Motives of Dutch men who have sex with men for daily and intermittent HIV pre-exposure prophylaxis usage and preferences for implementation: A qualitative study

A psychosocial network approach studying biomedical HIV prevention uptake between 2017 and 2019

Biomedical HIV-prevention strategies (BmPS) among men who have sex with men (MSM), such as pre-exposure prophylaxis (PrEP) and viral load sorting (VLS), are essential but relatively new and their uptake gradual. Using an extension of the causal attitude network approach, we investigated which beliefs are related to uptake of PrEP and VLS at each time-point. We included 632 HIV-negative MSM from the Amsterdam Cohort Studies from four data-waves between 2017 and 2019. We estimated weighted, undirected networks for each time-point, where we included pairwise interactions of PrEP and VLS uptake and related beliefs. PrEP use increased from 10 to 31% (p < 0.001), while VLS was reported by 7-10% at each time-point. Uptake of both BmPS was directly related to the perceived positive impact of the strategy on one's quality of sex life and perceived supportive social norms. Overall network structure differed between time points, specifically in regard to PrEP. At earlier time points, perceptions of efficacy and affordability played an important role for PrEP uptake, while more recently social and health-related concerns became increasingly important.The network structure differed across data-waves, suggesting specific time changes in uptake motives. These findings may be used in communication to increase prevention uptake.

The experienced positive and negative influence of HIV on quality of life of people with HIV and vulnerable to HIV in the Netherlands

This qualitative study aimed to explore the experienced influence of HIV on the quality of life (QoL) of people with HIV (PHIV) and key populations without but are vulnerable to HIV in the Netherlands. We conducted and thematically analyzed interviews with 29 PHIV and 13 participants from key populations without HIV (i.e., men who have sex with men). PHIV and key populations shared positive meaningful experiences regarding HIV, i.e., feeling grateful for ART, life, and the availability of PrEP, being loved and supported in the light of HIV, and providing support to the community. Negative predominant experiences regarding HIV were described by both PHIV and key populations as the negative effects of ART, challenges with regards to disclosing HIV, social stigmatization, and self-stigma. It remains important to support HIV community organizations in their efforts to reduce social stigmatization and to continue improving biomedical interventions for HIV.

Pre-Exposure Prophylaxis Stigma and Beliefs in the Efficacy of Pre-Exposure Prophylaxis: An Analysis of a Cross-Sectional Survey of Male Couples in the United States

ABSTRACT

Increasing the use of pre-exposure prophylaxis (PrEP) among male couples is critical to the success of the United States' Ending the HIV Epidemic campaign. By leveraging dyadic data from a larger cross-sectional study of male couples, the present analysis examined individual, partner, and relationship characteristics associated with PrEP stigma and perceived efficacy of PrEP. Actor-Partner Independence Models were fit separately for both outcomes. Individual and partner risk behaviors, including substance use, binge drinking, and higher number of condomless casual sex partners, were associated with lower levels of both PrEP stigma and belief in the efficacy of PrEP. Networks that supported PrEP use were associated with decreased PrEP stigma and increased belief in PrEP efficacy. Stigma-informed PrEP interventions for couples should be considered foundational to the success of the United States' Ending the HIV Epidemic campaign.

How Has HIV Pre-Exposure Prophylaxis (PrEP) Changed Sex? A Review of Research in a New Era of Bio-behavioral HIV Prevention

In 2012, the U.S. FDA approved the first drug for use as HIV Pre-Exposure Prophylaxis (PrEP), which is nearly 99% effective when taken as prescribed. Although the manifest function of PrEP is to prevent HIV infection in the event of exposure, the drug has also had a significant impact on various facets of sexuality. In this review, we focus on research that emerged in the near decade since PrEP's approval, with a specific focus on the ways in which different elements of sex and sexuality have been impacted by gay, bisexual, and other men who have sex with men (GBMSM), cisgender women, and transgender individuals. We highlight evidence showing how PrEP has enhanced sexual self-esteem, improved sexual pleasure, reduced sexual anxiety, and has increased sexual agency for those taking it. For many, PrEP also serves as a gateway to improve routine health and increase sexual health-care utilization. Additionally, we review the question of whether PrEP is associated with increased sexual risk taking (i.e. risk compensation), and note that, although some data are mixed, PrEP is not intended as an intervention to reduce condomless anal sex or STIs: it aims to prevent HIV. Finally, our review highlights that, although the volume of research on PrEP among GBMSM is robust, it is underdeveloped for cisgender women and transgender populations and insufficient for inclusion in such a review for cisgender heterosexual men was. PrEP research with these populations is an important direction for future research. Finally, from 2012 to 2019, a single PrEP formulation and delivery method was FDA approved (oral emtricitabine/tenofovir disoproxil fumarate). As additional drug formulations (ie.g., emtricitabine/tenofovir alafenamide) and delivery methods (e.g., microbiocides, vaginal ring, injectable) come to market, it will be important to examine how these, too, impact the spectrum of sexuality.

