偏好或是情況？到底是什麼讓澳大利亞的男同性戀和雙性戀男性選擇不使用暴露前預防投藥 (PrEP)？

資料來源：Oğuzhan Nuh / 2022 年 4 月 14 日 /aidsmap news

 

圖片由 4U 醫生提供。知識共享許可。

–

認為無關緊要、個人知曉情況、獲取問題、副作用、負面社會影響以及缺乏對性傳染病感染之保護、有效性和順從性的擔憂是澳大利亞男同性戀和雙性戀男性不使用 PrEP 的最常見原因。這是根據最近發表在《行為醫學》雜誌上的一項研究得出的，該研究根據個人特徵和性行為分析了男同性戀和雙性戀男性不使用 PrEP 的原因。

–

該研究於 2018 年從透過臨床試驗提供 PrEP 過渡到由澳大利亞全民醫療保健系統 Medicare 下提供的階段中進行。儘管這使 PrEP 更容易獲得，但同性戀和雙性戀男性對 PrEP 的接受仍然不理想。目前，估計有 31,000 名男同性戀和雙性戀男性感染 HIV 的風險較高，並且有資格在澳大利亞接受 PrEP，但只有 18,500 人（主要是男同性戀和雙性戀男性）接受 PrEP。

柯比研究所的 Steven Philpot 博士及其同事根據 2018 年 Flux 研究的線上調查所收集的數據進行了混合方法分析。定量分析包括 1,039 名從未使用過 PrEP 的 HIV 陰性男同性戀和雙性戀男性的回應。樣本中的大多數男性（86%）被認定為同性戀，9% 被認定為雙性戀。一半的參與者年齡在 30 歲以上，60% 受過大學教育，大多數人從事全職或兼職工作。

除了人口特徵外，參與者還被問及最近的愛滋病毒檢測、成癮藥物使用和性行為。有關性行為的數據分為五類：與男朋友發生性關係、與砲友發生性關係、隨機式性行為、群體性行為和藥愛性行為。參與者被分為感染愛滋病毒的低風險和高風險組別。在過去三個月中，感染 HIV 的高風險被定義為以下任何一種情況：與 HIV 陽性伴侶且病毒載量為可檢測或未接受治療者的無保險套肛交、與隨機式伴侶無保險套的接受性性交、直腸中性傳染病感染的診斷，或甲基安非他命之使用。

大多數非 PrEP 使用者 (79%) 被歸類為低風險。一半的參與者表示他們在過去六個月中與至少一名男子有過關係，五分之四的人報告說與至少一名男子發生過性關係。在過去的六個月裡，一半的男性進行了 HIV 檢測，而高風險組的人更有可能做HIV 檢測。高風險組的男性在過去六個月中平均報告了 17 位性伴侶，而低風險組的男性報告了 5 位。此外，與低風險組相比，高風險組中有更多的男性表示他們與隨機式伴侶（74%）和砲友（33%）進行了無保險套性行為，低風險組則為（0%和6%）。此外，在高風險組中，不到一半的參與者表示他們使用了非法藥物，其中 21% 的人在過去六個月中使用過增強性功能的藥物。他們也更有可能發現 PrEP 太貴並且不好意思去要求它，而低風險組的男性則更有可能認為 PrEP 無關緊要。

參與者還被要求回答調查中的一個自由開放的問題：「您想告訴我們更多關於您為什麼不使用 PrEP（抗 HIV 藥丸）來幫助預防您感染 HIV 的原因嗎？」。從更大的樣本中，696 名參與者 (67%) 也回答了這個問題，並被納入定性分析。答案中出現了不使用 PrEP 的六個主題：無關緊要、個人知曉情況和藥物的獲取、健康上的副作用、負面社會影響、缺乏對性傳染病感染之保護和有效性的擔憂以及順從性。

