Preparing for the impact of PrEP and the

diversification of gay men’s sex practices in WA:

insights from local and national behavioural data

Martin Holtm.holt@unsw.edu.au

@martinxholt

PrEP in Australia: some history

• PrEP initially shown to be effective in 2010 (Grant et al, 2010)

• Multiple studies have found >90% effectiveness in preventing HIV acquisition, particularly for gay and bisexual men, if users are adherent (Fonner et al, 2016)

• Debate began in Australia in 2011 about how to introduce PrEP

• In the absence of access, some GBM began personally importing

• Small demo projects ‘over East’ in 2014-15, followed by larger studies in 2016 e.g. EPIC-NSW, PrEPX, QPrEPD

• PrEPIT-WA opened in late 2017 (>700 enrolled)

• PBS listing of PrEP in April 2018

Now PrEP is here, what should we expect?

• Experience in eastern States shows introducing PrEP ‘at scale’ with GBM has had a variety of effects:

– demand on health systems/services

– engaging GBM at risk of HIV

– prevention of HIV among users

– increased STI diagnoses among users

– rapidly changing norms and sexual behaviour among GBM

– debate about who has been missed in early rollout

• PrEP roll out is experimental, and its effects (good and bad) will depend on local epidemic context (Holt & Murphy, 2017)

HIV testing (Perth GCPS)

83.4% 89.1%

62.0%73.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Ever tested

Tested in last 12 mths

Proportion who have ever been tested for HIV has increased since 2010.

Among non-HIV-positive men, proportion who have been tested in last year has stabilised since 2010.

Source: Perth Gay Community Periodic Survey, CSRH

Place of last HIV test (Perth GCPS 2017)

41%

25%

32%

2%

General practice

Sexual health clinic/hospital

Community-based service

Other

Community-based services (i.e. M Clinic) have become more popular over time.

Source: Perth Gay Community Periodic Survey, CSRH

4.9%

82.4%

1.7% 10.9%

HIV-positive

HIV-negative

No results

Untested

HIV status (Perth GCPS 2017)

Source: Perth Gay Community Periodic Survey, CSRH

HIV-positive men (Perth GCPS)

71.4%

90.0%82.9% 92.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

On treatment

Undetectable viral load

Proportion on treatment has increased.

Proportion of men on ART with an undetectable viral load has varied, but reached highest level in 2016.

Source: Perth Gay Community Periodic Survey, CSRH

23.0% 17.2%

42.5%

38.1%39.3%

44.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

No anal intercourse

Consistent condom use

Any condomless sex

Condomless sex has become more common during 2012-17.

Sex with casual male partners (last 6 mths)

Source: Perth Gay Community Periodic Survey, CSRH

60.0%

52.4%

27.3%

29.0%

44.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

HIV-positive

HIV-negative

Untested/unknown

CAIC by HIV status (Perth GCPS)

Source: Perth Gay Community Periodic Survey, CSRH; CAIC = condomless anal intercourse with casual partners

HIV-positive men HIV-negative men

Frequently used risk reduction strategies during CAIC

0%

10%

20%

30%

40%

50%

60%

70%

80%

2012 2014 2016 2017 2012 2014 2016 2017

Serosorting

Undetectableviral load

Strategicpositioning

PrEP

Source: Perth Gay Community Periodic Survey, CSRH; CAIC = condomless anal intercourse with casual partners

39.9%

63.7%

32.5%

67.8%

1.9% 1.2%4.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2010 2011 2012 2013 2014 2015 2016 2017

Aware of PEP(all men)

Aware of PrEP(all men)

Used PEP (non-HIV-positive)

Used PrEP (non-HIV-positive)

PEP and PrEP awareness have significantly increased.Low levels of recent use of PEP and PrEP.

Of the 26 men receiving PrEP in 2017, most (69%) were

Post- and pre-exposure prophylaxis (Perth GCPS)

Source: Perth Gay Community Periodic Survey, CSRH

Attitudes to PrEP (PrEPARE, national data)

52.158.1

41.0

36.127.9

23.030.0

36.5

0

10

20

30

40

50

60

70

80

90

100

2011 2013 2015 2017

%

Concerned aboutusing PrEP

Willing to use PrEP

21.5% 17.9% 17.2%

38.7%40.0% 38.1%

1.0% 3.0% 3.1%1.3% 5.1%

11.4% 10.7% 11.9%

25.9% 26.2% 25.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008 2010 2012 2014 2016 2017

CAIC (any receptive): HIV-negative/untested not on PrEP

CAIC (only insertive): HIV-negative/untested not on PrEP

CAIC: HIV-positive not on treatmentor detectable viral load

CAIC: HIV-negative on PrEP

CAIC: HIV-positive on treatment withundetectable viral load

Consistent condom use

No anal intercourse

The beginning of PrEP uptake in Perth

Source: Perth Gay Community Periodic Survey, CSRH

What has happened elsewhere? (GCPS)

17.8% 17.2% 18.3%

39.8%30.2% 26.5%

5.5%

6.5% 7.7%

4.5%15.6% 18.7%

0.8% 0.5% 0.8%9.8% 9.2% 8.9%

21.7% 20.8% 19.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2013 2014 2015 2016 2017 2018

CAIC (any receptive): HIV-negative/untested not on PrEP

CAIC (only insertive): HIV-negative/untested not on PrEP

CAIC: HIV-positive not ontreatment or detectable viral load

CAIC: HIV-negative on PrEP

CAIC: HIV-positive on treatmentwith undetectable viral load

Consistent condom use

No anal intercourse

Source: Gay Community Periodic Surveys, CSRH

Summary

• PrEP is being introduced to GBM in Perth against a backdrop of:– High levels of HIV testing

– HIV prevalence of ~5%

– High levels of treatment and viral suppression among HIV-positive men

– Gradually increasing condomless sex between casual partners

– HIV-positive men increasingly relying on undetectable viral load

– HIV-negative men relying on serosorting for condomless sex

– Increasing awareness of and willingness to use PrEP

• 2017 data from Perth GCPS show low uptake (<5%) & impact of PrEP, before PrEPIT-WA and PBS listing

• National GCPS data suggests large-scale PrEP uptake is likely to disrupt condom use

Questions & considerations

• It remains unclear whether declining condom use will impede population impact of PrEP (Holt et al, in press)

• If sustaining condom use is important, it remains unclear how to maintain it among GBM who don’t use PrEP

• Lower levels of condom use and higher levels of testing = more STI diagnoses and treatment

• Survey (& qualitative) data suggest rapid changes in experiences of GBM negotiating sex due to PrEP (good and not so good)

• Encouraging effective and supportive negotiation while new norms are being established is likely to be critical to long-term success.

Acknowledgments

• All the gay and bisexual men who participated

• WAAC: Matt Bacon, Matt Creamer, Andrew Burry, David Kernohanand the team of GCPS peer recruiters

• WA Department of Health: Sue Laing, Lisa Bastian

• Curtin University: Roanna Lobo

• CSRH: Evelyn Lee, Toby Lea, Dean Murphy, Limin Mao, John de Wit

• Kirby Institute: Iryna Zablotska, Garrett Prestage

• CSRH, the GCPS and PrEPARE are supported by the Australian Government Department of Health