Abstract
While HIV infections among men who have sex men (MSM) have started to decline in the United States, Black MSM continue to experience disproportionate rates of HIV infection. The purpose of this secondary analysis is to examine risk perception and its influence on PrEP adherence among Black MSM from HPTN 073. Risk perception was measured using the adapted Perceived Vulnerability to HIV Scale. The associations between risk perception and PrEP adherence were tested using generalized estimation equation model for time-variant repeated measures. Risk perception was not significantly associated with PrEP adherence. These findings suggest an there was no risk compensation among PrEP users, and inconsistency in perceived risk for HIV. Future studies should investigate the rationale for long term adherence to PrEP among Black MSM.
Keywords: Black MSM, HIV pre-exposure prophylaxis, behavioral compensation, HIV prevention
Background
Black men who have sex with men (BMSM) continue to experience disproportionate rates of HIV in the US. In 2016, BMSM accounted for 38% of all new HIV acquisitions (CDC, 2019). While recent trends show a slight decline in HIV incidence among BMSM, these modest decreases are far less than among men who have sex with men (MSM) of other racial groups (CDC, 2016).
The declines in the overall HIV incidence in the US has been attributed to both a strong emphasis on comprehensive HIV prevention interventions and advances in biomedical primary and secondary HIV prevention. Pre-exposure prophylaxis (PrEP) with oral tenofovir/emtricitabine (Truvada®) demonstrated 44% efficacy versus placebo, but a 92% reduction in the risk of HIV acquisition among MSM with quantifiable drug concentrations (Grant et al., 2010), however, it is important to note only 9% of BMSM were represented in this study (Mehrotra et al., 2019)
One of the challenges to PrEP use is inconsistent and non-persistent use. PrEP uptake has been concentrated among White MSM, with an estimated 10% of PrEP users being BMSM (Huang et al., 2018; Kelley et al., 2015a). In several studies among BMSM taking PrEP, only between 12% to 20% of BMSM achieved protective levels (Chen & Dowdy, 2014; Kelley et al., 2015b).
Risk compensation has been offered as an explanation for low protective levels of PrEP for MSM. Risk compensation suggests individuals weigh potential risk and benefits of adopting different health behaviors based on their subjective level of risk acceptability (Holt & Murphy, 2017). The impact of risk compensation on sustained use of PrEP has been mixed. Several trials and demonstration projects reported greater risk compensation among those using PrEP (Hojilla et al., 2016; Koester et al., 2017), however, a meta-analysis of 18 PrEP trials found no evidence of risk compensation (Fonner et al., 2016; Koechlin et al., 2017). In these studies differences based on racial identity were not investigated. The purpose of this secondary analysis was to examine the relationship between risk perception and engagement in risk compensation (PrEP adherence) among BMSM from the HIV Prevention Trials Network (HPTN) 073 study. Risk compensation was defined as individuals who reported high levels of risk perception and engaged in a biomedical prevention method as a way to reduce their perceived risk for acquisition of HIV (e.g., BMSM who reported high risk perception and adherence to PrEP).
Methods
The secondary data analysis was conducted with data from HPTN 073. Demographic characteristics, substance use, sexual behavior, risk perception, depression symptomology, and HIV testing history data was captured from the psychosocial audio computer assisted self-interview (ACASI) measured at baseline, and at weeks 13, 26, 39, and 52. PrEP adherence was measured used dried blood spot (DBS) collected at weeks 8, 26, and 52. For the analysis, we used matched data for participants at weeks 26 and 52. A comprehensive description of the HPTN 073 study methods was published in a previous paper (Wheeler et al., 2019)
Measures
PrEP Adherence.
To assess for PrEP adherence, we collected DBS to measure intracellular tenofovir-diphosphate (TFV-DP) and emtricitabine-triphosphate (FTC-TP) in red blood cells, which provides an estimate of averaged adherence in the preceding 6–8 weeks prior (Anderson et al., 2018). We used ≥ 700 fmol/punch cutoff as an indicator of protective levels of PrEP based on 100% effectiveness in the iPrEx OLE among MSM (Grant et al., 2014).
Risk Compensation.
The outcome variable of risk compensation was operationalized as the combination of risk perception of HIV and condomless anal sex with a main partner and/or condomless anal sex with casual partners . Risk perception of participants was measured using the adapted Perceived Vulnerability to HIV Scale (Brooks, Lee, Stover, & Barkley, 2011). The 6-item Likert-like (1–6 range) scale assesses perceived risk for acquisition of HIV (strongly agree to strongly disagre). The items are summed with higher total score indicating greater risk perception. The internal consistency of this scale for the sample was moderate (α = 0.63). For analysis, the sum of the median possible score ≥ 19 was used as a cutpoint to categorize participants with high risk perception of HIV. Condom use with main partner and/or casual partner was assessed with three questions about condom use with partners based on sexual positioning and the HIV status of their sexual partner. For analysis, these questions were recoded so any “yes” response was coded as having condomless anal sex.
