Over half of men who have sex with men (MSM) living in Berlin who were
using HIV pre-exposure prophylaxis (PrEP) accessed it through informal sources,
without consistent medical monitoring, according to a recent study published in
PLOS ONE.
The results also revealed that while a high percentage of men in the
study were aware of PrEP, a sizable proportion also felt that they were not well-informed
about it, mainly getting their information through word-of-mouth sources as
opposed to formal channels. Almost a quarter of participants were engaging in
risky sexual behaviours without accessing PrEP.
While the incidence of
HIV among MSM in Germany has fallen from 2500 cases in 2013 to 2100 cases in
2016, Berlin has a higher HIV incidence than the rest of the country – 10.1 per
100,000 as opposed to 4.2 per 100,000. The nationwide decline in
infection rates has been attributed to Treatment as Prevention (TasP).
Generic PrEP has been available,
with a doctor’s prescription, since the autumn of 2017, but public health
insurance in Germany does not cover the cost of PrEP or its associated tests.
This is in contrast to
a country such as France where PrEP has been authorised for use and has been fully reimbursed
since 2016. The city of Paris accounts for 92% of PrEP usage and the vast
majority of those who access PrEP in France are MSM. The focused use of PrEP in specific communities has helped bring down
HIV infection rates in large cities such as San Francisco where PrEP has been
used since 2012.
Considering the
powerful role PrEP can play in reducing new infections, the authors of this
study wanted to look more closely at knowledge and use of PrEP, factors
predictive of a desire to use it and a history of PrEP use among MSM in Berlin.
They conducted a cross-sectional survey of adult MSM whose HIV status was
negative or unknown, between October 2017 and April 2018. The surveys were
distributed at HIV testing and counselling centres and HIV specialist practices
in Berlin. While the former are walk-in centres offering anonymous testing for
HIV and other STIs, the latter are owned and staffed by doctors and offer a
range of services to LGBTQ individuals, whether or not they are living with
HIV.
A total of 470 questionnaires
were suitable for final data analysis. Participants’ mean age was 37 years and
two-thirds were university educated.
Eighty-one of the
respondents (17.2%) had used PrEP, with under half of those (44.4%) receiving a
prescription from a doctor. Other sources included foreign import (35.8%),
using pills originally prescribed as post-exposure prophylaxis (PEP, 18.5%) and
using a friend’s HIV medication (11.1%).
Factors that were
positively associated with PrEP use included having a university degree, having
been born outside Germany, belonging to a higher sexual risk group, and having
friends or acquaintances living with HIV.
Regarding attitudes
towards the cost of PrEP, the majority of all participants felt that the cost
should be covered by public health insurance. If PrEP had to be paid for, an
acceptable price for most participants was 50 euros or less (59.1%), followed
by 100 euros or less for a smaller number of participants (21.3%).
While awareness of
PrEP was good (90% of the sample reported that they were already aware of it),
one third of those who were aware of PrEP said that they were not well-informed
about PrEP. Sources of information about PrEP revealed that a high percentage
gained knowledge from friends or acquaintances (61.7%), while a much lower
percentage gained information from doctors (22.7%) or other formal sources.
In terms of sexual risk
behaviour, 17.4% of participants had been diagnosed with an STI in the last six
months, while 32.1% had had anal sex with two or more partners without using a
condom. Interestingly, among participants who reported never having used PrEP,
almost a quarter indicated that they had recently had condomless anal sex with multiple
partners.
Of those who had never
used PrEP, 42.4% indicated that they would like to use PrEP. Factors that were
positively associated with, and positive predictors of, the desire to take PrEP
included higher-risk sexual behaviour, perceived riskiness of own sexual
behaviour as well as expressing the need for a doctor to prescribe PrEP. Having
condomless sex with multiple partners emerged as the strongest predictor of a
desire to use PrEP, indicating that higher-risk groups would benefit from
widely available PrEP.
Two-thirds of
participants agreed that PrEP is a safe way to prevent HIV infection. Men who
felt well informed about PrEP were more likely to see PrEP as safe. The main
perceived risks were acquiring other STIs while on PrEP and side-effects.
While this study
showed a high awareness of PrEP among MSM in Berlin, it also indicated that
fewer than half of those who knew about PrEP felt well informed. A lack of
information was also cited as a barrier by almost one-third of those who had
never used PrEP.
The lack of education
and knowledge regarding PrEP is of particular concern as a high number of those
using PrEP accessed it through informal sources. This raises public health
concerns associated with informal PrEP usage in the absence of prior testing
and ongoing monitoring. Informal PrEP usage could lead to the development of
drug-resistant HIV strains which are harder to treat. Indeed, the survey revealed that those who
were taking PrEP correctly were significantly more likely to have received a
prescription from a doctor.
As Berlin has joined UNAIDS’
Fast-Track Cities initiative and has committed to reaching the 90-90-90 targets
(90% of those with HIV should be diagnosed, 90% of those
diagnosed should be on treatment and 90% of those on treatment should be
virally suppressed), it is imperative that knowledge and uptake of PrEP is
increased. Considering that this study revealed that a sizable number of men who
engaged in condomless intercourse had never used PrEP, the authors recommend
that access to PrEP and education regarding it should be improved in regular
health services.