American gay men who have chosen to take pre-exposure
prophylaxis (PrEP) are aware of their own risk of being exposed to HIV and see
PrEP as providing 'an extra layer of protection' on top of their efforts to use
condoms, some or all of the time. The use of PrEP can help reduce anxiety and provide
greater 'peace of mind', men reported in in-depth interviews.
The study also sheds light on the motivations of men who
stopped taking PrEP or who chose not to take it at all. Most frequently this was
because their sexual relationships or behaviour had changed, but concern about
potential side-effects also deterred a number of men.
The findings were presented to the 9th
International Conference on HIV Treatment and Prevention Adherence in Miami
earlier this week. Hailey Gilmore and colleagues interviewed 87 American men
who have sex with men who were enrolled in iPrEx
OLE – a programme which offered men who had participated in a clinical
trial of PrEP the possibility to take, or continue to take, PrEP after the
randomised study had ended. Whereas the effectiveness of PrEP had previously
been unknown, by this stage men had learnt that it could help prevent HIV
infection.
Around seven-in-ten participants chose to take PrEP. Those
who did so generally saw themselves as being at risk of acquiring HIV, whereas
staying HIV negative was very important to them. One man mentioned that a lot
of his friends and sexual partners were HIV-positive and described himself as
having a “higher exposure rate” than other people. Another man talked about
having sex without condoms:
“It’s not something I
do all the time, but it happens, it has happened, you know. It’s happened in
various points of my life, when I’ve been down or something like that. That
said, you know for me risky sex is... you know, you hook up and people want to
have sex without condoms, it’s just what happens today. This is a reality. And
sometimes that person is me, and sometimes it’s the other person.”
When describing PrEP, interviewees made analogies with
safety devices such as seat belts or parachutes. They said PrEP provided an
extra layer of protection, especially in the event of condoms not being used or
not working properly.
“We all have our slips
sometimes where we’re, like, engaged in sex and stuff like that and either
we’re intoxicated or we just feel a certain way about a person, you know, we
really don’t take, you know, the safest route all the time. But I make sure I
take my pill, like, everyday or especially the times where I go out and have
sex, whether I'm protected or not. So, because all the time... I’m not protected
all the time.. I guess that makes me feel comfortable in a way...so that
helps.”
“In the end where you
wake up, F*** what did I do? It’s not as bad, it’s not; you don’t have this
guilt-ridden thing. You’re not sweating for two weeks before you get a test at Magnet. You can breathe a little
easier knowing all right; it’s not quite as bad.”
PrEP made some situations easier:
“After he disclosed
his status to me that was almost like the big hurdle for me. I was trying to
figure out like how exactly can I get around it?... How exactly could I get
around to having sex with him and being confident and okay and comfortable? And
then I realised an opportunity like this, you know, how PrEP is like, 'Ah, here
is the opportunity to do so'.”
Some men found that PrEP had 'fringe benefits' that they
weren’t expecting. For example, one said that the routine of daily pill taking
had given him stability in other aspects of his life too.
Turning to those men who stopped taking PrEP or who never
took it, this was most frequently because the individual’s relationships and
sexual behaviour had evolved.
“Well, so my
circumstances have changed a little since when I first entered the study, the
first half of it. I’ve been living with the same guy for two and a half years
now and we’re both negative. And there’s no sex outside of the house... and it
just doesn’t seem worthwhile to take the active drug.”
However, some men were also concerned about PrEP having side-effects:
“If it’s bad for my liver, I don’t wanna take
that stuff. I think that’s the answer. If it’s, if there’s any side effects,
especially, I mean, I’m healthy right now...I feel really good and I am healthy
and so I don’t, I don’t want to take something that’s gonna give me side
effects.”
The researchers noted that this most frequently reflected a
fear of side-effects than actual experience of them. They recommend greater
dissemination of accurate information about the safety of PrEP. Moreover, during audience discussion, Jim Pickett of the AIDS
Foundation of Chicago urged health agencies to reflect the interview themes in
the information they provide about PrEP. He said it should be described in
positive terms – as a thoughtful, smart and healthy choice. Messages about ‘peace
of mind’ are more likely to be appealing than a focus on risky behaviours and
partners, he suggested.