Motives of Dutch men who have sex with men for daily and intermittent HIV pre-exposure prophylaxis usage and preferences for implementation: A qualitative study.

Although PrEP is not yet registered in Europe, including the Netherlands, its approval and implementation are expected in the near future. To inform future pre-exposure prophylaxis (PrEP) implementation, this study aimed to gain insight into motives and preferences for daily or intermittent PrEP use among Dutch HIV-negative men having sex with men (MSM).Between February and December 2013, semistructured interviews were conducted until data saturation was reached (N = 20). Interviews were analyzed using the Grounded Theory approach.Motives for (not) using daily PrEP were based on beliefs about PrEP efficacy and side effects, preferences for other prevention strategies, self-perceived HIV risk, self-perceived efficacy of PrEP adherence, beliefs about possible benefits (e.g., anxiety reduction, sex life improvement), and barriers of PrEP use (e.g., costs, monitoring procedures). The perceived benefits of intermittent versus daily PrEP use were the lower costs and side effects and the lower threshold to decision to start using intermittent PrEP. Barriers of intermittent PrEP versus daily PrEP use were the perceived need to plan their sex life and adhere to multiple prevention strategies. Although some perceived PrEP as a condom substitute, others were likely to combine PrEP and condoms for sexually transmitted infections (STI) prevention and increased HIV protection. Participants preferred PrEP service locations to have specialized knowledge of HIV, antiretroviral therapy, sexual behavior, STIs, patients' medical background, be easily approachable, be able to perform PrEP follow-up monitoring, and provide support.To maximize the public health impact of PrEP, ensuring high uptake among MSM at highest risk is important. Therefore, targeted information about PrEP efficacy and side effects need to be developed, barriers for accessing PrEP services should be minimized, and perceived self-efficacy to use PrEP should be addressed and improved. To prevent increases in STIs, condom use should be monitored and PrEP should be integrated into routine STI screening and counseling.

Introduction

HIV transmission among men who have sex with men (MSM) continues, despite widespread implementation of behavioral interventions and high coverage of antiretroviral therapy (ART).[ Recent studies have shown that pre-exposure prophylaxis (PrEP), that is, offering HIV-negative MSM a daily or intermittent regime of lower-intensity ART, can significantly reduce risk of HIV infection.[ The US Food and Drug Administration approved PrEP, and the Centers for Disease Control and Prevention (CDC) and the World Health Organization implemented daily PrEP for high-risk MSM in their HIV guidelines.[ Although PrEP is not yet registered in Europe, including the Netherlands, its approval and implementation are expected in the near future.

The cost-effectiveness of PrEP and its impact on HIV incidence will highly depend on PrEP uptake among MSM at increased risk of HIV infection, PrEP costs, epidemic context, and adherence.[ Regarding uptake, it is important to understand why MSM would choose to use or not use PrEP. Though several qualitative and quantitative studies have been conducted outside Europe regarding possible motives for PrEP use among MSM,[ only 1 (quantitative) study included European MSM. In this study, the intention to use PrEP was relatively low, but higher among high-risk MSM, those with a high perceived self-efficacy to use PrEP, and high perceptions of anticipated relief when using PrEP.[ To inform future PrEP implementation in the Netherlands, in-depth understanding of motives behind PrEP use among Dutch MSM is needed. In particular, knowledge regarding specific motives for intermittent versus daily PrEP use and preferred PrEP service characteristics. These results can guide future implementation strategies to ensure high uptake of PrEP and maximize PrEP's public health impact.

This qualitative study aims to explore more thoroughly the motives for wanting or not wanting to use PrEP if it becomes available, motives for daily versus intermittent PrEP use, the anticipated motives for condom use when using PrEP, and preferences for PrEP implementation (e.g., service characteristics).

