Use of an HIV‐risk screening tool to identify optimal candidates for PrEP scale‐up among men who have sex with men in Toronto, Canada: disconnect between objective and subjective HIV risk

Abstract

IntroductionIdentifying appropriate pre-exposure prophylaxis (PrEP) candidates is a challenge in planning for the safe and effective roll-out of this strategy. We explored the use of a validated HIV risk screening tool, HIV Incidence Risk Index for Men who have Sex with Men (HIRI-MSM), to identify “optimal” candidates among MSM testing at a busy sexual health clinic's community testing sites in Toronto, Canada.MethodsBetween November 2014 and April 2015, we surveyed MSM undergoing anonymous HIV testing at community testing sites in Toronto, Canada, to quantify “optimal” candidates for scaling up PrEP roll-out, defined as being at high objective HIV risk (scoring ≥10 on the HIRI-MSM), perceiving oneself at moderate-to-high HIV risk and being willing to use PrEP. Cascades were constructed to identify barriers to broader PrEP uptake. The association between HIRI-MSM score and both willingness to use PrEP and perceived HIV risk were explored in separate multivariable logistic regression analyses.ResultsOf 420 respondents, 64.4% were objectively at high risk, 52.5% were willing to use PrEP and 27.2% perceived themselves at moderate-to-high HIV risk. Only 16.4% were “optimal” candidates. Higher HIRI-MSM scores were positively associated with both willingness to use PrEP (aOR=1.7 per 10 score increase, 95%CI=1.3–2.2) and moderate-to-high perceived HIV risk (aOR=1.7 per 10 score increase, 95%CI=1.2–2.3). The proportion of men who were “optimal” candidates increased to 42.9% when the objective HIV risk cut-off was changed to top quartile of HIRI-MSM scores (≥26). In our full cascade, a very low proportion (5.3%) of MSM surveyed could potentially benefit from PrEP under current conditions. The greatest barrier in the cascade was low perception of HIV risk among high-risk men, but considerable numbers were also lost in downstream cascade steps. Of men at high objective HIV risk, 68.3% did not perceive themselves to be at moderate-to-high HIV risk, 23.6% were unaware of PrEP, 40.1% were not willing to use PrEP, 47.6% lacked a family physician with whom they felt comfortable discussing sexual health, and 31.6% had no means to cover the cost of PrEP.ConclusionsA higher HIRI-MSM cut-off may be helpful for identifying candidates for PrEP scale-up. Improving engagement in the PrEP cascade will require interventions to simultaneously address multiple barriers.

Clinical exigencies, psychosocial realities: negotiating HIV pre‐exposure prophylaxis beyond the cascade among gay, bisexual and other men who have sex with men in Canada

“…PrEP users and non‐users largely expressed similar sexual practices, but for the most part only PrEP users perceived themselves as engaging in high‐risk sexual practices that warranted PrEP use. Low perception of HIV risk among those considered objectively at high risk has been described as a principal barrier to PrEP uptake . However, we identified other motivations for PrEP use, including the opportunity to safely decrease condom use in order to enhance sexual pleasure and that of reducing the widespread psychological burden of HIV‐related anxiety.…”

Motives for choosing, switching and stopping daily or event‐driven pre‐exposure prophylaxis – a qualitative analysis

“…Healthcare providers should evaluate whether such choices correspond to actual reduced risk and advice men accordingly. The observed discordance between objective and subjective HIV risk among potential PrEP users and documented cases who acquired HIV after stopping PrEP show that provider training must incorporate early and extensive counselling on alternative risk‐reduction strategies when stopping PrEP.…”

Pre-exposure prophylaxis (PrEP) for men who have sex with men in Europe: review of evidence for a much needed prevention tool

“…Raising HIV risk awareness therefore is an important step in increasing PrEP uptake 24 25. Other potential barriers for PrEP uptake include concerns about the short-term and long-term effects, the high costs of PrEP, or potential stigmata surrounding PrEP use (eg, being linked to HIV, or to promiscuity) 8 21 23 26–29.…”