RISHA IRVIN, MD/MPH SAN FRANCISCO DEPT. OF PUBLIC HEALTH PREVENTION UMBRELLA FOR MSM IN THE AMERICAS (PUMA) Risk Compensation and Pre-Exposure Prophylaxis (PrEP): A Post-iPrEx Survey of US Men who have Sex with Men (MSM)

Background iPrEx trial demonstrated 44% reduction in HIV acquisition with FTC/TDF PrEP in MSM Risk practices decreased in both FTC/TDF and placebo arm; participants provided a comprehensive package of prevention services Similar decreases in risk behaviors seen among MSM in the US CDC safety study (Liu- Poster #MOPE381) However, with known PrEP efficacy, sexual practices may change among individuals using PrEP Previous surveys suggest potential for risk compensation 1 which could undermine benefits 2 iPrEx Open Label Extension and planned demonstration projects will evaluate sexual practices among MSM taking open-label PrEP We conducted an internet survey of MSM to evaluate potential for changes in sexual behaviors with PrEP and identify factors associated with PrEP uptake 1 Golub JAIDS 2010; 2 Abbas Plos One 2007

Online survey -- methods Participants recruited from social networking sites (Facebook, Black Gay Chat) – Facebook: men interested in men, and US state – Black Gay Chat: All users Banner ads used to recruit men to a screener and informed consent process Analysis restricted to those who reported sex with men, were not HIV-infected, and completed questions about risk perception

Online survey – Methods, cont. Data collected from November 30 – Dec 19, 2010 Administered through a secure, online survey provider (SurveyGizmo) Of 2,701 men initiating the survey by providing demographic information, 1,155 (43%) provided all required data for this analysis

Methods, continued Topic areas include: – Knowledge and willingness to use PrEP – Perception of HIV risk from unprotected insertive (UIAI) and receptive (URAI) anal intercourse with/out PrEP (known efficacy) – Perception of pleasure from sex with/out PrEP – Perception of likelihood to feel pressure to have sex without a condom with/out PrEP We used multivariate logistic regression to evaluate factors associated with willingness to use PrEP

Participant characteristics (n=1,155) CharacteristicProportion Age in yrs, mean33 Race White Hispanic African American Multi-racial Other 73% 12% 7% 4% 5% Education Completed college Some college, Associates degree, and/or technical school High school or less 38% 44% 18% U.S. Region West South Midwest Northeast 28% 27% 24% 20% Insurance status Insurance-Private/Public No health insurance 73% 27% Sexual practices Unprotected anal sex at last sex Last partner was HIV+ or unknown HIV status 51% 33% HIV test in the past 12 months45%

Data-PrEP knowledge and intent to use PrEP 70% 30%

If you had anal sex as a TOP/BOTTOM without a condom, to what extent do you believe that you would be at risk of getting HIV? Perceived risk of UAI Perceived Risk of UAI Decreased risk Increased risk

Data-Risk Compensation Given that the daily pill is 44% effective in preventing HIV, how would this affect your use of condoms if you were taking the pill?

If you had anal sex as a BOTTOM without a condom, to what extent would it provide you with pleasure or other benefits? To what extent do you feel pressure from other people to have UAI? If you had anal sex as a BOTTOM without a condom, to what extent would it provide you with pleasure or other benefits? To what extent do you feel pressure from other people to have UAI? Pleasure from and pressure to have unprotected anal sex Pleasure and pressure to have UAI Decrease Increase

Intent to use PrEP

Factors associated with intent to use PrEP Multivariate Model VariableAdj ORLower 95% CI Upper 95% CI P value Personal risk from URAI without PrEP Belief that PrEP decreases risk of URAI <0.001 Higher pleasure from URAI Pressure to have unsafe sex <0.001 Unsafe sex avoidable *Model adjusted for age, race, and education

Summary Almost half of participants reported that they were very/extremely likely to use PrEP While most participants believed that PrEP offered no change or decreased risk of HIV from UAI, most did not anticipate that PrEP would change their risk practices concerning condom use; a small minority did anticipate less condom use which would offset benefit About 1/3 felt PrEP may increase pressure from others to have unprotected anal sex Belief that PrEP reduces HIV risk of URAI, higher levels of pleasure with URAI, and feeling pressured to have unprotected anal sex were associated with willingness to use PrEP

Conclusions PrEP offers much promise as the first biomedical intervention to have success in at-risk MSM Providing education and accurate messaging around PrEP may help increase uptake and reduce risk compensation—these strategies can be evaluated in future demonstration projects

Acknowledgements San Francisco Department of Public Health PUMA Prepare SF Team Susan Buchbinder, Albert Liu, Liz Kroboth, Eric Vittinghoff, Russ Tarver, Patrick Sullivan, Sarit Golub, Beryl Koblin (co-authors) HIV Prevention Trials Network (Scholar)