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Journal of Prevention & Treatment of HIV/AIDS

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Research Article

HIV Preexposure Prophylaxis among U.S. Adults: Awareness of and Willingness to Recommend or Take - HealthStyles Surveys, 2009-2014

Romeo R. Galang, Maria C. B. Mendoza, Dawn K. Smith

Correspondence Address :

Romeo R. Galang
Epidemiology Branch
Division of HIV/AIDS Prevention
National Center for HIV/AIDS, Viral Hepatitis
STD and TB Prevention, Centers for Disease Control and Prevention
USA
Tel: 404-639- 6387
Email: RGalang@cdc.gov

Received on: November 01, 2017, Accepted on: November 16, 2017, Published on: November 23, 2017

Citation: Romeo R. Galang, Maria C. B. Mendoza, Dawn K. Smith (2017). HIV Preexposure Prophylaxis among U.S. Adults: Awareness of and Willingness to Recommend or Take - HealthStyles Surveys, 2009-2014

Copyright: 2017 Romeo R. Galang, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract
Background: Because adults in the U.S. at substantial risk for HIV acquisition would benefit from effective prevention using HIV preexposure prophylaxis (PrEP), information is needed about knowledge and attitudes toward PrEP in this population. We described trends in awareness and willingness to recommend or take PrEP using data from the HealthStyles surveys.
Methods: U.S. adults aged ≥18 years were surveyed between 2009-2010 and 2012-2014 to assess awareness of PrEP, willingness to recommend PrEP, and willingness to take PrEP. Prevalence ratios and adjusted linear trend analyses were computed using modified Poisson regression analysis.
Results: Among 19,806 adults surveyed in years 2009-2010 and 2012-2014, 6.5% reported wareness of PrEP. Following a description of PrEP, 78.6% of respondents indicated willingness to recommend PrEP for friends or family members at risk of getting HIV, and 39.8% were willing to take PrEP themselves. Awareness of PrEP increased while willingness to recommend or take PrEP decreased significantly over the 5 surveys.
Conclusions: Among adults in the general U.S. population, awareness of HIV preexposure prophylaxis is low but increasing. U.S. adults have strong but decreasing interest in recommending or taking PrEP after it has been described to them. It will be important to continue monitoring knowledge and attitudes among adults as the use of PrEP increases.
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Introduction
The prevention of human immunodeficiency virus (HIV) infection represents a substantial public health challenge in the United States. An estimated 1.2 million adults in the United States are at substantial risk for HIV acquisition and would benefit from effective prevention methods, including the use of HIV Preexposure Prophylaxis (PrEP) [1].
The potential impact of PrEP on HIV infection risk was widely discussed as early as 2007 in anticipation of clinical trial results [2,3]. Based upon clinical trials which demonstrated the effectiveness of daily tenofovir dixoproxil fumurate and emcitirabine (TDF/FC) in preventing HIV acquisition, the Centers for Disease Control and Prevention published interim guidelines in 2011 for use of PrEP for prevention of HIV infection in men who have sex with men and in 2012 for heterosexually active adults [2-10].
The use of PrEP was approved by the U.S. Food and Drug Administration (FDA) in 2012, and in 2014, the U.S. Public Health Service issued clinical practice guidelines for PrEP, recommending evaluation of patients and prescribing PrEP as one prevention option for those whose sexual or injection behaviors and epidemiologic context place them at substantial risk of acquiring HIV infection [11]. To achieve the goal of reducing the number of new HIV infections, the 2015 National HIV/AIDS Strategy recommends full access to comprehensive PrEP services [12]. Studies of awareness of PrEP and willingness to take PrEP that focused on populations at high risk of HIV infection (e.g., men who have sex with men [MSM]) have demonstrated varying levels of awareness of PrEP, but high interest in taking PrEP after it has been described [13-27].
Lack of awareness within the general public may be an important barrier for uptake of PrEP. Health communication efforts could be broadened to reach not only people who are at substantial risk of HIV infection but also members of the general public and healthcare professionals to reduce barriers related to lack of awareness about PrEP. This analysis was undertaken to guide PrEP education and prevention efforts by describing trends, during 2009-2014, in overall awareness of and willingness to recommend or take PrEP among members of the general U.S. adult population, and by describing associated demographic characteristics.