Covariate.
Substance use was assessed with a frequency of alcohol, marijuana, and non-injection drug use in the last 3 months. Injection drug use was not included in the substance use variable due to the small sample size. Depression was assessed using the Center for Epidemiologic Studies Depression (CES-D) Scale. The sum of the median possible score, ≥ 10 was used as a cutpoint to categorize participants with depressive symptoms. HIV testing was measured by asking participants, “When was your most recent HIV test before joining this study?” with response options ranging from “less than one month” to “1 year or more.” Self-efficacy was assessed due to the influence of self-effiacy in engaging in a prevention strategy. PrEP self-efficacy was measured using a 4-item scale measuring the degree in which individuals feel capable of taking PrEP (1- not true at all to 7- very true) with a higher score indicating high self-efficacy. The internal consistency of is scale for the sample was high (α = 0.95).
Data Analysis
The participants’ characteristics were summarized for each clinical research site and the overall sample. The prevalence of behavioral compensation was analyzed using chi-square test of independence. The associations between risk compensation and PrEP adherence were analyzed using logistic regression. We used generalized estimation equation model to account for the repeated outcomes measured at months 6 and 12, and adjusted for each clinical research site. We conducted analysis using SAS version 9.4.
Results
A full description of the participants in HPTN 073 was provided in the primary outcomes paper (Wheeler et al., 2019). Briefly, of the 226 participants enrolled, 60% were older than 25 years old, two-thirds had at least some college education, and almost half (48%) of the participants reported an annual income of less than $20,000. Participants who reported condom use with a main partner, condom use with casual partners, and accepted PrEP at baseline are described in Table 1.
Table I:
Baseline Characteristics of Black Men Who Have Sex with Men (MSM) Enrolled in HIV Prevention Trials Network Study 073; N=226
| GWUǂ N = 75 | UCLAǂ N = 76 | UNC AIDSǂ N = 75 | Totalǂ N = 226 | |
|---|---|---|---|---|
| Demographic characteristics | ||||
| Age ≥25 years | 55% (41) | 70% (53) | 55% (41) | 60% (135) |
| Median (IQR) | 28 (23–29) | 32 (24 – 39) | 28 (22–31) | 26 (23–32) |
| Highest education level attained | ||||
| HS or less | 17% (13) | 34% (26) | 23% (17) | 25% (56) |
| Some college or vocational school | 40% (30) | 36% (27) | 48% (36) | 41% (93) |
| Two-year college or greater | 43% (32) | 30% (23) | 29% (22) | 34% (77) |
| Annual income | ||||
| No response | 4% (3) | 0% (0) | 0% (0) | 1% (3) |
| <$20K | 23% (17) | 66% (50) | 55% (41) | 48% (108) |
| $20K - $40K | 21% (16) | 21% (16) | 31% (23) | 25% (55) |
| ≥$40K | 52% (39) | 13% (10) | 15% (11) | 27% (60) |
| Health insurance (current) | 80% (60) | 63% (48) | 63% (47) | 69% (155) |
| Married/significant other | 25% (19) | 13% (10) | 13% (10) | 17% (39) |
| Substance use in the last three months | ||||
| Any alcohol use | 89% (67) | 83% (63) | 92% (69) | 88% (199) |
| Any marijuana use | 53% (40) | 57% (43) | 36% (27) | 49% (110) |
| Any other drug use | 85% (64) | 72% (55) | 92% (69) | 83% (188) |
| Any poly drug use | 7% (5) | 18% (14) | 11% (8) | 12% (27) |
| Sexual behaviors in the last three months | ||||
| Number of male partners, median (IQR) | 2 (1,4) | 3 (1,5) | 3 (1,4) | 3 (1,4) |
| Sex with a male partner | 93% (70) | 93% (71) | 92% (69) | 93% (210) |
| Had a primary male partner | 35% (26) | 38% (29) | 25% (19) | 33% (74) |
| Any condomless anal sex with HIV+ or unknown primary male partner | 13 % (10) | 9% (7) | 9% (7) | 11% (24) |
| Had a casual male sex partner | 64% (48) | 71% (54) | 79% (59) | 71% (161) |
| Any condomless anal sex with HIV+ or unknown casual male partner | 28% (21) | 37% (28) | 37% (28) | 34% (77) |
| Exchanged sex for money | 11% (8) | 16% (12) | 9% (7) | 12% (27) |
| Depression symptomology | ||||
| CESD 10 scores, median (IQR) | 6.5 (3.0, 10.0) | 7.0 (4.0, 11.0) | 7.0 (5.0, 11.0) | 7.0 (4.0, 11.0) |
| HIV Risk perception median (IQR) | 24.0 (22.0 , 27.0) | 25.0 (23.0 , 26.0) | 24.0 (22.0 , 27.0) | 24.0 (22.0 , 27.0) |
| Most recent HIV test | ||||
| < 1 month | 27% (20) | 38% (27) | 20% (14) | 28% (61) |
| 1–6 months | 60% (44) | 50% (36) | 54% (38) | 55% (118) |
| 7–11 months | 8% (6) | 10% (7) | 9% (6) | 9% (19) |
| 1 year or more | 4% (3) | 3% (2) | 17% (12) | 8% (17) |
| Condom Self-Efficacy *** | ||||
| Condom Competency Scale, median (IQR), N | 25.0 (21.0, 28.0), 67 | 28.0 (19.0, 28.0), 70 | 27.0 (21.0, 28.0), 71 | 26.0 (19.0, 28.0), 208 |
| PrEP Self-Efficacy*** | ||||
| PrEP Competency Scale , median (IQR), N | 26.0 (20.0, 28.0), 67 | 26.0 (18.0, 28.0), 70 | 25.0 (20.0, 28.0), 71 | 27.0 (20.0, 28.0), 208 |
CESD10 score of 10+
It was not collected at baseline; four week visit data presented instead.
