Non-Occupational HIV Post-Exposure Prophylaxis Among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis of Global Data

Abstract

Background: Non-occupational HIV post-exposure prophylaxis (nPEP) has been prescribed to men who have sex with men (MSM) for decades, but the global situation of nPEP implementation among this population remains unclear. We reviewed all available evidence on nPEP awareness, uptake, and factors associated with uptake among MSM. Methods: In this systematic review and meta-analysis, we searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science for studies reporting nPEP uptake among MSM published before May 19, 2019. Interventional or observational studies reporting original data on nPEP awareness, uptake, and associated factors were included. We estimated pooled rates and their 95% confidence intervals of awareness, uptake and completion using a random-effects model. Findings: We identified 74 studies, three studies (4·1%) from upper-middle-income regions and 71 (95·9%) from high-income regions. The pooled rate of nPEP awareness and uptake was 51·6% (95% CI: 40·6%-62·5%, k=30) and 6·0% (5·0%-7·1%, k=38), respectively. Pooled uptake rate was higher in upper-middle-income regions (8·9% [7·8%-10·0%], k=3) than in high-income regions (5·8% [4·8%-6·9%], k=35). Among MSM initiating nPEP, unprotected anal sex was the most common type of exposure (range:55·0% to 98·6%, median: 62·9%). Pooled completion of nPEP was 86·9% (79·5%-92·8%, k=11). Of 19,546 MSM prescribed nPEP, 500 HIV seroconversions (2·6%) were observed. Having risky sexual behaviors and history of sexually transmitted infections were associated with higher nPEP uptake, while insufficient knowledge, underestimated risk of exposure to HIV, the lack of accessibility, and social stigma might hinder nPEP uptake. Interpretation: Awareness and uptake of nPEP among MSM worldwide are low. Further efforts are needed to combat barriers to access nPEP, including improving accessibility and reducing stigma. Seroconversions post nPEP uptake suggests jointed prevention precautions aside from nPEP are needed for high-risk MSM. More evidence from low-income and middle-income regions on nPEP among MSM are needed. Funding Statement: This work is funded by the National Natural Science Foundation of China (grant ID 81703278), the Australian National Health and Medical Research Council Early Career Fellowship (grant ID APP1092621), the Sanming Project of Medicine in Shenzhen, China (grant ID SZSM201811071), and High Level Project of Medicine in Longhua, Shenzhen, China (HLPM201907020105). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This systematic review and meta-analysis was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Metaanalysis Of Observational Studies in Epidemiology (MOOSE) guidelines.