Gay and bisexual men’s attitudes to antiretroviral-based prevention

HIV Australia | Vol. 13 No. 2 | July 2015

Martin Holt

Martin Holt discusses research showing conflicting views and beliefs about biomedical prevention among Australian gay and bisexual men.

In 2011, the Centre for Social Research in Health began a program of work to investigate attitudes to biomedical HIV prevention technologies among gay and bisexual men, including HIV pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP).

PrEP involves HIV-negative people regularly taking antiretroviral drugs to prevent infection with HIV. It has been shown to be efficacious in preventing HIV for gay and bisexual men, transgender women and heterosexual people at risk of HIV, although efficacy is highly dependent on drug adherence.¹

PrEP is not currently available in Australia as a subsidised medicine, although small demonstration projects began in three states in 2014.

HIV treatment as prevention is based on the finding that HIV-positive people who consistently take antiretroviral treatment and achieve viral suppression are highly unlikely to transmit HIV to their sexual partners.²

Treatment as prevention is tacitly acknowledged in Australia’s current National HIV Strategy, which emphasises the benefits of early diagnosis and treatment for people living with HIV, and the strategy acknowledges that PrEP may be useful for high risk populations (like gay and bisexual men).³

Why assess community attitudes to PrEP and TasP? Firstly, to know whether affected communities are interested in new prevention methods; there is not much point developing relatively expensive strategies (like PrEP) if people do not want to use them.

Secondly, to identify who is most willing to use the new strategies, to see if there is an alignment between interest in using the strategies and potential public health benefit (i.e. do those who are at high risk of HIV want to use the strategies or not?).

Thirdly, research can gauge community support, to see if those who use biomedical prevention strategies will be supported by others.

For example, at this stage, it is unlikely that many HIV-negative gay men will use PrEP in Australia, as it is a relatively costly intervention and the risk of infection is concentrated among a relatively small group of men.⁴

However, for PrEP to be successful and become an accepted part of gay and bisexual men’s sexual practices, arguably you need broad levels of support, including among those men who might never use PrEP.

When we started our research, the first area we looked at was gay and bisexual men’s attitudes to PrEP.

We conducted national, online surveys in 2011 and 2013 (and we have just finished recruitment for 2015, although at the time of writing we were still working on the results). In 2011, we found that 28% of HIV-negative and untested gay and bisexual men were willing to use PrEP.⁵

This was a much lower level of interest in PrEP than had been seen before in international studies,⁶ particularly those from the United States, but our measure of willingness to use PrEP took into account readiness to regularly take pills, that PrEP might not be 100% effective and that you might have to pay for the drug.

In 2013, willingness to use PrEP fell slightly to 23%.⁷ It is far from clear why willingness to use PrEP declined between 2011 and 2013; it is possible that as knowledge of PrEP has grown, interest in it has become more concentrated among gay and bisexual men who find it acceptable, while other men have decided it is unsuitable for them.

We are very keen to see what has happened this year, given that there has been a lot more media coverage about PrEP since the Australian demonstration projects began.

Although willingness to use PrEP appears to have declined between 2011 and 2013, the profile of men who are most interested in using it appears to have remained largely unchanged.

In 2011, we found that willingness to use PrEP was concentrated among younger men, those who had anal intercourse without condoms with casual partners, men who perceived themselves to be at risk of HIV, and those who had fewer concerns about side effects.⁸

In 2013, we found a similar profile; younger men, those who had HIV-positive partners, men who perceived themselves to be at risk of HIV, who had previously taken post-exposure prophylaxis (PEP) or had fewer concerns about side effects were the most interested in using PrEP.⁹

So although willingness to use PrEP declined a little, it remained concentrated among HIV-negative and untested men at increased risk of HIV.

These findings show that the targeted rollout of PrEP is feasible in Australia, because there is a minority of gay and bisexual who are interested in using PrEP and who would benefit from its protection.

This appears to be borne out by the rapid uptake of places in the demonstration projects in Victoria and New South Wales by gay and bisexual men at high risk of HIV.

The other major area that we looked at our surveys was attitudes to HIV treatments and TasP. In general, we have found that gay and bisexual men are positive about the health benefits of HIV treatments.^{10 11}

However, in both 2011 and 2013 we found that participants were highly sceptical about the preventative benefits of HIV treatments and they were unlikely to believe that having an undetectable viral load prevented transmission.

HIV-positive men appeared to be slightly less sceptical than HIV-negative men, but it was clear that community attitudes to TasP were far from optimistic.

In 2013, we included a range of additional items about HIV treatment and found an interesting contradiction.¹²

While very few men believed that HIV treatment prevented transmission (<3%), a large majority (72%) agreed that early treatment was necessary.

Why this apparent contradiction? We think that this is because most gay and bisexual men understand the health benefits of HIV treatment but they view TasP as an unproven or unreliable strategy for prevention.

