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Research Letter
On-demand HIV pre-exposure prophylaxis: what are the healthcare workers’ barriers to delivery in a culturally and linguistically diverse population?
  1. Melissa Power1,
  2. David A Lewis1,2,
  3. Daniel Richardson1
  1. 1 Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, New South Wales, Australia
  2. 2 University of Sydney Medical School (Westmead Campus), Westmead, New South Wales, Australia
  1. Correspondence to Dr Daniel Richardson, Western Sydney Sexual Health Centre, Parramatta, New South Wales, Australia; daniel.richardson2{at}

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The Western Sydney Sexual Health Centre is a publicly funded sexual health service which provides sexual healthcare for a large population of non-Australian-born, non-English-speaking and culturally diverse men who have sex with men (MSM). As some of these MSM do not have access to universal healthcare coverage (Medicare) and many find the cost of the daily HIV pre-exposure prophylaxis (PrEP) too expensive, they would benefit from more affordable (PrEP) access.

The Centre’s multidisciplinary team are experienced at delivering daily PrEP, and approximately 500 MSM access PrEP per year. However, given that the proportion of incident HIV infection among non-Australian-born MSM is increasing locally, it is important to engage such individuals and offer cheaper effective HIV prevention options.1 On-demand HIV PrEP offers a solution as an effective HIV prevention strategy for MSM having condomless anal sex, including those who do not have frequent condomless anal sex.2 3 To support wider use of this strategy, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) has recently updated its advice on on-demand PrEP in a draft revised guideline.4

There are circumstances where on-demand PrEP would be more acceptable than daily PrEP, but to deliver advice about on-demand PrEP, healthcare workers need to have appropriate knowledge and feel confident in their discussions with MSM. As part of a team quality improvement project, we asked sexual healthcare workers (doctors, nurses and social workers) to complete a short anonymous online survey about on-demand PrEP. The survey consisted of eight questions on healthcare workers’ role, experience and confidence in discussing on-demand PrEP and explored the barriers to on-demand PrEP using free text.

Seventeen out of 26 healthcare workers responded to the survey (10 nurses, 4 social workers, 3 doctors). Most (60%, 10 of 17) had worked in sexual health for 6 or more years, and 60% (10 of 17) reported prior discussions with MSM about on-demand PrEP. On a 0–5 Likert scale, healthcare workers scored a median of 2 out of 5 (IQR 0–3) for feeling confident in discussing on-demand PrEP with MSM. Most of the healthcare workers (71%, 12 of 17) stated that it should be a doctor’s role to discuss on-demand PrEP. Healthcare workers rated on-demand PrEP as less important (ranked in order of importance) than condoms, HIV treatment as prevention, daily PrEP and HIV testing. Healthcare workers stated several barriers to discussing on-demand PrEP, including uncertainty about the current ASHM draft guideline, feeling that the on-demand PrEP schedule is confusing and a belief that there is currently not enough evidence to recommend on-demand PrEP. Most healthcare workers (88%, 15 of 17) suggested that they would like more training about on-demand PrEP.

In summary, we have shown that healthcare workers who are experienced at delivering advice on daily PrEP do not necessarily have the same skills and confidence about on-demand PrEP. Appropriate resources and tools are thus required to increase healthcare workers’ knowledge and confidence to both discuss and provide on-demand PrEP to MSM, particularly those from diverse backgrounds.



  • Handling editor Anna Maria Geretti

  • Contributors MP and DR designed this study and analysed the data. All authors contributed to the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.