The authors have declared that no competing interests exist.
Antiretroviral pre-exposure prophylaxis (PrEP) against HIV acquisition has been shown to be safe and effective in populations at risk of HIV acquisition. We examined PrEP awareness, experience and acceptance among men who have sex with men (MSM) in southwest Switzerland.
Between 1st June 2011 and 31st August 2012, individuals attending 1) MSM screening clinics (Checkpoint Geneva) and 2) meeting areas were invited to complete an anonymous questionnaire covering sexual practices and PrEP awareness, experience and interest in participating in future PrEP trials.
Of 918 men approached, 654 (71%) agreed to participate, the majority (536/654, 82%) enrolled via Checkpoint. Most participants (512/654, 78%) were homosexual; 21/654 (3.2%) disclosed being HIV-positive; 140/654 (21%) had unknown HIV status. Unprotected anal intercourse (UAI) with a partner of different or unknown HIV status (non-serosorting) was practised by 49% of participants during the preceding year, more by participants of positive / unknown HIV status than by those negative / undisclosed status (68% vs 43%,
This is the first study exploring MSM PrEP awareness in Switzerland. Although overall awareness was 42%, interest in participating in future PrEP trials was low, against high frequencies of UAI and non-serosorting. If interest in using PrEP in practice is similar, alternative measures to curb HIV transmission are required in this population.
Antiretroviral pre-exposure prophylaxis (PrEP) has been shown to be safe and effective in specific populations at substantial risk of HIV acquisition, including sexually-active men who have sex with men (MSM) (iPrEx Study
Little is known regarding PrEP awareness in Switzerland. In the Swiss cantons of Geneva and Vaud, southwest Switzerland, HIV incidence figures are among the highest in the country, with up to 12-16 new positive tests per 100,000 inhabitants in 2012
The study was approved by the Ethical Commission of the Canton of Vaud (approval number 71/11) and consisted of a questionnaire-based survey conducted between 1st June 2011 and 31st August 2012. Trained field workers recruited individuals from 1) Checkpoint Geneva, a health centre for MSM providing counselling and screening for sexually transmitted infections (STIs), and 2) targeted meeting places, both indoor (saunas, sex clubs) and outdoor (cruising areas and Pride event).
Questionnaires, completed anonymously under field-worker supervision, covered demographic information, sexual preference, HIV status and testing history, STI history, practice of unprotected anal intercourse (UAI) and partner number in the preceding twelve months. Participants were asked if they were aware of a prophylactic treatment taken before exposure to HIV (response options: ‘very aware’, ‘slightly aware’ and ‘unaware’), if they had ever taken antiretroviral therapy (ART) to protect themselves against HIV acquisition before sex (response options: ‘yes’ and ‘no’), and if they would agree to participating in a clinical trial examining the protective efficacy of ART taken before potential HIV exposure (response options: ‘yes’ and ‘no’).
Continuous and categorical data were analysed using Student’s t-test and the Chi squared or Fisher’s exact test, respectively, using Microsoft Excel 2008 (Microsoft Corporation, Redmond, WA, USA). The percentage of individuals recruited of those approached was calculated but individuals declining to participate were not assessed.