Use of HIV Pre-exposure Prophylaxis (PrEP) Associated With Lower HIV Anxiety Among Gay and Bisexual Men in Australia Who Are at High Risk of HIV Infection: Results From the Flux Study

BACKGROUND

Many gay and bisexual men (GBM) experience HIV anxiety, particularly around condomless anal intercourse. HIV pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy that may reduce HIV anxiety among GBM.

METHODS

The Following Lives Undergoing Change (Flux) Study is a national, online, open-prospective observational study of licit and illicit drug use among GBM in Australia. In 2018, participants responded to newly included items regarding anxiety about HIV transmission. Stratifying GBM as high or low risk as determined by the Australian PrEP Guidelines, we assess whether PrEP use is associated with lower levels of HIV anxiety. Multivariate logistic regression was used to compare factors associated with PrEP use among GBM at high risk (PrEP-eligible) and low risk (PrEP-ineligible) of HIV infection. Results are reported as adjusted odds ratios and corresponding 95% confidence intervals.

RESULTS

Among 1547 men, the mean age was 37.1 years (SD 13.1). Men aged 25 years or younger had higher HIV anxiety scores than older men. Among PrEP-eligible men, men who use PrEP reported lower levels of HIV anxiety (adjusted odds ratio = 0.92; 95% confidence interval = 0.87 to 0.99; P < 0.001). No differences were observed on HIV anxiety among PrEP-ineligible men.

CONCLUSIONS

Among PrEP-eligible men, PrEP use was independently associated with lower levels of HIV anxiety. In addition to avoiding HIV infection, PrEP use may help reduce anxiety among men at risk of HIV. This feature of PrEP could be promoted as part of demand creation initiatives to increase PrEP uptake.

Motives for choosing, switching and stopping daily or event-driven pre-exposure prophylaxis - a qualitative analysis

INTRODUCTION

In settings where both daily and event-driven pre-exposure prophylaxis (PrEP) are offered to men who have sex with men (MSM), a clear understanding of the motives to choose between the different dosing-regimens can facilitate more effective PrEP implementation. We therefore studied the motives for choosing for, switching between, and stopping daily or event-driven PrEP.

METHODS

We used data (August 2015-June 2017) from the prospective, longitudinal, open-label Amsterdam PrEP demonstration study, in which daily (dPrEP) and event-driven PrEP (edPrEP) were offered to 374 HIV-negative MSM and two transgender persons. Participants self-selected the preferred PrEP-regimen at baseline and could switch regimens at three-monthly follow-up visits. We measured motives for choosing PrEP-regimen at baseline and for switching and stopping PrEP at follow-up visits. Open- and closed-end items were combined and qualitatively analysed.

RESULTS

Choices of PrEP-regimens were determined by personal and contextual factors, involving the perceived self-efficacy concerning adherence, the risk-context, and the anticipated impact of PrEP on physical and sexual wellbeing. dPrEP was preferred because of the anticipated better adherence and the fear of side-effects relating to edPrEP re-initiations. Moreover, dPrEP was perceived to be more effective than edPrEP. Motives to choose edPrEP were the expected physical burden of dPrEP, anticipated side-effects of dPrEP, and fear to forget daily doses. Regarding the risk-context: dPrEP was preferred for unplanned and/or frequent sex, while edPrEP was chosen when risk was predictable and/or less frequent. While some chose for dPrEP to gain more sexual freedom, others chose for edPrEP to minimize sexual risk episodes. Changes in the above factors, such as changing risk patterns, changing relationships or changing physical conditions, resulted in switching regimens. Choices to stop PrEP were related to lower sexual risk, adherence issues and side-effects.

