AIDS 2012A “substantial minority” of men who have sex with men (MSM) anticipated that they would use condoms less if they were taking PrEP, or pre-exposure prophylaxis, according to results of a survey conducted by Douglas Krakower, MD, of Harvard Medical School/Beth Israel Deaconess Medical Center, and his colleagues. The survey findings were presented Tuesday, July 24, at the XIX International AIDS Conference in Washington, DC.

Specifically, 20 percent of 3,245 respondents said they would decrease condom use while “topping”—engaging in insertive anal sex—while using PrEP. And 14 percent of 3,237 respondents said they would forgo condoms while “bottoming”—engaging in receptive anal sex—while taking PrEP.

The researchers also associated the likelihood of anticipating unsafe sex on PrEP with several variables, such as a recent history of engaging in unprotected anal intercourse prior to participating in the survey and being treated for alcohol and drug use.

Krakower and his colleagues also found that survey participants were generally interested in PrEP—half said they would use it.

PrEP, which is when an HIV-negative person takes daily medication to prevent potential infection, is a controversial and timely topic. The Food and Drug Administration this month approved the use of the antiretroviral Truvada (tenofovir plus emtricitabine) as PrEP.

A 2010 study called iPrEx showed that among men who have sex with men (MSM) and transgender women, Truvada as PrEP reduced HIV infections by 42 percent. However, not everyone took the meds as prescribed. Those who followed the daily regime received higher protection—as much as 92 percent.

But in real world settings, will PrEP’s potential benefit be reduced by risk compensation?

In other words, will men who take PrEP perceive themselves to be protected and as a result stop using condoms?

PrEP is often a divisive topic, in part because some fear an increase in risky behavior. During the discussion session at Krakower’s presentation, a physician who identified himself as working with the AIDS Healthcare Foundation—an agency that has generally been opposed to the approval of PrEP—suggested that it went against the Hippocratic Oath to prescribe PrEP when condoms were available without any of the side effects.

“As practicing physicians,” Krakower answered, “we have to look at evidence; we have to listen to patient preference; and we have an ethical obligation not to withhold strategies that may be protective. On an individual level, if I have patients who are interested in this and I thought they would benefit, I would not withhold it.”

He continued: “If the evidence ends up being against it, then I certainly think it would be within the Hippocratic Oath to change my position over time. But at this point in time, the evidence is powerful and impressive. We have to keep an open mind in our ethical obligations to let the evidence guide what we do.”

To assess whether MSM anticipated reduced condom use while taking PrEP, Krakower and his colleagues surveyed 5,035 North Americans who were members of an online partner-seeking website. The survey was conducted between December 2010 and January 2011. Participants self-reported being HIV negative and 18 or older. The average age was 39. Eighty-four percent were Caucasian, 6 percent were Latino, 3 percent were African American, and 3 percent were Asian American. Eighty-four percent identified as homosexual/gay and 16 percent as bisexual. Ninety percent were from the United States, and 10 percent from Canada. In addition, 93 percent had at least some college education, 67 percent were employed full-time, 87 percent had health insurance, and 25 percent had a history of depression.

Researchers noted that the respondents reported high-risk behaviors but their perception of risk was low-to-moderate. Specifically, 61 percent reported unprotected anal intercourse with one or more partners in the previous three months, 23 percent reported unsafe anal sex with one or more partners who were either HIV positive or whose status was unknown. Twenty-four percent reported unsafe anal sex after five or more drinks, and 11 percent while using recreational drugs. Twenty-eight percent had a previous history of a sexually transmitted infection. Yet on a scale of 1 to 10, with 10 being at extreme risk, the men ranked their own risk, on average, as being 3.3.

In addition, 19 percent of respondents had heard of PrEP, but 50 percent said they would use it. Thirty-seven percent had heard of PEP, or post-exposure prophylaxis, when HIV meds are taken within 72 hours after possible exposure (three meds are taken daily for about a month), and 88 percent of respondents would use PEP—4 percent actually had used it.

A “substantial minority” anticipated decreases in condom use while using PrEP—20 percent said they’d decrease condom use during insertive sex while on PrEP, and 14 percent said the same for receptive sex.

Certain factors were associated with this anticipated decrease in condom use. Participants who had been treated for alcohol or drug abuse had 2.04 greater odds of anticipating less condom use during insertive anal sex while on PrEP. Participants who engaged in unprotected anal intercourse in the three months before the survey had 1.58 greater odds of anticipating they would use fewer condoms while topping. Those who reported unsafe anal sex after five or more drinks had 1.27 greater odds of anticipating less condom use, and those who were aware of PEP had 1.23 greater odds of anticipating increased unsafe anal sex while being a top.

Participants who engaged in unsafe anal sex in the three months before the survey were at 1.57 greater odds of anticipating decreased condom use during receptive anal sex while using PrEP. Those who reported unprotected anal intercourse after five or more drinks had 1.43 greater odds of anticipating unsafe receptive sex while on PrEP; those who screened positive for depression had 1.31 greater odds of anticipating unsafe bottoming on PrEP; and those who had a self-perceived risk for acquiring HIV had 1.10 greater odds of unsafe receptive sex.

As a result of these findings, Krakower and his team recommend that clinicians who prescribe PrEP for at-risk MSM be aware that these patients may need more intensive counseling. Areas to look for include recent risky behavior, substance abuse and increased self-perceived risk of contracting HIV infection. Finally, more studies are needed to examine increased risky behavior among MSM on PrEP.