Informal pre-exposure prophylaxis use in France: results from the Flash PrEP survey (2014).

Abstract

Strong evidence exists that daily pre-exposure prophylaxis (PrEP) is effective as an HIV preventive tool provided that there is good individual adherence 1. In 2014, the World Health Organization (WHO) issued new guidelines recommending PrEP use 2. In France, as a consequence of HIV/AIDS organizations' advocacy and the Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS) Intervention Préventive de l'Exposition aux Risques avec et pour les Gays (IPERGAY) trial results proving high efficacy of on-demand tenofovir (TDF)/emtricitabine (FTC) use in men who have sex with men (MSM) 3, health authorities have approved PrEP use for most-at-risk populations. Literature on awareness and acceptability of PrEP, and willingness to use it, mainly among MSM, 4 shows that, in countries where it is not officially accessible, some people are informally using antiretroviral (ARV) medication obtained in several ways outside of biomedical trials as a prevention tool 5, but data on this are still insufficient. In this context, AIDES, a French community-based organization (CBO), conducted the cross-sectional national “Flash PrEP” survey to characterize informal PrEP use in France. All people benefitting from AIDES' on-site and outreach activities filled in paper or online questionnaires, from March to May 2014, collecting data on: sociodemographic characteristics; awareness of PrEP authorization in the USA; willingness and intention to use PrEP when authorized; sexual behaviour; drug injection; risk perception and sexually transmitted infection (STI) awareness; HIV testing; post-exposure prophylaxis (PEP). Informal PrEP use at least once during one's lifetime was explored using the statement: “I have used ARV treatment at least once in my lifetime (received from a friend or partner, for example) before sexual intercourse to avoid HIV infection” (yes/no). The sampling bias introduced by collecting data with online and paper questionnaires was corrected by implementing the inverse propensity score weighting technique. Groups of respondents to paper (treatment group) and online (control group) questionnaires were balanced in terms of sociodemographic and socioeconomic characteristics, ensuring their comparability. Statistical analysis was performed using spss statistical software (version 17). A total of 2668 people filled in the questionnaire (71% online survey), of whom 4.6% (n = 123) declared informal PrEP use. Informal PrEP users were 74% MSM and 14.6% women; 91.9% were born in France, 61.8% had a university degree, and their median age was 31 [interquartile range (IQR) 25–41] years. More than one-third (38.2%) of the PrEP users self-perceived themselves to be at high or very high risk of HIV infection compared with 10.1% of those not using PrEP (P < 0.001). Seventy informal PrEP users had a main partner (56.9%), and this partner was serodiscordant for 14 MSM and one woman (21.4%). Factors associated with informal PrEP use, estimated using multivariate logistic regression adjusting for participants' sexual orientation (women, MSM, or heterosexual men), were as follows (Table 1): MSM; younger age; being aware of PrEP authorization in the USA; high or very high HIV risk self-perception; having, in the previous 12 months, injected drugs, used PEP or had at least two HIV tests; and never having used condoms with one's main partner. In contrast, being aware of having had (or not) an STI in the previous 12 months was inversely associated with informal PrEP use. These results show that informal PrEP use exists in France. Associated factors indicate that users are well informed about prevention tools, are highly exposed to HIV and monitor their risks, as they use both PEP and frequent HIV testing, suggesting that these people are linked with the health system and HIV/AIDS CBOs. The experiences reported by informal PrEP users in this study may be helpful in the design of future PrEP services, now that PrEP is authorized in France. We thank all the people who completed the “Flash PrEP” survey and all those who participated in the data collection. We would also like to thank our colleague Thomas Gonçalvez for his valuable help with the first steps of the database work.