We have shown that MSM who continue to use PEPSE in 2021 are significant more likely to be younger, identify as black or from another minority ethnic group, have engaged in group sex, used recreational drugs during sex and initiated PEPSE in the emergency department compared with those attending for PEPSE in 2017. Furthermore, MSM using PEPSE in 2021 are less likely to attend for follow-up appointments than in 2017. We suggest that this may be because older MSM are less likely to face barriers to accessing and using PrEP and therefore no longer seek PEPSE following condomless anal sex. It has already been shown that populations of MSM who use PEPSE have relatively high HIV seroconversion rates.
It is important that sexual health services and public health strategies focus on increasing access to sexual health services and PrEP for marginalized groups of MSM, especially MSM who are from black or minority ethnic groups, younger MSM and those who use recreational drugs and engage in group sex. In the UK currently, PrEP is only available from sexual health clinics and therefore these clinics need to work more closely with other stakeholders such as emergency departments, primary care and community settings (such as youth groups, charitable organizations or community health centres) to increase awareness of PrEP and access to PrEP. Furthermore, nationally, these data serve as a message to broaden access to PrEP outside of sexual health clinics, for example in community settings. Particular focus should be on settings that attract MSM from black and minority ethnic groups, and MSM who use recreational drugs and engage in group sex, which may include non-traditional settings such as sports groups and sex-on-premises venues. A further challenge is to maintain marginalized groups in follow-up for PEPSE and PrEP and this can be done by ensuring that clinical services are acceptable to all MSM. It is concerning that in an era where PrEP is readily accessible, some MSM continue to attend the emergency department for PEPSE, as these MSM miss other sexual health interventions including hepatitis A and B vaccination, human papilloma virus vaccination, provision of condoms and STI testing from sexual health clinics. However, it may be appropriate for some MSM to access PEPSE from emergency departments as sexual health clinics are not open 24 h a day.
We also found that of the 71% (20/28) MSM who attended for follow-up in 2021, all were offered transition to PrEP and 19/20 (95%) transitioned to PrEP. Given the high rates of HIV seroconversion seen in MSM who previously used PEPSE, appropriately transitioning patients on PEPSE to PrEP is important to further reduce HIV transmission.[4,5] These data also demonstrate the high level of acceptability and uptake of daily PrEP following attendance and discussion with a clinician. Overall there were numerically fewer MSM accessing PEPSE in 2021, and despite the COVID-19 pandemic the clinic was able to provide an optimal PrEP service, providing PrEP to an estimated 700 MSM, suggesting that the reason for the reduction in overall PEPSE use was individuals' access to PrEP.
There are several limitations to this study, including this being a small single-centre study, so the findings may not be generalizable to other populations of MSM. There were only 28 MSM accessing PEPSE in 2021, meaning that our analysis should be interpreted with caution. We were unable to capture MSM who attended the emergency department and either never attended follow-up in the sexual health clinic or attended a different sexual health clinic outside of the region. Furthermore, we relied on the clinician's contemporaneous notes for the retrospective collection of the data. The COVID-19 pandemic may have affected access and MSM attending for PEPSE and could be an under-representation of MSM who needed PEPSE in 2021. The COVID-19 pandemic may have reduced the number of MSM attending in 2021, adding to the small numbers of MSM attending for PEPSE in 2021. There were only four people who self-identified as transgender and therefore we have not been able to identify specific characteristics of transgender people who attend for PEPSE who may face specific barriers to accessing PrEP.
In conclusion, we have shown in this UK clinic-based study that some MSM are not using PrEP and continue to attend for PEPSE. These MSM are disproportionally young, from black and minority ethnic groups, engage in group sex and use recreational drugs during sex. Further qualitative research is needed to understand why particular groups are struggling to access PrEP and how PrEP services should be modified to extend their reach. We need to focus on increasing the accessibility to PrEP for all MSM in order to optimize the effect of PrEP as an effective HIV prevention strategy.
We would like to acknowledge the clinical team at University Hospitals Sussex NHS foundation Trust's Sexual Health and Contraception team.
This research was conducted in accordance with the World Medical Association Declaration of Helsinki. This was an anonymous database review so no patient consent was required.
1. MSM continue to use PEPSE despite PrEP being available
2. MSM using PEPSE in 2021 were significantly younger, from black or minority ethnic groups, engage in group sex involving recreational drugs and attend the emergency department for PEPSE compared with MSM using PEPSE in 2017.
3. Increasing the accessibility of PrEP for this group of MSM is important to optimize HIV prevention strategies.
HIV Medicine. 2022;23(5):553-557. © 2022 Blackwell Publishing