Materials and Methods

Survey methods

Data for this study were obtained from Porter Novelli's Styles surveys, an annual series of cross-sectional surveys designed to be nationally representative of U.S. consumers. Responses to survey questions are used to assess awareness, attitudes, and behaviors for various health-related topics and obtain information on selfreported diseases and conditions.
Each year for the ConsumerStyles survey, potential respondents were randomly recruited from a large, nationally representative sample of non-institutionalized adults aged ≥18 years living in the 50 United States or the District of Columbia. A random subset of respondents who completed the ConsumerStyles survey was then sent a second survey, HealthStyles. Completion of each survey took approximately 40 minutes. The 2009 and 2010 HealthStyles surveys were administered via mail; beginning in 2011, surveys were administered online.
We analyzed responses to PrEP-related questions on the 2009-2010 and 2012-2014 surveys. PrEP-related questions were not included in the 2011 ConsumerStyles or HealthStyles surveys.
- Have you ever heard of HIV preexposure prophylaxis or PrEP before today?
- If you had friends or family members who were at risk of getting HIV infection, would you want them to be given PrEP?
- Would you want to take PrEP yourself?
In 2012, the description of PrEP that accompanied survey questions was updated to reflect the published clinical-trial data on the effectiveness of PrEP. In the 2009 and 2010 HealthStyles surveys, respondents were asked to imagine that studies show that PrEP is safe and prevents HIV infection in 75% of persons who take it every day. In 2012, the description was updated to state that HIV infection can be prevented among approximately 90% of persons who take their pills nearly every day.
The description of PrEP was similarly updated to reflect a change in FDA status-from experimental to approved status: Scientists are now doing studies to find new ways to keep people from becoming infected with HIV. In these studies, people take a pill every day that contains some of the same medicines that are used to treat people after they are infected with HIV. Scientists want to see if taking this kind of medicine will block infection when people are exposed to HIV. This method is called preexposure prophylaxis or PrEP. (HealthStyles Surveys 2009-2010).
- A new way to help keep people from becoming infected with HIV has been found. If people take one pill every day, the two medicines in the pill can block infection when people are exposed to HIV. This method is called preexposure prophylaxis or PrEP. (HealthStyles Surveys 2012-2014).

The number of respondents for the years 2009, 2010, 2012, 2013, and 2014 are as follows:

- 2009 surveys: Of the 21,420 respondents invited, 10,587 (49.4%) completed the ConsumerStyles survey. Of 7,004 eligible respondents, 4,556 completed the HealthStyles survey (response rate, 65%).

- 2010 surveys: Of the 20,000 respondents invited, 10,328 (51.6%) completed the ConsumerStyles survey. Of 6,255 eligible respondents, 4,184 (66.9%) completed the HealthStyles survey.

- 2012 surveys: Of the 11,636 respondents invited, 6,728 (57.8%) respondents completed the ConsumerStyles survey. Of 4,703 eligible respondents, 4,044 completed the HealthStyles survey (response rate, 86.0%).

- 2013 surveys: Of the 11,188 respondents invited, 6,717 (60.0%) respondents completed the ConsumerStyles survey. Of 4,420 eligible respondents, 3,502 (72.5%) completed the HealthStyles survey.

- 2014 surveys: Of the 11,018 respondents invited, 6,713 (60.9%) respondents completed the ConsumerStyles survey. Of 4,594 eligible respondents, 3,520 completed the HealthStyles survey (response rate, 76.6%).

