Article Text
Abstract
Objective We assessed interest in using rectal microbicides to prevent HIV transmission among gay men in Australia.
Methods A national online survey was conducted in 2013. Interest in using rectal microbicides was measured on a seven-item scale (α=0.81). Factors independently associated with greater interest in using a microbicide were identified using multivariate logistic regression.
Results Data were collected from 1223 HIV-negative and untested men. Mean age was 31.3 years (SD=10.8, range 18–65); 77% were born in Australia and 25% reported any condomless anal sex with a casual partner in the previous 6 months. Overall, there was moderate interest in using rectal microbicides (M=3.33, range 1–5). In multivariate analysis, greater interest in using microbicides was independently associated with being born outside Australia (adjusted OR (AOR)=1.59; p=0.009), greater self-perceived likelihood of becoming HIV positive (AOR=3.40; p<0.001), less uncertainty about the efficacy of microbicides (AOR=0.65; p=0.009), any condomless anal sex with casual partners in the previous 6 months (AOR=1.78; p=0.03) and ever having received postexposure prophylaxis (AOR=1.53; p=0.04). Interest in using microbicides was not associated with age, number of male sex partners or the HIV status of regular male partners.
Conclusions Interest in using rectal microbicides was associated with self-perceived vulnerability to HIV, engaging in sexual practices that increase the risk of HIV acquisition and less uncertainty about the efficacy of microbicides. There appears to be a group of men who would benefit from, and are highly motivated to use, a rectal microbicide product.
- HIV
- GAY MEN
- MICROBICIDES
- SEXUAL BEHAVIOUR
- ATTITUDES
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Introduction
Rectal microbicides may be an important addition to existing HIV prevention tools for people engaging in receptive anal sex. Microbicides are compounds applied topically to protect the user from viruses or bacteria. Although no microbicide product has been approved for use, safety studies have been conducted on various rectal microbicide candidates, and one phase 2 study, MTN-017, is underway.1 ,2
A microbicide may be preferable to using condoms because it can be applied prior to sex and its use can be controlled by the receptive partner. In high-income countries, the majority of men who have sex with men (MSM) report lubricant use for anal sex,3 ,4 so rectal microbicides that also provide lubrication are likely to be acceptable. Peinado et al5 found 92% of Peruvian MSM and transgender women found the concept of rectal microbicides highly acceptable and preferred a lubricant product over a pill. Taking the receptive role in anal sex was associated with higher acceptance. In the USA, there was high awareness of, and willingness to use, microbicides among MSM who reported sex without condoms.6 ,7
Some research has been undertaken on the preferred characteristics of a rectal microbicide. Efficacy in preventing HIV transmission has emerged as the most important factor associated with willingness to use a future product.8 ,9 Other considerations include side effects, suspicion of harm, cost, type of formulation, frequency and timing of use, partner type, requirement for a prescription, access, stigma and the incorporation of microbicide use into existing sexual practices.8–11 Clinical trials have provided some data on the experiences of using experimental or simulated microbicides. These trials indicate that increased acceptability is associated with a gel product compared with a rectal suppository, smaller gel volume and formulation with a reduced glycerin content.6 ,12 ,13
The aim of the current study was to assess interest in using a microbicide among gay men in Australia and to describe the characteristics associated with greater interest.
Methods
An online survey was constructed using NETQ software (NetQuestionnaires Nederland BV). Recruitment was conducted in 2013 through MSM chat sites, social media and gay community organisations. Data were collected on the number of sexual partners in the previous six months, current relationship status, HIV status of regular partners, use of condoms with regular and casual partners, any experience of receiving postexposure prophylaxis, previous use of antiretrovirals as pre-exposure prophylaxis and self-perceived likelihood of acquiring HIV. The following definition was provided.
Microbicides are products that are applied directly to the rectum (or vagina) prior to sex to prevent the transmission of HIV. They come in the form of a gel, cream, or in a slow release device. A number of products are currently being tested to see if they are effective.
Eligible participants were aged at least 18 years, lived in Australia and were gay, bisexual or other MSM. No incentive was provided to participate. This analysis formed part of a broader study on attitudes to different HIV prevention technologies.14 HIV-positive men did not complete the questions about personal interest in microbicides, so they are excluded from this analysis.
‘Interest in using rectal microbicides’ among non-HIV-positive men was measured on a seven-item scale (α=0.81). These items were: (1) I would be willing to use a rectal microbicide if I was the bottom; (2) I would be willing to use a rectal microbicide to prevent getting HIV; (3) I would be willing to take part in a clinical trial of rectal microbicides; (4) I will use a rectal microbicide as soon as it becomes commercially available; (5) I believe rectal microbicides will make sex more enjoyable; (6) I would be willing to use a rectal microbicide every day to prevent me getting HIV and (7) I would use a rectal microbicide before every occasion of anal sex. Each item was scored from 1=strongly disagree to 5=strongly agree. The scale score was a mean of the seven items. A score of 4 or more was regarded as indicating a strong interest in using microbicides.
