these guides.

Objective

Our primary objective was to measure the proportion of Ontario gay, bisexual, and other men who have sex with men (GBMSM) accessing these online guides who intended to use the border-crossing approach. Our secondary objectives were to explore their demographic characteristics, their completion of the steps in the border-crossing approach, and the barriers they perceived.

Methods

Between July 20, 2017, and May 18, 2018, we administered two online surveys of GBMSM accessing an online border-crossing guide posted by a gay men’s health organization in Ontario. Participants completed an open baseline survey posted on the border-crossing guide’s Web page and a follow-up survey 3 months later. The data were analyzed using descriptive statistics. We used multivariable logistic regression to identify characteristics associated with the intention to use the border-crossing approach.

Results

Most of the 141 participants were young (median age 23, interquartile range 22-25 years) and black (79.4%; 112/141) GBMSM who had completed a college or an undergraduate degree (62.4%; 88/141). In addition, 19.9% (28/141) of them reported a total family income less than Can $30,000 and another 53.9% (76/141) reported income between Can $30,000 and Can $60,000. 54.6% (76/141) paid for medications entirely out of pocket. Most participants indicated that they were likely to complete a border-crossing approach: 80.1% (113/141) at baseline and 79.1% (87/110) at follow-up. The characteristics associated with the intention to use the approach included being black (adjusted odds ratio [aOR] 5.73, 95% CI 2.06-16.61), paying for medications out of pocket (aOR 5.18, 95% CI 1.82-17.04), and having a provider who was thought to be willing to prescribe PrEP (aOR 4.42, 95% CI 1.63-12.41). Comparing baseline and follow-up for the 110 participants who completed both surveys, 65.4% (72/110) and 80.0% (88/110) had discussed PrEP with a health care provider, 18.1% (20/110) and 25.4% (28/110) had obtained a PrEP prescription, and 8.2% (9/110) and 5.5% (6/110) had ordered medications to that mailbox, whereas only 1.0% (1/110) and 0.0% (0/110) had crossed the border to collect them at baseline and follow-up, respectively. Reported barriers included perceived concerns about the approach’s legality (56.0%; 79/141), the security of personal health information (39.0%; 55/141), and the safety of online vendors (38.3%; 54/141).

Conclusions

Despite high interest in pursuing an online border-crossing approach to get PrEP medications, such an approach may not be a viable option for PrEP scale-up among interested GBMSM because of logistical challenges and perceptions of safety and legitimacy.

Promoting 'Equitable Access' to PrEP in Australia: Taking Account of Stakeholder Perspectives

As evidence of the safety and effectiveness of HIV pre-exposure prophylaxis (PrEP) has grown, so has attention to the views of prospective users and providers. However, far less attention has been paid to understanding the perspectives of other stakeholders in the rollout of PrEP access programs. We conducted 21 semi-structured qualitative interviews in 2017 with key stakeholders working across the policy, advocacy, research and/or clinical dimensions of the Australian HIV response, before federal support for a subsidised access scheme was achieved. Our analysis explored three areas of shared concern: who is a suitable candidate for PrEP; why are disparities in PrEP access important; and how can disparities be addressed? In examining how this diverse group of professionals grappled with the challenges of promoting 'equitable access' to PrEP in an increasingly resource rationed health system, we can see how the principles believed to underpin the Australian response to HIV were both reaffirmed and challenged through this period of significant change.

