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