Objective Assess willingness to use HIV pre-exposure prophylaxis (PrEP), support for others using it and willingness to have sex with partners using PrEP among Australian gay and bisexual men (GBM).
Methods National, online cross-sectional surveys of Australian GBM were conducted in 2011, 2013 and 2015. Scales measuring support for and willingness to have sex with men using PrEP were developed in 2015 using factor analysis. Trends and associations with key measures were analysed using multivariate logistic regression.
Results During 2011–2015, 3850 surveys were completed by GBM. Willingness to use PrEP among HIV-negative and untested men did not change between 2011 (28.2%) and 2015 (31.7%, p=0.13). In 2015, willingness to use PrEP was independently associated with younger age, having an HIV-positive regular partner, recent condomless anal intercourse with casual male partners (CAIC), more than 10 male sex partners in the previous 6 months, ever having taken postexposure prophylaxis and having fewer concerns about using PrEP. In 2015, 54.5% of GBM supported other GBM taking PrEP and 39% were willing to have sex with men using PrEP. Support for and willingness to have sex with PrEP users were both associated with being HIV-positive, having a university degree and having two or more male partners in the previous 6 months. Willingness to have sex with men on PrEP was also associated with recent CAIC and using party drugs for sex, but was less likely among men who consistently used or had a positive experience using condoms.
Discussion Interest in and support for using PrEP are concentrated among men who engage in higher risk practices and who know more about living with HIV. This is consistent with the targeting of PrEP in Australia.
- GAY MEN
- SEXUAL BEHAVIOUR
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Research on the factors that influence interest in and willingness to use HIV pre-exposure prophylaxis (PrEP), the regular use of antiretroviral drugs to prevent HIV infection, have burgeoned over the last decade.1 ,2 This research has become more common since a number of trials demonstrated high levels of efficacy, especially for men who have sex with men.3 ,4 Internationally, access to PrEP remains relatively limited,5 although the number of countries in which it is formally available has grown since WHO recommended it should be made available as part of a ‘combination prevention’ approach.6
In Australia, PrEP use by gay and bisexual men (GBM), the primary HIV-affected population, has been relatively limited to date. PrEP access has been facilitated by demonstration projects, by ‘off-label’ prescribing and private importation from overseas or purchasing full price drugs. Up until 2015, no more than 2% of Australian GBM reported any PrEP use.7–9 In early 2016, PrEP use increased to 4%–6% of GBM in Melbourne and Sydney.10 ,11 Prescription guidelines have been published, recommending that GBM at high risk of HIV should receive PrEP, as evidenced by receptive condomless sex with HIV-positive or unknown status partners, crystal methamphetamine use or diagnosis with a rectal STI.12 The Australian Therapeutic Goods Administration has recently approved the use of the drugs emtricitabine and tenofovir disoproxil fumarate for PrEP and the drugs have been considered for listing on the Pharmaceutical Benefits Scheme (which would provide a subsidy for their prescription). In 2016, PrEP use will increase significantly, as large-scale demonstration projects recruit thousands of participants in New South Wales, Queensland and Victoria.13–15
Our previous research has found that 23%–28% of Australian HIV-negative and untested GBM are willing to use PrEP, with interest concentrated among men who report condomless sex with casual partners, have HIV-positive partners, those who have taken postexposure prophylaxis (PEP) and men who perceive themselves to be at risk of HIV.7 ,8 As PrEP access expands, it is timely to assess whether willingness to use PrEP is increasing, and whether willingness remains concentrated in the target ‘high risk’ group of GBM. We have suggested that acceptability research needs to move beyond relatively narrow measures of willingness, and assess community support for PrEP.1 ,16 Whether PrEP users are accepted and supported by their peers is arguably an important factor in facilitating the efficient and effective uptake of the technology and the development of positive norms about PrEP use. In the most recent round of a longitudinal project evaluating Australian GBM's attitudes to biomedical HIV prevention, we included a range of measures evaluating peer and community attitudes to PrEP. The analysis that follows considers willingness to use PrEP, support for others using it and willingness to have sex with GBM using PrEP.
Participants and procedures
Data were collected as part of the PrEPARE Project, a study of Australian GBM's attitudes to biomedical HIV prevention, particularly PrEP.7 ,8 ,17 The University of New South Wales (UNSW) Human Research Ethics Committee approved the study design (ref. HC11034). After pilot testing, national, online, cross-sectional surveys of GBM were conducted in April–May 2011, June–July 2013 and April–May 2015 using NETQ survey software (NetQuestionnaires Nederland BV). We used adaptive, conditional questioning and the randomised presentation of attitudinal items within blocks. The 2015 survey contained 71 items, spread over multiple pages, and was advertised on Facebook (using paid advertising) and email lists aimed at GBM. Consenting participants from the 2013 survey were invited by email to participate in the 2015 survey. Potential participants were directed to the survey website, http://prepareproject.csrh.org, which explained the purpose of the study, the time required to complete the survey (up to 20 mins), the investigator team, data security and confidentiality and provided access to the online questionnaire. Participants were asked to provide consent at the start of the survey. Participants were eligible if they were at least aged 18 years, male, lived in Australia and were gay or bisexual. Participants could use a back button to review or change their answers. No incentive was offered for participation. After recruitment was completed, data were downloaded and stored on a password-protected server at the UNSW.
