Acceptability and willingness to use HIV pre-exposure prophylaxis among HIV-negative men who have sex with men in Switzerland.

Pre-exposure prophylaxis (PrEP) is discussed as an additional HIV prevention method targeting men who have sex with men (MSM). So far, PrEP has not been approved in Switzerland and only little is known about the acceptability of PrEP among MSM living in Switzerland. Given the slow uptake of PrEP among MSM in the USA, the objectives of the study were to investigate the acceptability for PrEP and to identify factors influencing the acceptability for this prevention method and the willingness to adopt it. During a 4-month period we conducted five focus group discussions with 23 consecutively sampled HIV-negative MSM aged 22-60 years living in Switzerland. We analyzed the data according to qualitative content analysis. The acceptability of PrEP varied considerably among the participants. Some would use PrEP immediately after its introduction in Switzerland because it provides an alternative to condoms which they are unable or unwilling to use. Others were more ambivalent towards PrEP but still considered it (1) an additional or alternative protection to regular condom use, (2) an option to engage in sexual activities with less worries and anxieties or (3) a protection during receptive anal intercourse independently of the sexual partner's protective behaviour. Some participants would not consider using PrEP at all: they do not see any benefit in PrEP as they have adopted safer sex practices and did not mention any problems with condom use. Others are still undecided and could imagine using an improved form of PrEP. The results provide a valuable basis for a model explaining the acceptability of PrEP among MSM and suggest including the personal HIV protection strategy in the considerations adopted.

Introduction

Men having sex with men (MSM) are disproportionately affected by HIV (Beyrer et al., 2012). This is mirrored in the HIV epidemic in Switzerland where MSM continued to be the group most affected (Lociciro, Jeannin, & Dubois-Arber, 2013a, 2013b; Marcus, Schmidt, Kollan, & Homouda, 2009). Within this context, Pre-exposure prophylaxis (PrEP) is considered as an additional prevention option.

Various studies have shown the efficacy of daily oral PrEP. Today, PrEP is only available in the USA and France. However, in the USA where PrEP was approved in 2012 a survey suggests that only 2.8% of eligible MSM reported ever having used PrEP (Sullivan, Sineath, Kahle, & Sanchez, 2015). If PrEP is to play a role in HIV prevention, it will be crucial to elicit decision-making of key populations.

PrEP has not yet been approved in Switzerland and little is known about the acceptability for PrEP among MSM living in Switzerland. Therefore, the objectives of the study were to elicit the acceptability of PrEP and to identify factors influencing the acceptability of this prevention method.

Methods

Design and procedure

Given the explorative purpose of this study we took a qualitative approach. From November 2014 to February 2015, we conducted five focus group discussions (FGD) (Schulz, Mack, & Renn, 2012) with 23 consecutively sampled HIV-negative MSM living in Switzerland. We approached participants through different communication channels: online dating platforms, Facebook and flyers distributed in various locations. We created a website where participants could register for the FGDs.

The FGDs took place in German- and French-speaking cities. Two focus group facilitators led through each discussion using a semi-structured interview guide (cf. Krueger & Casey, 2015). It broached the issues of prior knowledge about PrEP, estimated acceptability of PrEP, attitudes to PrEP, willingness to use it and the reasoning underpinning the personal stance. It probed ideal characteristics of PrEP using a corresponding question implemented by Galea et al. (2011). Finally, participants were asked to complete a questionnaire on social demographics.

During the FGDs, an oral description provided information on the application, the effectiveness and potential side effects of daily oral PrEP. This description was based on guidelines of the US Centers for Disease Control and Prevention and protocols of PrEP trials. It was reviewed by two experts.

Data analysis

The FGDs were digitally recorded and transcribed verbatim. We analysed the data according to structuring qualitative content analysis using inductively and deductively developed (sub-)categories drawn from sensitizing concepts of existing findings on the acceptability of PrEP and of technology acceptance theories (Kruse, 2012; Strauss & Corbin, 1996). We coded in teams of two researchers using ATLAS.ti. The codes were regularly reviewed by the whole research team.

Results

The 23 participants were between 22 and 60 years old and self-identified as gay or bisexual. They reported being single or living in a stable relationship with a male partner; some of them were living in a serodiscordant relationship. The participants’ monthly incomes ranged from no income to 15,000 Swiss francs. Their educational levels ranged from completed vocational training to university degrees.

The acceptability of PrEP and the willingness to adopt PrEP as a personal HIV prevention strategy varied considerably. Participants could be categorized in three groups.

Some MSM showed high levels of acceptability and were willing to use PrEP immediately once approved in Switzerland (for evidentiary quote, see Q1 in Table 1).

Table 1.

Quotes from participants accounts in the FGD.

MSM with high levels of acceptability
Quote 1	… I would definitely take it, this PrEP, so I would definitely go for it. (Adam/4:61)a
Quote 2	… it would reduce my HIV risk, or the risk of an infection, drastically, or eliminate it completely, or uhm … and now I've been living with the, with the risk for years. (Michael/4:79)
Quote 3	… the reason why I would perhaps take it, maybe, or uhm take it into consideration for me, is that I'm admittedly not able to do it with a condom. (Tom/4:51)
Quote 4	… how does society claim the right to dictate – and I deliberately phrase this rather provocatively – that we have to fuck a plastic bag all our lives long? (Michael/4:35) … if you simply want REAL, natural sex , it's just extremely unerotic and, and, and, and uhm, a turnoff, this condom, because it's nothing better than just plastic, ( … ) now if I, for example, start kissing ( … ) and then I see this plastic stuff, then … it completely spoils my mood, … or then, then, uhm, I'm like … well, I don't get a good erection anymore and … it's really difficult to get another erection and, and what's more there are the feelings to, whether you're active or passive, you just feel a lot less. (Adam/4:61-65)
Quote 5	… when you're in the passive position, o-o, whether you're using lubricating cream or not, it just hurts, this stuff, this plastic stuff, it scratches a lot and and and this bullshit causes bleedings and hemorrhoids, yes. (Adam/4:65)
Quote 6	Right, and above all I think that this PrEP would be something very reliable, that truly works, well that really uhm works out or and, yes. (Adam/4:5)

aThis description in parenthesis marks the place in the transcript as follows: participant's pseudonym/group: paragraph in the transcript.

