Knowledge, attitude, behaviour and acceptability of HIV pre-exposure prophylaxis amongst at risk MSM on the Maltese islands

Abstract

Introduction: Men who have sex with men (MSM) are at substantial risk of HIV infection i.e., an incidence of 3 or more per 100 person-years. Despite decades of research and public health interventions there is still a high burden of HIV new infections in this population. Daily PrEP was found to reduce HIV transmission by 86% in the PROUD clinical trial, while the IPERGAY clinical trial showed the same risk reduction using the on-demand PrEP. Literature identified various barriers to PrEP access and some of these included costs, drug efficacy, side-effects and not wanting to take daily tablets. Objectives: To assess the awareness, knowledge and attitudes about HIV prevention due to PrEP among the MSM population living in the Maltese islands. Risky sexual behaviours were also assessed, and how these have changed once PrEP was started. The role of how social determinants impacted awareness, knowledge, attitudes and acceptability were looked into. Finally, compliance to PrEP was also assessed. Methodology: An online anonymous questionnaire was sent to participants by various local NGOs and snowballing, and data from a GU clinic in Malta was collected. Findings were analysed using IBM SPSS 28 software, and survey data was weighted by age to make them more representative of the MSM population in Malta. Results: The vast majority were aware about PrEP (92.9%), but misinformation about PrEP was evident as a few participants did not know the correct dosing or confused PrEP with post-exposure prophylaxis. Interest to use PrEP was at 73%, and 53% thought that PrEP would meet their HIV prevention needs. Condom use went down when PrEP was started, but HIV testing rates increased. Compliance to this medication by MSM was low, with 83% of participants stopping it at some point. An interesting finding was that 0.6% of patients attending the GU clinic who on PrEP seroconverted and became HIV-positive. Age, nationality, relationship status, higher education and financial situation have various relationships with awareness about, interest to use and ever using PrEP. Discussion: While PrEP awareness is high, however there are barriers to its uptake which registered lower. Perceived HIV infection risk awareness amongst participating MSM is low. These misperceptions lead to increased risky sexual behaviours. Condom use decreased post PrEP initiation albeit having no objections to its use. Lack of knowledge about PrEP and the latter misperceptions are resulting in increased risk of other STIs which is similar to what was reported by Müller et al., (2022) in Germany. Daily PrEP users participating in this study admitted that they took it inconsistently, which is of great concern since acute HIV seroconversions tend to happen during times of inadequate adherence or when the drug is discontinued. Conclusion: Health education initiatives are required at both national and individual levels, to correct misinformation and address misperceptions about PrEP use and risk-taking behaviours. These initiatives could be targeted according to higher risk demographic profiles identified in this study. Barriers to PrEP access need to be addressed by policy makers through policy changes through free provision through schedule V of the Social Security Act Cap 318 Article 23 of the laws of Malta