A core set of questions, including demographics, sexual practices with men, relationships, HIV testing, HIV status, perceived risk of becoming HIV-positive and use of PEP and PrEP, has been used in all three survey rounds.7 ,8 Scales were identified in the 2011 survey and subsequently repeated to assess willingness to use PrEP (7 items, Cronbach's α=0.78–0.82), concern about using PrEP (2 items, α=0.64–0.72), the likelihood of decreased condom use if using PrEP (2 items, α=0.71–0.77) and personal experience in using condoms (9 items, α=0.88–0.91).7 ,8
Using factor analysis, two new scales were identified in the 2015 round to assess community support for PrEP, and were presented to all participants, irrespective of HIV status. The first scale, support for GBM taking PrEP (α=0.88), included seven items:
GBM taking PrEP are being reckless (reverse scored)
GBM taking PrEP are being responsible
GBM taking PrEP are helping to prevent HIV
GBM taking PrEP are protecting themselves
GBM taking PrEP are putting their partners at risk (reverse scored)
GBM taking PrEP are undermining condom use (reverse scored)
I support other GBM taking PrEP
The second scale, willingness to have sex with men taking PrEP (α=0.60), included three items:
I would have sex with someone on PrEP
I would have sex without condoms with someone on PrEP
I would refuse to have sex with someone on PrEP (reverse scored)
As in previous rounds, all attitudinal items were scored from 1=strongly disagree to 5=strongly agree. Scale scores were calculated from the mean of the items in the scale (ranging from 1 to 5) with a mean score of ≥4 indicating positive agreement with the subject of the scale. This was the scoring method used in our previous publications.7 ,8
Before analysis, the database was inspected manually for duplicate or suspicious entries (identical IP or email addresses, responses or free text). Stata V.13.1 (StataCorp, College Station, Texas, USA) was used for data analysis. Only responses from participants who had completed the 2011, 2013 and 2015 surveys were included in the analyses. Statistical significance was set at p<0.05. The characteristics of the 2011, 2013 and 2015 samples were compared using logistic regression and linear regression to identify changes in the sample profile over time and potentially confounding variables. Multivariate logistic regression was used to compare the proportions of HIV-negative and untested men willing to use PrEP and the likelihood of decreased condom use if using PrEP across the three survey rounds (2011–2015). Multivariate logistic regression was also used to identify independent associations with willingness to use PrEP, the likelihood of decreased condom use if using PrEP, support for GBM taking PrEP and willingness to have sex with men taking PrEP (analyses restricted to the 2015 sample). Adjusted ORs (AOR) and 95% CIs are reported.
In 2011, the survey was completed by 1283 men, of whom 919 self-reported that they were HIV-negative, 122 HIV-positive and 242 untested.8 In 2013, the survey was completed by 1316 men, of whom 966 were HIV-negative, 93 HIV-positive and 257 untested.7 In 2015, the first page of the survey was viewed 2451 times and 1795 eligible people commenced the survey (73% participation rate). The survey was completed by 1251 men (70% completion rate), of whom 990 were HIV-negative, 106 HIV-positive and 155 untested.
The mean age of all respondents was 32.4 years (SD=11.3) and 93.5% identified as gay. The majority were born in Australia (79.9%), lived in the capital city of their state or territory (73.6%), were in full-time employment (58.1%) and almost half had a university degree (47.1%).
Between 2011 and 2015, there were increases (all p<0.001) in the mean age of respondents (from 31.5 to 33.7 years), the proportion of respondents who identified as gay (92.3%–96.9%), who had tested for HIV in the previous 12 months (58.7%–66.5%), reported condomless anal intercourse with regular male partners (CAIR) in the previous 6 months (45.8%–54.2%) or reported condomless anal intercourse with casual male partners (CAIC) in the previous 6 months (28.2%–35.7%). The proportion of men who lived in a capital city declined (76.2%–68.7%, p<0.001). We controlled for these changes in subsequent analyses.
Trends in PEP and PrEP use
The proportion of all men who reported ever having taken PEP did not change between 2011 (14.2%) and 2015 (17.3%; AOR=1.02, 95% CI 0.97 to 1.08, p=0.42). In contrast, the proportion of men who reported ever having taken PrEP increased between 2011 (0.6%) and 2015 (3.0%; AOR=1.54, 95% CI 1.25 to 1.90, p<0.001).
