Investigating attitudes towards HIV Pre-exposure Prophylaxis A questionnaire study in men who have sex with men attending sexual health clinics Lauren Bull, Pavle Dimitrijevic, Alex Scarborough, Sophie Beverley, Tristan Barber, Iain Reeves, Sheena McCormack, Michael Rayment Thank you , im delighted to present the results of this questionnaire study regarding prep

Background PROUD study demonstrated that use of PrEP affords a relative reduction of 86% in the incidence of HIV Anecdotal evidence of service users acquiring PrEP NHS England decision(s) Investigate attitudes towards, and experience of PrEP There is now a fairly substantial evidence base regarding the efficacy of prep and last year the proud and ipergay studies provided evidence of real world effectiveness with an 86% reduction in hiv incidence. Last year we presented data from an anonymous survey of service users acquiring hiv medication to use as prep. With the recent decision from nhs England regarding prep, its widespread provision remains elusive currently. We undertook this study to provide further insite into service users attitudes towards prep and whether there were any demographic or behavioural data that would predict particular opinions.

Method Prospective questionnaire study of self selecting HIV negative men who have sex with men attending multiple genitourinary clinics in urban settings. November 2015 to April 2016 This was an ethically approved prospective questionnaire study of self selecting hiv neg msm in a no sites in London. This survey was available at different times between nov-april,

Results 664 questionnaires 20 discarded N=644 Average age: 38 (18-78) Sexuality Percentage of respondents (N) Gay/homosexual 90.5% (583) Bisexual 7.3% (47) Straight/heterosexual 1.2% (8) Other 0.9% (6) In this analysis 664 questionnaires were available. Once inappropriate forms were discarded N=644 average age was 38, the majority identified as homosexual.

Educational Attainment Education level Percentage of respondents (N) University degree or above 79.0% (493) Higher school/ A levels 11.5% (72) High school/GCSE/O levels 4.2% (26) Still in education 2.7% (17) No qualifications 2.1% (13) Other 0.5% (3) The educational breakdown is as follows, with 79% holding a degree

Country of Birth/Ethnicity 72 different countries 50% UK born, 25% European 78% white 72 different nationalities were represented, half were uk born and an additional 25% hailed from European countries. 78% white: so to emphasise the majority of these respondents are highly educated, white, uk or european born males.

NUMBER OF PARTNERS IN LAST MONTH Mean (Range) Sexual Activity 88% (567/624) anal sex in the last month 59% (366/620) had at least one UPAI in the last month NUMBER OF PARTNERS IN LAST MONTH Mean (Range) YOUR POSITION Total number Number without a condom Top / active  4.2 (0-80)  1.6 (0-30) Bottom / passive  3.8 (0-90)  1.3 (0-20) The overwhelming majority reported anal sex in the last month

HIV STATUS OF YOUR PARTNER HIV STATUS OF YOUR PARTNER Perceived Risk YOUR POSITION HIV STATUS OF YOUR PARTNER HIV+ and not on meds HIV+ and on meds HIV NEG HIV status not discussed Top / active   Bottom / passive YOUR POSITION HIV STATUS OF YOUR PARTNER HIV+ and not on meds HIV+ and on meds HIV NEG HIV status not discussed Top / active 7.1 3.3  1.2  6.2 Bottom / passive 8.9 4.3  1.4  7.4 We wanted to gauge the risk people associated with anal sex in different circumstances therefore we asked them to fill in this table stating on a scale of 1-10 the risk they associated with each sex act (1 being low) Trend passive higher risk, most understand preventative effects bein gon meds but risk still relatively high, decreased risk when on meds-unknown high risk

Drugs 53% (342/642) taken recreational drugs in last three months Percentage of respondents taken Amphetamine 11% (37/342) Poppers 42% (143/342) Ecstasy 27% (94/342) Ketamine 14% (48/342) G/GHB/GBL 43% (147/342) Crystal meth 15% (56/342) Mephedrone 59% (202/342) Crack 1% (5/342) Cannabis 27% (91/342) Viagra/Cialis 37% (125/342) Cocaine 40% (138/342) 28% (177/642) used drugs for sex (chemsex) 6% (21/342) injected Median last sober sex: 1-2 weeks (range <1/52->3/12) Over half reported recent drug use in the last 3/12. proportion for g crystal mephedrone pretty high-percentage actually reporting chem sex lower still significant at 28% 6% reported ijecting drug use (all chemsex drugs) No sharing equipment. The last sober sex ranged from a few dyas to several months.

STIs 40.5% (241/595) had STI in last 6 months Sexually Transmitted infection Proportion of respondents with STI Chlamydia/Gonorrhoea throat/penis 27% (165/595) Chlamydia/Gonorrhoea rectum 15% (91/595) LGV 1% (6/595) Syphilis 6% (38/595) Hepatitis C 0.5% (3/595) 40% reported an sti in the last 6/12 with c/g the most common infection. 6% also acquired syphilis

Last HIV Test Time since last HIV test Percentage of respondents <3/12 Months 63% (356/563) 3-6 Months 37% (207/563) 6-12 Months 12% (70/563) 1-2 Years 5% (28/563) >2 Years 0.4% (2/563) Vast marjoity of respondents had undergone iv testing within the preceeding 3/12 of their visit to clinic that day.