In addition, an interesting qualification emerged when we looked at whether HIV status affected men’s attitudes.

HIV-positive men and men with HIV-positive partners were a little more likely than others to believe in TasP, but they were less likely to agree with the need for early treatment. Why might that be the case?

We think that this is because HIV-positive men and their partners are more aware of the risks and benefits of starting treatment, and they may be reticent about being encouraged to take treatment without a full consideration of these factors.

This is consistent with research conducted with HIV-positive people and HIV doctors which emphasises that decisions to commence treatment should be driven by the need to maximise individual wellbeing, and not determined solely by public health concerns.¹³¹⁴

So far the research we have conducted suggests that there is support for the introduction of PrEP in Australia, particularly among gay and bisexual men who appear to be at high risk of HIV.

Views of HIV treatment as prevention are more mixed, with belief in the health benefits of HIV treatment, but continuing scepticism about TasP.

Our research suggests that promoting the health benefits of treatment appears to be a more acceptable way to promote TasP to gay and bisexual men, rather than emphasising its preventative benefits.

However, in doing so we should be careful not to imply that HIV-positive men must go on treatment to benefit others; this violates beliefs that HIV-positive people should be free to make treatment decisions that are appropriate for their particular circumstances, supported by their partners and doctors.

For more information about the PrEPARE Project visit: prepareproject.csrh.org

References

1 Hankins, C., Dybul, M. (2013). The promise of pre-exposure prophylaxis with antiretroviral drugs to prevent HIV transmission: a review. Curr Opin HIV AIDS, 8(1), 50–8. doi: dx.doi.org/10.1097/COH.0b013e32835b809d

2 Cohen, M., Chen, Y., McCauley, M., Gamble, T., Hosseinipour, M., Kumarasamy, N., et al. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med., 365(6), 493–505. doi: dx.doi.org/10.1056/NEJMoa1105243

3 Australian Government Department of Health. (2014). Seventh National HIV Strategy 2014–2017. Commonwealth of Australia, Canberra.

4 Schneider, K., Gray, R., Wilson, D. (2014) A cost-effectiveness analysis of HIV preexposure prophylaxis for men who have sex with men in Australia. Clin Infect Dis., 58(7), 1027–1034. doi: dx.doi.org/10.1093/cid/cit946

5 Holt, M., Murphy, D., Callander, D., Ellard, J., Rosengarten, M., Kippax, S., et al. (2012). Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected anal intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual Men. Sex Transm Infect., 88(4), 258–63. doi: dx.doi.org/10.1136/sextrans-2011-050312

6 Holt, M. (2014). HIV pre-exposure prophylaxis and treatment as prevention: a review of awareness and acceptability among men who have sex with men in the Asia-Pacific region and the Americas. Sex Health., 11(2),166–70. doi: dx.doi.org/10.1071/SH13060

7 Holt, M., Lea, T., Murphy, D., Ellard, J., Rosengarten, M., Kippax, S., et al. (2014). Willingness to use HIV pre-exposure prophylaxis has declined among Australian gay and bisexual men: results from repeated national surveys, 2011–2013. J Acquir Immune DeficSyndr., 67(2), 222–6. doi: dx.doi.org/10.1097/qai.0000000000000287

8 Holt, M., Murphy, D., et al. (2012). op. cit.

9 Holt, M., Lea, T., et al. (2014). op. cit.

10 Holt, M., Murphy, D., Callander, D., Ellard, J., Rosengarten, M., Kippax, S., et al. (2013). HIV-negative and HIV-positive gay men’s attitudes to medicines, HIV treatments and antiretroviral-based prevention. AIDS Behav., 17(6), 2156–61. doi: dx.doi.org/10.1007/s10461-012-0313-z

11 Holt, M., Lea, T., Murphy, D., Ellard, J., Rosengarten, M., Kippax, S., et al. (2014). Australian gay and bisexual men’s attitudes to HIV treatment as prevention in repeated, national surveys, 2011–2013. PLOS ONE, 9(11), e112349. doi: dx.doi.org/10.1371/journal.pone.0112349

12 ibid.

13 Mao, L., de Wit, J., Adam, P., Post, J., Crooks, L., Kidd, M., et al. (2013). Australian prescribers’ perspectives on ART initiation in the era of “treatment as prevention”. AIDS Care, 25(11), 1375–9. doi: dx.doi.org/10.1080/09540121.2013.766304

14 Newman, C., de Wit, J., Persson, A., Holt, M., Slavin, S., Kidd, M., et al. (2015). Understanding concerns about treatment-as-prevention among people with HIV who are not using antiretroviral therapy. AIDS Behav., 19(5), 821–31. doi: dx.doi.org/10.1007/s10461-014-0959-9

Dr Martin Holt is Associate Professor at the Centre for Social Research in Health (CSRH), UNSW Australia.