PrEP: A Leap Forward but not Far Enough

PrEP, PrEP, PrEP…we have had our good share of information on Pre-Exposure Prophylaxis (PrEP) not only at this conference, but also after the recent approval of Truvada as treatment-based prevention. But, even with all of this information, the question remains: “is everybody ready for this?” That was part of the discussion during the Antiretroviral Prophylaxis: Attitudes and Implementation session at the conference.

The first presentation by Martin Holt, “HIV-negative and HIV-positive gay men’s attitudes towards antiretroviral-based prevention: similar attitudes to pre-exposure prophylaxis (PrEP) but greater skepticism among HIV-negative men about “treatment as prevention,” presented the results of a survey conducted in Australia among gay men. This is a population that is primarily affected by HIV, and the survey aimed to measure the attitudes toward PrEP, medicine and HIV treatment. There were 1,041 men participating in the survey, with 88.3% (919) being HIV negative, and 11.7% (122) being HIV positive.

The survey result showed that both HIV negative and HIV positive have similar attitudes towards PrEP: both groups are cautiously optimistic about it but agree that it should be made available free of charge. However, both groups also think that it would make people less responsible. There were divergent attitudes towards antiretroviral treatment with HIV positive men seeing it as beneficial to their health and HIV negative men seeing is as difficult to take. Likewise, HIV negative men are more skeptical about HIV treatment being effective in preventing transmission.

In summary, survey results indicate that, in the population surveyed in Australia, there are mixed attitudes towards PrEP, with HIV positive men being more optimistic about it, while HIV negative men are more doubtful about its effectiveness, which indicates a need for more debate and education in this area.

This presentation was a good entryway to the next topic, “Anticipated risk compensation with pre-exposure prophylaxis among North American men who have sex with men using an Internet social network,” by Douglas Krakower. Mr Krakower presented the results of a survey conducted with North American men who were part of an Internet social network for men who have sex with men (MSM). The study sought out to assess whether condom use would decrease with PrEP, after the iPrEx study results were released, demonstrating that PrEP can reduce the incidence of HIV among MSM.

There were 5,035 men participating in the study; most of the participants were White and self-reported as homosexual/gay. Among the findings of the survey are:

·   Many respondents reported high-risk behaviors but the average self-perception of risk was low to moderate.

·   Awareness of PrEP was modest and prior use was rare; half of the participants indicated interest in using daily oral PrEP.


·   20% of the participants anticipated decrease in condom use for insertive anal sex while on PrEP, while 14% indicated the same for receptive anal sex.


·   Unprotected anal sex with prior drug/alcohol abuse was associated with anticipated decrease in condom use for insertive anal sex.

The survey results indicate that while there is an interest in PrEP, there is also a need to implement interventions to minimize risk compensation.

It is not over yet. PrEP is definitively a great advance in the fight against HIV, but measures must be taken so that it is not seen as a “magic pill,” but as another weapon to win the battle. We have to make sure that we do not regress, that there is not a new wave of infections. To do so would be like starting over.