Introduction Contemporary responses to HIV embrace biomedical prevention, particularly treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). However, large-scale implementation of biomedical prevention should be ideally preceded by assessments of their community acceptability. We aimed to understand contemporary attitudes of gay and bisexual men (GBM) in Australia towards biomedical-based HIV prevention and propose a framework for their measurement and ongoing monitoring.
Methods A cross-sectional, online survey of GBM ≥18 years has been conducted annually in Victoria, Australia, since 2008. In 2016, 35 attitudinal items on biomedical HIV prevention were added. Items were scored on five-point Likert scales. We used principal factor analysis to identify key constructs related to GBM’s attitudes to biomedical HIV prevention and use these to characterise levels of support for TasP and PrEP.
Results A total of 462 HIV-negative or HIV-status-unknown men, not using PrEP, provided valid responses for all 35 attitudinal items. We extracted four distinct and interpretable factors we named: ‘Confidence in PrEP’, ‘Judicious approach to PrEP’, ‘Treatment as prevention optimism’ and ‘Support for early treatment’. High levels of agreement were seen across PrEP-related items; 77.9% of men agreed that PrEP prevented HIV acquisition and 83.6% of men agreed that users were protecting themselves. However, the agreement levels for HIV TasP items were considerably lower, with <20% of men agreeing treatment (undetectable viral load) reduced HIV transmission risk.
Conclusions Better understanding of community attitudes is crucial for shaping policy and informing initiatives that aim to improve knowledge, acceptance and uptake of biomedical prevention. Our analyses suggest confidence in, acceptability of and community support for PrEP among GBM. However, strategies to address scepticism towards HIV treatment when used for prevention may be needed to optimise combination biomedical HIV prevention.
Statistics from Altmetric.com
The HIV prevention toolkit has rapidly expanded in the past decade to include antiretroviral treatment (ART) to prevent onward transmission (treatment as prevention; TasP) and pre-exposure prophylaxis (PrEP) to prevent acquisition of HIV.1–3 Compared with established forms of primary prevention, such as condoms, biomedical prevention may be less well understood by affected communities, presenting new challenges for communicating evidence of effectiveness, increasing public health knowledge and influencing preventive behaviour. In addition, levels of understanding and acceptability of biomedical prevention within the affected and broader community are likely to affect demand and implementation success; mistrust and stigma of PrEP and TasP4 have the potential to undermine the uptake and therefore the individual-level and population-level effectiveness of biomedical HIV prevention.5
In Australia, there have been over 1000 new HIV diagnoses per year since 2012, predominantly among gay and bisexual men (GBM).6 The contemporary response to HIV in Australia emphasises biomedical prevention including the target of 90% of people living with diagnosed HIV accessing treatment, to achieve the goal of the ‘virtual elimination’ of HIV by 2020.7 In the context of changes to Australian clinical guidelines in 2015 to facilitate early initiation of treatment8 and more recent social marketing campaigns that promote HIV treatment for individual health and prevention of onward transmission (eg, www.treathivnow.org.au), an estimated 90% of people living with diagnosed HIV were receiving treatment in 2015.6 However, repeated surveys among Australian GBM (2011–2015) have shown doubts about the perceived efficacy of TasP, particularly among HIV-negative and untested men.9 Biomedical-based HIV prevention now also includes PrEP, and consistent with international studies10–13 and in contrast to TasP, Australian GBM have indicated high acceptability of and willingness to use PrEP.14 15 Alongside this demand, Australia’s HIV elimination goal has driven the recent scale-up of PrEP demonstration projects in the cities of Sydney16 and Melbourne.17 It is largely unknown how the rapid scale-up of PrEP and new messaging around TasP in the previous 12–24 months have influenced community attitudes. The lack of a framework for measuring and monitoring community attitudes to new prevention strategies has also contributed gaps in our knowledge.