PEP Use 36% (212/596) have used PEP before 22% (134/596) in the last year with median frequency 1 (1-12) Perceived effectiveness of PEP: 85% (153/181) rated PEP as very or completely effective 36% had previous use of pep with nearly a quarter in the preceeding year. We then asked them to state how effective they thought pep was ….

PrEP 79.8% (509/638) had heard of PrEP So in summary thus far we have a highly educated predominantly white group of men of whom the majority report upai , nearly half report sti, significant mount drug use and nearly a quarter used pep in last year. Therefore represents a reasonably high risk group. 80% have heard of prep

How effective do you think PrEP is likely to be when taken as instructed? (N=550) Not very effective Completely effective Asked some questions on a likert scale of 1-120 representing their agreement with a number of statements. The majority of respondents view prep as being highly effective-probably aware of research results.

I think I would benefit from taking PrEP (N=539) 19% no UPSI Completely Disagree Completely Agree Then asked whether respondents thought they would benefit from taking prep. 215 (40%) rated this as 10/10, and (63%) 338 8-10/10(38/215 64/338 ) we noticed that 18% of these however reported no upai. Vast majority reposndents agreed that they would benefit from prep however initial analysis 19% of those with high perceived benefit from prep of these had no upai. To investigate this further wanted to see If there were any independent factors that influenced the likelihood of agreeing with this statement. we used the mean reposnse to create a dichotomous category of agreeing or disagreeing with this statement and then undertook univariate and multivaritate logistic regression analysis to see if any variables independently predicted liklihhod of thinking prep would be beneficial

Multivariable logistic regression model   Odds Ratio (95% CI) p-value UPRAI 1.45 (1.00 to 2.11) 0.048 Perceived risk of UPRAI 1.41 (1.05 to 1.89) 0.022 Perceived effectiveness of PrEP 1.65 (1.17 to 2.32) 0.002 Multivariate analysis shows when adjusting for potential confounders, the people who demosntrate high risk behaviour, understand the risk of behaviour and have the most belief in prep effectiveness most likely to think they would benefit from prep

I think PrEP should be available to anyone who wants it 63% (353/557)   Agree Not sure I think PrEP should be available for free in sexual health centres to men who have sex with men  85% (481/565) 9% (52/565)  I think PrEP should be available for free at all NHS locations to men who have sex with men  75% (420/564)  16% (89/564) I think PrEP should be available to anyone who wants it  63% (353/557)  18% (100/557) I think there should be a prescription charge for PrEP in most cases  32% (180/555)  26% (142/555) Number of questions regarding access and provision of prep respondents were asked to agree/disagree or state not sure

Preference for PrEP (N=479) Respodnents were asked on their preference of prep regimen 55 %wanted daily ,versus 42% before/after sex few stated other other however only one person wrote weekly Daily 263 Before/after sex 200 Not applicable 54 Other 16 (1x weekly)

Use of PrEP 7.0% (38/543) taken PrEP before Duration of PrEP Number of respondents (%) Up to 1 Month 17 (50%) 1-6 Months 10 (29%) 6-12 Months 1 (3%) >12 Months 6 (18%) PrEP Regimen Number of respondents (%) Daily 32 (84%) Before/After sex 5 (13%) Other 1 (3%) Then looked at who was already taking prep. Since this study now a number of dedicated clinic services to prep users so likely to get much more significant data from these. 4 cant remember how long

Number sexual partners 3 (8%) 10 (28%) 23 (64%) Condom use 6 (17%) Increased (%) Decreased (%) Same (%) Number sexual partners 3 (8%) 10 (28%) 23 (64%) Condom use 6 (17%) 11 (31%) 19 (53%) Sexual Position Number of respondents (%) Top More 4 (11%) Bottom More 5 (13%) Stayed Same 28 (76%) Source of PrEP Number of respondents (%) PEP 19 (54%) Research 5 (14%) Private in UK 4 (11%) Friend/Partner Online 3 (9%) Numbers of sexual partners and condom use is not reported to have changed vastly. This has not been subject to statistical analysis given small numbers involved. Of people taking > yr 4/6 research 1 pep 1 friend

Discussion Group of high risk MSM demonstrating good awareness of PrEP High levels of expected personal benefit particularly amongst those reporting UPRAI Limitations: Self selecting, no response rate, incompletion, highly educated homogenous group Limitations: Don’t have response rate, some questions missed, self selecting, highly educated homogenous group. 300 people to add Unvlaidted qu

Acknowledgements C&W: Michael Rayment, Tristan Barber, Eleanor Hamlyn, Kathryn Stacey Homerton: Iain Reeves, Sifiso Mguni, Rebecca Clark PROUD Network: Sheena McCormack, Mitzy Gafos, Monica Desai, Ann Sullivan, David Dolling, David Dunn PHE: Adamma Aghaizu This study was completed budgetless! Therefore I would like to take this opportunity to extend my sincere thanks to the following people for erring questionnaire completeion and also to member of the proud network for their assistance in questionnaire design.