Background: Since 1998, French HIV prevention guidelines have recommended the use of HIV post-exposure prophylaxis (PEP) after unprotected sex with a HIV-positive partner who should be informed about this option. This study analysed factors associated with PEP awareness in a population of individuals living with HIV/AIDS (PLHAs).
Methods: In 2003, a face-to-face survey was conducted among PLHAs selected from a random stratified sample of 102 French hospital departments delivering HIV care. Those who knew about PEP and those who did not were compared to identify factors related to PEP awareness in the sub-sample who reported that they had been sexually active in the prior 12 months.
Results: Among the 2,280 sexually active PLHAs, the median age was 40 years. Women comprised 26% of the sample, 41% were homosexual men and 16% were immigrants. Thirty percent of individuals reported not being aware of the availability of PEP. After multiple adjustment, factors associated with lack of PEP awareness were a low educational level, unemployment, older age, and CD4 cell counts <200. In addition, homosexual men showed a higher level of PEP awareness compared with the other participants, especially when compared with immigrant heterosexual men and women. Individuals who reported having unprotected sex with a non-HIV-positive steady partner also independently showed lower levels of PEP awareness. Finally, reporting having casual partners was associated with better awareness.
Conclusion: Awareness of PEP is insufficient among PLHAs, especially among immigrants. Programmes aimed at improving positive prevention among PLHAs are much needed and should be promoted.
From the aSouth-Eastern Health Regional Observatory (ORS PACA), Marseille, France
bHealth and Medical Research National Institute (INSERM), Research Unit 379, Social Sciences Applied to Medical Innovation, Institut Paoli Calmettes, Marseilles, France.
*See Appendix for members of the VESPA Study Group.
Received 19 April, 2006
Revised 17 October, 2006
Accepted 18 October, 2006
Correspondence to Bruno Spire, INSERM U379/ORS-PACA, 23 rue Stanislas Torrents, 13006 Marseilles, France. Tel: +33 4 96 10 28 77; fax: +33 4 96 10 28 99, e-mail: email@example.com
Since April 1998, the French government has issued recommendations on the management of HIV exposure in the non-occupational context . National guidelines on non-occupational postexposure prophylaxis (PEP) are available at every hospital . Anyone who may have been exposed to HIV can begin prophylaxis within 48 h of exposure at any hospital. Individual risk exposure is assessed by a physician and free-of-charge PEP is offered if the risk is considered to be high . A 3-day starter kit of treatment is prescribed by the emergency physician, and the individual is then referred to an ‘HIV reference physician’ to decide whether treatment should be continued or stopped. If this physician considers the risk of HIV to be high, he or she prescribes a one- month treatment regimen and monthly laboratory testing for HIV over a 6-month follow-up period.
The French media made brief mention of the possibility of obtaining PEP after HIV exposure in the emergency care departments of hospitals at the time of the Ministry's decision to make it available in 1998. Since then, however, there has been a limited dissemination of information about PEP in France. A national survey in a representative sample of the adult French population, carried out in 2001, showed that only 15% of respondents knew that PEP existed . Another survey , also carried out in 2001, in a sample of people living with HIV from the two French regions with the highest HIV prevalence, showed that even among people living with HIV only 65% of the interviewed participants were aware of the existence of non-occupational PEP. To date, public information about PEP has mainly been circulated through the gay press, in HIV prevention leaflets for homosexual men or injecting drug users (IDU), and via a limited number of healthcare centres (emergency units and departments in charge of HIV-related care in some hospitals, sexually transmitted disease clinics, and so on). As a result of the success of harm reduction in France (needle exchange programmes and drug maintenance treatments) there are now very few new infections among drug users that occur through the exchange of syringes or other injection material . Consequently, sexual exposure to the risk of HIV transmission is the main focus of non-occupational PEP in the country.
The VESPA Study, carried out in 2003, is a representative national sample of French people living with HIV. Data from this survey provided the opportunity both to evaluate the awareness of HIV prophylaxis at a national level and to identify factors that may be related to a lack of PEP awareness. The analysis presented in this paper primarily deals with factors related to PEP awareness in the sexually active part of the population living with HIV, which is the priority target for non-occupational PEP in France.
Data from the VESPA Study were used in this investigation. A detailed description of the study design is provided elsewhere in this issue , as well as a description of the weighting procedure that ensures national representativeness within this sample.