Analysis Methods

Unweighted frequencies and both weighted and unweighted percentages were calculated to describe the sample population (Figure 1). Survey weights were created by Porter Novelli using the Current Population Survey (CPS) of the U.S. Census. Data from 2009-2010 surveys were weighted to be representative of the U.S. population for gender, age, income, race, and household size (http://www.census.gov/cps). Each year was weighted to the CPS of the preceding year. Data from 2012-2014 surveys were weighted to be representative of the U.S. population using the latest March supplement of the CPS for gender, age, income, race, and household size, education, census region, metro status, and prior internet access. Both unweighted and weighted percentages were computed for demographic characteristics. Comparison of the weighted and corresponding unweighted percentages showed that for the most part weighted percentages were similar to unweighted percentages except for the age distribution among the total sample population, and among the subsample of respondents who reported if they were or were not aware of PrEP.
Weighted percentages were calculated to describe the percent of respondents aware of PrEP and willing to recommend or take PrEP, by demographic characteristics (age category, sex, race, highest level of education, household income, marital status, self-perceived risk of HIV infection, sexual orientation). For the purpose of this analysis, sexual orientation was inferred from reported sex (male, female) and reported sex of sex-partners in the past year (men, women, both men and women). Generalized estimating equations using a robust variance estimator and assuming a Poisson model with an independent working correlation matrix were used to compute weighted univariable and adjusted multivariable prevalence ratios, and their weighted adjusted linear tests of trend. All 8 demographic characteristics, and each of their interactions with survey year, were considered in adjusted linear trend analyses to determine significant changes over the 5 survey years in the proportion of U.S. adults aware of PrEP, willing to recommend PrEP, and willing to take PrEP.
Modeling involved backward elimination using a criterion of p ≤ 0.05 for variable inclusion, with the exception that demographic characteristic variables with p > 0.05 were retained in models if their interactions with year were statistically significant (p ≤ 0.05). Prevalence ratios were estimated to describe the proportions of respondents aware of PrEP, willing to recommend PrEP, and willing to take PrEP relative to referent groups. The following characteristics were chosen for referent groups: Age 65+ years; white race; male sex; income > $65,000; college graduate level education; married or domestic partnership marital status; not sexually active; and low self-perceived risk of HIV infection. For each outcome, weighted univariable prevalence ratios were calculated to determine its association with each of the 8 demographic characteristics. Additionally, weighted adjusted multivariable prevalence ratios for each outcome were based on the final model obtained from weighted adjusted linear trend analyses. All analyses were completed using SAS software, version 9.3 (SAS Institute Inc., Cary, NC).

Results

A total of 19,806 respondents were included in this analysis: female (51.8%), white (67.7%), <35 years of age (30.1%), annual household income of >$40,000 (63.6%), some college education or higher (64.2%), married or in domestic partnership (60.9%), medium-to-high self-perceived risk of HIV infection (3.0%), maleto- male sexual activity (3.4%) (Table 1).

Awareness of PrEP

Of respondents who answered the question "Have you ever heard of HIV pre-exposure prophylaxis or PrEP before today?", 6.5% reported ever hearing of PrEP prior to the survey (awareness of PrEP). The proportion of persons reporting awareness of PrEP ranged from 5.1% in 2009 to 7.4% in 2012; the increasing trend from 2009 to 2014 was statistically significant (p < .05) (Figure 1).
Awareness of PrEP was highest among respondents who were: aged 18-24 years (8.6%); "other" race (9.8%); male (7.1%); with income of >$60,000 (7.5%); with college graduate education (9.5%); never married (8.6%); who reported male-to-male sexual activity (19.7%); and among respondents who reported mediumhigh self-perceived risk of HIV infection (13.8%) (Table 2). In univariable analysis, awareness of PrEP was significantly higher among respondents who were aged 18-24 years (PR, 2.11; 95% confidence interval [CI], 1.39-3.21); aged 25-34 years (PR, 2.04; 95% CI, 1.63-2.56); aged 35-44 years (PR, 1.44; 95% CI, 1.14-1.81); aged 45-54 years (PR, 1.56; 95% CI, 1.26-1.93); aged 55-64 years (PR, 1.49; 95% CI, 1.20-1.85); "other" race (PR, 1.59; 95% CI, 1.20-2.11); never married (PR, 1.40; 95% CI, 1.11-1.75); MSM (PR, 3.76; 95% CI, 2.83-4.99) or women who reported sex with men (PR, 1.29; 95% CI, 1.01-1.65); and among respondents who reported medium-to-high self-perceived risk of HIV infection (PR, 2.23; 95% CI, 1.65-3.03). Awareness of PrEP was significantly lower among respondents who had income of $40,000 to $59,999, were not college graduates, and among respondents who were widowed, divorced, or separated.
Multivariable analysis indicated that awareness of PrEP was significantly higher among respondents aged of 18-24 years (adjusted PR [aPR], 2.96; 95% CI, 1.52-5.75); and respondents who reported male-to-male sexual activity (aPR, 2.33; 95% CI, 1.67-3.26). Awareness of PrEP was significantly lower among respondents with high school education or less (aPR, 0.33; 95% CI, 0.26-0.40) or some college education (aPR, 0.70; 95% CI, 0.59- 0.84) (Table 3).