Trends in Attitudes to and the Use of HIV Pre-exposure Prophylaxis by Australian Gay and Bisexual Men, 2011-2017: Implications for Further Implementation from a Diffusion of Innovations Perspective

Using repeated, national, online, cross-sectional surveys of Australian gay and bisexual men (GBM), we analysed trends related to HIV pre-exposure prophylaxis (PrEP). Specifically, we analysed trends in PrEP use, willingness to use PrEP, and concern about using PrEP during 2011-2017. We assessed support for GBM using PrEP and willingness to have sex with men taking PrEP between 2015 and 2017. For time-based analyses, we used multivariate logistic regression, controlling for sampling variations over time. We constructed new scales assessing reduced concern about HIV among PrEP users and non-users in 2017, and used multivariate logistic regression to identify independent correlates of PrEP use (vs. non-use). The analyses included 4567 HIV-negative and untested participants (2011-2017). PrEP use increased from 0.5% in 2011 to 25.5% in 2017 (p < 0.001). Willingness to use PrEP increased from 27.9% in 2011 to 36.5% in 2017 (p < 0.001) while concern about using PrEP fell (52.1-36.1%, p < 0.001). Support for GBM using PrEP remained stable (52.5% in 2015, 51.9% in 2017, p = 0.62), and willingness to have sex with men taking PrEP increased from 34.9% in 2015 to 49.0% in 2017 (p < 0.001). In 2017, 22.8% of non-PrEP-users had reduced HIV concern because of PrEP, while 73.6% of PrEP users had reduced HIV concern and greater sexual pleasure because of PrEP. The analysis of PrEP users vs. non-users in 2017 indicated that PrEP users were more sexually active and reported higher risk sexual practices, were more likely to live in New South Wales and Victoria, and to be in full-time employment. They were also more likely to know HIV-positive people and other PrEP users. Diffusion of Innovations theory suggests that future PrEP users in Australia may be less adventurous and require greater reassurance about PrEP's efficacy and legitimacy, to sustain rollout and address current disparities in uptake.

Predictors of Daily Adherence to HIV Pre-exposure Prophylaxis in Gay/Bisexual Men in the PRELUDE Demonstration Project

Adequate adherence to pre-exposure prophylaxis (PrEP) is critical to prevent HIV infection, but accurately measuring adherence remains challenging. We compared two biological [blood drug concentrations in plasma and peripheral blood mononuclear cells (PBMC)] and two self-reported measures (facilitated recall to clinicians and self-report in online surveys) and identified predictors of daily PrEP adherence among gay and bisexual men (GBM) in their first 12 months on PRELUDE, an open-label, single-arm PrEP demonstration project in New South Wales, Australia. 327 participants were enrolled; 263 GBM attended their 12-month follow-up visit (81% retention). Overall, 91% of blood samples had plasma drug concentrations indicative of taking 7 pills/week, and 99% had protective drug concentrations (≥ 4 pills/week). Facilitated recall to clinicians identified 99% of participants with protective adherence as measured by PBMC drug concentrations. Daily adherence measured by facilitated recall was associated with behavioural practices including group sex (aOR 1.33, 95% CI 1.15-1.53, p < 0.001). Retained participants maintained high adherence to daily PrEP over 12 months, confirmed by four different measures. Facilitated recall to clinicians is a suitable measure for assessing PrEP adherence in populations engaged in care where there is established trust and rapport with patients. Trial registration: ClinicalTrials.gov NCT02206555.

Correlates Associated With Willingness to Start Pre-exposure Prophylaxis Among Young Black Men Who Have Sex With Men (MSM) in Jackson, Mississippi

Black men who have sex with men have the greatest risk for human immunodeficiency virus infection. Pre-exposure prophylaxis (PrEP) is a highly effective prevention method. However, uptake in this group is extremely low. Data from a sample of 225 human immunodeficiency virus-negative young black men who have sex with men residing in Jackson, Mississippi, were analyzed to examine correlates associated with willingness to start PrEP. Consistent condom users for both insertive and receptive sex were more likely to be willing to start PrEP than inconsistent condom users. Heterogeneity among this high-risk population is an important consideration for future studies assessing PrEP uptake and evaluating prevention efforts.