Of 918 men approached, 654 (71%) agreed to participate, the majority of whom (536/654, 82%) were enrolled via Checkpoint Geneva (
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Approached, n | 918 | 665 | 165 | 88 |
Participating, n (%) |
654 (71) | 536 (81) | 86 (52) | 32 (36) |
Median age, years (range) | 33 (16-80) | 33 (16-80) | 33 (17-69) | 34 (24-61) |
Nationality, n (%) | ||||
Swiss | 347 (53) | 294 (55) | 37 (43) | 16 (50) |
Neighbouring countries |
139 (21) | 103 (19) | 27 (31) | 9 (28) |
Sexual preference, n (%) | ||||
Homosexual | 512 (78) | 422 (79) | 60 (70) | 30 (94) |
Bisexual | 140 (21) | 112 (21) | 26 (30) | 2 (6.3) |
Missing data | 2 (0.003) | 2 (0.004) | 0 (0) | 0 (0) |
HIV status, n (%) | ||||
HIV positive | 21 (3.2) | 14 (2.6) | 2 (2.3) | 5 (16) |
HIV negative | 431 (66) | 336 (63) | 74 (86) | 21 (66) |
Unknown | 140 (21) | 127 (24) | 9 (11) | 4 (13) |
Undisclosed | 62 (9.5) | 59 (11) | 1 (1.2) | 2 (6.3) |
HIV testing history |
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Tested in last 12 months, n (%) | 414 (65) | 340 (63) | 57 (66) | 17 (53) |
Never tested, n (%) | 72 (11) | 63 (12) | 7 (8.1) | 2 (6.3) |
STI screen in last 12 months, n (%) | 337 (52) | 273 (51) | 46 (54) | 18 (56) |
STI treated in last 12 months, n (%) | 72 (11) | 53 (9.9) | 15 (17) | 4 (13) |
UAI practised, n (%) | 357 (55) | 296 (55) | 41 (48) | 20 (63) |
UAI without sero-sorting, n (%) | 321 (49) | 280 (52) | 24 (28) | 17 (53) |
Median partner number |
5 (0-400) | 5 (0-160) | 7 (0-241) |
10 (0-400) |
107 (16) | 97 (18) | 8 (9.3) | 2 (6.3) | |
Aware of PrEP | ||||
Very aware, n (%) | 110 (17) | 103 (19) |
4 (4.7) | 3 (9.4) |
Slightly aware, n (%) | 164 (25) | 152 (28) |
9 (11) | 3 (9.4) |
Previous PrEP experience | 10 (1.5) | 10 (0.9) | 0 (0) | 0 (0) |
Agree to participate in PrEP trial | 132 (20) | 119 (22) | 8 (9.3) | 5 (16) |
Other venues = sex clubs, cruising areas and Pride event;
All subsequent percentages are calculated taking participant number, not number approached, as the denominator;
French, German and Italian;
In participants of non-positive HIV status, n=633;
Partner number referred to the number of sexual partners in the last 12 months, whether intercourse was protected or unprotected.
P<0.001.
Abbreviations: STI, sexually transmitted infection; UAI, unprotected anal intercourse; PrEP, pre-exposure prophylaxis.
Regarding PrEP, 110 (17%) were very aware and 164 (25%) slightly aware. Awareness was significantly higher among Checkpoint participants than those recruited from meeting places (47% versus 16%,
In this group of predominantly HIV-negative, European MSM, we observed that 42% had some PrEP awareness but PrEP experience was very low. Only 20% (132/654) were interested in participating in a future PrEP trial, against 59% (360/633) potentially eligible for PrEP (non-HIV-positive and reporting UAI and/or a recent STI diagnosis
The low PrEP acceptance we observed might be related to the then non-endorsement by the Swiss federal office of public health, drug costs, and the timing of the study. Our survey was conducted between six and eighteen months after the publication of the iPrEx Study
Between 2012 and 2014, two multi-centre trials were conducted among high-risk MSM using either daily (PROUD
This study has limitations. Selection bias is possible, as the majority of participants were recruited from Checkpoint rather than from meeting venues, and this might have increased PrEP awareness and experience. We have no information regarding the MSM approached but not recruited, so it is not possible to quantify potential selection bias. Finally, as described above, the timing of the study in relation to subsequently published PrEP data may have led to awareness and acceptance figures which are not currently valid.
In conclusion, we observed 42% PrEP awareness and low acceptance among MSM in Switzerland after the iPrEx study, against high frequencies of UAI and UAI without sero-sorting. In the light of new data on the efficacy of daily and intermittent PrEP in high-risk MSM, PrEP acceptance in practice, as opposed to trial participation, may grow. In the meantime, and while PrEP costs are charged to the individual, measures to prevent HIV acquisition such as condom use, regular HIV screening and immediate access to ART still need to be promoted in Switzerland.
We express our sincere gratitude to the team at Checkpoint Geneva for recruiting participants for this study, from Checkpoint and other venues, and for conducting all the questionnaires.