Willingness to Recommend PrEP

Of respondents who answered the question "If you had friends or family members who were at risk of getting HIV infection, would you want them to be given PrEP?" 78.6% reported that they would want friends or family members who were at risk of getting HIV to be given PrEP (willingness to recommend PrEP). The proportion of respondents willing to recommend PrEP ranged from 82.3% in 2009 to 72.9% in 2013; the decreasing trend from 2009 to 2014 was statistically significant (p < .05) (Figure 1).
Willingness to recommend PrEP was highest among respondents who were aged ≥65 years (83.3%); white (80.2%); female (79.8%); had income of >$60,000 (80.8%); college graduates (81.5%); widowed, divorced, or separated (81.3%); females who reported heterosexual activity (81.9%); and among respondents who reported low self-perceived risk of HIV infection (79.4%) (Table 2).
In univariable analysis, willingness to recommend PrEP was significantly higher among women (PR, 1.03; 95% CI, 1.01-1.05); who were widowed, divorced, or separated (PR, 1.03; 95% CI, 1.01-1.06); and among men who reported sexual activity with women (PR, 1.08; 95% CI, 1.05-1.10) or women who reported sexual activity with men (PR, 1.09; 95% CI, 1.06-1.12). Willingness to recommend PrEP was significantly lower among respondents who were aged 18-24 years (PR, 0.91; 95% CI, 0.86-0.96); aged 25-34 years (PR, 0.90; 95% CI, 0.87-0.93); aged 35-44 years (PR, 0.94; 95% CI, 0.91-0.96); aged 45-54 years (PR, 0.94; 95% CI, 0.91-0.96); Hispanic (PR, 0.93; 95% CI, 0.90-0.97) or "other" race (PR, 0.88; 95% CI, 0.83-0.93); income <$15,000 (PR, 0.87; 95% CI, 0.84-0.91) or income $15,000 to $24,999 (PR, 0.94; 95% CI, 0.91-0.98) had high school education or less (PR, 0.92; 95% CI, 0.89-0.94); and among respondents who reported medium-tohigh self-perceived risk of HIV infection (PR, 0.89; 95% CI, 0.82- 0.96).
Multivariable analysis indicated that willingness to recommend PrEP was significantly higher among women (aPR, 1.06; 95% CI, 1.02-1.10); respondents who were never married (aPR, 1.08; 95% CI, 1.04-1.12) or who were widowed, divorced, or separated (aPR, 1.08; 95% CI, 1.05-1.11); and among respondents who reported male-male sexual activity (aPR, 1.19; 95% CI, 1.07-1.34) or men who reported sex with women (aPR, 1.09; 95% CI, 1.03-1.15). Willingness to recommend PrEP was significantly lower among respondents of "other" race (aPR, 0.91; 95% CI, 0.86-0.96); had income <$15,000 (aPR, 0.88; 95% CI, 0.84-0.93) or income $15,000 to $24,999 (aPR, 0.94; 95% CI, 0.91-0.98); had high school education or less (aPR, 0.96; 95% CI, 0.93-0.98); and among respondents who reported medium-tohigh self-perceived risk of HIV infection (aPR, 0.89; 95% CI, 0.82- 0.96) (Table 3).