These men perceived PrEP to be highly useful as they expected it to provide them with an alternative to condom use and former risk taking (Q2/Table 1). They evaluated the expected usefulness of PrEP against the background of their actual protective behaviour and the inherent risk. These participants turned out to be unable or unwilling to use condoms due to erectile dysfunctions or negative feelings owed to it (Q3/Table 1). To them, condoms were experienced as an impairment of erotic sensation and sexual pleasure, and were to some extent viewed as a societal imposition of restricted or even denaturalized sex (Q4/Table 1). The negative attitudes also drew from experiences of physical discomfort with condoms and rather less from experiences of condom failure (Q5/Table 1). In contrast, PrEP seemed to be adequate to their needs as it allows a positive experience of corporeality while offering effective protection. These MSM trusted the effectiveness of PrEP and imagined being able to adhere to the prescription regime (Q6/Table 1). They, along with all other participants, considered the price to be high. However, men embracing PrEP hoped that its advantages were so obvious that they assumed it would be covered by health insurance.

Some MSM refused to consider the use of PrEP. They did not see any possible benefit from this prevention method (Q7/Table 1).

On a personal level, these MSM expressed concerns about insufficient effectiveness, potential side effects, long-term negative effects on their health and the high costs. Drawing from accounts by people under ART, they speculated about possible erectile dysfunction and the loss of libido due to the use of ARV. They were aware that PrEP offers no protection against other sexually transmitted infections. Some problematized the systematic exposure to chemicals in general. And there was the view that a failure of PrEP would be undetectable and leave them unaware of the risk they were exposed to, while condom failures would be visible (Q8/Table 1). On a philosophical, political and community level, these men objected the support of the pharmaceutical industry that the use of PrEP would entail. Some had concerns about the financial burden on the health system in case of public coverage of PrEP. And finally, there were participants who criticized the possible pathologizing of gay sex through the association of MSM's sexuality with medical treatment (Q9/Table 1).

Again, a connection between this evaluation of PrEP and the personal HIV protection strategy became apparent. These men had adopted safer sex practices and did not mention any problems in condom use. Therefore, they did not recognize any advantage provided by medical prophylaxis (Q10/Table 1).

MSM who were ambivalent about PrEP concluded that they saw both concerns and benefits related to the use of PrEP. Significantly, these MSM believed the benefits of PrEP to be limited or conditional. They either expected PrEP to be useful in specific situations only or they imagined that possible future forms of prescription might make PrEP useful.

So, MSM with ambivalent feelings assumed that PrEP had a potential to increase protection if applied in addition to regular condom use, for instance in case of condom failure in a situation with reduced behavioural control. Moreover, they viewed it as a means to gain increased independence from the conduct of the sexual partner, in particular when engaging in receptive anal intercourse (Q11/Table 1). At the same time they shared some of the worries stressed by those refusing to take PrEP. Weighing concerns and benefits, they concluded that PrEP could be used under certain circumstances as an alternative or additional protection to regular condom use. Therefore their willingness to use PrEP related to a specific context, for example, they could imagine using PrEP in a serodiscordant relationship or in an initial phase of a new relationship. Furthermore, some of the MSM refusing to take PrEP in the present prescription could imagine using an improved form of PrEP in terms of effectiveness or the substance applied. For example, if it was less expensive or if it was administered as depot injection, patch or a vaccine relieving them from daily medication (Q12/Table 1). For other MSM with ambivalent feelings, the price was not a major obstacle. Once decided to adopt PrEP, they would change their lifestyle in order to be able to afford the expenses for PrEP (Q13/Table 1).

Discussion

The study provides insights into the dynamics underlying MSM's decision-making processes regarding PrEP. The findings give a first idea on how they weigh the expected usefulness and costs of PrEP against the benefits and efforts of condom use including the high costs, concerns about the effectiveness, potential side effects, long-term negative effects and the lack of protection against other STIs. Furthermore, the findings offer a vision of the crucial role of PrEP's fit into their adopted protection strategy and their experiences with it: MSM who were not able or not willing to use condoms welcomed PrEP and expressed willingness to use it. However, it became obvious that for them PrEP is an opportunity to free themselves from condoms.

Our study has certain limitations. The FGDs varied in size, and few participants were from the French-speaking part of Switzerland. Moreover, it is possible that the acceptability of PrEP among MSM in Switzerland might change once PrEP becomes available in Switzerland.

Conclusion

The findings of this study go beyond the known descriptions of socio-demographic characteristics of MSM either willing or not willing to use PrEP (e.g. Bil, Stolte, van der Veldt, & Davidovich, 2014; Philbin et al., 2014). The findings suggest that the acceptability of PrEP is not only determined by usefulness or expected performance. It also seems to be influenced by the personal HIV protection strategy and is weighed in the light of the evaluation of ones experiences with it. These results provide a valuable basis for modelling acceptability of PrEP among MSM.