–

無關緊要

認為 PrEP 無關緊要有兩個主要原因。 25% 的男性表示，第一個原因是處於固定單一伴侶或於非固定單一伴侶的關係中，只允許低風險性行為或使用保險套的性行為。

「愛滋病毒並不是我真正關心的問題。我處於長期關係中，我的伴侶是 HIV 陰性。儘管我們是開放的關係，但我們實際上只將自己限制在不危險的性行為中，例如與隨機式伴侶進行口交或手交工作，並且肯定會在非上述狀況時使用保險套——即使是隨機式伴侶也很少或是遠離的。」 （22 歲，新南威爾斯州）。

第二個不需要使用 PrEP 的原因由20% 的參與者表示，是因為性行為的頻率和類型。

「我的性生活並未頻繁到足夠需要每天服用 PrEP。」 （30 歲，南澳大利亞）

–

個人對PrEP的知曉情況和藥物的獲取

有 19% 的人表示不使用 PrEP 的原因是個人對PrEP的知曉情況和藥物的取得，其中一些人對 PrEP 本身或如何獲取它的了解不夠。相較之下，其他人是知道它，但卻很難得到處方。一些人分享了他們在等待被安排診所預約的經歷，或認為他們的醫生不願意開具處方或根本就不了解 PrEP。

「我想參加 PrEP，但當地診所的開放時間非常有限，而我係全職工作。」 （26歲，澳大利亞首都直轄區）

其他人則對要求開處方感到不適。

「老實說，我根本無概念可以從哪裡去得到它們，且這是否甚至是一項現在我在我西澳大利亞的鄉村小鎮就可以買到的東西。和我的家庭醫生交談就已經夠尷尬了。」（46 歲，西澳大利亞）

–

健康上的副作用

在 14% 表示擔心副作用的人中，一些人擔心短期或長期副作用以及其他現有的醫療狀況。

「文獻對長期使用保持沉默，作為糖尿病患者，我不希望 PrEP 增加腎損傷的風險。」 （48 歲，維多利亞）

一些人還認為 PrEP 是有毒的，並質疑為什麼他們應該服用不需要發揮作用的藥物。

「寧願不要在我的系統中添加一些可能對我造成傷害的藥物。」 （57 歲，維多利亞）

–

負面社會影響

對於 11% 的大多數人來說，他們不使用 PrEP 的原因是負面的社會影響，使用保險套是唯一負責任的預防策略，他們擔心廣泛使用 PrEP 會損害社區。這些參與者認為，任何不戴保險套的性行為都是不負責任和濫交的。他們認為 PrEP 是對他們社區的威脅，而不是擴大安全性行為的機會。

「我對自己的行為負責；接受 PrEP 的人有超越界限的傾向，對安全性行為採取漠不關心的態度。」 （25 歲，新南威爾士州）

–

缺乏對性傳染病感染之保護和有效性的擔憂

只有 4% 的受訪者在回答中提到了這個主題。他們表示他們寧願使用保險套來預防愛滋病毒和其他性傳染病感染。

「PrEP 也不能預防其他性傳染病之感染，保險套仍然至關重要。」 （24 歲，新南威爾士州）

一些人還質疑 PrEP 和可用數據的有效性。

「我沒有發現文獻上證明 PrEP比使用保險套提供更高水準的保護。」 （48 歲，維多利亞）

–

順從性

只有 14 名參與者 (2%) 提到了順從性問題。他們擔心無法遵循推薦的使用方法。

「我的記憶力往往很差。每天都要接受它是一個挑戰。」 （32 歲，新南威爾士州）

–

結論

大多數表示他們很少做任何有風險的事情並發現 PrEP 無關緊要的參與者，在評估他們目前感染 HIV 的風險方面可能是正確的；在調查時，他們並沒有資格參加 PrEP。然而，作者強調「雖然 PrEP 可能在特定時間點與某些人無關，但如果他們的性行為發生變化，這可能會改變」。他們補充說，一些人「可能會從『按需求使用 PrEP』的方式 中受益，這包括在高風險時期或特定的高風險事件中使用 PrEP，只要提供有關正確使用的明確信息」。

 

