Cost and anonymity as factors for the effective implementation of pre-exposure prophylaxis: an observational study among gay, bisexual and other men who have sex with men in Singapore

Abstract

Background HIV pre-exposure prophylaxis (PrEP) is currently offered by several public and private clinics at unsubsidised prices in Singapore, but to date, no information is available on the effect of these services. This study sought to assess the knowledge and uptake of, and willingness to use PrEP among gay, bisexual and other men who have sex with men (GBMSM) in Singapore. Methods: Recruitment was conducted through Grindr®, a geosocial networking application for GBMSM. Results were quantitatively analysed through descriptive statistics and multivariate Poisson regression models, while open-ended responses were qualitatively coded and categorised. Results: Of the 1339 participants who responded, 1098 participants who indicated their knowledge and use of PrEP were included in the analytic sample. Overall, 15.0% (n=154) had taken PrEP, 66.2% (n=678) had heard of but not taken PrEP, while 18.8% (n=193) had never heard of PrEP. Of those who had ever taken PrEP, 59.6% (n=90) had obtained PrEP from overseas or other unofficial sources. Of those who had heard of but never taken PrEP, 73.3% (n=486) reported that they would consider taking PrEP. Those who had taken PrEP were older and had higher educational attainment. Conclusions: The gap between the willingness to use PrEP and its uptake may be attributed to the cost of PrEP and issues of anonymity at healthcare settings in Singapore. National financing schemes are needed to expand access to PrEP if it is to make a meaningful effect to the Singapore HIV/AIDS response.

HIV Pre-Exposure Prophylaxis, Condoms, or Both? Insights on Risk Compensation Through a Discrete Choice Experiment and Latent Class Analysis Among Men Who Have Sex With Men

“…First, this study found that accessing PrEP at the anonymous testing site (compared with government-run hospitals and clinics) and follow-up care visits at nongovernment hospital settings with a longer follow-up time of once a year (compared with quarterly visits) were valued by potential users and could encourage PrEP use, as would lower prices. These findings corroborate findings from prior studies in Singapore, 14,15 which suggest that anonymity of sexual health services and costrelated issues were the main barriers to accessing PrEP among GBMSM. Second, this study also found that utility for PrEP use decreased with increasing perceived risk of HIV and other STI acquisition per sexual act while using PrEP for participants in general, however this inverse relationship exhibited a steeper curve for perceived risk of HIV acquisition compared with that of perceived STI acquisition risk, likely due to greater perceptions of HIV severity and susceptibility in GBMSM.…”

“…This study follows a qualitative study on the acceptability of PrEP and a cross-sectional study on PrEP use among GBMSM in Singapore. 14,15 This study was conducted as a web-based survey hosted on Sawtooth Software (Sawtooth Software, Inc, Provo, UT), and disseminated by Grindr. Grindr is a popular application (app) for smartphones and tablets that was designed to allow GBMSM to connect with other individuals through the geolocation capabilities of individual devices.…”

“…Several preliminary studies informed the selection of attributes for the DCE. 14,15 From these studies, 2 key concerns around PrEP access emerged: first, access to PrEP medication, and second, follow-up care visits while taking PrEP. Attributes identified for PrEP medication included the cost and location of accessing the medication, whereas attributes for follow-up care visits included the cost, location, and frequency per visit.…”

“…A study among 1098 GBMSM conducted in 2017 on Grindr, a geosocial networking smartphone application, had found that about 15.0% of GBMSM surveyed had ever taken PrEP, although many participants had obtained PrEP overseas owing to the high cost of PrEP in Singapore, which remains unsubsidized by the government. 14 Singapore provides a compelling setting to explore such considerations, as its small geographical area, standardized compulsory sexual education programs for all school students, and intense community-based sexual health promotion efforts around condom use and distribution in the GBMSM community allow us to standardize several assumptions regarding perceptions around condom use efficacy and access to healthcare services that may arise in other more heterogeneous settings. Participants are also asked to compare these considerations for accessing PrEP in lieu of, or accompanied by, condom use.…”

Getting pre-exposure prophylaxis (PrEP) to the people: opportunities, challenges and examples of successful health service models of PrEP implementation

“…Tan et al describe some other PrEP implementation challenges from the experience in Singapore, 25 where PrEP is available at unsubsidised prices. Tan et al argue that even in high-income settings, national financing schemes will be important to ensure large-scale access to PrEP.…”