High Interest in PrEP Among MSM at Risk for HIV Infection
Despite early reports of slow PrEP uptake in the United States, we show high levels of interest in PrEP among MSM offered PrEP as part of a comprehensive prevention program in STD clinics and a community health center. Almost half of eligible clinic-referred clients, most of whom had never heard of PrEP, and 87% of self-referrals enrolled in The Demo Project. PrEP uptake was high across sites, age groups, race/ethnicities, and levels of education. These findings are consistent with a number of previous surveys of MSM conducted before and after the release of iPrEx results indicating high levels of willingness to use PrEP if efficacious and provided at low or no cost. This suggests that previous "slow uptake" may have been because of a lack of PrEP knowledge and availability, and efforts to facilitate both can lead to high uptake of PrEP among at-risk MSM.
Rates of self-referral to the study were high in SF and DC and increased throughout the enrollment period at all 3 sites. A substantial proportion (15%) of participants reported having a sexual partner on PrEP, with almost half of these enrolled in The Demo Project, suggesting the potential influence of peer referrals in driving PrEP uptake. However, black and Latino MSM, younger individuals, and those with a lower educational level were less likely to self-refer, and very few TGW were assessed for participation. These findings highlight the importance of reaching out to these populations, to increase PrEP awareness and interest, and to ensure that PrEP is available at sites where young MSM of color and TGW seek sexual health services. In adjusted analyses, blacks and Latinos were no less likely to enroll than whites, suggesting PrEP uptake can be high in these individuals when provided information and access to PrEP. Reasons for lower PrEP uptake among those of other race/ethnicity are unclear; this was a heterogenous group and included multirace individuals.
A substantial number of participants who declined PrEP reported not having enough time for participation. Whether the time required to access PrEP outside of a study would also be a deterrent is unclear, and strategies for optimizing the efficiency and convenience of delivering PrEP are needed. Concern about side effects was also a common reason for declining, a finding reported in previous acceptability surveys. These results underscore the importance of accurate community education regarding the safety profile and tolerability of FTC/TDF PrEP when taken by HIV-uninfected individuals. Although participants who declined PrEP had lower reported risk behaviors and lower perceived risk of HIV acquisition than those who enrolled, their risk behaviors and self-reported STD history still reflected substantial HIV risk. Risk assessment tools could be used to assist individuals in making more accurate assessments of their HIV risk and selecting from a range of HIV prevention tools, including PrEP.
Modeling studies suggest that the uptake of PrEP among those at highest risk of HIV will maximize the cost-effectiveness and public health impact of PrEP. The cohort of participants who enrolled in The Demo Project reported high rates of recreational drug use, condomless receptive anal sex, and had a high prevalence of early syphilis or rectal infections; all factors strongly associated with HIV acquisition. Furthermore, 20 individuals were diagnosed with HIV infection during the screening process, including 3 with acute HIV. These findings show that MSM at high risk for HIV acquisition are interested in PrEP and highlight the role that PrEP programs play in identifying those with undiagnosed and early HIV infection and those at risk for HIV acquisition who may benefit from PrEP. Although interest in PrEP was high among our cohort, additional strategies to increase PrEP uptake and coverage may be required to maximize population-level impact.
There are several limitations to our study. First, the process by which clients were referred from clinic staff to study staff varied by site and may have led to an overestimate of uptake for clinic referrals in SF and Miami, where some clients declined before assessment by the PrEP team. Second, sociodemographics, risk behavior data, and reasons for declining were not available for all participants who declined, and differential patterns in missing data may have biased the results. Third, questionnaires on sexual and drug risk behaviors were interviewer administered and may be subjected to social desirability bias. Finally, these results may not be generalizable to clients offered PrEP in other clinical settings, without the commitment required of a clinical study, or when there are some cost or other barriers to accessing PrEP clinical services and medication.
Overall, our findings illustrate substantial interest in PrEP among a diverse population of MSM at elevated risk for HIV infection when offered in STD clinics and a community health center and highlight the role that these clinics play in expanding PrEP access nationwide. Additional strategies are needed to increase community awareness about PrEP and engage TGW and young MSM of color in PrEP programs. Additional PrEP demonstration projects are underway to evaluate the feasibility, acceptability, and safety of PrEP delivery in a variety of populations. As adherence to PrEP is critical to its effectiveness, this and other PrEP demonstration projects will evaluate this important PrEP implementation outcome in longitudinal follow-up. Appropriate PrEP uptake among those at highest risk, coupled with high adherence, will help maximize PrEP's public health impact.