Willingness to Take PrEP

Of respondents who answered the question "Would you want to take PrEP yourself?", 39.8% reported that they would want to take PrEP themselves (willingness to take PrEP). The proportion of respondents willing to take PrEP ranged from 42.9% in 2009 to 36.9% in 2012; the decreasing trend from 2009 to 2014 was statistically significant (p < .05) (Figure 1).
Willingness to take PrEP was highest among respondents who were aged 18-24 years (43.1%); black (47.9%); female (40.5%); had income of <$15,000 (44.2%); had high school education or less (41.2%); never married (44.7%); reported male-to-male sexual activity (52.2%); and among respondents who report medium-to-high self-perceived risk of HIV infection (56.4%) (Table 2).
In univariable analysis, willingness to take PrEP was significantly higher among respondents who were black (PR, 1.23; 95% CI, 1.15-1.33); had income <$15,000 (PR, 1.18; 95% CI, 1.09-1.28), income $15,000 to $24,999 (PR, 1.18; 95% CI, 1.08- 1.29), or income $25,000 to $39,999 (PR, 1.17; 95% CI, 1.08-1.26); with high school education or less (PR, 1.11; 95% CI, 1.05-1.18) or some college education (PR, 1.10; 95% CI, 1.03-1.17); never married (PR, 1.21; 95% CI, 1.13-1.29) or divorced, widowed, or separated (PR, 1.16; 95% CI, 1.09-1.23); MSM (PR, 1.37; 95% CI, 1.21-1.55) or women who reported sex with men (PR, 1.08; 95% CI, 1.01-1.15); and among respondents who reported mediumto- high self-perceived risk of HIV infection (PR, 1.43; 95% CI, 1.28-1.60). Multivariable analysis indicated that willingness to take PrEP was significantly higher among respondents who were black (aPR, 1.15; 95% CI, 1.07-1.24); had income of $25,000 to $39,999 (aPR, 1.11; 95% CI, 1.02-1.20); high school education or less (aPR, 1.11; 95% CI, 1.04-1.18); never married (aPR, 1.19; 95% CI, 1.11-1.29);divorced, widowed, or separated (aPR, 1.17; 95% CI, 1.09-1.26); sexually active [MSM (aPR, 1.38; 95% CI, 1.21-1.57), men who reported sex with women (aPR, 1.12; 95% CI, 1.05-1.20), or women who reported sex with men (aPR, 1.16; 95% CI, 1.08-1.24)]; and among respondents who reported medium-to-high self-perceived risk of HIV infection (aPR, 1.55; 95% CI, 1.35-1.78) (Table 3).

Discussion

Awareness of PrEP


Overall, awareness of PrEP among survey respondents was low. Awareness was highest among respondents who were relatively young, sexually active, and among respondents who are known to be a group at higher risk of HIV infection (e.g., MSM). After adjustment for other demographic characteristics, awareness of PrEP was significantly higher among younger respondents and among respondents who reported male-to-male sexual activity compared to their respective referent groups. Our findings are consistent with those of studies that show awareness of PrEP among more than 80% of MSM who use geosocialnetworking smartphone applications to meet sex partners [20,21]. In contrast, studies among black MSM and among women at risk for HIV infection have shown limited awareness of PrEP [15,18,19,23,24,27]. Our analysis also found lower awareness of PrEP among respondents who are black and among respondents who are female, although these findings were not statistically significant.
The surveys in this analysis were conducted over the period of time beginning before the first trial result showed PrEP efficacy through the publication of U.S. clinical practice guidelines for use of PrEP. Given that discussions regarding the impact of PrEP on HIV risk were widely published as early as 2007, it might have been expected that there would be a more obvious increase in awareness of PrEP after publication of the interim guidelines. Overall low levels of awareness of PrEP among the general adult population in the U.S. may be attributable to the segmentation of information about PrEP that did not reach into the general population of adults. In addition, the slow dissemination of information to clinical providers meant they could not provide knowledge of PrEP to their patients [28-30].