CONCLUSIONS

The great diversity of motives illustrates the importance of offering a choice of PrEP-regimens. In counselling of MSM starting PrEP, choices for PrEP-regimens may be addressed as a continuum of flexible and changeable options over time. This may help individuals choose the PrEP-regimen that best fits their current sexual context, priorities and personal capabilities and therefore will be more easily adhered to.

Thematic synthesis HIV prevention qualitative studies in men who have sex with men (MSM)

BACKGROUND

Qualitative studies on HIV prevention strategies and methods among men who have sex with men (MSM) allow identify knowledge gaps and improve preventive actions.

OBJECTIVE

To make a thematic synthesis of the scientific productions that use the qualitative methodology in the strategies and methods of HIV prevention area among MSM.

METHODS

We conducted a literature review following the guidelines of the ENTREQ protocol. The analysis included 48 empirical studies published in Portuguese, English and Spanish between 2001 and 2018 available in the Medline, Embase, Scielo, Scopus, Bireme and Web of Science databases.

RESULTS

Where an increased production in the last six years and concentration in northern countries. Seven prevention methods were part of the study, with emphasis on pre-exposure prophylaxis, testing, condoms and behavioral strategies. The main topics discussed were stigma and support and care networks.

CONCLUSION

we notice that an increasing production on prevention in the men who have sex with men segment results from the emergence of multiple preventive methods and strategies and their combined actions beyond the star role of condoms.

Men who have sex with men more often chose daily than event-driven use of pre-exposure prophylaxis: baseline analysis of a demonstration study in Amsterdam

INTRODUCTION

The Amsterdam PrEP project is a prospective, open-label demonstration study at a large sexually transmitted infection (STI) clinic. We examined the uptake of PrEP; the baseline characteristics of men who have sex with men (MSM) and transgender persons initiating PrEP; their choices of daily versus event-driven PrEP and the determinants of these choices.

METHODS

From August 2015 through May 2016, enrolment took place at the STI clinic of the Public Health Service of Amsterdam, the Netherlands. MSM or transgender persons were eligible if they had at least one risk factor for HIV infection within the preceding six months. Participants were offered a choice between daily or event-driven use of tenofovir/emtricitabine. Baseline data were analysed using descriptive statistics and multivariable analysis was employed to determine variables associated with daily versus event-driven PrEP.

RESULTS

Online applications were submitted by 870 persons, of whom 587 were invited for a screening visit. Of them, 415 were screened for eligibility and 376 initiated PrEP. One quarter (103/376, 27%) chose event-driven PrEP. Prevalence of bacterial STI was 19.0% and mean condomless anal sex (CAS) episodes in the preceding three months were 11. In multivariable analysis, older age (≥45 vs. ≤34, aOR 2.1, 95% CI 1.2 to 3.9), being involved in a steady relationship (aOR 1.7, 95% CI 1.0 to 2.7), no other daily medication use (aOR 0.6, 95% CI 0.3 to 0.9), and fewer episodes of CAS (per log increase aOR 0.7, 95% CI 0.6 to 0.9) were determinants for choosing event-driven PrEP.

DISCUSSION

PrEP programmes are becoming one of the more important intervention strategies with the goal of reducing incident HIV-infection and we were unable to accommodate many of the persons applying for this study. Offering a choice of dosing regimen to PrEP users may enable further personalization of HIV prevention strategies and enhance up-take, adherence and cost-effectiveness.

CONCLUSIONS

The majority of participants preferred daily versus event-driven use. Within this majority, a high number of CAS episodes before PrEP initiation was reported and we observed a high prevalence of STI. Determinants of choosing event-driven PrEP were older age, fewer CAS episodes, no other daily medication use, and involved in a steady relationship.

Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men

Data indicate that diffusion of pre-exposure prophylaxis (PrEP) programs for HIV prevention is increasing in the United States; however, persistent disparities in PrEP access remain. Earlier waves of PrEP implementation focused on development (2012-2015) and diffusion (2016-2018). To reduce disparities, the next wave of PrEP implementation should focus on integration; that is, the assimilation of PrEP service as an integral part of HIV prevention, sexual health, and primary care. This review analyzes PrEP implementation literature in the context of three "next-wave" challenges: increasing patient demand, enhancing provider investment and competency, and improving health systems capacity. Our review revealed five activities we consider critical to successful next-wave PrEP implementation efforts: (1) redefining PrEP eligibility assessment, (2) de-emphasizing risk perception as a strategy to increase demand, (3) rejecting risk compensation arguments, (4) altering guidelines to make PrEP follow-up less onerous, and (5) focusing directly on strategies to reduce the cost of PrEP medication. This article ends with a case study of a research-practice partnership designed to instantiate new approaches to integrative implementation efforts.