Comfort Relying on HIV Pre-exposure Prophylaxis and Treatment as Prevention for Condomless Sex: Results of an Online Survey of Australian Gay and Bisexual Men

HIV-negative and untested gay and bisexual men from Victoria, Australia (n = 771) were surveyed during August-September 2016 about their comfort having condomless sex with casual male partners in scenarios in which pre-exposure prophylaxis (PrEP) or treatment as prevention were used. Men not using PrEP were most comfortable with the idea of condomless sex with HIV-negative partners (31%), followed by partners using PrEP (23%). PrEP users were more comfortable with the idea of condomless sex with these partner types (64 and 72%, respectively). Very few men not taking PrEP were comfortable with condomless sex with HIV-positive partners (3%), even with undetectable viral loads (6%). PrEP users were more comfortable with condomless sex with HIV-positive partners (29%), and those with undetectable viral loads (48%). Being on PrEP, having recent condomless sex with casual partners or a HIV-positive regular partner were independently associated with comfort having condomless sex.

The estimated number of potential PrEP users among gay-identifying men who have sex with men in Australia

We estimated the size of the population of gay-identified men who have sex with men (gay men) eligible for PrEP in Australia under the current national PrEP guidelines. Using input indicators from the Australian Bureau of Statistics, the national representative survey Second Australian Study of Health and Relationships, and national HIV- behavioural surveillance, we calculated the size of the population of sexually active gay men and estimated a range for the number eligible for PrEP using different scenarios based on the guidelines. In 2015, an estimated 108,850 sexually-active 16-69-year-old gay men were classified as at risk of acquiring HIV in Australia. Of these men, 10,558 to 30,913 (9.7%-28.4%) were classified as being at high risk and therefore eligible for PrEP, most commonly due to recent receptive condomless intercourse with casual partners (6.1% to 15.5%), STI infections (5.4% to 10.6%) or the use of crystal methamphetamine (1.4% to 9.4%). The higher estimates included men who may have been at HIV risk for shorter time periods or with fewer partners. Australian PrEP guidelines recommend targeting PrEP to people at high HIV risk. Our estimation of potential PrEP users informed PrEP implementation in Australia. The choice of PrEP eligibility criteria, and interpretation of the guidelines, strongly affects the population estimates. In the future, higher numbers of gay men may become eligible for PrEP, because the estimates are largely defined by and follow trends in condomless anal intercourse. Our estimation methods can be adapted to other settings.

Protocol for an HIV Pre-exposure Prophylaxis (PrEP) Population Level Intervention Study in Victoria Australia: The PrEPX Study

Background: Pre-exposure prophylaxis (PrEP) is the use of HIV anti-retroviral therapy to prevent HIV transmission in people at high risk of HIV acquisition. PrEP is highly efficacious when taken either daily, or in an on-demand schedule. In Australia co-formulated tenofovir-emtricitabine is registered for daily use for PrEP, however, this co-formulation is not listed yet on the national subsidized medicines list. We describe a study protocol that aims to demonstrate if the provision of PrEP to up to 3800 individuals at risk of HIV in Victoria, Australia reduces HIV incidence locally by 25% generally and 30% among GBM.

Methods: PrEPX is a population level intervention study in Victoria, Australia in which generic PrEP will be delivered to 3800 individuals for up to 36 months. Study eligibility is consistent with the recently updated 2017 Australian PrEP guidelines. Participants will attend study clinics, shared care clinics, or outreach clinics for quarterly HIV/STI screening, biannual renal function tests and other clinical care as required. Study visits and STI diagnoses will be recorded electronically through the ACCESS surveillance system. At each study visit participants will be invited to complete behavioral surveys that collect demographics and sexual risk data. Diagnosis and behavioral data will be compared between PrEPX participants and other individuals testing within the ACCESS surveillance system. A subset of participants will complete in depth surveys and interviews to collect attitudes, beliefs and acceptability data. Participating clinics will provide clinic level data on implementation and management of PrEPX participants. The population level impact on HIV incidence will be assessed using Victorian HIV notification data.