In order to take into account the heterogeneity of the studied population in terms of social and lifestyle-related characteristics, we classified participants into seven exclusive groups according to their sex, their origin and their HIV mode of transmission. This classification is used elsewhere in this issue . Men were divided into ‘homosexual men’, current or former injecting drug users (IDU), referred to as ‘male IDU’, those infected through heterosexual contact and born in France (‘native-born heterosexual men’), and those infected through heterosexual contact but born abroad (‘immigrant heterosexual men’). In a similar way, women were divided into ‘female IDU’, ‘native-born heterosexual women’ and ‘immigrant women’. In order for these categories to be mutually exclusive, we chose to give priority to the HIV mode of transmission. For example, an immigrant homosexual man would be classified as a homosexual man.
Socioeconomic characteristics included employment status and satisfaction with housing conditions. Another question was based on a qualitative assessment of the household financial situation: a three-level variable was computed identifying individuals reporting having an acceptable financial situation (‘wealthy’ plus ‘satisfactory’ plus ‘have just enough to get by’), those reporting a difficult situation (‘it's hard to make ends meet’), and those reporting a very difficult situation (‘we have to get into debt’).
Awareness of postexposure prophylaxis
Participants were asked the following question: ‘Have you heard about the existence of an emergency treatment to prevent HIV infection that can be taken after unprotected sex (no condom or condom breakage)? (Yes/No)’.
The following measures of sexual activity were obtained: the number of partners in the previous 12 months and the existence of a relationship with a regular partner. Specific questions were also asked about condom use with the regular partner and with casual partners.
Participants who reported inconsistent condom use for penetrative sex in the previous 12 months with a regular partner who did not have HIV or one whose serostatus was unknown were compared with those who always had protected sex with him/her. Individuals reporting inconsistent condom use for penetrative sex with casual partners during the previous 12 months were also compared with those who had always had protected sex with casual partners.
A health questionnaire filled in by the medical staff sought to elicit information on viral load, CD4 cell count, clinical stage, time of diagnosis and HIV treatment.
Individuals who knew about PEP were compared with those who did not, using chi-square tests for categorical variables and the t-test for continuous variables. To identify factors independently associated with a lack of PEP awareness, logistic regression was used in the subsample of respondents who declared that they had been sexually active in the previous 12 months. A stepwise procedure was used to select statistically significant factors in a multivariate model (entry threshold P < 0.20). Statistical analyses were performed using SPSS version 12.0.1 software (SPSS, Inc., Chicago, Illinois, USA).
Of the 2932 individuals included in the study, 22.3% reported that they had had no sexual activity during the previous 12 months. The sexually active 2280 participants were younger and were more often homosexual men with a higher level of education and a higher likelihood of having a job than those who declared they had had no sexual activity in the previous 12 months. Not surprisingly, awareness of PEP was significantly higher among sexually active respondents (69.7 versus 52.6% among the non-sexually active, P < 0.001). Current IDU (i.e. respondents who declared that they had injected drugs at least once in the previous 12 months) only accounted for a small proportion of the whole sample (2.1%), and this proportion was similar in both the sexually active and non-sexually active subsamples (1.7 versus 3.5%, P = 0.104). Awareness of PEP was similar among current IDU whether or not they had been sexually active in the previous 12 months (66.7 versus 60.9%, respectively, P = 0.645).
Postexposure prophylaxis awareness in the sexually active population living with HIV
Men constituted the majority of the subsample of sexually active participants (74%), and more than 40% were homosexuals (Table 1). The mean age was 41 years, almost 32% had at least graduated from high school, and most were employed (58%). Seventy-three per cent of individuals reported having a satisfactory household financial situation, whereas 18 and 9% reported having a difficult and a very difficult situation, respectively.
From a medical point of view, a large majority of individuals were receiving antiretroviral treatment, with 20% being in the C stage of the illness. Two-thirds had an undetectable viral load and nearly 91% had a CD4 cell count greater than 200 cells/μl.
With respect to sexual behaviour, 34% reported having no steady partner, 17% reported having a regular partner who was HIV-positive, whereas the remaining 49% reported having a regular partner who was not HIV-positive. Thirteen per cent of this latter group had practised unprotected sex with their partner during the previous 12 months.
Forty-seven per cent of all participants reported having had casual partners during the previous 12 months, and 11% of these reported unprotected sex in such situations.
Within our study population, 30% reported that they had never heard of PEP. This lack of PEP awareness was not equally distributed among participants. As shown in Table 1, among men, a majority of immigrant men did not know about PEP. Among the minority unaware of PEP, lack of awareness was significantly higher among native-born heterosexual men and male IDU than among homosexual men. Among women, the majority of immigrants were also not aware of PEP, whereas approximately one third of both IDU and native-born heterosexual women did not know about PEP. It must also be noted that PEP awareness was similar among both current and ex-IDU (66.7 versus 69.7%, respectively, P = 0.681).