Pre-exposure prophylaxis among men who have sex with men in the Amsterdam Cohort Studies: Use, eligibility, and intention to use

Objective

Currently, HIV pre-exposure prophylaxis (PrEP) is not covered by health insurance in the Netherlands. We examined time trends in use of PrEP, characteristics of PrEP users, PrEP eligibility and intention to use PrEP among HIV-negative men who have sex with men (MSM) participating in the Amsterdam Cohort Studies (ACS).

Design

Prospective cohort study.

Methods

We used data from four 6-monthly questionnaire waves, collected between 2015–2017. PrEP use over time was examined in logistic regression models using generalized estimating equations. Using descriptive statistics, we compared PrEP users before first-time initiation to non-PrEP-users. We used national guidelines to assess PrEP eligibility.

Results

We included 687 MSM. Median age was 40 (IQR 33–47) years in 2015. Recent PrEP use was reported by 57/687 (8%) MSM. PrEP use increased over calendar time (P<0.001) to 7% in 2017. PrEP users did not differ from non-PrEP users in socio-demographic characteristics, but reported a significantly higher median number of casual sex partners, more often reported condomless anal sex and chemsex with casual partners, and more often had an sexually transmitted infection in the preceding 6 months (all P<0.05). PrEP eligibility increased over time, but the effect was not statistically significant (P = 0.075). PrEP eligibility criteria were met by 149/460 (32%) at wave 4, of whom 31/149 (21%) reported use of PrEP. The proportion with a high intention to use PrEP was greater among eligible than non-eligible MSM (51% vs. 24%, P<0.001).

Conclusion

PrEP use increased over time but remained under 10%, even though 32% met the eligibility criteria, of whom 51% had a high intention to use PrEP. This suggests that a large proportion of Dutch MSM at risk could benefit from PrEP.

The Acceptability of Pre-Exposure Prophylaxis: Beliefs of Health-Care Professionals Working in Sexually Transmitted Infections Clinics and HIV Treatment Centers

Background

Pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV infections, but is not yet implemented in the Netherlands. As the attitudes of health-care professionals toward PrEP can influence future PrEP implementation, we studied PrEP knowledge and beliefs and their association with PrEP acceptability among professionals in clinics for sexually transmitted infection (STI professionals) and HIV treatment centers (HIV specialists). In addition, we examined preferred regimens, attitudes toward providing PrEP to key populations and to reimbursement of PrEP costs.

Methods

An online questionnaire was distributed among 24 public health STI clinics and 27 HIV treatment centers nationwide in the Netherlands between January and August 2015. The acceptability of PrEP was measured on a 7-point Likert scale ranging from 1 = low to 7 = high acceptability. Univariable and multivariable linear regression analyses were used to explore associations between demographic characteristics, PrEP knowledge, beliefs about PrEP, and PrEP acceptability.

Results

In total, 209 people (143 STI professionals and 66 HIV specialists) completed the questionnaire. The mean acceptability of PrEP implementation was 4.28 (SD 1.68) among STI professionals and 4.42 (SD 1.67) among HIV specialists. The mean score on self-perceived knowledge related to PrEP efficacy was 3.90 (SD 1.57) among STI professionals and 5.68 (SD 1.08) among HIV specialists (p-value of <0.001). Beliefs associated with lower PrEP acceptability among both groups were the fear that PrEP use will lead to a decrease in condom use and an increase in STI, the high costs of PrEP and ethical issues regarding prescribing antiretroviral medication to healthy individuals. No preference for a daily or an event-driven regimen was detected. Most participants deemed the following groups to be eligible for PrEP: men who have sex with men (MSM) who regularly get post-exposure prophylaxis, MSM who never used condoms with casual partners and MSM with an HIV-positive partner with a detectable viral load. Over half of the participants indicated that PrEP users should partly (54.1%) or fully (35.4%) pay the costs of PrEP.

Conclusion

In 2015, PrEP acceptability was only moderate among Dutch STI professionals and HIV specialists, which is far from an optimal setting. Addressing barriers to PrEP acceptability in educational programs for various types of health-care professionals is needed to successfully implement PrEP in the Netherlands.

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.