Row numbers may not add up to column total due to missing data (not shown)
IQR = interquartile range
Prevalance of risk compensation
In total, 79% of participants initated PrEP during the study period. At week 26, 64% of participants on PrEP were adherent based on DBS. Nine percent of participants who accepted PrEP, reported high risk for HIV and engaged in condomless anal sex with a main partner (χ2 (1, 175) = 1.96, p = .16). Among participants who accepted PrEP, 29% of particpants who reported high perceived risk for HIV acquisition engaged in condomless anal sex with casual partner or partners( χ2 (1,175) = 2.67, p = .10) (Table 2).
Table II:
Percentage of participants reporting high HIV risk perception by condomless anal sex partner type in HPTN 073
| Total Enrolled | Accepted PrEP | |||
|---|---|---|---|---|
| n | % | n | % | |
| Condomless anal sex | ||||
| Main Partner | 18 | 8.1 | 16 | 9.1 |
| Casual Partner(s) | 55** | 24.7 | 50 | 28.6 |
indicates p-value < 0. 05 and
indicates p-value < 0.001
Risk compensation and PrEP adherence
Knowledge of HIV-negative men on PrEP (OR = 2.13; p .02), knowledge of PrEP to prevent HIV infection (OR = 2.17; p = .02) PrEP self-efficacy (OR = 1.15; p < .01), and number of partners (OR, 1.02, p 0.01) were significantly associated with PrEP adherence. Neither of the two components of risk compensation were associated with PrEP adherence: high HIV risk perception (OR = .99; p = .54) and increased condom self-efficacy (OR = 1.01; p = .75). In the adjusted model, high PrEP self-efficacy was strongly associated with PrEP adherence (aOR = 1.19; p > .01) (Table 3).
Table III:
Unadjusted and Adjusted Associations between PrEP Adherence and Condomless Anal Sex among Black Men Who Have Sex with Men Enrolled in HIV Prevention Trials Network Study 073 (Visits week 26 and week 52)
| PrEP adherence (DBS) | ||
|---|---|---|
| Unadjusted OR± (95% CI) | Adjusted OR± (95% CI) | |
| Demographic characteristics | ||
| Age < 25 years | Ref | Ref |
| Age ≥25 years | 0.23 (0.12, .045) | 0.43 (0.19, 0.99) |
| Highest education level attained | ||
| HS or less | Ref | Ref |
| Some college or vocational school | 2.50 (1.00, 6.22) | 2.73 (0.86, 8.65) |
| Two-year college or greater | 6.66 (2.72, 16.30) | 2.38 (0.80, 6.26) |
| Annual income | ||
| <$20K | Ref | Ref |
| $20K - $40K | 3.27 (1.57, 6.81) | 1.83 (0.61, 5.49) |
| ≥$40K | 6.31 (2.83, 14.10) | 1.34 (0.53, 3.41) |
| Health insurance (yes vs. no) | 1.47 (0.79, 2.72) | |
| Married/significant other (yes vs. no) | 1.06 (0.51, 2.21) | |
| Substance use in the last three months | ||
| Alcohol use (yes vs. no) | 0.90 (0.54, 1.49) | |
| Marijuana use (yes vs. no) | 0.64 (0.38, 1.08) | |
| Other drug use (yes vs. no) | 1.07 (0.64, 1.76) | |
| Poly drug use (yes vs. no) | 0.82 (0.48, 1.41) | |
| PrEP Adherence | NA | |
| Sexual behaviors in the last three months | ||
| Number of male partners | 1.02 (1.01, 1.04) | 1.04 (1.02, 1.07) |
| Sex with a primary male partner (yes vs. no) | 1.15 (0.69, 1.90) | |
| Condomless anal sex with HIV+ or unknown primary male partner | 1.84 (1.01, 3.35) | 1.19 (0.53, 2.67) |
| Sex with casual male partner (yes vs. no) | 1.08 (0.68, 1.71) | |
| Condomless anal sex with HIV+ or unknown casual partner (yes vs. no) | 1.25 (0.67, 2.42) | |
| Exchanged sex for money (yes vs. no) | 0.60 (0.24, 1.53) | |
| Depression symptomology | ||
| CES-D symptom level (yes vs. no) | 0.77 (0.49, 1.19) | |
| Most recent HIV test | ||
| Less than 1 month | 5.48 (1.02, 29.40) | 7.36 (1.43, 37.9) |
| 1–6 months | 4.26 (0.84, 21. 6) | 9.15 (1.53, 54.8) |
| 7–11 months | 2.07 (0.28, 15.30) | 1.71 (0.14, 20.6) |
| 1 year or more | Ref | Ref |
| PrEP Knowledge | ||
| Knowledge of HIV negative men on PrEP (yes vs. no) | 2.13 (1.14, 3.96) | 1.21 (0.43, 2.91) |
| Knowledge of PrEP efficacy (yes vs. no) | 2.17 (1.14, 4.13) | 1.54 (0.55, 4.29) |
| HIV risk perception (yes vs. no) | 1.01 (0.95, 1.07) | |