Monitoring prevailing community attitudes towards biomedical prevention is crucial to the successful implementation and ongoing refinement of comprehensive HIV prevention strategies. Given the changing landscape of HIV prevention and the inclusion of biomedical prevention messages in current campaigns targeting GBM in Australia, we adapted the most recent survey from an ongoing online cohort study of GBM to capture data on attitudes towards biomedical HIV prevention. We aimed to measure and understand GBM’s attitudes to biomedical prevention using factor analyses, thus providing a framework for monitoring changes in attitudes to help inform the optimisation of biomedical-based HIV prevention strategies.
The Burnet Institute has maintained a prospective online cohort of GBM since 2008 with the primary purpose of monitoring engagement with sexual health social marketing campaigns.18 19 As part of the project, data collection includes periodic (annual) surveys of GBM with recruitment and data collection completed online; each survey round included follow-up of previous participants and active recruitment of new participants.18 Recruitment occurred through referrals from previous participants (snowballing) and advertising through social networking sites, online dating sites and at gay community venues in early survey rounds.18
Participants self-identified as being eligible; the survey stated that it was ‘…aimed at men, trans men or trans women who have sex with men…’. Participants also self-identified as being over 18 years of age and lived in Victoria, Australia, in the past 12 months. No reimbursement was offered; however, a competition for a $A200 retail voucher was used as an incentive. Participants completed an online participant information and consent form.
The survey included questions on socio-demographics, engagement with gay community, sexual behaviours, access to sexually transmissible infection testing, alcohol and other drug use and HIV and sexually transmitted infection prevention marketing campaign reach and engagement. In the most recent survey (2016; wave 9), 35 attitudinal items were added to capture attitudes towards biomedical HIV prevention (online supplementary table 1). The response option for each item was a five-point Likert scale (1=strongly disagree, 5=strongly agree) with additional ‘I don’t know’ and no response options. Items were: new (not previously used), used in the previous round (survey 8) or used verbatim or adapted from previous national studies among Australian gay men measuring attitudes towards PrEP15 and TasP9 (online supplementary table 1). Items previously used by Holt et al included two scales, ‘Early treatment is necessary’ (items 28, 29, 32) and ‘HIV treatment prevents transmission’ (items 22–24). Items 2–4 were an adaptation of the ‘HIV treatment prevents transmission’ scale to capture attitudes to PrEP instead.9 Specific items were intended to broadly capture PrEP knowledge and beliefs (items 1–5), attitudes towards community use of PrEP (items 6–8), perception of personal risk of HIV in the context of community uptake of PrEP (items 9–16), attitudes towards personal use of PrEP (item 17), attitudes towards HIV treatment (items 18–24), perception of personal risk of HIV in the context of community uptake of HIV treatment (items 25–27) and the necessity of early HIV treatment (items 28–35). Before being presented with questions about PrEP, participants were informed that ‘Pre-exposure prophylaxis (PrEP) refers to HIV-negative individuals regularly taking anti-HIV drugs to lower their chances of getting HIV. This is different to post-exposure prophylaxis (PEP) which is a month-long course of anti-HIV drugs taken within 72 hours of potential exposure to HIV’. There was no primer about TasP as the term was not used. Self-reported HIV-positive men were precluded from answering non-applicable questions (eg, ‘If more men are on PrEP, then I am less likely to get HIV’), and men reporting current PrEP use were precluded from answering two specific items (items 15 and 16; online supplementary table 1).
Supplementary file 1
Analysis included participants that provided a valid response (options 1–5 on the Likert scale) to all 35 items. The survey design meant that men who self-reported using HIV PrEP or self-identified HIV-positive men were precluded from answering some items; therefore, data from these men were excluded from analyses. Data were first assessed for suitability for data reduction analyses; a polychoric correlation matrix and a Kaiser-Meyer-Olkin test of sampling adequacy were used to assess for sufficient correlation in the dataset (criterion of ≥0.5). The first data reduction step was principal component factor analysis (PCA); items (survey statements) that were closely related were grouped, allowing summarisation of attitudes (factors) towards TasP and PrEP in the sample.20 The PCA narrowed the range of possible solutions (number of factors) that best fit the data; we considered solutions with eigenvalues ≥1 and visually inspected a scree plot for further guidance.20 We then ran separate principal factor analyses (PFAs), each with a number of factors suggested by the PCA (eg, PFA with two factors, PFA with three factors, etc). We used Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) scores in selecting the final solution (number of factors). The model structure was also inductively determined on the basis of the theoretical and conceptual interpretability of the factors consistent with established steps in exploratory principal component analysis.21 On selecting the final solution, we restricted factor loadings ≥0.50; restricting the factor loadings reduces data further and alongside using orthogonal (varimax) rotation aids interpretation of factors.20 We included cross-loadings of ≥0.30 and item uniqueness to assess the validity of the factors and utility of items. For the final included items, means scores and proportion of ‘agreement’ (agree or strongly agree) were described. Analysis was conducted in Stata V.14.1 (Stata).