Willingness to recommend or Take PrEP

In contrast to the low proportion of U.S. adults aware of PrEP, willingness to recommend PrEP was high after its potential efficacy was explained. Willingness to recommend PrEP was highest among persons of higher socioeconomic status (higher income and some college education or greater), among persons no longer married or no longer in a domestic partnership, heterosexual females, and among persons who reported low self-perceived risk of HIV infection. After adjustment, willingness to recommend PrEP was significantly higher among respondents who were female; unmarried or no longer married; and among male respondents who reported male-to-male or heterosexual activity.
Willingness to take PrEP was relatively strong: the highest percentages among members of demographic groups in which HIV incidence is relatively high (unmarried persons, young persons, black race, MSM); groups with markers of low socieconomic status (low income and high school education or less); and persons that perceive themselves to be at higher risk of HIV infection. After adjustment, willingness to take PrEP was higher among respondents of black race; had a high school education or less; who are sexually active (MSM or heterosexual orientation); and among respondents who reported medium-tohigh self-perceived risk of HIV infection.
The high levels of willingness to recommend or take PrEP are consistent with those in studies demonstrating that PrEP for prevention of HIV infection is appealing to survey respondents after efficacy and safety have been described to them [13,16- 18,26,27]. It is notable that while the awareness of PrEP has been increasing over time, the willingness to recommend or take PrEP declined over the time period. While the decline in willingness to recommend or take PrEP cannot be explained by the data from our analysis, studies have suggested unwillingness due to burden of daily administration of PrEP, concerns about potential side effects, anticipated cost of medication, or the testing and regular clinical visits to monitor for adherence to medication [13,15,19,20,22,23,25-27].

Limitations

This analysis is subject to several limitations. First, the change in data collection method from mail to online survey may have biased sampling to persons for whom online methods were favorable. Nevertheless, response rate and survey estimates were comparable across years of the survey. Second, small sample sizes for subpopulations (e.g., medium-to-high risk of HIV infection, MSM) precluded analysis of data for subpopulations. Additionally, it is likely that some respondents participated in more than one year of the survey and therefore the assumption of independence would be violated. This should have little impact on point estimates but standard errors would be greater. Finally, survey responses were self-reported, which could have resulted in social desirability response bias.

Conclusions

This study is the first to assess awareness and attitudes about PrEP among a nationally representative sample of adults in the general U.S. population. The level of awareness of PrEP in this population is rising slowly, but surveys demonstrate that U.S. adults have strong interest in recommending or taking PrEP after it has been described to them. Health education efforts could be broadened to reach the general public thereby increasing awareness of PrEP and reducing this barrier, especially among populations that may be at risk for HIV acquisition but who have not been the focus for health communications.
These findings serve as a baseline for future, annual use of HealthStyles surveys to evaluate awareness of PrEP and willingness to recommend or take PrEP. Results from the HealthStyles surveys contribute to an accurate picture of the overall awareness of PrEP among adults in the United States and highlight opportunities for targeted PrEP health communications as well as the need to better understand barriers to the use of PrEP.

Acknowledgments
This work was funded by the Centers for Disease Control and Prevention. The authors do not have any conflicts of interest to disclose.

Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Tables & Figures


Figure 1: Responses to selected PrEP- related survey questions- HealthStyles 2009-2010, 2012-2014.



Table 1:
Demographic characteristics of included survey respondents -HealthStyles 2009-2010, 2012-2014 (N = 19,806).




Table 2: Proportion of respondents, by demographic characteristic, who are aware of PrEP, willing to recommend PrEP, and willing to take PrEP - HealthStyles, 2009-2010, 2012-2014.




aStatistically significant values are displayed in bolded font; *Referent group; bAdjusted for survey year, age category, sex, highest level of education, sexual orientation, self-perceived HIV risk, and interactions with survey year that were significant at p<0.05 (age category, sex, and self-perceived HIV risk); cAdjusted for survey year, age category, race, sex, income, highest level of education, marital status, sexual orientation, self-perceived risk of HIV infection and interactions with survey year that were significant at p<0.05 (age category and sexual orientation); d Adjusted for survey year, race, sex, income, highest level of education, marital status, sexual orientation, self-perceived risk of HIV infection and interaction of survey year with self-perceived HIV risk.

Table 3:
Unadjusted and adjusted prevalence ratios for selected outcomes by demographic characteristics - HealthStyles 2009-2010, 2012-2014a.

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