Anticipated Risk Compensation with Pre-Exposure Prophylaxis Use among North American Men who have Sex with Men Using an Internet Social Network D Krakower, M Mimiaga, J Rosenberger, D Novak, JA Mitty, J White, K Mayer.

PrEP can decrease HIV incidence among MSM, but risk compensation could reduce its potential benefit American men who have sex with men (MSM) at high-risk of HIV acquisition 1 1 Prejean 2011

PrEP can decrease HIV incidence among MSM, but risk compensation could reduce its potential benefit American men who have sex with men (MSM) at high-risk of HIV acquisition 1 iPrEx: oral antiretroviral pre-exposure prophylaxis (PrEP) can reduce the risk of HIV acquisition among MSM 2 1 Prejean 2011; 2 Grant 2010

PrEP can decrease HIV incidence among MSM, but risk compensation could reduce its potential benefit American men who have sex with men (MSM) at high-risk of HIV acquisition 1 iPrEx: oral antiretroviral pre-exposure prophylaxis (PrEP) can reduce the risk of HIV acquisition among MSM 2 If persons using PrEP decrease condom use with anal sex (i.e., risk compensation), net benefits of PrEP may be reduced 1 Prejean 2011; 2 Grant 2010

Our objective was to assess whether MSM anticipated decreased condom use with anal sex while using PrEP Cross-sectional survey  members of on-line partner-seeking network for MSM US + Canada 1 month after iPrEx (Dec 2010-Jan 2011)

Our objective was to assess whether MSM anticipated decreased condom use with anal sex while using PrEP Cross-sectional survey  members of on-line partner-seeking network for MSM US + Canada 1 month after iPrEx (Dec 2010-Jan 2011) Outcome questions: –“If I used the PrEP pill, I would decrease my condom use for insertive (top) anal sex.” –“If I used the PrEP pill, I would decrease my condom use for receptive (bottom) anal sex.”

5035 HIV-uninfected MSM participated in the study Eligibility: –Biologic male –≥18 years of age –HIV-uninfected by self-report –Able to read English/use the Internet

We assessed factors associated with anticipated decreases in condom use while using PrEP Descriptive statistics

We assessed factors associated with anticipated decreases in condom use while using PrEP Descriptive statistics Bivariate  multivariable logistic regression analyses to assess correlates of anticipated decreases in condom use

We assessed factors associated with anticipated decreases in condom use while using PrEP Descriptive statistics Bivariate  multivariable logistic regression analyses to assess correlates of anticipated decreases in condom use –Demographics –Sexual Risk Behaviors, Self-perceived Risk of HIV Acquisition –Engagement in Healthcare –Awareness, Interest and Prior Use Regarding PrEP and Post-exposure Prophylaxis (PEP) –Psychosocial Characteristics, Substance use

Most participants were White and self-identified as homosexual/gay # Responding (Total N = 5035) AgeMean (SD)39 (12.8)5035 % Race/Ethnicity:Caucasian/White Hispanic/Latino/Chicano63252 Multiracial/Other43252 African American/Black33252 Asian/Asian Amer./Pacific Isl Sexual Orientation: Homosexual/Gay Bisexual NationalityUS Canada105035

Participants were highly-educated and moderately affluent; depression was common % # Responding (Total N = 5035) EducationAt least some college EmploymentFull-time Annual Income>$30, Health Insurance Covered Healthcare Engagement Contact with provider past 12 months Identifies PCP PsychosocialHistory of depression Ever treated for drug/alcohol abuse PCP = primary care provider.

Many respondents reported high-risk behaviors, but average self-perception of risk was low-to-moderate % # Responding (Total N = 5035) High-Risk Sexual Behaviors 1 UAI ≥ 1 partner UAI ≥ 1 partner HIV-infected or of unknown serostatus UAI after ≥ 5 drinks UAI while using recreational drugs Prior sexually transmitted infection Self-perceived risk of HIV acquisition (1 = no risk, 10 = extreme risk): Mean (SD) 3.3 (2.3) Prior 3 months. UAI = unprotected anal intercourse, male partner(s).

