Perception of Risk Increases PrEP Uptake When Access Is Not a Factor

Sarit A. Golub, PhD, MPH

Patients who believe themselves to be at a high risk of contracting HIV are more likely to accept pre-exposure prophylaxis (PrEP) than their peers. That’s one key finding from a new study that looked at how individual factors affect PrEP uptake.

Much of the research into PrEP uptake has centered around demographic factors, as well as patients’ awareness levels and ability to access and pay for the drug.

While those factors are important, investigators from the City University of New York (CUNY) and the Callen-Lorde Community Health Center—also in New York—wanted to find out what factors might affect uptake on an individual level among patients who have access to PrEP.

“Little, if any, of the current research on PrEP uptake has examined intervenable factors at the patient-level, ie, specific psychological, attitudinal, or motivational factors that could be addressed to enhance the likelihood of PrEP uptake,” wrote corresponding author Sarit A. Golub, PhD, MPH, of the Department of Psychology at CUNY’s Hunter College.

To get a better handle on those factors, Golub and colleagues analyzed data from a PrEP study conducted at the community health center, which is the largest LGBT health center in the city.

Between 2014 and 2016, the center recruited HIV-negative men who have sex with men (MSM) and transgender women into the study and gave them a choice between a PrEP group and a non-PrEP comparison group. Those who chose the PrEP group were given up to 12 months' worth of PrEP and agreed to make quarterly visits for monitoring, testing, and check-ups. The non-PrEP comparison group, meanwhile, was simply asked to come at 3 months and 12 months to get tested for HIV and other sexually transmitted infections.

A total of 267 participants enrolled in the PrEP group and 101 people joined the comparison group.

When comparing uptake data to individualized factors, investigators found men and transgender women whose main sexual partner was HIV positive were more likely to accept PrEP. Participants who had engaged in risky sexual behavior in the past 3 months were also more open to PrEP, as were patients who perceived themselves to be at high risk for HIV.

The analysis only included a small number of transgender and gender non-binary individuals (14), but the data suggested cisgender men who have sex with men were 3 times more likely than transgender and gender non-binary individuals to agree to PrEP.

Age, income, and education level did not appear to correlate with PrEP uptake, nor did race, except in the case of people with Asian heritage. They were less likely to agree to take PrEP.

The study also found that people who were more concerned about HIV-related stigma were less likely to accept PrEP. The investigators noted that this might seem counter-intuitive since one might assume patients who worried most about HIV might be most likely to take measures to prevent it. However, Golub and her colleagues wrote that that’s not always how the human mind works.

“This finding can be understood in the context of psychological avoidance, in which individuals choose to distance themselves from potential psychological or interpersonal threat,” they wrote.

More broadly, the team found that when access and cost are not a factor, real or perceived risk is a major indicator of whether or not a patient will accept PrEP. They noted that’s a good sign since people at highest risk benefit most from PrEP.

Golub and colleagues said their research underscores the importance of improving access to PrEP. However, they also said clinicians should also deal with psychological barriers, such as stigma, that might keep people from taking PrEP.

“Developing interventions that reduce stigma in clinical settings and develop self-efficacy and agency among potential PrEP users will be critical to promoting equitable access,” they concluded.

The study, titled, “Predictors of PrEP Uptake Among Patients with Equivalent Access,” was published online in AIDS and Behavior.