HIV Risk Perception and Preexposure Prophylaxis Interest Among a Heterosexual Population Visiting a Sexually Transmitted Infection Clinic

Abstract

Low perception of HIV risk despite behaviors associated with increased risk is thought to be a contributing factor for a higher prevalence of HIV in blacks than other groups in the United States. We sought to determine HIV risk perception and its impact on safer sex practices and interest in preexposure prophylaxis (PrEP). From August 1 to October 31, 2010, an anonymous survey was conducted at a sexually transmitted infection clinic asking questions about demographics, risk behaviors, and PrEP interest. Participants were categorized into high-risk, moderate-risk, and low-risk groups according to predefined HIV risk characteristics. Only heterosexual high-risk participants were further assessed for their risk perception, condom use and PrEP interest. There were 494 participants; 63% male, 70% blacks, 88% heterosexual; 83% were categorized into the high-risk group. Of the 359 heterosexual high-risk participants, 301 (84%) perceived themselves at no or low-risk. Rates of consistent condom use with vaginal, oral, and anal sex were low (<20%) in this group despite high levels of knowledge about HIV transmission risks. Rates of condom use were not affected by risk perception. No interest in PrEP was associated with low education level (adjusted odds ratio 4.97; p=0.02) and low risk perception. These findings suggest that despite having knowledge about HIV transmission risks, the majority of high-risk participants did not recognize their risks and used condoms with low frequency. Low risk perception and low education level may impact PrEP interest. Enhanced interventions are needed to improve HIV risk perception, safer sex practices, and knowledge about PrEP.

Introduction

T here are more than 1 million people living with HIV in the United States, of whom 21% are unaware of their infection. Despite several modalities and interventions implemented to prevent HIV transmission, the annual number of new HIV infections has remained relatively stable with an estimation of 56,300 new cases each year. Populations that are severely affected by HIV include men who have sex with men (MSM) and blacks (53% and 46% of all new infections, respectively).¹

The disparities in the prevalence of HIV among blacks compared to other groups have been suggested to be due to factors such as low age at first intercourse, higher number of sexual partners, or decreased use of safer sex practices.² However, a recent study suggests that blacks are at higher risk for HIV than whites even when their behavior is normative or low risk.³ The authors of this study suggest that blacks with low-risk behavior are more likely than low-risk behavior whites to interact with high-risk behavior persons, thus creating a “perfect storm” effect for blacks that results in higher HIV rates. In other words, blacks may perceive themselves at low risk based upon their personal behaviors despite being at high risk based upon their partner's behaviors. Low perception of risk has been shown to be associated with ongoing increased risk behaviors, which facilitate HIV transmission.^4,5 Furthermore, it may lead to lower uptake of prevention messages and strategies resulting in failure to reduce HIV infections.

One of the newer preventive strategies being evaluated in randomized controlled trials globally is preexposure prophylaxis (PrEP). PrEP is the strategy of using antiretroviral agents to prevent HIV infection in HIV-negative persons. This strategy has evolved from studies of nonhuman primates that have demonstrated reduced risk of infection from simian immunodeficiency virus in animals that were pretreated with antiretroviral agents.⁶ The first published study of PrEP in humans reported that women who received tenofovir were three times less likely to acquire HIV infection than women who received placebo.⁷ Although this represented a 65% reduction in the rate of HIV acquisition among these women, the difference did not reach statistical significance possibly suggesting the study was underpowered. The CAPRISA 004 is the first PrEP study to show the significant HIV protective effect of 39% among high-risk South African women who used pericoital tenofovir gel.⁸ Subsequently, the iPrEX study, which is the first randomized controlled study of oral PrEP, demonstrated 44% reduction in the incidence of HIV among MSM taking tenofovir-emtricitabine (TDF/FTC) daily compared to placebo.⁹ At the 2011 International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, two randomized controlled trials of oral PrEP were presented. The Partner PrEP study demonstrated that daily tenofovir alone lowered HIV risk by 62% and daily TDF/FTC lowered HIV risk by 73% compared with placebo in HIV-negative partners of discordant couples in Kenya and Uganda.¹⁰ The other study conducted among heterosexual men and women in Botswana, TDF2, showed the overall 63% HIV protective effect of TDF/FTC daily regimen.¹¹ The reduced rate of infection and the high tolerability of the PrEP drugs has stimulated increased interest in PrEP and suggests that PrEP may be another effective preventive strategy in high prevalence populations. However, before widespread implementation of PrEP can be advised, improved understanding and acceptance of PrEP in diverse populations is required.

The aims of this study were to: (1) assess HIV risk perception; (2) identify risk factors associated with low risk perception; (3) determine association between low risk perception and use of HIV preventive strategies, such as condom use and interest in PrEP; and (4) assess the interest in PrEP and the potential impact of PrEP use on risk behaviors among high-risk heterosexual populations, especially blacks, who visited a sexually transmitted disease (STI) clinic.

