Acceptability of HIV Pre-Exposure Prophylaxis (PrEP) and Implementation Challenges Among Men Who Have Sex with Men in India: A Qualitative Investigation

Abstract

This qualitative study explored the acceptability of HIV pre-exposure prophylaxis (PrEP) among MSM in India, and identified facilitators and barriers to future PrEP uptake. In 2014, we conducted 10 focus groups (n=61) among a purposive sample of diverse MSM recruited through community-based organizations in Chennai and Mumbai, and 10 key informant interviews with community leaders and health care providers. Participants' mean age was 26.1 years (SD 4.8); 62% completed secondary education, and 42% engaged in sex work. No focus group participants had heard of PrEP, but once explained, most reported they would likely use it. PrEP was alternately perceived as a 'back-up plan', a condom substitute, or a burden with concurrent condom use. Facilitators were potential for covert use, sex without condoms, and anxiety-less sex. Potential barriers emerged around stigma associated with PrEP use, fear of disclosures to one's family, wife, or male steady partner, and being labeled as HIV-positive or promiscuous by peers. Preferences emerged for intermittent rather than daily PrEP use, injectable PrEP, and free or subsidized access through community organizations or government hospitals. Key informants expressed additional concerns about risk compensation, non-adherence, and impact on ART availability for treatment. Demonstration projects are needed in India to support PrEP implementation tailored for at-risk MSM. Educational interventions for MSM should address concerns about PrEP effectiveness, side effects, and mitigate risk compensation. Community engagement may facilitate broad acceptability and challenge stigma around PrEP use. Importantly, provision of free or subsidized PrEP is necessary to making implementation feasible among low socioeconomic status MSM in India.

“Since both of us are using antiretrovirals, we have been supportive to each other”: facilitators and barriers of pre‐exposure prophylaxis use in heterosexual HIV serodiscordant couples in Kisumu, Kenya

“…Some HIV-uninfected individuals fear being labelled as HIV-infected if identified as using PrEP, which is consistent with findings from other studies [8,11,12,15]. Some participants associated PrEP use with promiscuity or commercial sex, while others worried that PrEP use would encourage riskier sexual behaviour, findings replicated in other studies [8,12]. On the contrary, analysis from the Partners PrEP study suggests that PrEP use does not lead to sexual disinhibition or reduced condom use in heterosexual couples [30].…”

“…Others have shown how PrEP can facilitate trust or enhance intimacy in a relationship [8,12,25]. Interestingly, some participants noted that their PrEP use motivated their infected partners to initiate ART, which is a novel finding of our study.…”

“…As PrEP moves from clinical trials to real-world use, understanding barriers to initiation of and adherence to PrEP is critical to successful PrEP implementation. In studies to date, which are mostly conducted among populations of men who have sex with men, certain facilitators of and barriers to PrEP use have been identified [8–12]. Factors that appear to facilitate PrEP use and adherence include certain drug characteristics, such as daily over intermittent dosing and ability to use PrEP covertly or when condom use may be difficult, and perceived support from study staff, family and friends.…”

Preference of Oral Tenofovir Disoproxil Fumarate/Emtricitabine Versus Rectal Tenofovir Reduced-Glycerin 1% Gel Regimens for HIV Prevention Among Cisgender Men and Transgender Women Who Engage in Receptive Anal Intercourse with Men

“…Although its definition varies among studies, acceptability in general is high [1] and may be affected by cost [2–8], perceived effectiveness [3–5], potential side effects [4,5,7], risk perception [1,7–10], dosing regimen (i.e., daily or intermittent) [2,11], and stigma (i.e., user being perceived as promiscuous) [7]. …”

Fórum PrEP: um debate on-line sobre uso da profilaxia pré-exposição no Brasil

“…Saúde Pública 2017; 33(11):e00112516 balhadores do sexo e HSH que praticam sexo anal desprotegido 20,21 . Isso faz com que os participantes busquem por conteúdos relacionados e que se reúnam para discuti-los.…”