A total of 844 respondents completed the survey. Self-identified HIV-positive individuals (n=63) were excluded from 10 non-applicable items, and men currently using PrEP (n=85) were excluded from answering 2 non-applicable items (online supplementary table 1). A further 235 men did not provide a valid response to all 35 items, leaving a total of 462 respondents that contributed data for all 35 items in the factor analyses.
Table 1 describes the sociodemographic, HIV testing status and gay community engagement of respondents included in the analyses. The majority of respondents identified as male and gay, HIV negative, Australian born and living in inner metropolitan Melbourne. The most common types of gay community social engagement reported by respondents were visiting gay venues and reading the gay press at least monthly, reported by just over one-third of respondents.
Principal factor analysis
The PCA of the 35 items identified six factors with eigenvalues ≥1, accounting for 90% of the total variance (table 2). The scree plot of eigenvalues, however, suggested retaining only three or four factors (figure 1). A PFA with three factors and then four factors was estimated to allow comparison of best fit to the data. The AIC and BIC scores were lower for the four-factor (3312 and 3866, respectively) compared with the three-factor solution (4078 and 4500, respectively) and the four-factor solution better captured attitudes to the uptake of PrEP, so we proceeded with this solution. Factors retained 23 of 35 items when restricted to factor loading ≥0.50, suggesting that factors captured a common attitude (stability of the factor). Factor 1 was correlated (0.57) with factor 2 as was factor 2 with factor 3 (0.71). The final four factors were labelled as follows: ‘Confidence in PrEP’, ‘Judicious approach to PrEP’, ‘Treatment as prevention optimism’ and ‘Support for early treatment’.
Mean scores and the proportion of participants with scores ≥4 showed levels of general agreement and consistency of items within each factor identified (table 3). Four of seven items in factor 1 had mean scores >3.5, with men agreeing with statements around PrEP being effective and that other men taking PrEP were being conscientious. All six items in factor 2 had mean scores <3; there was low agreement with statements relating to PrEP use among others affecting their preventive behaviours, such as condom use and disclosure of HIV status. For example, the lowest agreement across all 23 items was for the statement ‘If my partner doesn’t suggest using condoms, then I assume they’re on PrEP’, with 3% agreement. There was relatively low agreement across five items in factor 3; approximately one-third of men agreed with the statement ‘If more HIV positive men have an undetectable viral load, then I’m less likely to get HIV’. For factor 4, three of five items had mean scores >4, all relating to support for the early commencement of HIV treatment (soon after diagnosis). The two statements in factor 4 that suggested delaying treatment had low agreement.
Taking account of cross-loading and higher levels of uniqueness (as indicators that items may not be measuring independent constructs), we suggested 14 items for future use to measure attitudes to four HIV biomedical factors (box 1). In factors 1 and 2 particularly, several items had cross-loadings of between 0.30 and 0.42 on another factor. Factor 1 also had three items with uniqueness >0.4; therefore, we suggest that four items could measure the factor 1 adequately as opposed to the seven original items (table 3).
Suggested minimum set of questions to capture proposed constructs related to gay and bisexual men attitudes towards HIV prevention
Trust of and support for PrEP:
PrEP is effective in preventing HIV infection.
An HIV-negative person who is on PrEP is unlikely to get HIV.
Gay and bisexual men who take PrEP are being responsible.