Of the 38 men who reported ever having taken PrEP in the 2015 survey, 13 reported they had accessed it from overseas, 11 from a research study, 11 from a doctor's prescription and 3 from an HIV-positive person. Of the 24 participants who were taking PrEP at the time of the 2015 survey, nearly all (n=21) reported that they were taking PrEP daily.
Willingness to use PrEP
The proportion of HIV-negative and untested men who were classified as willing to use PrEP fluctuated over time, from 28.2% in 2011, 23.3% in 2013 to 31.7% in 2015. There was no change in willingness between 2011 and 2015 (AOR=1.04, 95% CI 0.99 to 1.09, p=0.13), although there was an increase between 2013 and 2015 (AOR=1.23, 95% CI 1.11 to 1.36, p<0.001).
Among HIV-negative and untested respondents in 2015, willingness to use PrEP was independently associated with age, with willingness decreasing as age increased (AOR=0.96, 95% CI 0.95 to 0.98, p<0.001). Willingness to use PrEP was positively associated with having an HIV-positive regular partner (AOR=2.68, 95% CI 1.35 to 5.30, p=0.005), CAIC in the previous 6 months (AOR=1.72, 95% CI 1.07 to 2.76, p=0.03), more than 10 male sex partners in the previous 6 months (AOR=2.37, 95% CI 1.34 to 4.17, p=0.003) and ever having taken PEP (1.46, 95% CI 1.01 to 2.11, p=0.046). Men who had more concerns about using PrEP were less willing to use it (AOR=0.40, 95% CI 0.30 to 0.53, p<0.001).
Likelihood of reduced condom use if using PrEP
Among HIV-negative and untested respondents who were willing to use PrEP, the proportion who reported that they were likely to reduce condom use if using PrEP increased from 8.0% in 2011 to 15.8% in 2015 (AOR=1.18, 95% CI 1.04 to 1.34, p=0.01).
Among HIV-negative and untested respondents who were willing to use PrEP in 2015, a higher likelihood of reduced condom use if using PrEP was independently associated with older age (AOR=1.03, 95% CI 1.02 to 1.05, p<0.001), having an HIV-positive regular partner (AOR=2.42, 95% CI 1.03 to 5.65, p=0.04), reporting CAIR in the previous 6 months (AOR=1.74, 95% CI 1.02 to 2.98, p=0.04), reporting 2–10 male sex partners in the previous 6 months (rather than 0–1 partner; AOR=2.09, 95% CI 1.02 to 4.27, p=0.04) and using party drugs for sex in the previous 6 months (AOR=2.02, 95% CI 1.30 to 3.15, p=0.002).
Support for GBM taking PrEP
The mean score on the support for GBM taking PrEP scale was 3.98 (SD=0.67) out of 5. More than half of respondents (54.5%) were classified as supporting GBM taking PrEP (ie, score of ≥4). HIV status had little effect on responses to items within the scale (see table 1), although HIV-positive men were slightly more likely to agree that GBM taking PrEP were being responsible.
In multivariate analysis (see table 2), support for GBM taking PrEP was more likely among men who were HIV-positive, had a university degree and had two or more male sex partners in the previous 6 months. Support was less likely among older men and men who lived in regional, rural and remote areas.
Willingness to have sex with men taking PrEP
The mean score on the willingness to have sex with men taking PrEP scale was 3.63 (SD=0.74) out of 5. Thirty-nine per cent of respondents were classified as willing to have sex with men using PrEP according to the scale (score of ≥4). HIV-positive men were more likely than HIV-negative and untested men to agree that they would have sex (or condomless sex) with someone on PrEP (see table 1).
In multivariate analysis (see table 3), willingness to have sex with men taking PrEP was more likely among respondents who were HIV-positive, had a university degree, reported recent CAIC, had two or more male sex partners in the previous 6 months and those who had recently used party drugs for sex. Willingness to have sex with men taking PrEP was less likely among men who had a regular partner of untested/unknown HIV status, those who consistently used condoms with their regular partners and men who had a positive experience of using condoms.
