Many men who have sex with men (MSM) who cited low HIV risk as a reason for not wanting to start pre-exposure prophylaxis (PrEP) actually had key HIV risk factors, according to results of a cross-sectional survey analysis presented at IDWeek 2016. Compared with white MSM, black MSM were more likely to consider PrEP only if it were free.
The CDC estimates that almost a half-million MSM in the United States are candidates for PrEP. Emory University researchers who conducted the survey study noted that Atlanta ranks seventh on the list of most new HIV diagnoses in the United States, and MSM account for 76% of those diagnoses. They hypothesized that reasons for starting or declining PrEP may differ between black and white MSM because of disparities between those groups in HIV incidence, sociodemographic factors, and health care access.
To test that hypothesis, the investigators conducted a cross-sectional analysis of 482 HIV-negative MSM enrolled in the Emory-based InvolveMENt PrEP study. From February 2012 through April 2013, participants completed a survey on willingness to take PrEP and motivators and barriers to using PrEP. Most men, 82%, took the survey just before FDA approval of daily tenofovir/emtricitabine (Truvada) PrEP.
Among the 219 black men and 263 white men, blacks included a higher proportion of 18- to 25-year olds (55% versus 34%, P = .004), a higher proportion with less than a college education (65% versus 41%, P = .0004), a higher proportion without health insurance (43% versus 23%, P < .0001), a higher proportion without a primary care visit in the past year (40% versus 24%, P < .0001) and a lower proportion reporting substance use (28% versus 50%, P < .0001). A higher proportion of black than white MSM got diagnosed with a sexually transmitted infection (STI) during follow-up (38% versus 19%, P < .0001), but a lower proportion of black men had condomless anal intercourse in the past 12 months (65% versus 76%, P = .007).
Nearly identical proportions of black and white men (44.8% and 44.5%) expressed a willingness to use PrEP. Multivariate logistic regression analysis identified only one factor that independently predicted willingness to use PrEP -- having condom-free anal sex in the past 12 months (adjusted odds ratio 1.7, 95% confidence interval 1.1 to 2.6). Insurance status, HIV/STI incidence and number of anal sex partners in the past 12 months were not associated with PrEP willingness in this analysis.
White MSM were more likely than black MSM to say they would consider PrEP if a doctor recommended it (45% versus 22%, P = .002) or if a counselor or other health care worker recommended it (39% versus 21%, P = .012). Whites differed from blacks in four reasons explaining unwillingness to start PrEP: not being sexually active (8% versus 17%, P = .017), partner HIV-negative (33% versus 11%, P < .0001), not wanting to take a pill every day (42% versus 29%, P = .038) and not wanting to go to doctor every three months (25% versus 7%, P = .0003).
Among 137 men who listed "low risk behavior" as a reason for unwillingness to start PrEP, 77 (56%) actually had high risk indicated by condomless anal sex in the last 12 months, while 39 (28.5%) had a new STI during study follow-up. Overall, most men said they would consider PrEP if it cost less than $50 per month. But a higher proportion of black than white men (26% versus 18%, P = .03) said they would use PrEP only if it were free.
Because of the discordance between perceived and actual HIV risk in this study group, the Emory investigators recommended "formal population-specific risk assessment tools which combine risk behavior assessment with local epidemiologic risk ... to identify high-risk men who may benefit from PrEP."