| PrEP Self-efficacy (yes vs. no) | 1.15 (1.06, 1.25) | 1.16 (1.08, 1.25) |
| Condom Self-Efficacy (yes vs. no) | 0.99 (0.96, 1.02) | |
indicates p-value < 0. 05 and
indicates p-value < 0.001
All models were adjusted for study site.
Adherence is defined as ≥ 700 fmol/punch
Discussion
Overall, the prevalence of high risk perception for HIV was moderate (32%) among BMSM in the study. As expected, risk perception was higher among participants who accepted PrEP, with 61% of participants who accepted PrEP reporting high perceived risk for HIV acquisition. The current study found a high proportion of PrEP initiation among BMSM, which to date is one of the highest initiation rates in clinical studies for this population (Lelutiu-Weinberger & Golub, 2016; Smith et al., 2012).
The results found no risk compensation occurring among participants with respect to PrEP adherence. Among participants, HIV risk perception was not associated with adherence to PrEP. These findings are contradictory to the theoretical understanding of risk compensation and risk perception, which posits indivduals who engage in health promoting behavior would appraise their risk as low (Pinkerton, 2001) and furthermore the lack of association suggest other factors are motivating persons on PrEP to be adherent and/or that persons on PrEP may not equate PrEP use and HIV risk level. Future studies should investigate the rationale for long term adherence to PrEP among BMSM.
Limitations
While these findings have important implications for biomedical HIV prevention interventions, the study has several limitations. Risk perception is a subjective concept (Holt & Murphy, 2017). Individuals appraise their behavior based on contextual factors and determine if those factors carry significant risk. Previous research demonstrates individuals frequently underreport sexual risk behavior and perception of risk (Maulsby et al., 2014). While using an ACASI is effective at reducing social desirability bias when reporting sexual behavior, in previous studies using ACASI, we found contrary evidence in sexual behavior reporting (Daley et al., 2003). Even though these challenges exist, the results demonstrate the impact of risk compensation in BMSM over several months, illustrating inconsistency in psychological and behavior patterns (low perceived risk and PrEP use).
Conclusion
Findings from HPTN 073 contribute to advancing knowledge about the role of risk compensation among BMSM in the era of biomedical HIV prevention. The study demonstrated high levels of PrEP use and low risk compensation among BMSM. This study’s findings suggest perceived risk and risk compensation are not always congruent.
Acknowledgements:
The study was funded by the HIV Prevention Trials Network. The HIV Prevention Trials Network is funded by the NIAID of the NIH under award UM1AI068619 (HPTN Leadership and Operations Center), UM1AI068617 (HPTN Statistical and Data Management Center), and UM1AI068613 (HPTN Laboratory Center). Additional support was provided by the National Institute on Drug Abuse and the National Institute of Mental Health, of the NIH, US Department of Health and Human Services. The study product, tenofovir disoproxil fumarate/emtricitabine, was donated by Gilead Sciences, Inc.
Footnotes
Disclosure of Potential Conflict of Interest
L. N. has a patent on client-centered care coordination pending. M. M. reports textbook royalties from Jones and Bartlett Learning Inc unrelated to the present work. All other authors report no potential conflicts of interest.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Ethical Approvals
The institutional review boards at the University of California at Los Angeles, University of North Carolina at Chapel Hill, and George Washington University approved the parent study protocol. All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Boards of these institutions and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
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