Willingness to Use HIV PrEP Among Gay and Bisexual Men
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. In line with our previous survey, 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. 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.
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). 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 HIV but is not likely to be representative of all Australian MSM. 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%). 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.
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. 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. Whatever the explanation, it seems that willingness to use PrEP may have been overestimated in many acceptability studies. 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.
Discussion
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. In line with our previous survey, 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. 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.
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). 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 HIV but is not likely to be representative of all Australian MSM. 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%). 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.
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. 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. Whatever the explanation, it seems that willingness to use PrEP may have been overestimated in many acceptability studies. 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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