A scale measuring ‘confidence in the efficacy of rectal microbicides’ (α=0.61) among non-HIV-positive men included four items: (1) I would not trust a rectal microbicide to protect me from HIV if a sexual partner came inside me; (2) I would use condoms with rectal microbicides; (3) I would not trust a rectal microbicide to provide protection for extended periods of sexual activity and (4) I would use a rectal microbicide only as a backup to other forms of prevention. ‘Personal experience in using condoms’ and ‘confidence in discussing condoms’ were measured on a nine-item and two-item scale, respectively.14
Variables associated with greater interest in using a microbicide were identified through bivariate logistic regressions. All factors significant at p<0.05 were entered into a multivariate logistic regression model using block entry to identify independent associations with greater interest in using a microbicide.
Results
This analysis includes data collected from 1223 men (79% self-reported HIV negative; 21% untested or unknown status). The mean age of respondents was 31.3 years (range 18–65, SD=10.8), 91.6% self-identified as gay and 6.5% bisexual, 77% were born in Australia, 76% lived in a capital city and 25% reported any condomless sex with a casual partner in the previous 6 months.
Overall, responses to the ‘interest in using rectal microbicides’ scale were moderately positive (M=3.33, SD=0.69, range 1–5). A minority of men (17%) scored 4 or more, indicating a strong interest in using microbicides. On a separate, single-item measure, respondents indicated a preference for a microbicide product to be similar to existing lubricants for anal sex (M=4.29, SD=0.72, range 1–5). In bivariate analyses, the following factors were related to increased interest in using a rectal microbicide: being born outside Australia, having more than 10 male sex partners in the past 6 months, having either no regular partner or having an HIV-positive or unknown status partner (compared with having an HIV-negative partner), having any anal sex with casual partners (either with or without condoms), perceiving a greater likelihood of becoming HIV positive, having ever received HIV postexposure prophylaxis and being less uncertain about the efficacy of microbicides (see table 1). There was no association with personal experience in using condoms or confidence in discussing condoms with partners.
In the multivariate analysis, greater interest in using a rectal microbicide was independently associated with being born outside Australia, having a greater self-perceived likelihood of becoming HIV positive, less uncertainty about the efficacy of microbicides, having any condomless anal sex with casual partners in the previous 6 months and ever having received postexposure prophylaxis. Interest in using microbicides was not associated with the number of male sex partners or the HIV status of regular partners (see table 1).
Conclusion
Our analysis found that gay and bisexual men who perceived themselves to be more vulnerable to HIV and who were at greatest risk of infection (as indicated by their sexual practices and previous use of postexposure prophylaxis) were much more interested in using microbicides than other men. These men also reported much less uncertainty about the efficacy of microbicides.
Our finding that only 17% of men have a strong interest in using microbicides is a much lower level of interest than that found in other studies. For example, in Peru, over 90% of MSM and transgender women found microbicides acceptable.1 This difference may be due, in part, to the different geographical settings and populations, but we believe that it is primarily due to our use of a more comprehensive seven-item scale compared with a single-item measure. The items in the scale used in our study included a range of factors that may influence uptake, such as readiness to use a microbicide product, motivation to use microbicides on a regular or event-driven basis, reliance on a microbicide when taking the receptive sexual position in anal sex and expectations of increased sexual pleasure. Use of a single item, I would be willing to use a rectal microbicide to prevent getting HIV, would have found that 75% of men in our sample were ‘willing’ to use microbicides, which is similar to other studies. However, such a measure would not have taken into consideration other factors that may influence use.
A potential limitation of our study is that knowledge of rectal microbicides was not assessed. Also, unlike some other studies, we did not seek to determine the preferred or ideal characteristics that may influence interest in using microbicides, such as price level, and mode and timing of application.8–11 Although men indicated a preference for a rectal microbicide to be similar to existing lubricants for anal sex, this was presumably because lubricants were a familiar point of reference and most men would be unaware of alternative formulations. However, despite these limitations, our findings clearly show that if a rectal microbicide product is found to be efficacious, then there is an appropriate group of Australian gay and bisexual men who are very interested in using it.
References
Footnotes
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Handling editor Jackie A Cassell
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Contributors MH, DAM and JME took primary responsibility for designing and executing the study. DAM developed the concept for the paper and wrote the majority of the paper. TL conducted the statistical analyses, with input from DAM and MH. All authors had input into the study design, contributed to earlier drafts of the paper and agreed to the final content.
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Funding This study was supported by a UNSW Australia GoldStar Award. The Centre for Social Research in Health is supported by the Australian Government Department of Health.
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Competing interests None.
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Patient consent The study used an anonymous online survey to collect data. Starting and completing the survey was taken as evidence of consent.
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Ethics approval UNSW Human Research Ethics Committee (HREC 11034).
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Provenance and peer review Not commissioned; externally peer reviewed.