September 20, 2018 at 8:00 am PDT | by Christopher Kane
Williams Institute: Culture, not PrEP, linked to spike in STIs

Only a small minority of eligible patients are taking Truvada as pre-exposure prophylaxis for HIV prevention, according to a recent study.

Rates of HIV screening are alarmingly low in some populations of gay and bisexual men in the United States and only a small minority of eligible patients are taking Truvada as pre-exposure prophylaxis (PrEP) for HIV prevention, according to a recent study by the Williams Institute of the University of California, Los Angeles School of Law.

The Centers for Disease Control and Prevention (CDC) recommends all sexually active men who have sex with men (MSM) test annually for HIV and include PrEP in their HIV prevention methods. With a probability sample, the first that offers nationwide estimates, researchers found only 4% of MSMs are using PrEP and as many as 25% of young gay and bisexual men have never been tested for HIV—while fewer than half are screened at least once per year.

“Our findings suggest that health education efforts are not adequately reaching sizable groups of men at risk for HIV infection,” the study’s principal investigator, Ilan H. Meyer, Distinguished Senior Public Policy Scholar at the Williams Institute, said in a press release. “It is alarming that high- risk populations of men who are sexually active with same-sex partners are not being tested or taking advantage of treatment advances to prevent the spread of HIV.”

Nationwide, the number of new HIV infections has decreased year-over-year since 2010, a public health achievement that still does not mitigate the potential risks associated with low rates of HIV screening and PrEP use. Meanwhile, the spike in sexually transmitted infections (STI) like gonorrhea, chlamydia, and syphilis among MSM has been partially attributed to riskier behaviors among men who use PrEP. That conclusion, which is fueled in part by peer- reviewed research—and also, perhaps, by some sexual shaming or stigma—is challenged by the findings reported in the Williams Institute paper.

Lead study author Phillip Hammack, Ph.D., professor of psychology at the University of California, Santa Cruz, told the Los Angeles Blade: “Our data don’t support the idea that we can attribute the rise in STIs to PrEP use, at least not in a direct manner. I personally don’t think that’s what’s happening.” More responsible are a constellation of different cultural factors, from the availability of easy sex via hook-up apps to decreased anxiety about HIV/AIDS, Hammack explained. “I would speculate it has more to do with a culture shift about sex. More people are having sex today. We’re in sort of a quiet sexual revolution when it comes to new identities, new labels, and sexual behavior.”

To an extent, Hammack said, low rates of HIV testing and PrEP use can be explained in the same way, along with various other factors, including stigma, which often prevents gay and bisexual men from discussing their sexual behaviors or identities with healthcare providers and non-LGBT-specific clinics are not always familiar with the full spectrum of diverse sexual identities and behaviors. Additionally, limited access to medications and financial barriers are in large part responsible for the low numbers of eligible patients using PrEP.

Hammack told the Los Angeles Blade that HIV prevention efforts must focus on better educating healthcare providers, especially in more rural areas. “A really encouraging finding of ours was that if folks had access to LGBT-specific resources and were out to their providers, they were much more likely to be tested and to be on PrEP,” he said. Physicians and healthcare providers must talk with men in sensitive, non-stigmatizing ways in order to really understand patients’ sexual risk profiles. For example, some MSMs may identify as straight and disavow membership in the LGBT community.

Such a shift in approach is likely to result in an increased number of men who choose to take PrEP, the Williams Institute study suggests. Hammack explained that prior research, with samples of gay/bisexual men in urban areas, found only moderately- higher numbers of PrEP users, typically between five and 10%—still well below the rates recommended by the CDC and World Health Organization.

More of the factors that can explain the low number of PrEP users, both nationwide and in large metropolitan areas, will be borne out in a forthcoming study that will include in-depth interviews of gay and bisexual men. Despite public campaigns about the safety and efficacy of PrEP, Hammack explained, “In this [forthcoming] study, what we’ve seen is, frankly, a lot of misinformation about PrEP.” Along with undue fears about side effects, Hammack and his team discovered “a fair amount of sexual shame. ‘Well, I don’t want to be considered a PrEP whore’—that kind of language.”

Some of the findings in the Williams Institute study are cause for celebration, however. HIV testing rates among black MSMs are higher than rates among white men. “What our findings on that suggest is that the testing campaigns that have targeted African-American men are paying off,” Hammack said. Still, while rates of new HIV infections have decreased in the general population, there has been an increase in new diagnoses among black gay and bisexual men. “I think we’re in a transitional moment in which we’re starting to see the effects of the aggressive efforts to reduce the impact of HIV on communities of color,” Hammack explained. “And it’s going to take some time before we see the actual infection rate numbers go down.”

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