Community-level changes in condom use and uptake of HIV PrEP by gay and bisexual men in Melbourne and Sydney

Lancet HIV (2018). Published online 06 June 2018. doi: 10.1016/S2352-301830072-9.

Abstract:

Background

Pre-exposure prophylaxis (PrEP) has been rapidly rolled out in large, publicly funded implementation projects in Victoria and New South Wales, Australia. Using behavioural surveillance of gay and bisexual men, we analysed the uptake and effect of PrEP, particularly on condom use by gay and bisexual men not using PrEP.

Methods

We collected data from the Melbourne and Sydney Gay Community Periodic Surveys (GCPS), cross-sectional surveys of adult gay and bisexual men in Melbourne, VIC, and Sydney, NSW. Recruitment occurred at gay venues or events and online. Eligible participants were 18 years or older (face-to-face recruitment) or 16 years or older (online recruitment), identified as male (including transgender participants who identified as male); and having had sex with a man in the past 5 years or identified as gay or bisexual, or both. Using multivariate logistic regression, we assessed trends in condom use, condomless anal intercourse with casual partners (CAIC), and PrEP use by gay and bisexual men, controlling for sample variation over time.

Findings

Between Jan 1, 2013, and March 31, 2017, 27 011 participants completed questionnaires in the Melbourne (n=13 051) and Sydney (n=13 960) GCPS. 16 827 reported sex with casual male partners in the 6 months before survey and were included in these analyses. In 2013, 26 (1%) of 2692 men reported CAIC and were HIV-negative and using PrEP, compared with 167 (5%) of 3660 men in 2016 and 652 (16%) of 4018 men in 2017 (p<0·0001). Consistent condom use was reported by 1360 (46%) of 2692 men in 2013, 1523 (42%) of 3660 men in 2016, and 1229 (31%) of 4018 men in 2017 (p<0·0001). In 2013, 800 (30%) of 2692 men who were HIV-negative or untested and not on PrEP reported CAIC, compared with 1118 (31%) of 3660 men in 2016, and 1166 (29%) of 4018 in 2017 (non-significant trend).

Interpretation

A rapid increase in PrEP use by gay and bisexual men in Melbourne and Sydney was accompanied by an equally rapid decrease in consistent condom use. Other jurisdictions should consider the potential for community-level increases in CAIC when modelling the introduction of PrEP and in monitoring its effect.

Public health and HIV viral load suppression

UNAIDS, 19 JULY 2017

Key messages:

1. There is growing scientific consensus that people living with HIV who are taking effective antiretroviral therapy and whose virus is suppressed to undetectable levels will not transmit HIV sexually.

2. Treatment is first and foremost about enabling the person living with HIV to regain and maintain good health. Globally, there needs to be better access to viral load assays at affordable prices, combined with effective laboratory systems and robust health services. Stronger efforts should be in place to ensure that all people living with HIV have access to treatment as soon as they are diagnosed.

3. The Positive Health, Dignity and Prevention10 framework of the Global Network of People Living with HIV (GNP+) and UNAIDS lays out important principles for involving people living with HIV and ensuring that everyone is responsible for prevention, irrespective of their HIV status. The framework calls for ending stigma, discrimination and unjust criminalisation that violate human rights and deter people living from HIV from accessing HIV prevention, treatment and care services.

4. The UNAIDS Fast-Track approach and the 2016 United Nations Political Declaration on Ending AIDS lay out recommendations that address the primary prevention and structural changes required to reach everyone affected and to provide accessible and affordable treatment for all people living with HIV.

5. Male and female condoms and other combination prevention strategies remain a key part of the HIV response as primary prevention tools. Stronger condom programming is essential to ensure sexual and reproductive health in general, not just HIV.