Discussion: This study will collect evidence on the real world impact of delivery of PrEP to 3800 individuals at risk of acquiring HIV in Victoria. This study will provide important information for the broader implementation of PrEP planning upon listing of the tenofovir-emtricitabine on the national subsidized list of medicines. The study is registered on the Australian New Zealand Clinical Trials Registry (ACTRN12616001215415)

Trends in the awareness, acceptability, and usage of HIV pre-exposure prophylaxis among at-risk men who have sex with men in Toronto

OBJECTIVES

Pre-exposure prophylaxis (PrEP) with daily oral tenofovir/emtricitabine dramatically reduces HIV risk in men who have sex with men (MSM). However, uptake is slow worldwide.

METHODS

We administered anonymous cross-sectional questionnaires to MSM presenting for anonymous HIV testing at a Toronto sexual health clinic at four successive time points during the period 2013-2016. We assessed trends in PrEP awareness, acceptability, and use over time using the Cochran-Armitage Trend Test, and identified barriers to using PrEP by constructing "PrEP cascades" using 2016 data. We assumed that to use PrEP, MSM must (a) be at risk for HIV, (b) be at objectively high risk (HIRI-MSM score ≥ 10), (c) perceive themselves to be at medium-to-high risk, (d) be aware of PrEP, (e) be willing to use PrEP, (f) have a family doctor, (g) be comfortable discussing sexual health with that doctor, and (h) have drug coverage/be willing to pay out of pocket.

RESULTS

MSM participants were mostly white (54-59.5%), with median age 31 years (IQR = 26-38). PrEP awareness and use increased significantly over time (both p < 0.0001), reaching 91.3% and 5.0%, respectively, in the most recent wave. Willingness to use PrEP rose to 56.5%, but this increase did not reach statistical significance (p = 0.06). The full cascade, ABCDEFGH, suggested few could readily use PrEP under current conditions (11/400 = 2.8%). The largest barriers, in descending order, were low self-perceived HIV risk, unwillingness to use PrEP, and access to PrEP providers.

CONCLUSION

To maximize its potential public health benefits, PrEP scale-up strategies must address self-perceived HIV risk and increase access to PrEP providers.

Awareness of Prevention Strategies and Willingness to Use Preexposure Prophylaxis in Brazilian Men Who Have Sex With Men Using Apps for Sexual Encounters: Online Cross-Sectional Study

Background

Geosocial networking (GSN) smartphone apps are becoming the main venue for sexual encounters among Brazilian men who have sex with men (MSM). To address the increased HIV incidence in this population, preexposure prophylaxis (PrEP) was recently implemented in the Brazilian public health system in the context of combined HIV prevention.

Objective

This study aimed to describe the characteristics of MSM using GSN apps for sexual encounters, their awareness of prevention strategies, and willingness to use PrEP.

Methods

This study was an online cross-sectional study conducted in 10 Brazilian state capitals from July 1 to July 31, 2016. The questionnaire was programmed on SurveyGizmo and advertised in two GSN apps used by MSM to find sexual partners (Hornet and Grindr). Inclusion criteria were >18 years of age, cisgender men, with an HIV-negative status. Eligible individuals answered questions on: demographics; behavior; and knowledge, preferences, and willingness to use PrEP, nonoccupational postexposure prophylaxis (nPEP), HIV self-testing (HIVST), and condoms. Logistic regression modeling was performed to assess the factors associated with daily oral PrEP willingness.

