ObjectiveCurrently, HIV pre-exposure prophylaxis (PrEP) is not covered by health insurance in the Netherlands. We examined time trends in use of PrEP, characteristics of PrEP users, PrEP eligibility and intention to use PrEP among HIV-negative men who have sex with men (MSM) participating in the Amsterdam Cohort Studies (ACS).DesignProspective cohort study.MethodsWe used data from four 6-monthly questionnaire waves, collected between 2015–2017. PrEP use over time was examined in logistic regression models using generalized estimating equations. Using descriptive statistics, we compared PrEP users before first-time initiation to non-PrEP-users. We used national guidelines to assess PrEP eligibility.ResultsWe included 687 MSM. Median age was 40 (IQR 33–47) years in 2015. Recent PrEP use was reported by 57/687 (8%) MSM. PrEP use increased over calendar time (P<0.001) to 7% in 2017. PrEP users did not differ from non-PrEP users in socio-demographic characteristics, but reported a significantly higher median number of casual sex partners, more often reported condomless anal sex and chemsex with casual partners, and more often had an sexually transmitted infection in the preceding 6 months (all P<0.05). PrEP eligibility increased over time, but the effect was not statistically significant (P = 0.075). PrEP eligibility criteria were met by 149/460 (32%) at wave 4, of whom 31/149 (21%) reported use of PrEP. The proportion with a high intention to use PrEP was greater among eligible than non-eligible MSM (51% vs. 24%, P<0.001).ConclusionPrEP use increased over time but remained under 10%, even though 32% met the eligibility criteria, of whom 51% had a high intention to use PrEP. This suggests that a large proportion of Dutch MSM at risk could benefit from PrEP.
Since the introduction of effective anti-retroviral therapy, early diagnosis and treatment of HIV have become increasingly important from individual and public health perspectives. People who are diagnosed with a CD4 count below 350 cells/µL blood are today considered to be "late" diagnoses. In an effort to understand the reasons for late diagnosis, we conducted in-depth interviews (n = 14) in Amsterdam, the Netherlands. Two main factors were identified: psychosocial factors and health-system factors. Psychosocial factors relate to people's personal relationship with health professionals, low risk perception, fear related to the outcome of testing, and trauma from observed past experiences of living with HIV. Health-system factors relate to institutional barriers and missed opportunities during client-provider interactions. We conclude that in order to mitigate late diagnosis, the social and institutional context within which HIV testing is conducted should be addressed. ResumenDesde la introducción de la terapia antirretroviral eficaz, el diagnóstico temprano y el tratamiento del VIH ha aumentado en importancia desde las perspectivas individuales y de salud pública. Personas que son diagnosticadas con VIH y que tienen un conteo de CD4 menor de 350 células/µL de sangre, se consideran de diagnóstico "tardío". En un esfuerzo por comprender las razones de este diagnóstico tardío del VIH, realizamos entrevistas en profundidad (n = 14) en Amsterdam, Países Bajos. Se identificaron dos factores principales: factores psicosociales y factores relacionados con el sistema de salud. Los factores psicosociales incluyen la relación entre el paciente y los profesionales de la salud, la baja percepción del riesgo, el miedo relacionado con el resultado de la prueba de VIH y el trauma luego de observar experiencias pasadas de personas que padecen VIH. Los factores relacionados con el sistema de salud incluyen las barreras institucionales y las oportunidades perdidas durante las interacciones entre el cliente y el proveedor de salud. Concluimos que, para mitigar el diagnóstico tardío, se deben abordar los contextos sociales e institucionales dentro de los cuales se realiza la prueba de VIH.This study is part of the HIV Transmission Elimination Amsterdam Initiative (H-TEAM) which aims to design and implement innovative interventions with the ultimate goal of a future with no new HIV infections.
Results 28 interviews were conducted (15 MSMO, 13 MSMW). Half of MSMW reported predominantly male partners and half predominantly female. MSMO viewed STIs as "an annoying reality of life" and both groups had positive perceptions of STI testing; however, MSMW described more STI stigma and less frequent testing. MSMO and MSMW who were more involved with the queer community had better sexual health knowledge. Many MSMW noted it was easier to have sexual health discussions with male partners; however, many also described the pressure of condom use, "with men, [was] to not use a condom a fair bit of time and probably by women, [was] to use a condom." There was significant fear in both groups about disclosing sexual practices to general practitioners and some MSMW preferred the anonymity of specialist sexual health clinics. Biphobia and bisexual erasure were frequently discussed by both groups. Conclusion MSMW described less comprehensive sexual health knowledge and more barriers to accessing sexual health care. Service provision and health promotion messaging must be broadened to capture the reality of increasing sexual fluidity. Destigmatising MSM behaviour and sexual health discussions, particularly in primary care, is crucial to ensuring all people receive appropriate sexual health care. Disclosure No significant relationships.
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