Gay and bisexual men who take PrEP are protecting themselves.
Judicious approach to PrEP:
If more men are on PrEP, I would feel like I don’t need to use condoms to avoid getting HIV.
If my partner doesn’t suggest using condoms, then I assume they’re on PrEP.
Because of PrEP and HIV treatments, I’m less likely to ask my partners to use condoms.
HIV treatment optimism:
A person with an undetectable viral load cannot pass on HIV.
An HIV-positive person on treatment is unlikely to transmit the virus.
If every HIV-positive person was on treatment, new infections would stop.
If more HIV-positive men have an undetectable viral load, then I’m less likely to get HIV.
Support for early treatment:
HIV-positive people should go on treatment to protect their partners.
People should start treatment as soon as they are diagnosed.
People should delay HIV treatment until they are completely ready.
PrEP, pre-exposure prophylaxis.
This paper contributes to understanding contemporary attitudes of GBM towards biomedical-based HIV prevention. Using an exploratory approach, four distinct and interpretable factors emerged that captured and characterised men’s attitudes towards biomedical HIV prevention approaches. Two factors clearly described attitudes towards PrEP. First, ‘Confidence in PrEP’ indicated belief in PrEP efficacy and support for other PrEP users. Agreement was relatively high for statements like PrEP was ‘effective’ and PrEP users were ‘protecting themselves’. Second, ‘Judicious approach to PrEP’ indicated a more cautious approach to PrEP with responses to items suggesting men were unlikely to rely on PrEP use by others for their own protection from HIV. Levels of agreement with survey items will reflect local context of community dialogue, health promotion and structural interventions and the utilisation of biomedical prevention approaches. The framework for understanding and monitoring community responses our findings propose offers an approach for comparing attitudes towards, and potentially intended uptake of, biomedical prevention strategies between jurisdictions and over time.
While regulatory and structural barriers have meant that the uptake of PrEP among GBM in Australia has been limited until recently, PrEP has been on the community’s agenda for some time. Since 2011, Australian GBM at high risk of HIV have reported high levels of willingness to use PrEP and community support for men using PrEP has grown.14 15 Men in our sample were overwhelmingly supportive of PrEP, even though no respondents included in the analysis were using PrEP. PrEP use in the overall sample (781 HIV-negative/unknown men) remained relatively low (at 10%), although it represented an increase on the most recent Victorian gay community periodic survey conducted in early 2016, which found that 6% of GBM in Victoria were using PrEP.22 Low PrEP uptake, outside of demonstration projects, is due partly to lack of affordability, as PrEP is not currently subsidised under the Pharmaceutical Benefit Scheme, Australia’s insurance scheme for medications.23 In the context of restricted access, the positive attitudes seen here and in previous studies11 13 may be due to the visible community-based advocacy for PrEP (PrEPaccessNOW; www.pan.org.au) alongside publicity about the cumulative evidence of PrEP’s safety and effectiveness.7 Existing research among Australian GBM suggests that there is an unmet demand for PrEP in Australia,14 15 and our results indicate that structural barriers, rather the community support, are limiting its scale-up.
Attitudes towards HIV TasP in this study were more complex. Responses to ‘Treatment as prevention optimism’ items that related to the individual-level and population-level effectiveness of TasP suggested community doubt about TasP effectiveness; levels of agreement were low and only one in five men agreed that ‘An HIV-positive person on treatment is unlikely to transmit the virus’. However, responses to items in factor 4 suggest that men supported individuals commencing treatment in a timely manner. In factor 4, men agreed with the concept of TasP when the statement referred to treatment being used to ‘protect partners’. Mixed agreement across HIV TasP items raises concerns about potential misconceptions or mistrust of HIV treatment for prevention of transmission or, similar to responses to items in factor 2, men may hold strong beliefs about taking personal responsibility for HIV prevention (rather than relying on others); for HIV-negative men, TasP is reliant on partners being adherent to ART and monitoring their viral load. Scepticism about TasP is consistent with cross-sectional studies of Australian GBM that found that only 13% of GBM agreed that HIV treatment prevents transmission.9 Although positive attitudes to early treatment are consistent with considerable increases in treatment uptake seen in Australia,6 22 24 there remains a need to increase community knowledge around treatment for HIV prevention.
