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Men at high risk for HIV may misjudge their vulnerability

By Andrew M. Seaman

NEW YORK (Reuters Health) - Many gay, bisexual and queer men who are good candidates for a drug that prevents HIV don’t believe their risk of being infected with the virus is high enough to warrant the drug’s use, suggests a new study.

The poor perception of HIV risk suggests people need to be educated about how to lower the chance of being infected, according to the researchers, who do HIV testing and other research in commercial sex venues in New York City.

“Our testers and counselors were always amazed that a lot of these guys underestimated their risk for HIV - anecdotally,” said Dr. Demetre Daskalakis, the study’s senior author and medical director of ambulatory HIV services at Mount Sinai Hospital in New York City.

“It seemed as if it would be an opportune time to ask the population where they were in accessing their own risk given that PrEP was recently approved,” he said.

PrEP, which stands for pre-exposure prophylaxis, is a way for people who are at risk of HIV but not infected to prevent infection by taking a pill every day. The pill currently approved by the U.S. Food and Drug Administration for PrEP is Truvada, which is manufactured by Gilead.

The risk of contracting HIV is up to 92 percent lower among people who take PrEP consistently, compared to those who don’t take the medicine, according to the U.S. Centers for Disease Control and Prevention (CDC).

Currently, more than 1.1 million people in the U.S. are living with HIV, but about 16 percent are unaware of their infection, according to the Department of Health and Human Services.

Daskalakis and his colleagues write in the journal LGBT Health that more than half of new HIV infections diagnosed in the U.S. are attributed to unprotected sex between men.

They write that the use of PrEP remains low despite its ability to reduce the risk of HIV infection.

For the new study, the researchers had men attending two bathhouses and a sex club in New York City fill out questionnaires about their sexual behaviors to find out whether they would be candidates for PrEP. They also asked people if they thought their sexual behavior warranted the use of PrEP.

The data were collected from 629 men between June 2011 and June 2012.

The men were considered eligible for PrEP if they met the entry criteria for iPrEX, one of the largest clinical trials of the drug. Some of those criteria include having anal sex with three or more partners, having condomless anal sex with a partner who is HIV positive or of unknown status and getting a recent diagnosis of a sexually transmitted infection (STI).

Overall, 505 men who were questioned met the PrEP criteria, but of those men who answered questions about their self-perceived risk 78 percent said their behaviors didn’t warrant its use.

“It wasn’t a big shock, because people who have been working on the project in the field doing HIV testing always remark that self-assessment of risk was pretty low,” Daskalakis said.

On the other hand, there was a small proportion of men who said their behaviors made them candidates for PrEP. Of those men, over 90 percent were right and did meet the criteria to use the pill.

“If you look at our data and look at the other side, the people who think they’re candidates usually are,” Daskalakis said.

While men attending bathhouses and sex clubs in New York City do not represent the behavior of all gay, bisexual and queer men across the country, other recent research at STI clinics reports the phenomenon of low self-perceived risk.

Dr. Albert Liu said his team’s research in Miami, San Francisco and Washington, D.C. showed a substantial number of men who decline PrEP report behaviors that may put them at risk for HIV infection.

Liu is the director of HIV prevention and intervention studies at Bridge HIV within the San Francisco Department of Public Health. He was not involved with the new study.

He added that his group’s research also shows that about 60 percent of men agree to take PrEP when it’s offered as part of a comprehensive prevention program.

“I think the research does suggest there could be room for improvement in terms of improving people’s risk perception,” Liu said. “At the same time, when we offered PrEP to people who are eligible, there are high levels of uptake.”

Daskalakis said people should look at their own risks and ask if PrEP is something they should consider. People with a healthcare provider should discuss their sexual behaviors with their provider, he said, and those without a healthcare provider should get one.

More information on PrEP can be found on the CDC’s websites (see here: http://1.usa.gov/1o5Xxjg.)

Daskalakis said the pill costs between $1,200 and $1,500 per month, but is covered by most insurance. The manufacturer also offers an assistance program. He added that people sometimes report bloating and flu-like symptoms when first taking Truvada and doctors should monitor PrEP patients for kidney function and bone loss.

“The side effects of Truvada exist and are things to worry about but the side effects of HIV are also not so good,” Daskalakis said.

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