Discussion
Despite early reports of slow PrEP uptake in the United States, we show high levels of interest in PrEP among MSM offered PrEP as part of a comprehensive prevention program in STD clinics and a community health center. Almost half of eligible clinic-referred clients, most of whom had never heard of PrEP, and 87% of self-referrals enrolled in The Demo Project. PrEP uptake was high across sites, age groups, race/ethnicities, and levels of education. These findings are consistent with a number of previous surveys of MSM conducted before and after the release of iPrEx results indicating high levels of willingness to use PrEP if efficacious and provided at low or no cost. This suggests that previous "slow uptake" may have been because of a lack of PrEP knowledge and availability, and efforts to facilitate both can lead to high uptake of PrEP among at-risk MSM.
Rates of self-referral to the study were high in SF and DC and increased throughout the enrollment period at all 3 sites. A substantial proportion (15%) of participants reported having a sexual partner on PrEP, with almost half of these enrolled in The Demo Project, suggesting the potential influence of peer referrals in driving PrEP uptake. However, black and Latino MSM, younger individuals, and those with a lower educational level were less likely to self-refer, and very few TGW were assessed for participation. These findings highlight the importance of reaching out to these populations, to increase PrEP awareness and interest, and to ensure that PrEP is available at sites where young MSM of color and TGW seek sexual health services. In adjusted analyses, blacks and Latinos were no less likely to enroll than whites, suggesting PrEP uptake can be high in these individuals when provided information and access to PrEP. Reasons for lower PrEP uptake among those of other race/ethnicity are unclear; this was a heterogenous group and included multirace individuals.
A substantial number of participants who declined PrEP reported not having enough time for participation. Whether the time required to access PrEP outside of a study would also be a deterrent is unclear, and strategies for optimizing the efficiency and convenience of delivering PrEP are needed. Concern about side effects was also a common reason for declining, a finding reported in previous acceptability surveys. These results underscore the importance of accurate community education regarding the safety profile and tolerability of FTC/TDF PrEP when taken by HIV-uninfected individuals. Although participants who declined PrEP had lower reported risk behaviors and lower perceived risk of HIV acquisition than those who enrolled, their risk behaviors and self-reported STD history still reflected substantial HIV risk. Risk assessment tools could be used to assist individuals in making more accurate assessments of their HIV risk and selecting from a range of HIV prevention tools, including PrEP.
Modeling studies suggest that the uptake of PrEP among those at highest risk of HIV will maximize the cost-effectiveness and public health impact of PrEP. The cohort of participants who enrolled in The Demo Project reported high rates of recreational drug use, condomless receptive anal sex, and had a high prevalence of early syphilis or rectal infections; all factors strongly associated with HIV acquisition. Furthermore, 20 individuals were diagnosed with HIV infection during the screening process, including 3 with acute HIV. These findings show that MSM at high risk for HIV acquisition are interested in PrEP and highlight the role that PrEP programs play in identifying those with undiagnosed and early HIV infection and those at risk for HIV acquisition who may benefit from PrEP. Although interest in PrEP was high among our cohort, additional strategies to increase PrEP uptake and coverage may be required to maximize population-level impact.
There are several limitations to our study. First, the process by which clients were referred from clinic staff to study staff varied by site and may have led to an overestimate of uptake for clinic referrals in SF and Miami, where some clients declined before assessment by the PrEP team. Second, sociodemographics, risk behavior data, and reasons for declining were not available for all participants who declined, and differential patterns in missing data may have biased the results. Third, questionnaires on sexual and drug risk behaviors were interviewer administered and may be subjected to social desirability bias. Finally, these results may not be generalizable to clients offered PrEP in other clinical settings, without the commitment required of a clinical study, or when there are some cost or other barriers to accessing PrEP clinical services and medication.
Overall, our findings illustrate substantial interest in PrEP among a diverse population of MSM at elevated risk for HIV infection when offered in STD clinics and a community health center and highlight the role that these clinics play in expanding PrEP access nationwide. Additional strategies are needed to increase community awareness about PrEP and engage TGW and young MSM of color in PrEP programs. Additional PrEP demonstration projects are underway to evaluate the feasibility, acceptability, and safety of PrEP delivery in a variety of populations. As adherence to PrEP is critical to its effectiveness, this and other PrEP demonstration projects will evaluate this important PrEP implementation outcome in longitudinal follow-up. Appropriate PrEP uptake among those at highest risk, coupled with high adherence, will help maximize PrEP's public health impact.
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