Awareness of PrEP was modest, and prior use was rare; half indicated interest in using daily oral PrEP % # Responding (Total N = 5035) ChemoprophylaxisHeard of PrEP Prior PrEP use Would use daily PrEP Heard of PEP Prior PEP use43693 Would use PEP883690

A substantial minority anticipated decreases in condom use while using PrEP % # Responding (Total N = 5035) Would decrease condom use during INSERTIVE anal sex while using PrEP Would decrease condom use during RECEPTIVE anal sex while using PrEP

UAI and prior drug/alcohol abuse were assoc. w/ anticipated ↓ in condom use for insertive sex Multivariable Odds Ratio 1 95% CIP Would decrease condom use during INSERTIVE anal sex while using PrEP UAI in prior 3 mo Ever treated for drug/alcohol abuse Aware of PEP UAI after ≥ 5 drinks Adjusted for Age, race/ethnicity, education, income.

UAI, ↑ self-perceived risk, and UAI after ≥ 5 drinks were assoc. with anticipated ↓ in condom use for receptive sex Multivariable Odds Ratio 1 95% CIP Would decrease condom use during RECEPTIVE anal sex while using PrEP UAI in prior 3 mo Self-perceived risk of HIV acquisition UAI after ≥ 5 drinks Positive screen for depression Adjusted for Age, race/ethnicity, education, income.

In summary, a substantial minority of at-risk MSM anticipate decreased condom use while using PrEP MSM engaged in on-line networking report high- risk behaviors

In summary, a substantial minority of at-risk MSM anticipate decreased condom use while using PrEP MSM engaged in on-line networking report high- risk behaviors Interest in PrEP use exists: half would use daily PrEP

In summary, a substantial minority of at-risk MSM anticipate decreased condom use while using PrEP MSM engaged in on-line networking report high- risk behaviors Interest in PrEP use exists: half would use daily PrEP A substantial minority of MSM anticipate risk compensation for insertive (20%) or receptive (14%) anal sex while using PrEP

In summary, a substantial minority of at-risk MSM anticipate decreased condom use while using PrEP MSM engaged in on-line networking report high- risk behaviors Interest in PrEP use exists: half would use daily PrEP A substantial minority of MSM anticipate risk compensation for insertive (20%) or receptive (14%) anal sex while using PrEP Recent unprotected anal sex behaviors, greater self-perceived risk for HIV acquisition, and substance abuse are associated with anticipated risk compensation

Clinicians who prescribe PrEP to at-risk MSM should assess for changes in risky sexual behaviors More intensive counseling may be merited for MSM with recent risky behaviors increased self-perceived risk of HIV acquisition substance abuse

Clinicians who prescribe PrEP to at-risk MSM should assess for changes in risky sexual behaviors More intensive counseling may be merited for MSM with recent risky behaviors increased self-perceived risk of HIV acquisition substance abuse Studies to assess for risk compensation among persons using PrEP are needed

Abstract Authors Krakower, Douglas (Harvard Medical School/Beth Israel Deaconess Medical Center) Mimiaga, Matthew (Harvard Medical School/Massachusetts General Hospital and The Fenway Institute) Rosenberger, Joshua (George Mason University) Novak, David (Online Buddies, Inc., Cambridge, MA) Mitty, Jennifer A. (Harvard Medical School/Beth Israel Deaconess Medical Center and The Fenway Institute) White, Jaclyn (The Fenway Institute) Mayer, Ken (Harvard Medical School/Beth Israel Deaconess Medical Center and The Fenway Institute) Funding: Harvard T32 post-doctoral HIV Clinical Research Fellowship (NIAID AI ). Project support: Gilead Sciences. Thanks to the staff of the Fenway Institute, and the study participants.

Abstract Authors Krakower, Douglas (Harvard Medical School/Beth Israel Deaconess Medical Center) Mimiaga, Matthew (Harvard Medical School/Massachusetts General Hospital and The Fenway Institute) Rosenberger, Joshua (George Mason University) Novak, David (Online Buddies, Inc., Cambridge, MA) Mitty, Jennifer A. (Harvard Medical School/Beth Israel Deaconess Medical Center and The Fenway Institute) White, Jaclyn (The Fenway Institute) Mayer, Ken (Harvard Medical School/Beth Israel Deaconess Medical Center and The Fenway Institute) Funding: Harvard T32 post-doctoral HIV Clinical Research Fellowship (NIAID AI ). Project support: Gilead Sciences. Thanks to the staff of the Fenway Institute, and the study participants. Thank you!