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The use of drugs to reduce the transmission of HIV has increased substantially in recent years. New research found that two in five men who have sex with men (MSM) attending sexual health clinics in London and Brighton had taken drugs as a precaution in case they encounter the virus.

At the time of the study, the drugs - called pre-exposure prophylaxis (PrEP) - were not yet widely available in England through the NHS. The research, carried out between 2013 and 2018, found that about half the men bought the drugs online.

There was unequal knowledge and use of PrEP among the men. Younger men, those who were unemployed and those with lower disposable incomes were less likely than others to use PrEP. One in five (22%) men at high risk through having sex with multiple partners, were not using PrEP.

The NHS is now reimbursing PrEP for the prevention of HIV. The results from this study (called AURAH2) will inform public health officials as the scheme is rolled out in England. It could help them tailor public health messages and services for the men least likely to be using PrEP.

What’s the issue?

Taking the drug combination of tenofovir and emtricitabine daily can significantly reduce the chances of MSM contracting HIV. This combination is called PrEP. If the drugs are already present in a person’s cells before HIV enters the body, they can block the virus in the very early stages of infection. PrEP is recommended by the World Health Organisation for those at substantial risk of acquiring HIV through sex.

Countries including Scotland and Wales already have national programmes to make PrEP freely available to MSM. The scheme in England started in 2020.

Before this study, there was limited information about attitudes to, and use of, PrEP among at-risk men in England. Such data can help inform and guide the rollout of the national programme: for example by identifying groups of men who are less likely to use PrEP and gaining insight into potential barriers to PrEP access and use.

What’s new?

This study included 1162 MSM who attended sexual health clinics in London and Brighton from 2013 to 2016. Follow up questionnaires were sent three times a year; half the men (622 or 54%) completed at least one between 2015 and 2018. Not all men answered all questions, so the numbers available to analyse selected topics including PrEP use varied.

No men in the study group reported using PrEP in 2013. At that time, some were using post exposure prophylaxis (PEP), in which drugs are taken as an emergency after possible exposure to HIV. PrEP is highly effective is reducing the risk of acquiring HIV and a better prevention strategy; guidelines recommend that men at continuous risk should switch from PEP to PrEP. This was reflected in the study, which saw PrEP use rise and a corresponding fall in PEP.

The study found that, by 2018:

  • PrEP was being used by two in five respondents (23 of 53 or 43%)
  • among men who reported condomless sex with two or more partners and were therefore most at risk, almost four in five reported using PrEP (21 of 27 or 78%). That means one in five of this high risk group (6 in 27 or 22%) were not using PrEP
  • most bought PrEP from online sites (112 of 190 responses or 59%); fewer sourced it from clinics (65 of 190 responses or 34%) and the rest from friends or others.

The study also found that differences in the men’s circumstances affected how likely they were to start using PrEP. Among a group of 460:

  • those aged 40 – 44 years were four times more likely to start using PrEP (and those aged over 45 years three times more likely), than those under 25 years
  • men without a job or stable housing were less likely to use PrEP
  • certain behaviours within the previous three months – such as having an HIV test, condomless sex, group sex and using stimulant drugs during sex – were associated with the decision to start PrEP.

Why is this important?

The results offer the first online assessment of how MSM view, source and use PrEP. This is important and timely information as the NHS scheme in England to make the drugs freely and widely available is being rolled out.

The study highlights that certain groups – such as younger men from lower socioeconomic backgrounds – might be at increased risk of HIV but less likely to be aware of, or using, PrEP. Tailored public health messages and services might be needed to reach these men.

The study found that about one in two men were willing to buy the drug online using their own money. This suggests that there is likely to be high demand for PrEP through the national programme.

What’s next?

Further research is needed to address some questions raised by the study. One is to identify the reasons that some men do not use PrEP, especially those in high-risk groups. One possibility is perceived stigma, or the need to take the drug every day. As PrEP use becomes more widespread in England it will be important to identify such barriers to the drug’s use and to find ways to reach those not accessing it.

Another unresolved question is whether men who use PrEP will suffer more from other sexually-transmitted infections (STIs). Perceived protection against HIV when using PrEP, for example, might make some men less likely to use condoms, and so increase the risk of other STIs. This suggests that strong public health messages are needed to encourage the continued use of condoms.

You may be interested to read

The full study: Hanum N, and others. Use of HIV pre-exposure prophylaxis among men who have sex with men in England: data from the AURAH2 prospective study. Lancet Public Health. 2020;5:e501-511

The Impact trial has now closed but its website includes information on accessing PrEP

NHS policy on reimbursement for sexual health clinics prescribing PrEP


Funding: This project was funded by the NIHR Programme Grants for Applied Research Programme.

Conflicts of Interest: One author has received fees and funding from pharmaceutical companies.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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Study author

This is really important information and should send a message to policy makers to not further delay the implementation of the national programme. It’s been a good development since we published this study, that now there is reimbursement for the use of generic drugs for PrEP for the prevention of HIV.

The size of the increase in the number of men taking the drug over the study period could be because we recruited them through sexual health clinics, that we are asking those who are already better informed.

Nadia Hanum, Global Health Researcher, University College London

Member of the public

The respondents in this survey might not be representative of the broader MSM population. The majority (90-95%) of respondents identified as gay, but what about all the bisexual, bi-curious, straight men (also called HI-MSM) who are looking for sex with other men? Most MSM on dating/hook-up websites and apps identify in the continuum outside of gay, especially in the north, away from the metrosexual south. Surveying MSM from sexual health clinics in London and Brighton, rather than a wider grass-roots approach has left a big hole in identifying possibly similar, but more likely different motivators and predictors of potential uptake of PrEP in the rest of the UK. Good policy & funding streams cannot be developed without more detailed socio-demographic knowledge of some two-thirds of the MSM population.

During the study period the uptake of PrEP was vigorously promoted by the gay media and take-up has increased amongst reasonably-well educated, internet-savvy, LGBTQ community-supported, metropolitan gay men. This promotion has down-played the importance of condoms. But STIs are still a significant public health risk.

Any national roll-out of PrEP for all MSM must be based on an understanding of the diverse cultural contexts under which men seek sex with other men, and to promote condoms along with PrEP. A national programe will have to treat PrEP roll-out as if it was a vaccine, with the right narrative to counter condom vs PrEP or individual choice arguments. If policy makers and funders adopt the progressive policies recommended, then this research could significantly advance HIV/STI prevention, and enable better sexual health care for men.

Neil Campling, Public Contributor, Darlington 

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