Table 1 shows that a number of characteristics related to greater socioeconomic vulnerability were associated with a lack of PEP awareness in univariate analyses. Multivariate analysis confirmed that individuals who did not know about PEP were older and were more likely to have a lower level of education and to be unemployed. Individuals with a CD4 cell count below 200 cells/μl and those who have been diagnosed with HIV more recently were also less likely to be aware of PEP, although this relationship was not confirmed for the latter in multivariate analysis. It must, however, be noted that being HAART-treated did not influence the awareness of PEP.
Multivariate analysis presented in Table 1 confirms that immigrant heterosexual men and women were less well informed about PEP than the rest of the population living with HIV in France. It also confirms that homosexual men were better informed about the availability of PEP than both male and female IDU and heterosexuals.
No difference in PEP awareness was found between participants reporting a regular relationship and those who did not. However, participants who reported unprotected sex with regular partners who were not HIV-positive were less aware of PEP than those who did not [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.3–2.3]. Participants who reported having casual partners had a better awareness of PEP (OR 0.6, 95% CI 0.5–0.9), but no difference was found between those who reported unprotected sex with casual partners and those who did not.
Results of animal studies  and experience in the administration of antiretroviral agents in the prevention of mother-to-child transmission  have together led to the conclusion that PEP may reduce HIV transmission, especially if the treatment is administered in the first few hours after exposure. Even if primary prevention should remain the mainstay response, information about PEP is crucial in order to help individuals obtain prompt medical evaluation in case of HIV risk exposure followed by PEP treatment if needed. With more widespread information about PEP, people living with HIV could also inform their sexual partners about obtaining prophylactic treatment if needed.
Although non-occupational PEP has been available in France since 1998, approximaely one third of a national representative sample of sexually active people living with HIV and benefiting from care in French hospital departments did not know about the availability of this prophylactic treatment 5 years later. This proportion is close to that already observed in a previous similar survey carried out in 2001 in two regions of France .
Despite both the limits of social research based on participants' self-reports, which may be affected by desirability bias, and the fact that we used cross-sectional data, which does not permit the measurement of a change in people's awareness over the course of time, the ANRS-EN12-VESPA 2003 Study was the first French survey carried out among a large national sample of people living with HIV. Our analysis was limited to the subsample of sexually active respondents in the VESPA survey, which cannot be considered fully representative of the entire population of people living with HIV in France. The survey also did not include those who are not aware of their HIV serostatus as well as those not in regular contact with the healthcare system. Moreover, our analysis did not include VESPA respondents who were not sexually active, especially non-sexually active current IDU. However, there are a limited number of people living with HIV who remain active IDU, and consequently this number is very low in the VESPA sample (2.1% of the total sample). Previous studies have shown that very few active IDU come to PEP medical consultations after sharing injection material, probably partly because injecting drug use remains illegal in France . Although efforts to improve information about PEP among active IDU should be considered from a public health point of view, sexually active individuals who benefit from HIV care remain the primary target for information about the availability of non-occupational PEP for HIV.
Although there is a growing proportion of immigrants among newly HIV-diagnosed cases in France , the VESPA survey reveals a dramatic lack of awareness about PEP among immigrants of both sexes who are living with HIV. This situation may be partly explained by the non-inclusion of information about PEP in the HIV prevention messages diffused through the mass media, and by the additional fact that leaflets about PEP distributed by public health authorities and non-governmental organizations have mainly targeted other groups, such as gay men or IDU. In this study, homosexual men living with HIV had the highest level of information about PEP, and awareness of PEP among both homosexual men and IDU living with HIV in France seems higher than in the same groups of some other developed countries [10,11].
Our results are also consistent with findings from other surveys showing the persistence of unprotected sex in a significant portion of people living with HIV, notably in serodiscordant couples  as well as in sexual encounters with casual partners of unknown HIV status . However, our data suggest that both situations are not similar with regard to PEP awareness. Whereas most individuals who engage in casual relationships have been informed of the existence of PEP, within HIV serodiscordant couples only those who always practise protected sex seem to be well informed. The challenge for secondary prevention is therefore particularly important within serodiscordant couples, because regular partners have in recent years become a major source of HIV infection, according to several studies among gay men [14–16].
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.
Sponsorship: This study was supported by the French National Agency for AIDS Research (ANRS, France, ANRS-EN12-VESPA).
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