Results

During the study period, 8885 individuals provided consent and started the questionnaire. Of these, 23.05% (2048/8885) were ineligible, 6837 (6837/8885, 76.94%) initiated, and 5065 (5065/8885, 57.00%) completed the entire questionnaire and were included in the present analysis. Median age was 30 years (interquartile range: 25-36), most self-declared as MSM (4991/5065, 98.54%), white (3194/5065, 63.06%), middle income (2148/5065, 42.41%), and had 12 or more years of schooling (3106/5062, 61.36%). The majority of MSM (3363/5064, 66.41%) scored >10 points (high risk) on The HIV Incidence Risk for MSM Scale, but only 21.39% (1083/5064) had a low perceived likelihood of getting HIV in the next year. Daily use of apps for sex was reported by 35.58% (1798/5054). Most MSM (4327/5065, 85.43%) reported testing for HIV at least once in their lifetime and 9.16% (464/5065) used nPEP in the previous year. PrEP, nPEP, and HIVST awareness was reported by 57.89% (2932/5065), 57.39% (2907/5065), and 26.57% (1346/5065) of participants, respectively. Half of all respondents (2653/5065, 52.38%) were willing to use daily oral PrEP, and this finding was associated with higher numbers of male sexual partners (adjusted odds ratio [AOR] 1.26, 95% CI 1.09-1.47), condomless receptive anal intercourse (AOR 1.27, 95% CI 1.12-1.44), sex with HIV-positive partner versus no HIV-positive partner (one HIV-positive partner: AOR 1.36, 95% CI 1.11-1.67), daily use of apps for sexual encounters (AOR 1.48, 95% CI 1.17-1.87), high and unknown perceived likelihood of getting HIV in the next year (AOR 1.72, 95% CI 1.47-2.02 and AOR 1.39, 95% CI 1.13-1.70), sexually transmitted infection diagnosis (AOR 1.25, 95% CI 1.03-1.51), stimulant use (AOR 1.24, 95% CI 1.07-1.43), PrEP awareness (AOR 1.48, 95% CI 1.30-1.70), and unwillingness to use condoms (AOR 1.16, 95% CI 1.00-1.33).

Conclusions

Our results evidenced high-risk scores in the studied population, suggesting the importance of PrEP use. Those individuals presenting risky sexual behaviors were more willing to use PrEP. Nonetheless, only 58% (2932/5065) of individuals had heard about this prevention strategy. Efforts to increase awareness of new prevention strategies are needed, and mobile health tools are a promising strategy to reach MSM.

Measuring and understanding the attitudes of Australian gay and bisexual men towards biomedical HIV prevention using cross-sectional data and factor analyses

INTRODUCTION

Contemporary responses to HIV embrace biomedical prevention, particularly treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). However, large-scale implementation of biomedical prevention should be ideally preceded by assessments of their community acceptability. We aimed to understand contemporary attitudes of gay and bisexual men (GBM) in Australia towards biomedical-based HIV prevention and propose a framework for their measurement and ongoing monitoring.

METHODS

A cross-sectional, online survey of GBM ≥18 years has been conducted annually in Victoria, Australia, since 2008. In 2016, 35 attitudinal items on biomedical HIV prevention were added. Items were scored on five-point Likert scales. We used principal factor analysis to identify key constructs related to GBM's attitudes to biomedical HIV prevention and use these to characterise levels of support for TasP and PrEP.

RESULTS

A total of 462 HIV-negative or HIV-status-unknown men, not using PrEP, provided valid responses for all 35 attitudinal items. We extracted four distinct and interpretable factors we named: 'Confidence in PrEP', 'Judicious approach to PrEP', 'Treatment as prevention optimism' and 'Support for early treatment'. High levels of agreement were seen across PrEP-related items; 77.9% of men agreed that PrEP prevented HIV acquisition and 83.6% of men agreed that users were protecting themselves. However, the agreement levels for HIV TasP items were considerably lower, with <20% of men agreeing treatment (undetectable viral load) reduced HIV transmission risk.

CONCLUSIONS

Better understanding of community attitudes is crucial for shaping policy and informing initiatives that aim to improve knowledge, acceptance and uptake of biomedical prevention. Our analyses suggest confidence in, acceptability of and community support for PrEP among GBM. However, strategies to address scepticism towards HIV treatment when used for prevention may be needed to optimise combination biomedical HIV prevention.