最後，在定性分析中多次提到了難以取得和尷尬，這顯示生活在農村地區或擁有對 PrEP 不太了解的醫生會使男同性戀和雙性戀男性認為無法獲得 PrEP。「繼續教育醫生了解 PrEP 的使用和益處可能有助於提高男同性戀和雙性戀男性的接受度和可及性」，Philpot 及其同事說。「此外，實施去集中化分散的照護模式，可能有助於解決那些從事高風險行為但卻擔心與醫療保健提供者接觸的男性其不接受 PrEP 的問題」。

參考文獻：

Philpot SP等人。澳大利亞男同性戀和雙性戀男性未使用 HIV 暴露前預防 (PrEP) 的原因：來自國家、線上、觀察性研究的混合方法分析。行為醫學，2022 年 2 月 17 日線上出版。

DOI：10.1080/08964289.2022.2033159

 

 

 

 

 

 

 

 

 

 

Preferences or circumstances? What makes gay and bisexual men in Australia choose not to take PrEP?

Oğuzhan Nuh / 14 April 2022 / aidsmap news

 

Image by Doctor 4U. Creative Commons licence.

Perceived irrelevance, lack of awareness, problems with access, side effects, negative social impacts, and concerns about lack of STI protection, effectiveness and adherence are the most common reasons for not using PrEP among gay and bisexual men in Australia. This is according to a study recently published in the journal Behavioral Medicine which analysed reasons for not using PrEP among gay and bisexual men based on individual characteristics and sexual behaviour.

The study was conducted in 2018 during a transition phase from PrEP being available through clinical trials to being available under the Australian universal healthcare system, Medicare. Although this made PrEP more accessible, the uptake of PrEP among gay and bisexual men remains suboptimal. Currently, 31,000 gay and bisexual men are estimated to be at higher risk of acquiring HIV and are eligible for PrEP in Australia, however only 18,500 people – mostly gay and bisexual men – are on PrEP.

Dr Steven Philpot from the Kirby Institute and colleagues conducted a mixed-method analysis based on data collected via an online survey from the Flux study in 2018. The quantitative analysis included responses from 1039 HIV negative gay and bisexual men who had never used PrEP. Most men in the sample (86%) identified as gay, and 9% identified as bisexual. Half of the participants were over 30, 60% were university educated, and most were in full or part-time employment.

In addition to demographic characteristics, participants were also asked about recent HIV testing, drug use and sexual practices. Data on sexual practices was collected in five categories: sex with boyfriends, sex with fuckbuddies, causal sex, group sex and chemsex. Participants were grouped into lower risk and higher risk of acquiring HIV. Higher risk of acquiring HIV was defined as any of the following in the last three months: condomless anal sex with a HIV-positive partner with a detectable viral load or not on treatment, receptive condomless sex with a casual partner, diagnosis of a rectal STI, or methamphetamine use.

Most of the non-PrEP users (79%) were classified as lower risk. Half of the participants indicated they were in a relationship with at least one man in the last six months, and four-fifths reported having sex with at least one man. Half of the men had tested for HIV in the last six months, and those in the higher risk group were more likely to have done so. Men in the higher risk group reported an average of 17 sexual partners in the previous six months compared to five reported by those in the lower risk group. Furthermore, more men in the higher risk group said they had condomless sex with casual partners (74%) and fuckbuddies (33%) than in the lower risk group (0% and 6%). In addition, just under half of the participants in the higher risk group said they used an illicit drug with 21% having used drugs to enhance sex in the last six months.  They were also more likely to find PrEP too expensive and were too embarrassed to ask for it, while men in the lower risk group were more likely to perceive PrEP as irrelevant.

Participants were also asked to answer a free text question in the survey: “Would you like to tell us more about why you do not use PrEP (anti-HIV pills) to help prevent you from getting HIV?“. From the bigger sample, 696 participants (67%) also answered this question and were included in the qualitative analysis.  Six themes for not using PrEP emerged from the answers: irrelevance, awareness and access, health side effects, negative social impacts, concerns about lack of STI protection and effectiveness, and adherence.

Irrelevance

There were two main reasons for perceiving PrEP as irrelevant. The first reason, stated by 25% of men, was being in a monogamous or a non-monogamous relationship that only allowed lower-risk sex or sex with condoms.