There were limitations to this study that need to be considered, including that data were self-reported and therefore potentially subject to recall and social desirability biases. We were only able to include data from HIV-negative or HIV-unknown men not currently using PrEP, potentially limiting the range of attitudes captured. The missed opportunity to collect data from HIV-positive men will be redressed in future surveys. The survey collected key socio-demographic characteristics, consistent with the study’s original aims and informed by local HIV epidemiology. It was not feasible to collect an extensive range of variables; therefore, we could not report on characteristics such as country of birth, ethnicity, income or education. Survey questions were developed in consultation with project partners, which include representatives of gay community/HIV organisations and research team members who are gay men. Some questions have been used in previous state and national surveys; however, new questions were not field-tested prior to the 2016 survey release. While the survey questions likely measure attitudes towards biomedical prevention comprehensively, it was not feasible to measure attitudes towards the suite of HIV prevention strategies, nor the full array of risk contexts experienced by GBM. PFA is an exploratory approach and not intended for inferential statistics; therefore, while results are informative for future research, they may not be generalisable.
The advent of biomedical HIV prevention has challenged attitudes about prevention within affected communities in a relatively short period. While clinicians and policy-makers may have digested the evidence and adopted the promotion of biomedical prevention strategies, support for biomedical prevention within the community is perhaps more important for uptake and ultimately effectiveness. Understanding community attitudes towards biomedical prevention is a crucial part of shaping policy and informing initiatives that aim to improve knowledge and the uptake of biomedical prevention. Our analysis contributes to an enhanced understanding of community attitudes, highlighting relatively positive attitudes to PrEP but mixed views about TasP. Findings from our PFA also provide a potential framework from which to monitor changes in attitudes towards biomedical prevention over time. We believe our research will assist in refining health promotion messages and improving methods to measure and monitor attitudes among GBM.
While gay and bisexual men are highly supportive of pre-exposure prophylaxis, there remains some scepticism towards HIV treatment when used for prevention.
Increasing community understanding of treatment as prevention is needed to optimise treatment-based HIV prevention strategies.
Ongoing monitoring of attitudes of gay and bisexual men towards biomedical prevention is an important part of HIV prevention strategies as it allows for refinement of interventions such as health promotion messaging.
We propose a framework for monitoring attitudes towards biomedical prevention among gay and bisexual men.
The authors acknowledge Adam Hynes and Colin Batrouney from the Victorian AIDS Council for consulting on survey items.
Handling editor Jackie A Cassell
Contributors ALW contributed to conceptualising the analysis, analysing and interpreting the data and drafting and revising the manuscript. BLD contributed to participant recruitment, data acquisition, interpreting the data, drafting and revising the manuscript. AEP contributed to participant recruitment, data acquisition, conceptualising the analysis, interpreting the data and revising the manuscript. JA contributed to data acquisition, interpreting the data and revising the manuscript. MH contributed to conceptualising the analysis, interpreting the data and revising the manuscript. MEH contributed to interpreting the data and revising the manuscript. MS contributed to participant recruitment, data acquisition, conceptualising the analysis, interpreting the data, drafting and revising the manuscript. All authors have read and approved the final manuscript.
Funding The Victorian Department of Health funded the 2016 HIV Prevention Initiatives Evaluation project. The National Health and Medical Research Council provided funding to MH as a Principal Research Fellow (1112297), MS as a Career Development Fellow (1090445) and AEP as an Early Career Fellow (1072943). The authors gratefully acknowledge the Victorian Operational Infrastructure Support Program. The Centre for Social Research in Health receives funding from the Australian Government Department of Health.
Competing interests None declared.
Ethics approval Alfred Health Human Research Ethics Committee (Project 62/16).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data requests can be directed to Associate Professor MS, Head of Public Health Discipline, Burnet Institute, email@example.com.
Correction notice This paper has been amended since being published Online First. The affiliation addresses have been corrected.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.