Methods

Recruitment

Participants were recruited through the Amsterdam Cohort Studies (ACS). The ACS is an open, prospective cohort study initiated in 1984 aiming to investigate HIV epidemiology, natural history, pathogenesis, and evaluate the effect of interventions among MSM.[ Participants visit the Public Health Service Amsterdam biannually to complete self-administrated questionnaires on sexual behavior and give blood for HIV and sexually transmitted infection (STI) testing and storage.

To identify eligible participants, we used quantitative data regarding awareness, beliefs, and intention to use PrEP obtained among HIV-negative participants during one wave (June 2012–January 2013).[ For the present study, we included: MSM with a high intention-to-use PrEP (irrespective of HIV risk and type of steady partner); and MSM with a low intention-to-use PrEP who have been defined as eligible candidates for PrEP,[ that is, MSM at increased risk for HIV (having >5 casual partners and/or reporting condomless anal sex with casual partners in the preceding 6 months) and HIV-negative MSM in serodiscordant relationships. To increase the group of MSM with a high intention-to-use PrEP, we placed online advertisements on the Public Health Service of Amsterdam website and on 2 HIV information websites to find men interested in using PrEP in the future. Recruitment continued until data saturation was reached.

The ACS research nurse contacted eligible ACS participants by phone, email, or personally during their biannual ACS visit for participation in this study. Those who accepted to participate in the study were then contacted by the researcher. The researcher contacted participants recruited through websites directly.

Procedure

Semistructured interviews of approximately 60 minutes each were conducted between February and December 2013 by 1 female interviewer (JPB, PhD-student) in Dutch or English at the Public Health Service Amsterdam or at the participants’ homes. Before the interviews, participants received study information, including study purpose, a short description of daily PrEP, the iPrEX study results on effectiveness and side effects,[ CDC recommendations on PrEP follow-up check-ups,[ and the estimated Dutch costs of PrEP (tenofovir disoproxyl fumarate/emtricitabine: approx. €580 monthly). During one interview, the participant's steady partner was present.

As this study was conducted before the IPERGAY trial indicated PrEP can be effectively taken up to 2 hours before a risk episode,[ we defined intermittent PrEP as using PrEP 3 days before until 3 days after a high-risk period of sexual behavior, which was explained during the interview. Before the start of the interview, the interviewer introduced herself, the study purpose and interview procedure were explained, and oral informed consent was obtained. Information regarding level of education, income, age, most recent HIV-test result and test location, and relationship status (having a steady partner and HIV-status of steady partner) were obtained at the start of the interview and recorded on tape.

The central interview topics were: intention-to-use PrEP in the future, reasons for wanting or not wanting to use daily PrEP, and perceived benefits and barriers of using PrEP. The following topics were also addressed: motives for wanting or not wanting to use intermittent PrEP, perceived motives for using or not using condoms when using PrEP, and opinions about preferred PrEP services (location of PrEP prescription and service characteristics).

All interviews were audiotaped and transcribed verbatim (quotes are translated) and short-field notes were made during and shortly after the interviews. Person identifiers were deleted from the transcripts and only the involved interviewer had access to the audiotapes. Participants received a gift certificate of €20 for participating.

Ethical approval by an ethics committee or institutional review board was not necessary for this study according to Dutch legislation as participants were not subjected to procedures or rules of behavior, which resulted in an infringement of the physical and/or psychological integrity of the participant.[

Analyses

The data analysis team consisted of 4 researchers from different disciplines (health sciences [JPB, IGS], medical anthropology [WMvdV], epidemiology [IGS], and psychology [UD]). Data analysis was done in accordance with the Grounded Theory approach and consisted of 3 phases.[ First, JPB and WMvdV independently read and coded (open and inductive) each transcript. Labeling was concise and self-explanatory and discussed until consensus was reached. Second, after developing the provisional coding scheme, codes were combined into categories. Third, core themes were defined in which categories could be placed. Core themes consisted of at least 1 category. Categories and core themes emerged from discussions with the complete data analysis team. Analyses were performed using MAXQDA 11.0.6 (Verbi GmbH, Berlin).

