Taking antiretroviral drugs, known as pre-exposure prophylaxis (PrEP), has been shown to be efficacious in reducing the risk of HIV acquisition among gay, bisexual, and other men who have sex with men (MSM).1 This strategy is available for prescription in the United States but remains formally unavailable in most other countries.2 In Australia, PrEP is not licensed for prescription, but demonstration projects have begun in 3 states. Gay, bisexual, and other MSM at increased risk of HIV will be primary targets for PrEP in Australia, given that they continue to account for the large majority of new HIV diagnoses.3 Evaluating willingness to use PrEP among gay and bisexual men is therefore important, both to assess the general level of interest in using PrEP, but also to specifically address whether men at increased risk of HIV are willing to use it.
International reviews of acceptability research suggest that there are generally low levels of awareness but high levels of interest in PrEP among gay, bisexual, and other MSM.4,5 Younger men, those who have anal intercourse without condoms, perceive themselves to be at risk of HIV, and men with fewer concerns about potential side effects seem to be the most interested in taking PrEP. Assessments of risk compensation or behavioral disinhibition (the idea that men would be more willing to have sex without condoms as a result of PrEP) have produced equivocal findings.6 However, the majority of acceptability studies and US trial data suggest that few men would further reduce their condom use as a result of PrEP.4,7 In various countries, awareness of PrEP and interest in using it do not seem to have changed significantly since the first positive randomized controlled trial results were announced at the end of 2010.5 However, no studies have assessed attitudes toward PrEP (or the likelihood of behavioral disinhibition) within the same population over a longer period of time, that is, more than a few months.8
In 2011, we found that 28% of Australian HIV-negative and untested gay and bisexual men were willing to use PrEP.9 We found very few men (8%) who indicated that they would use condoms less often if they were taking PrEP. In 2013, we repeated our national, online survey of gay and bisexual men to see if interest in using PrEP and the likelihood of reduced condom use had changed over time.
Participants and Procedures
Data were collected as part of the PrEPARE project, a study of Australian gay and bisexual men's attitudes to PrEP and other HIV prevention technologies.9,10 The study design was approved by the UNSW Human Research Ethics Committee. National online surveys of gay and bisexual men were conducted in April to May 2011 and June to July 2013 using NETQ survey software (NetQuestionnaires Nederland BV, Amsterdam, The Netherlands). The survey was advertised on Facebook and e-mail lists aimed at gay and bisexual men. Participants from the 2011 survey who had agreed to be contacted were invited to participate in the 2013 survey by e-mail. Potential participants were directed to the survey website, http://prepareproject.csrh.org, which explained the purpose of the study and provided access to the online questionnaire. Participants were eligible if they were at least 18 years old, male, lived in Australia and were gay, bisexual, or other MSM. No incentive was offered for participation. Participants were not given specific details about PrEP trial results or efficacy.
Wherever possible, the same questions were used in both survey rounds. We included questions about demographics, sexual practices with men, relationships, HIV testing and HIV status, adapted from behavioral surveillance questionnaires.11 The perceived likelihood of becoming HIV positive was assessed with the question, “How likely do you think it is you will become HIV positive?” (scored from 1 = very unlikely to 5 = very likely). We asked participants if they had ever had a course of PrEP (yes/no) or if they had ever taken antiretroviral drugs as PrEP (yes/no). The questionnaires contained Likert-type attitudinal items (each scored from 1 = strongly disagree to 5 = strongly agree) about PrEP, HIV treatments, and condoms. The following reliable scales (all Cronbach's ɑ ≥ 0.7) were included: willingness to use PrEP (7 items); likelihood of decreased condom use if using PrEP (2 items); personal experience in using condoms (9 items); confidence in discussing condoms with partners (2 items); concern about using PrEP (2 items). Scale scores were a mean of the items within the scale (from 1 to 5) with a score of ≥4 indicating positive agreement, for example, participants who scored ≥4 on the willingness scale were classified as willing to use PrEP. Details of these scales have been previously published.9
SPSS version 20 was used for data analysis. Statistical significance was set at P < 0.05. Only results from HIV-negative and untested men were included in these analyses. The characteristics of the 2011 and 2013 samples were compared using t tests and χ2 tests. Multivariate logistic regression was used to compare the proportions of men willing to use PrEP in 2011 and 2013, identify the characteristics of men willing to use PrEP in 2013, compare the likelihood of decreased condom use if using PrEP in 2011 and 2013, and the characteristics of men who were likely to decrease condom use in 2013, controlling for confounding factors.
In 2011, the online survey was completed by 1283 men, of whom 919 were HIV negative and 242 untested. In 2013, the online survey was completed by 1316 men, of whom 966 were HIV negative and 257 untested. The 2384 HIV-negative and untested men form the sample for the following analyses (Table 1). The 2011 and 2013 samples were similar in terms of age, sexual identity, residential location, employment status, and HIV testing. The 2011 and 2013 participants were also similar in terms of male partner numbers, sexual practices with regular and casual male partners, and the perceived likelihood of becoming HIV positive. Across both surveys, 14% of men said that they had ever received HIV postexposure prophylaxis, but very few men (n = 12, 0.5%) said that they had used antiretroviral drugs as PrEP.
