Factors associated with the informal use of HIV pre‐exposure prophylaxis in Germany: a cross‐sectional study

Abstract

Introduction Until September 2019, pre‐exposure prophylaxis (PrEP) with tenofovir disoproxil/emtricitabine for HIV prevention was not covered by health insurance plans in Germany, and was only available through private prescriptions with self‐pay or through informal non‐prescription sources. The objective of this study was to investigate the proportion of informal PrEP use among PrEP users and to identify factors of public health relevance that might be associated with informal PrEP use. Methods We conducted a cross‐sectional study recruiting PrEP users independent of their PrEP source. Clients from anonymous community testing checkpoints, users of three dating apps for men who have sex with men residing in Germany and users of a PrEP community website, were recruited to complete a short anonymous online survey. Participants were recruited between 24 July and 3 September 2018. The results were analysed using univariable and multivariable logistic regressions. Results We recruited 2005 participants currently using PrEP. The median age was 38 years, and 80.3% of the participants identified themselves as male (missing: 19.1%). Overall, 71.6% obtained PrEP through medical services with a private prescription or a clinical trial, and 17.4% obtained PrEP through informal sources (missing: 11.0%). The most common informal sources were ordering online from another country (8.8%), travel abroad (3.6%), and friends (2.5%). Factors associated with informal PrEP use were on demand/intermittent dosing (adjusted OR: 3.5, 95% CI 2.5 to 5.0) and not receiving medical tests during PrEP use (adjusted OR: 3.2, 95% CI 2.0 to 5.2). In addition, informal PrEP users who did not take PrEP daily had a strongly increased risk of starting PrEP without prior medical tests (adjusted stratum‐specific OR = 31.7, 95% CI 4.6 to 219.5). Conclusions Informal PrEP use was associated with a higher risk of not getting tested before and during PrEP use, which could lead to HIV infections resistant to tenofovir and emtricitabine if people with undiagnosed HIV use PrEP. Health insurance plans that cover PrEP and the accompanying routine tests could ensure adequate medical supervision of PrEP users and reduce barriers to PrEP use. Our findings strongly support the implementation of PrEP programmes in countries with similar patterns of informal PrEP use.

Where are we with pre‐exposure prophylaxis use in Central and Eastern Europe? Data from the Euroguidelines in Central and Eastern Europe (ECEE) Network Group

“…Results from the 2017 European Center for Disease Control (ECDC)/Hornet survey on PrEP in Europe and Central Asia also showed high rates (54%) of informal PrEP use [10]. These rates are in contrast with Western European countries, where the percentage of informal PrEP use is as low as 4.6% in France (Flash PrEP study) and as high as 17.4% in Germany [11]. Informal PrEP use could be explained by the absence of national programmes covering PrEP, which can cause intermittent PrEP use and be the reason of not receiving medical tests before and during PrEP use [11].…”

Barriers to using HIV pre-exposure prophylaxis (PrEP) and sexual behaviour after stopping PrEP: a cross-sectional study in Germany

“…The PrApp study is a cross-sectional study investigating PrEP use in Germany [ 23 ]. Current and former PrEP users were recruited on dating apps, a community website, in anonymous testing sites and through peers.…”

Eligibility for HIV Preexposure Prophylaxis, Intention to Use Preexposure Prophylaxis, and Informal Use of Preexposure Prophylaxis Among Men Who Have Sex With Men in Amsterdam, the Netherlands

“…The high level of PrEP eligibility, the high proportion of men with STI diagnoses, and chemsex show a clear need for sexual health care for informal PrEP users. This is further underlined by recent findings from Koppe et al, 12 showing that informal PrEP use is associated with suboptimal STI, HIV, and renal function testing before and during periods of informal PrEP use. The attention of public health organizations for the specific health care needs for this subgroup of PrEP users is urgently warranted.…”

“…Recent evidence suggests that informal PrEP use is associated with suboptimal STI and HIV testing before and during PrEP use, which may lead to resistant HIV infections and ongoing transmission. 12 …”