There is a lack of data on ability and willingness of men who have sex with men (MSM) to self-fund HIV pre-exposure prophylaxis (PrEP). We aimed to explore how many eligible (PROUD study criteria) men may want PrEP and how many lower-risk MSM would be willing and able to self-fund this intervention. A self-completed anonymous questionnaire was distributed to MSM populations attending services. Of 377 participants, 81.5% were aware of PrEP. Fifty-three (15.5 %) were eligible, of whom 43 (81%) were very/extremely likely to want it. Of those ineligible, 229 (80%) were aware of PrEP and 106 (37.3%) were very/extremely likely to want it. Of eligible respondents 23% would be willing and able to pay at least £50 a month for PrEP. Of ineligible respondents this proportion was 21%. Our survey revealed high levels of awareness, understanding and willingness to take PrEP among MSM at high and lower risk of HIV acquisition. It indicated that over 70% of high-risk men would be unwilling or unable to self-fund PrEP, should it not be available on the NHS. For lower-risk MSM we estimated that capacity requirements for monitoring self-funded PrEP will be 50% higher than numbers eligible for PrEP. These factors will need to be taken into account when planning services.

IntroductionART initiation in primary HIV infection (PHI) could reduce risk of transmission to sexual partners at a time of high viraemia, although health benefit for the individual remains unknown. We examined attitudes to early ART and associated beliefs in men who have sex with men (MSM) with PHI.Materials and MethodsSemi-structured face-to-face in-depth interviews were conducted with 13 MSM aged ≥16 years attending a central London HIV clinic, within 12 months of date of estimated HIV seroconversion. Audio recordings of interviews were transcribed verbatim and analyzed thematically.ResultsMedian age was 33 years (range 22–47), majority were white British (n=8), educated to university level (n=11) and were not on ART (n=10). Great diversity in ART knowledge and expectations around starting were observed, with some men assuming they would be prescribed ART immediately upon diagnosis. Deferral until CD4<350 came as a surprise and counterintuitive when put into the context of treating other diseases. For many, the decision to start ART was a balance of current and future health and quality of life. Fear of side effects was prevalent, with many believing them inevitable and a reason to avoid early ART. A perceived lack of “good quality” evidence showing a health benefit of early ART caused confusion. Avoiding the decision to start or deferring to their HIV clinician was common, however reported clinicians’ views also varied. Some men voiced a desire to be proactive and start early ART to control viral replication. In these cases men also reported a belief that ART could be temporary as they expected a cure in their lifetime. Men commonly described feeling “infected” and reducing this infectiousness was seen as a major benefit of ART; not purely to reduce the risk of transmission to sexual partners but to facilitate disclosure to partners, reduce anxiety and guilt and restore sexual confidence commonly lost after HIV diagnosis. Having a long-term HIV-negative partner was a strong facilitator to starting ART to reduce transmission in the absence of good evidence of individual health benefit.ConclusionsFactors involved in the decision to start ART in PHI were complex. Uncertainty over individual health benefits in conjunction with fear of toxicities were barriers to starting ART early. By contrast ART was seen as a facilitator to disclosure, and as a way to limit the consequences of infection until a cure is found.

Background Numerous prospective studies have demonstrated that HIV transmission is greatly reduced in heterosexual HIV serodiscordant couples when the HIV-positive partner (HPP) is receiving combination anti-retroviral therapy (cART) with undetectable viral load (UVL). Comparable data in homosexual male serodiscordant couples (HM-SDC) are extremely limited. We report a pre-specified interim analysis of the relationship between UVL and HIV transmission in the Opposites Attract observational cohort study of HM-SDC in Australia, Bangkok and Rio de Janeiro. Methods HM-SDC reporting regular anal intercourse with each other were recruited through clinical sites. Detailed information on sexual risk behaviours was collected at each visit from the HIV-negative partner (HNP). HNPs were tested at baseline and follow-up for HIV antibodies and STIs (sexually transmitted infections), and HPPs for HIV viral load and STIs. Incidence rates were calculated per couple-year of follow-up (CYFU) using person-year methods, and stratified by whether different forms of condomless anal intercourse (CLAI) were reported. UVL was defined as <200 copies/mL. One-sided confidence intervals (CI) were calculated using the exact Poisson method. Linked HIV transmission in couples was defined by phylogenetic analysis. Results By December 2014, 234 HM-SDC were enrolled: 135 from Australia, 52 from Bangkok and 47 from Rio de Janeiro. There were a total of 150.0 CYFU in 152 couples with at least one follow-up visit of whom 65 (42.8%) were in a non-monogamous relationship. At baseline, 84.2% of HPPs were on cART and in total 82.9% had UVL. STI prevalence was 11.2% in HPPs and 6.6% in HNPs. There were 90.8 CYFU in periods where CLAI was reported with a total of 5,905 acts of CLAI in 88 couples. There were no linked HIV transmissions. The upper limit of the 95% CI of the transmission rate was 4.06/100 CYFU for periods in which CLAI was reported, and 6.46/100 CYFU for periods in which receptive CLAI was reported. Conclusions There were no linked HIV transmissions in 150 CYFU in these HM-SDC, despite close to 6,000 acts of CLAI. The upper confidence limit of the transmission rate during follow-up in periods during which CLAI was occurring was 4.06/ 100 CYFU. These data add to emerging evidence that the rate of HIV transmission in HM-SDC is very low when the HIV-positive partner is on ART. Further follow-up of a larger sample size is required to accurately delineate any residual risk.