“HIV is not a concern I really have. I am in a long-term relationship, and my partner is HIV-negative. Although we are open, we really only restrict ourselves to unrisky sex practices, such as oral or hand jobs with casual partners, and are sure to use condoms where not – even casual partners are few and far between.” (22 years old, New South Wales)

The second reason stated by 20% of the participants was the frequency and type of sex not requiring PrEP use.

“I do not have sex often enough to warrant taking PrEP every day.” (30 years old, South Australia)

Awareness and access

Among the 19% that indicated awareness and access as the reason for not using PrEP, some did not know enough about PrEP or how to access it. In contrast, others knew about it but had difficulty getting a prescription. Some shared their experiences waiting to schedule a clinic appointment or believed their doctor was unwilling to prescribe or had no knowledge of PrEP.

“I want to get on PrEP, but the local clinics have very limited open hours and I work full time.” (26 years old, Australian Capital Territory)

Others felt discomfort asking for a prescription.

“To be honest, I have no idea where you would get them and if it’s a current thing I can even get in my rural town in Western Australia. It’s embarrassing enough talking to my regular GP.”(46 years old, Western Australia)

Health side-effects

Among the 14% that indicated concerns around side effects, some were concerned about short- or long-term side effects and other existing medical conditions.

“The literature is silent on long term usage and as a diabetic, I don’t want the increased risk of renal damage from PrEP.” (48 years old, Victoria)

Some also believed PrEP was toxic and questioned why they should take a medication they don’t need to function.

“Prefer to not add some drug into my system that could damage me.” (57 years old, Victoria)

Negative social impacts

For most of the 11% who stated negative social impacts as their reason for not using PrEP, condom use was the only responsible prevention strategy, and they worried wide use of PrEP would be damaging to the community. These participants believed any sex without condoms was irresponsible and promiscuous. They perceived PrEP as a threat to their community instead of a chance to broaden safer sex practices.

“I am accountable for my actions; guys who are on PrEP have a tendency to overstep boundaries and have a blasé approach to safe sex.” (25 years old, New South Wales)

Concerns about lack of STI protection and effectiveness  

Only 4% of the respondents mentioned this theme in their answers. They indicated that they would rather use condoms to prevent HIV and other STIs.

“PrEP also doesn’t protect against other sexually transmitted infections, condoms are still vitally important.” (24 years old, New South Wales)

Some also questioned the effectiveness of PrEP and available data.

“I don’t find the literature convincing that PrEP provides a higher level of protection than condom usage.” (48 years old, Victoria)

Adherence

Only 14 participants (2%) mentioned adherence concerns. They were worried about not following the recommended use.

“I tend to have a really bad memory. The need to take it on a daily basis would be a challenge.” (32 years old, New South Wales)

Conclusion

Most of the participants who said they rarely do anything risky and found PrEP irrelevant were probably correct in assessing their current risk of acquiring HIV as low; at the time of the survey they would not be eligible for PrEP. However, the authors highlight that “while PrEP may not be relevant for some at a given point in time, this may change if their sexual behaviour changes”. They add that some “may benefit from on-demand PrEP, which involves using PrEP during periods of high risk or for specific high-risk events, so long as clear messaging about its correct use is provided”.

 

Lastly, there were several mentions of inaccessibility and embarrassment in the qualitative analysis, which suggests that living in a rural area or having a doctor who does not know much about PrEP can make gay and bisexual men perceive PrEP to be inaccessible. “Continuing to educate doctors of the use and benefits of PrEP may facilitate increased acceptability and accessibility among gay and bisexual men,” say Philpot and colleagues. “Additionally, implementing decentralised models of care may help to address PrEP non-uptake among men who engage in higher-risk behaviours but are concerned about engaging with healthcare providers”. 

References

Philpot SP et al. Reasons for not Using HIV Pre-Exposure Prophylaxis (PrEP) among Gay and Bisexual Men in Australia: Mixed-Methods Analyses from a National, Online, Observational Study. Behavioral Medicine, online ahead of print 17 February 2022.

DOI: 10.1080/08964289.2022.2033159