Results

Sample characteristics

A total of 20 interviews were conducted after which data saturation was reached. Seventeen MSM were recruited through the ACS. Response rate among ACS participants was 44% (17/39). Three MSM were recruited online. Participants had a median age of 41 years (interquartile range 38–46), 80% lived in Amsterdam, 65% were college graduates, and 45% had a high annual income level (>€33,000) according to Dutch standards.[ Regarding steady relationships, 45% had no steady partner, 35% had an HIV-positive partner, and 15% had an HIV-negative steady partner. The HIV status of one participant's steady partner was not asked. Eight MSM expressed a high intention-to-use daily PrEP if it becomes available, 10 expressed a low intention, and 2 were in doubt about their future PrEP use.

Daily PrEP

We identified 8 motives for wanting to use daily PrEP if it becomes available (Table 1):

Table 1

Representative quotes from 20 HIV-negative men having sex with men in regards to motives for wanting to use daily pre-exposure prophylaxis, Amsterdam, the Netherlands (2013).

Daily PrEP can protect against possible HIV infection: Some participants believed that PrEP could give them the desired (additional) protection to prevent HIV infection (quote 1A, 1B). Also, some participants stated that PrEP would provide the opportunity to prevent the spread of HIV to others (quote 1C).

Daily PrEP in combination with other protection strategies offers complete coverage against HIV infection: Some participants believed that HIV protection of other prevention strategies was insufficient because of their self-perceived high HIV risk (quote 2A), they thought condoms could break or HIV could be transmitted in ways other than anal sex (quote 2B, 2C). Adding PrEP to their prevention strategies would provide the feeling of complete coverage.

Daily PrEP offers additional protection for discordant couples: Participants in serodiscordant steady relationships stated being worried about getting HIV from their HIV-positive steady partner. PrEP use, in combination with an undetectable viral load from their partner, would increase their perceived protection against HIV infection (quote 3A, 3B).

Daily PrEP reduces anxiety about HIV transmission: Because participants believed that PrEP could offer them (additional) protection against HIV infection, they believed that PrEP could increase their feeling of safety and reduce their anxiety of contracting HIV (quote 2A, 2B, 3A, 3B).

Daily PrEP is easier to use than condoms: Some participants stated different reasons why using condoms was difficult for them (quote 5A, 5B). The perceived advantage of daily PrEP is its continuous protection against HIV and the increase of participants’ self-perceived efficacy to adhere to PrEP.

Daily PrEP can improve quality of sex life: Some participants felt PrEP would facilitate condomless sex or decrease HIV anxiety, which would increase the potential to experiment with sex (quote 6A), increase their own or their partners’ sexual pleasure (quote 6B), and improve the quality of their sex life (quote 6C).

Daily PrEP makes engaging in (sexual) relationships with a potential HIV-positive partner easier: For some participants, a barrier for engaging in a steady relationship with an HIV-positive person is the necessity to use condoms during sex, as this reduces the feeling of intimacy (quote 7A). As PrEP would reduce the need for condoms, they would feel free to engage in a serodiscordant relationship (quote 7B).

Daily PrEP provides solidarity with HIV-positive partner: Some participants stated that PrEP would offer them the opportunity to support their HIV-positive partner in taking daily ART (quote 8A).

We identified 10 motives for not wanting to use daily PrEP in the future (Table 2 ):

Table 2

Representative quotes from 20 HIV-negative men having sex with men in regards to motives for not wanting to use daily pre-exposure prophylaxis, Amsterdam, the Netherlands (2013).

Daily PrEP is not sufficiently effective as an HIV risk reduction strategy: Some participants perceived the efficacy of daily PrEP as too low. Perceptions of insufficient efficacy differed between participants, for example, some participants felt <100% efficacy was insufficient (quote 1A), whereas others perceived efficacy <50% as insufficient (quote 1B).

Nonbelief in present research and data: Some participants stated distrusting the results of the published PrEP efficacy trials and were therefore not willing to consider taking PrEP (quote 2A).

