Pre–exposure Prophylaxis: Awareness, Acceptability and Risk Compensation Behaviour Among Men Who Have Sex With Men and the Transgender Population

CK Uthappa; RR Allam; R Pant; S Pal; M Dinaker; G Oruganti; VV Yeldandi


HIV Medicine. 2018;19(4):243-251. 

In This Article

Abstract and Introduction


Objectives This exploratory study examined the facilitators of and barriers to acceptance of pre–exposure prophylaxis (PrEP) and potential risk compensation behaviour emerging from its use among men who have sex with men (MSM) and transgender individuals (TGs) in India.

Methods A questionnaire was administered to 400 individuals registered with a targeted intervention programme. Logistic regression models were used to identify facilitators of and barriers to PrEP acceptance.

Results The respondents consisted of 68% MSM and 32% TGs. Risk behaviour categorization identified 40% as low risk, 41% as medium risk and, 19% as high risk for HIV infection. About 93% of the respondents were unaware of PrEP, but once informed about it, 99% were willing to use PrEP. The facilitators of PrEP acceptance were some schooling [odds ratio (OR) 2.16; P = 0.51], being married or in a live–in relationship (OR 2.08; P = 0.46), having a high calculated risk (OR 3.12; P = 0.33), and having a high self–perceived risk (OR 1.8; P = 0.35). Increasing age (OR 2.12; P = 0.04) was a significant barrier. TGs had higher odds of acceptance of PrEP under conditions of additional cost (OR 2.12; P = 0.02) and once–daily pill (OR 2.85; P = 0.04). Individuals identified as low risk for HIV infection showed lower odds of potential risk compensation, defined as more sexual partners (OR 0.8; P = 0.35), unsafe sex with new partners (OR 0.71; P = 0.16), and decreased condom use with regular partners (OR 0.95; P = 0.84), as compared with medium–risk individuals. The associations, although not statistically significant, are nevertheless important for public health action given the limited scientific evidence on PrEP use among MSM and TGs in India.

Conclusions With high acceptability and a low likelihood of risk compensation behaviour, PrEP can be considered as an effective prevention strategy for HIV infection among MSM and TGs in India.


With 2.1 million people living with HIV and 86 000 new infections in 2015, India has the third largest HIV epidemic in the world.[1] Unlike other high–burden countries, the HIV epidemic in India continues to be primarily concentrated among high–risk groups (HRGs) which include female sex workers (FSWs), men who have sex with men (MSM), transgender individuals (TGs) and injecting drug users (IDUs).[2]While the overall HIV prevalence among antenatal clinic (ANC) attendees (considered a proxy for prevalence among the general population) continues to decline, the prevalence among MSM and TGs remains high, at 4.3 and 8.8%, respectively.[2] The epidemic is characterized by a high degree of inter–state variability, with the state of Andhra Pradesh (undivided) having the highest burden among MSM, with a prevalence of 10.1%.[2]

Key HIV prevention strategys for HRGs in India have been targeted intervention (TI) encompassing behaviour change communication (BCC), condom promotion, and HIV testing and counselling.[3] Significant gains have been achieved in the past, but recent data have shown evidence of ongoing transmission of HIV among MSM/TGs.[4,5] This can be attributed, in part, to high–risk sexual behaviour among MSM/TGs in India.[6,7] Nondisclosure of HIV status remains high and is associated with high–risk behaviours such as having multiple sexual partners and unprotected anal intercourse.[8] Consistent condom use is low overall in self–identified MSM/TGs.[6,9–11] MSM in India also frequently report having both male and female sexual partners, and increased incidences of condom breakage and substance abuse (consumption of alcohol before or during sex).[12–15] This underscores the need for additional and novel prevention strategies to help halt and reverse the epidemic in India.

One such recent advancement in combatting the epidemic is pre–exposure prophylaxis (PrEP).[15–18] The efficacy of PrEP has been demonstrated in multiple randomized controlled trials across different geographical settings and among different HRGs.[19–22] The World Health Organization (WHO) recommends oral PrEP containing tenofovir disoproxil fumarate (TDF) as an additional prevention choice for people at substantial risk of HIV infection.[23]

Despite the demonstrated efficacy of PrEP as a new HIV prevention strategy, guidance for its use among HRGs in India remains unclear. Past experience of HIV prevention in India suggests that advocacy for PrEP can be successful only by ensuring effective community engagement and by remaining sensitive to beliefs.[24] To improve uptake of PrEP among HRGs, it is vital to understand existing knowledge of and attitudes towards use of PrEP and the anticipated change in risk behaviour pattern that may follow adoption of PrEP as an HIV prevention tool.

Currently, there is a paucity of literature on the acceptability of PrEP among the MSM/TG population in India. This study aimed to understand the facilitators of and barriers to PrEP uptake among MSM/TGs in a high HIV prevalence state in India and to determine whether there was an increase in high–risk sexual behaviour (risk compensation behaviour) after PrEP use. The evidence derived from this study will aid the national programme in designing tailored, efficient and high impact–driven prevention strategies required for control of the epidemic in India.