Our repeated national surveys of Australian GBM have found low but increasing levels of PrEP use between 2011 and 2015 (<3%). More recent Australian surveys are finding higher levels of PrEP use, reflecting rapidly increasing availability.10 Willingness to use PrEP has remained relatively stable, and was reported by nearly one in three HIV-negative and untested men in 2015. Consistent with international studies and our previous research,1 ,2 ,7 ,8 interest in using PrEP remains concentrated among younger men and those who appear to be at higher risk of HIV, particularly men with HIV-positive partners, those who engage in condomless sex with casual partners and previous PEP users. This is consistent with the current Australian prescribing guidelines,12 which recommend the targeted rollout of PrEP to people at high, ongoing risk of infection.13–15
Among men who indicate they are willing to use PrEP, we have seen a doubling of the proportion of GBM who indicate that they are likely to decrease condom use if they take PrEP (from 8% in 2011 to 16% in 2015). This still represents a minority of potential PrEP users, but it suggests that belief is growing among Australian GBM that PrEP is protective against HIV when having condomless sex, or that it is acceptable to take PrEP in order to have condomless sex (although we cannot determine the reason for this change with existing data). Consistent with our previous research,7 ,8 men who indicated they would use condoms less if taking PrEP were more likely to report higher risk practices, such as having HIV-positive partners, engaging in condomless sex or using party drugs for sex.
Findings from two new scales identified in the 2015 survey indicate that over half of Australian GBM support men using PrEP and over a third say they would be willing to have sex with someone using PrEP. These measures will be useful in assessing community support for PrEP as its availability increases and education campaigns are conducted.1 ,2 HIV-positive men are currently more supportive of PrEP use than HIV-negative and untested men and are more willing to consider having sex with someone using PrEP. This is consistent with our previous research that found that HIV-positive men were more aware and knowledgeable about PrEP, presumably because of their exposure to and engagement with HIV medicine.17 HIV-positive men may also be enthusiastic about PrEP because it reduces their concerns and sense of responsibility about preventing HIV transmission. Support for men using PrEP is also concentrated among better educated GBM, those who live in urban areas and those with more sex partners. This is also consistent with our research on knowledge about PrEP, which suggests a need for community education about PrEP, particularly for men in regional areas.17 Willingness to have sex with men on PrEP is concentrated among men who report higher risk sex practices (such as CAIC and using party drugs for sex), but is lower among men who consistently use and report a positive experience in using condoms. Consistent condom users may not want to have sex with PrEP users, because it raises the possibility of having condomless sex or an increased risk of STIs.18 ,19 This is worthy of further investigation.
Our findings have some limitations. The repeated, cross-sectional design meant that we could analyse trends and control for sampling variation over time, but we could not assess changes in the attitudes or practices of individual men. The samples of GBM we recruited are similar to community and online samples of Australian GBM who are at increased risk of HIV,20 ,21 but are not representative of all Australian men who have sex with men.22 Internationally, our measure of willingness to use PrEP remains a conservative one,1 ,2 but as we have previously argued we think it is a more realistic measure because it takes into account factors such as perceived need, willingness to pay and taking medication regularly.7 ,8
In conclusion, we have found that willingness to use PrEP has remained stable while the likelihood of condomless sex while using PrEP has increased among Australian GBM. There are reasonable levels of community support for PrEP at this early stage of its rollout in Australia. Interest in using PrEP and support for using it are concentrated among men who engage in higher risk practices and who know more about living with HIV (such as HIV-positive men and their partners). These patterns are consistent with the proposed targeting of PrEP to Australian GBM at high risk of HIV. At this stage, consistent condom users are less willing than other GBM to consider PrEP users as potential sex partners. Whether this signifies a lack of familiarity with PrEP, a preference for condoms or another reason is unclear.
Willingness to use pre-exposure prophylaxis (PrEP) among Australian gay and bisexual men (GBM) remains concentrated among the minority of men who are at higher risk of HIV.
Over half of GBM support other people using PrEP, and over a third are willing to have sex with someone using PrEP.
Consistent condom users are less willing to consider having sex with someone using PrEP.
Our results support the targeted rollout of PrEP in Australia to GBM at higher risk of HIV.
We thank all the gay and bisexual men who participated in this research. We acknowledge the other members of the PrEPARE Project reference group: David Crawford, Susan Kippax, Marsha Rosengarten and Marlene Velecky. The Centre for Social Research in Health and Australian Research Centre in Sex, Health and Society receive funding from the Australian Government Department of Health. The PrEPARE Project is supported by the Bloodborne virus and sexually transmissible infection Research, Intervention and Strategic Evaluation programme, funded by the New South Wales Ministry of Health.
Handling editor Jackie A Cassell
Contributors All authors contributed to the study design. MH conceptualised this article and undertook the bulk of writing and redrafting. TL undertook the statistical analysis, in consultation with MH. All other authors read and commented on drafts of the article and agreed with the final version.
Funding Australian Government Department of Health, New South Wales Ministry of Health.
Competing interests This work was supported with grants from the Bloodborne virus and sexually transmissible infection Research, Intervention and Strategic Evaluation programme, funded by the New South Wales Ministry of Health, and the Australian Government Department of Health. Non-financial support from Gilead Sciences was received for studies outside the submitted work.
Ethics approval UNSW Australia Human Research Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement A deidentified form of the data used in this article is available on request. Requests for data can be made to the first author.