Daily PrEP is not needed because of a low self-perceived HIV risk: Some participants stated not needing PrEP because of their sexual lifestyle (e.g., number of partners [quote 3A, 3B]), or because of their current use of other effective methods (e.g., condom use [quote 3C]; negotiated safety [quote 3D]) or subjectively perceived effective preventive methods (e.g., strategic positioning and no ejaculation [quote 3E]). Some participants willing to use PrEP also stated that their future willingness might be lower if they felt less HIV risk owing to sexual lifestyle changes.

Daily PrEP is not needed because of treatment (of HIV-positives) as prevention strategy: Some participants in serodiscordant relationships perceived an undetectable viral load of their partner as sufficiently effective (quote 4A). Also, as some participants considered almost all HIV-positives as having an undetectable viral load, HIV transmission risk was perceived as diminishable (quote 4B).

Preference for prevention strategies other than PrEP: Some participants preferred other prevention strategies, for example, condoms or post-exposure prophylaxis (PEP), over PrEP use owing to the higher perceived efficacy (quote 5A), easier accessibility (quote 5B), lower costs (quote 5C), absence or reduction of side effects (quote 5D), additional protection against other STIs (quote 5E), and provision of a hygienic function (quote 5F).

High costs of daily PrEP: Almost all participants stated that high costs of PrEP would be a barrier for its use (quote 6A, 6B). The perceptions of high costs varied; some participants were completely unwilling to pay for PrEP, whereas others were willing to contribute a certain amount. The majority however would not pay €580 per month.

Anticipated side effects of daily PrEP or ART resistance: Some participants were unwilling to use PrEP because they believed that PrEP has side effects (long-term or short-term) (quote 7A), the use of PrEP could increase the risk of ART resistance (quote 7B), PrEP has similar side effects to ART used for HIV treatment (quote 7A, 7C), or they felt knowledge about the potential future side effects of PrEP was insufficient (quote 7D).

Low perceived self-efficacy to adhere to daily PrEP: Most participants used past experience in taking pills as a reference for their perceived self-efficacy to adhere to PrEP. Some participants perceived adherence to a daily PrEP regimen as difficult and were worried about decreased PrEP effectiveness if they did not follow usage instructions (quote 8A). Also, participants were worried about PrEP adherence if treatment regimens were difficult (e.g., taking >1 daily pill or if regimens dictated food or alcohol restrictions, quote 8B).

Monitoring procedures during daily PrEP treatment are unacceptable: Some participants were unwilling to use PrEP because of the additional blood- and/or STI screening, or counseling required for PrEP usage (quote 9A, 9B).

Principle objections against taking daily PrEP: Some participants believed out of principle that healthy individuals should not use medication (quote 10A).

Intermittent PrEP

After discussing motives regarding daily use of PrEP, we asked participants about perceptions regarding intermittent PrEP usage. Of 19 participants, 12 had a low intention of using intermittent PrEP, 5 had a high intention, and 2 participants were in doubt about using intermittent PrEP. For the first participant, the intention to use intermittent PrEP was not explored as it was added as an interview topic after the first interview.

We identified 3 motives for preferring intermittent PrEP over daily PrEP (Table 3):

Table 2 (Continued)

Representative quotes from 20 HIV-negative men having sex with men in regards to motives for not wanting to use daily pre-exposure prophylaxis, Amsterdam, the Netherlands (2013).

The decision to start intermittent PrEP is easier compared to daily PrEP: Some participants thought it would be less hard to make the decision to use intermittent PrEP than the decision to use daily PrEP (quote 1A).

Intermittent PrEP has less side effects compared to daily PrEP: Some participants believed taking PrEP less frequently or for a short period (as in intermittent PrEP) reduces side effects and potentially harmful effects (quote 2A).

Intermittent PrEP reduces financial costs compared to daily PrEP: Some participants stated that intermittent PrEP would increase their control over the financial costs as they could choose the period and duration of PrEP use (quote 3A).