The men in the 2013 sample were less likely to be born in Australia, and more likely to have a degree. They were more likely to be in a monogamous relationship, have a negative or neutral experience in using condoms, or lack confidence in discussing condom use. They were also more concerned about using PrEP. We controlled for these differences in subsequent analyses.
Willingness to Use PrEP
In 2011, 327 of 1161 participants (28.2%) were classified as willing to use PrEP. In 2013, 285 of 1223 participants (23.3%) were willing to use PrEP. After adjusting for confounding variables, willingness to use PrEP remained marginally lower in 2013 than in 2011 [adjusted odds ratio (AOR) = 0.83, 95% CI: 0.68 to 1.00, P = 0.050].
The characteristics of men in 2013 who were willing to use PrEP (versus those who were not) are shown in Table 2 (variables with nonsignificant bivariate relationships have been excluded). Younger men and those with HIV-positive partners were more willing to use PrEP. Willingness to use PrEP was also associated with a greater perceived likelihood of becoming HIV positive and having previously taken HIV postexposure prophylaxis. Men with more concerns about PrEP were less willing to use it.
Likelihood of Decreased Condom Use If Using PrEP
In 2011, only 26 of 327 men (8.0%) who were willing to use PrEP were found likely to reduce condom use if using PrEP. In 2013, 34 of 285 men (11.9%) who were willing to use PrEP were found likely to reduce condom use if using PrEP. There were a number of differences between men who were willing to use PrEP in the 2011 and 2013 surveys (country of birth, education level, HIV status of regular partner, personal experience in using condoms, and confidence in discussing condom use). Controlling for these differences, we found that the likelihood of decreased condom use did not change significantly between 2011 and 2013 (AOR = 1.40, 95% CI: 0.80 to 2.45, P = 0.23).
There were 2 factors independently associated with an increased likelihood of reduced condom use among men in the 2013 survey who were willing to use PrEP: having any anal intercourse without condoms with casual partners in the last 6 months (AOR = 3.58, 95% CI: 1.37 to 9.34, P = 0.009) and ever having received HIV postexposure prophylaxis (AOR = 3.32, 95% CI: 1.50 to 7.32, P = 0.003).
Our repeated surveys of gay and bisexual men in Australia show that willingness to use PrEP has declined slightly between 2011 and 2013, with just under a quarter of HIV-negative and untested men remaining interested in using PrEP. Among men who were willing to use PrEP, the likelihood of reduced condom use if receiving PrEP remained low and did not change significantly between 2011 and 2013. Consistent with other research, we found very low levels (<1%) of the informal use of antiretroviral drugs as PrEP.12,13 In line with our previous survey,9 men who perceived themselves to be at higher risk of HIV infection and those with fewer concerns about taking PrEP were more likely to be interested in PrEP. We also found that men with HIV-positive partners and those who had previously received HIV postexposure prophylaxis were more willing to use PrEP, consistent with other research.14 Overall, our findings are in line with international research that suggests that gay, bisexual, and other MSM who are at higher risk of HIV tend to be more interested in PrEP and that there is a low expected level of reduced condom use as a result of PrEP.4,5
Our findings have some limitations. The cross-sectional design did not allow us to identify causal relationships or to assess changes in interest in using PrEP (or the potential for reduced condom use) among the same men over time. We did not measure knowledge or awareness of PrEP or inform participants about PrEP's efficacy or the importance of drug adherence (a limitation noted in reviews of acceptability research).4 Further research could explore the possibility that, as knowledge of PrEP increases among gay and bisexual men, interest becomes concentrated among those who find it most useful or acceptable (whereas other men decide it is unsuitable for them). Our sample appears similar to community and online samples of Australian gay and bisexual men who are at increased risk of HIV11,15,16 but is not likely to be representative of all Australian MSM.17 Because many other studies only use single items to measure interest in PrEP, our estimate of willingness to use PrEP is conservative by international standards (other studies report willingness to use PrEP among MSM in the range 33%–80%).4,5 However, we believe our measure is a more realistic assessment of factors likely to influence PrEP uptake, taking into account perceived need, a commitment to regularly taking pills, and willingness to pay for PrEP and use it even if it is only partially efficacious.9
It remains unclear whether (or how) the greater availability of PrEP will affect willingness to use the prevention technology. Uptake in the United States has been relatively modest and slow.2,18 Various (unproven) explanations have been offered, such as low levels of community awareness, reluctance to rely on drug-based prevention strategies, the potential stigma of taking PrEP or admitting to sex without condoms, and mixed feelings among clinicians and educators about PrEP.2,10,19,20 Whatever the explanation, it seems that willingness to use PrEP may have been overestimated in many acceptability studies.4,5 Now may be the time to develop more realistic acceptability measures to guide the appropriate implementation and targeting of PrEP.
In conclusion, a minority of Australian gay and bisexual men remain willing to use PrEP. These men could benefit from PrEP because they appear to be at increased risk of HIV. Interest in using PrEP seems to have declined slightly over time, for reasons that are unclear, whereas the expected likelihood of decreased condom use when using PrEP has remained low. Together, these findings suggest that the targeted rollout of PrEP in Australia is feasible and appropriate but requires active monitoring.
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Keywords:© 2014 by Lippincott Williams & Wilkins
acceptability; Australia; gay and bisexual men; HIV prevention; pre-exposure prophylaxis; risk compensation