Awareness and willingness towards pre-exposure prophylaxis against HIV infection among individuals seeking voluntary counselling and testing for HIV in Taiwan: a cross-sectional questionnaire survey

OBJECTIVES

We aimed to investigate the awareness and willingness towards pre-exposure prophylaxis (PrEP) among individuals seeking voluntary counselling and testing (VCT) for HIV in Taiwan, where PrEP is currently not reimbursed by the insurance.

METHODS

Between April and October 2016, a questionnaire interview was conducted among VCT clients to inquire about the attitudes towards PrEP against HIV infection. Multivariate logistic regression analysis was performed to identify the associated factors with willingness to initiate PrEP.

RESULTS

During the 6-month period, 1173 VCT clients (99.8%) completed the interviews, with 67.4% being homosexual or bisexual male. While 67.2% of the clients knew of postexposure prophylaxis, 40.2% heard of PrEP. Overall, 546 clients (46.5%) were willing to initiate PrEP and 89.5% of them would choose event-driven PrEP. In multivariate analysis, male gender (OR 1.796; 95% CI 1.165 to 2.768), full-time job (OR 1.354; 95% CI 1.052 to 1.742), one-night stand (OR 1.374; 95% CI 1.043 to 1.810), having casual sex partners within 3 months (OR 1.329; 95% CI 1.031 to 1.714), condomless anal sex (OR 1.405; 95% CI 1.122 to 1.878) and ever having chemsex or attending a drug party in the past 1 year (OR 2.571; 95% CI 1.541 to 4.287), regular screening for HIV infection (OR 1.321; 95% CI 1.021 to 1.711) and knowledge of PrEP (OR 1.504; 95% CI, 1.159 to 1.953) were associated with willingness to initiate PrEP.

CONCLUSIONS

Understanding the willingness to initiate PrEP against HIV among the VCT clients in Taiwan, which was associated with male gender, risky sexual behaviours and awareness of PrEP, will help inform the implementation of PrEP programme.

A multicentre double-blind randomised controlled trial evaluating the efficacy of daily use of antibacterial mouthwash against oropharyngeal gonorrhoea among men who have sex with men: the OMEGA (Oral Mouthwash use to Eradicate GonorrhoeA) study protocol

BACKGROUND

Gonorrhoea is one of the most common sexually transmissible infections in men who have sex with men (MSM). Gonorrhoea rates have increased substantially in recent years. There is concern that increasing gonorrhoea prevalence will increase the likelihood of worsening antibiotic resistance in Neisseria gonorrhoeae. A recent randomised controlled trial (RCT) demonstrated that a single-dose of mouthwash has an inhibitory effect against oropharyngeal gonorrhoea. We are conducting the first RCT to evaluate whether daily use of mouthwash could reduce the risk of acquiring oropharyngeal gonorrhoea.

METHODS/DESIGN

The OMEGA (Oral Mouthwash use to Eradicate GonorrhoeA) study is a double-blind RCT and will be conducted at several sexual health clinics and high caseload General Practice (GP) clinics in Melbourne and Sydney, Australia. A total of 504 MSM attending the participating sites will be recruited. Participants will be randomised to either using 'Study mouthwash A' or 'Study mouthwash B' for 12 weeks. Study mouthwash A was inhibitory against N. gonorrhoeae in vitro, whereas study mouthwash B was not. Participants will be instructed to rinse and gargle the study mouthwash for 60 seconds every day. The primary outcome is the proportion of participants with oropharyngeal gonorrhoea detected by nucleic acid amplification test by 12 weeks.

DISCUSSION

The results from this trial may provide a novel way to reduce gonorrhoea prevalence and transmission without the use of antibiotics that may be associated with development of resistance. If shown to be effective, the widespread use of mouthwash will reduce the prevalence of oropharyngeal gonorrhoea, which plays key role in driving the emergence of gonococcal antimicrobial resistance through DNA exchange with oral commensal bacteria. The anticipated net effect will be interruption of onward transmission of N. gonorrhoeae within high density sexual networks within MSM populations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616000247471 , registered on 23rd February 2016.