We identified 2 motives for preferring daily PrEP over intermittent PrEP (Table 3):

Intermittent PrEP requires unwanted planning of sex life: Most participants stated they did not plan their sex life and that sex usually happened spontaneously. As intermittent PrEP entails planning when to start taking PrEP, participants argued that intermittent PrEP would not work for them (quote 1B).

Using intermittent PrEP makes adherence to other HIV prevention strategies more difficult: Some participants believed using intermittent PrEP would necessitate different prevention strategies in different situations, when on or off PrEP, which makes adherence difficult (quote 2B).

Anticipated condom use when using daily PrEP

We identified 2 motives for combining PrEP with condom use (Table 4):

Table 3

Representative quotes from 19 HIV-negative men having sex with men in regards to motives for wanting and not wanting to use intermittent pre-exposure prophylaxis, Amsterdam, the Netherlands (2013).

Condoms are needed to prevent other STIs (quote 1A).

Combining the two strategies increases protection against HIV (quote 2A).

We identified one motive for solely using PrEP, that is, using PrEP solely is sufficiently effective to prevent an HIV infection (quote 1B, 1C).

Furthermore, some participants in serodiscordant relationships stated they would only use condoms in combination with PrEP if their HIV-positive partner's viral load was detectable.

Location of PrEP prescription

Participants preferred the following locations for PrEP prescription if it were to become available in the Netherlands: Public Health Service (i.e., STI clinic), general practitioner, and the hospital (i.e., HIV-specialist). Preference for locations was based on the following characteristics of healthcare providers (Table 5): having specialized knowledge of HIV (and ART) (quote 1); having specialized knowledge of sexual behavior and other STIs (quote 2); possibility of performing medical check-up and/or counseling (quote 3); having specialized knowledge of personal medical background and the use of current (medical) drugs (quote 4); easily accessible (quote 2); and having time to counsel men and provide support for PrEP users (quote 6). The perceived pros and cons for the distribution of PrEP services by different healthcare provider are presented in Table 5.

Table 4

Representative quotes from 20 HIV-negative men having sex with men in regards to anticipated condom use when using daily pre-exposure prophylaxis, Amsterdam, the Netherlands (2013).

Discussion

This qualitative study revealed several motives for wanting or not wanting to use PrEP and preferences with respect to PrEP implementation among HIV-negative Dutch MSM if PrEP becomes available in the Netherlands. These results can guide future implementation strategies to ensure high uptake of PrEP and maximize PrEP's public health impact.

First, we found the motives for PrEP use were based on beliefs regarding PrEP efficacy, PrEP side effects, and trust regarding published research data. Recent trial results have corroborated that PrEP is highly effective, has minimum side effects, and risk of ART resistance is low when PrEP is taken correctly.[ To correct wrong beliefs about PrEP and increase positive attitudes toward PrEP, knowledge about current and possible future data on PrEP efficacy and side effects should be increased.

Second, we found perceived self-efficacy to be an important motive for wanting or not wanting to use daily and or intermittent PrEP. To improve the perceived self-efficacy, it is important to carefully look at individual skills regarding PrEP use and adherence, and decide, based on the type of skill problems, whether daily or intermittent PrEP is most suited and which skill enhancing interventions is needed.

Third, we found environmental factors, for example, perceived difficulties in accessing PrEP services, frequent monitoring procedures, and high costs of PrEP, were potential barriers for PrEP uptake. To reduce these barriers, PrEP services should be set up in line with MSM preferences by offering PrEP in easily accessible facilities (e.g., involve efficient health monitoring procedures, offer services at convenient times and locations) with sufficient experience and specialized knowledge regarding PrEP prescription. Furthermore, it is important to advocate for the (partial) coverage of PrEP costs by insurance companies or other sources of cost coverage.

