What do men who have sex with women think about PrEP?

A study from Eswatini, where 27% of people are living with HIV, has provided important insight into heterosexual men’s views on pre-exposure prophylaxis (PrEP).

The study is part of a groundbreaking trial, which offered PrEP to men and women visiting six public health clinics in the country’s Hhohho Region between 2017 and 2019. Those offered PrEP were assessed as being at higher risk of HIV, based either on recent sexual behaviour or belonging to an at-risk group, for instance being in a mixed-status relationship (when one partner is living with HIV and one is not).

This study is based on data from these assessments, plus in-depth interviews and focus-group discussions. Men included in the study had either accepted PrEP or had been offered it. Views from PrEP providers, community leaders, and men in the general community were also included.  

Of all the people who started taking PrEP in the clinics, only a third (29%) were men. The majority were aged 26-35, although the men most at risk of HIV were older than this. Around 40% of men who accepted PrEP had multiple partners. What's more, half of the men who had accepted PrEP had stopped taking it after a month, and after six months 70% had stopped.

Overall, men saw HIV testing as a major reason not to take PrEP, even if they felt themselves to be at risk of HIV. Men also worried that taking antiretroviral drugs daily might lead to them being mistaken for a person living with HIV. Both these factors suggest HIV-related stigma is a major obstacle to PrEP uptake among heterosexual men.

Men also saw side effects (anticipated or experienced) as a major reason not to take PrEP. Daily pill-taking was also seen as an obstacle. Yet the majority of male PrEP users said taking a pill daily had ultimately proved manageable.  

Men primarily saw PrEP as a tool for their own protection. Yet some said they took it to protect their partner or family. The most important reasons men gave for taking PrEP were the fear of getting HIV (32%), having multiple partners (18%), not knowing the HIV-status of a partner (15%) and living in a mixed-status relationship (14%).

Similarities between taking PrEP and antiretroviral treatment (ART) had a positive effect on adherence in the joint pill-taking of mixed-status couples. But similarities between PrEP and ART could lead to the misconception that it is ok to stop ART because PrEP can be stopped and re-started. This is a possible area for concern.  

Many men in the study felt positive about PrEP. Some men viewed PrEP as a tool for more intimacy and greater pleasure, compared to condoms, and as a way to overcome condom-induced erection problems. They also expressed a preference for pills because condoms can be difficult to use correctly, especially when under the influence of alcohol.  

Distrusting a partner’s faithfulness or their HIV status were seen as reasons for taking PrEP. Being able or unable to talk about PrEP with their partner also played an important role for either starting or declining PrEP.  

About half of men who took PrEP said they intended to decrease or stop using condoms. But equally many said they would continue to use condoms because PrEP does not protect against anything other than HIV.  

Most men on PrEP reported having the same number of sexual partners as they had before they started taking it.  

Male-friendly spaces such as taxi ranks, churches and sports matches were suggested as places that would be more effective at reaching men with PrEP as men largely avoid health clinics.

Further PrEP studies are needed to test male-targeted PrEP education and services in communities and at places where men congregate, and to understand what both prevents and enables men who have sex with women to use PrEP.