Regarding motives for PrEP use among men in serodiscordant relationships, results showed that some men perceived PrEP as a good addition to current prevention methods since it could increase their protection, reduce their anxiety, and improve sexual satisfaction in their relationships. However, some men perceived PrEP as unnecessary in discordant relationships where the HIV-positive partner had an undetectable viral load because of the low transmission risk. As growing evidence supports the latter, also among MSM,[ using PrEP in serodiscordant relationships might become redundant.

Our results regarding intermittent PrEP show that most men were sceptical about its use, as it requires planning of their sex life and this would not fit in with their sex life habits. However, our study was conducted before the IPERGAY trial results indicated PrEP could be effectively taken up to 2 hours before a risk episode.[ We defined intermittent PrEP as using PrEP 3 days before high-risk sexual behavior. The shorter time frame of planning sex in advance might increase its acceptability. Furthermore, as men perceived using intermittent PrEP as having reduced costs and fewer side effects compared to daily PrEP, intermittent PrEP options could increase general PrEP acceptability.

Our results indicate that some men perceived PrEP as a substitute for condom use. Although a decrease in condom use was not observed in study settings,[ a decrease was seen among PrEP users in a clinical practice settings.[ To deal with possible decreases in condom use or increases in STIs when PrEP is implemented in real-life settings, STI prevalence should be monitored after PrEP initiation, PrEP programs should include routine STI screening, and address risk and severity perceptions in regard to other STIs.

The motives for daily PrEP use found in this study are comparable to those found in other studies among MSM.[ However, the following motives found in other studies were not considered important by our study population: PrEP will help link individuals to the healthcare system,[ fear that others will think users of PrEP have HIV,[ others will identify PrEP users as MSM,[ and generally feeling ashamed about using PrEP.[ These differences are probably explained by our study population and its context, as we included mainly older, native Dutch MSM participating in a cohort study and hence accustomed to disclosure, having overcome barriers for engaging with healthcare systems, and living in a country with well organized health provision and an open gay culture. Furthermore, participants of a qualitative study might be more open to discuss PrEP and feel less shame to use PrEP. As motives might differ in other countries, interventions for PrEP implementation should be adapted to the countries’ healthcare system, social norms, and risk population.

Regarding limitations, although MSM are likely to be the most important target group for PrEP in the Netherlands, other groups, for example, transgenders, high-risk heterosexuals, bisexual men, and sex workers, might also be considered eligible for PrEP. If PrEP also becomes available for those groups, their specific motives and preferences should be further explored as they might differ among those groups. Furthermore, as mentioned earlier, the selection of MSM participating in a cohort study might have influenced our results. Our findings may therefore not be generalized to the broader range of MSM living in the Netherlands or outside of it. We recommend that motives to use PrEP among high risk, for example, younger MSM and those not yet readily engaged with healthcare systems, should be further explored. Finally, we measured behavioral intentions and motives to use PrEP. Although behavioral intentions provide a good indication of the general willingness to use PrEP on the individual level, they do not absolutely predict actual PrEP uptake. Actual uptake of PrEP will most likely also be influenced by a variety of other external factors, such as social, organizational, or environmental factors, and these factors should also be addressed.[

In conclusion, the future use of daily PrEP among HIV-negative MSM depends on the personal evaluation of benefits, barriers related to PrEP, and the perceived self-efficacy to adhere to PrEP. To maximize the public health impact of PrEP, ensuring high uptake among MSM at highest risk is important. Therefore, targeted information aimed at improving knowledge about PrEP efficacy and side effects needs to be developed. Furthermore, barriers for accessing PrEP services should be minimized according to the indicated needs of the target population. Perceived self-efficacy to use PrEP should be improved and addressed differently based on individual assessments of skill problems and of preferences for daily or intermittent PrEP. Finally, as this study shows that some men perceived PrEP as a substitute for condom use, it is important to discuss, monitor, and study condom use change and its consequences, and work toward integrating routine STI screening and counseling in PrEP prescription programs.

Table 5

Choice and perceived pros and cons for distribution services for pre-exposure prophylaxis by different healthcare providers among 20 HIV-negative men having sex with men, Amsterdam, the Netherlands (2013).