Methods

Study population and setting

The study was conducted among a convenience sample of persons aged 23 years of age or older (excluding adolescents) who presented to the STI clinic of the Ruth M. Rothstein CORE Center, Chicago, Illinois from August 1 to October 31, 2010. The CORE Center is a public clinic jointly founded by the Cook County Health and Hospital Systems (CCHHS) and Rush University Medical Center and run by Cook County. It provides comprehensive health care to Chicago area residents affected by infectious diseases, especially HIV infection. The STI clinic provides screening for most STIs including gonorrhea, chlamydia, syphilis, and other conditions, HIV counseling and testing by health educators from Prevention and Education Department. In 2010, the STI clinic had 9813 annual patient visits with 3:1 male to female ratio. The clinic patients are largely minority (75% blacks and 13% Hispanic) and more than 90% are Chicago residents. This present study was approved by CCHHS Institutional Review Board.

Study design and protocol

A cross-sectional anonymous survey study was conducted among persons who presented to the STI clinic. The survey form questioned the patients about their demographics, health history, sexual risk behaviors, substance use, history of STIs, sexual partner's risk behaviors, self-knowledge about HIV transmission risks, and PrEP interest. The survey had fifth-grade reading level, was self-explanatory and available in both English and Spanish languages. Prior to being administered, the survey instrument was reviewed for its HIV content and validity by members of the CORE Center HIV Research Committee and also the Social and Behavioral Sciences Core of the Chicago Developmental Center on AIDS. Experts in survey research at the Survey Research Lab of University of Illinois at Chicago reviewed it for formatting and internal consistency. The survey form was completed by the participants while they were waiting to see doctors in the waiting area of the clinic. The participants were offered a $5 grocery store coupon after they had completed the survey and returned it in the blinded collecting box.

Study definitions

Participants self-identified their sexual orientation and HIV risk perception within the survey. To identify their own HIV risks, the participants chose “No risk at all,” “A little risk (low-risk),” “More than a little (moderate-risk),” and “A lot of risk (high-risk).” The investigators subsequently evaluated the participants' risk as “low-risk,” “moderate-risk,” and “high-risk” based on the prespecified risk characteristics and behaviors reported in the survey (Table 1). Only one characteristic or behavior that met the certain risk level was required to classify the participants into that risk level. This risk categorization tool was validated in our previous study for use in differentiating participants with different levels of risk behavior.¹²

Table 1.

HIV Risk Stratification According to the Prespecified Reported Characteristics and Behaviors of the Survey Participants

	HIV risk
Characteristics and behaviors	Low	Moderate	High
Number of different sexual partners within 30 days
0–1	✔
2–3		✔
>3			✔
Number of new sexual partners within 30 days
0–1	✔
2–3		✔
>3			✔
Using condom with vaginal sex
Always	✔
Most of the time	✔
About a half of time		✔
Sometimes			✔
Never			✔
Using condom with oral sex
Always	✔
Most of the time	✔
About a half of time		✔
Sometimes		✔
Never		✔
Using condom with anal sex
Always	✔
Most of the time	✔
About a half of time		✔
Sometimes			✔
Never			✔
Exchanging sex for money or drugs
No	✔
Yes			✔
Drinking alcohol with sex within 30 days
Never	✔
Sometimes		✔
About a half of time			✔
Most of the time			✔
Always			✔
Using drug with sex within 30 days
Never	✔
Sometimes		✔
About a half of time			✔
Most of the time			✔
Always			✔
Ever injected drug with needles
No	✔
Yes			✔
Ever shared needle to inject drugs
Never	✔
Sometimes			✔
About a half of time			✔
Most of the time			✔
Always			✔
Ever been in a jail or a prison
No	✔
Yes			✔
History of STIs within the past year
No	✔
Yes			✔
Sexual partner had STIs within the past year
No	✔
Yes			✔
Sexual partner had exchanged sex for money or drugs within 30 days
No	✔
Yes			✔
Sexual partner had used drug within 30 days
No	✔
Yes			✔
Sexual partner had been in a jail or a prison
No	✔
Yes			✔

STIs, sexually transmitted infections.

Data analyses

For the purposes of this report, we focused on investigator-defined high-risk heterosexual participants who were the majority of the population. These high-risk participants were then classified to have low HIV risk perception if they perceived their risks as no or low risk. The participants were classified into “no PrEP interest” group if their answers stated that they would not take a drug (pill) that could prevent them from getting HIV from sex. Primary outcomes of the study were HIV risk characteristics and behaviors among high-risk participants and risk factors associated with low HIV risk perception and no interest in PrEP. Secondary outcomes included rates of consistent condom use, knowledge about HIV transmission risks, and potential impact of PrEP on risk behaviors if it is taken.

All statistical analyses were performed using SPSS version 15.0 (SPSS, Chicago, IL). Categorical variables were compared using Pearson's χ² or Fisher's exact test as appropriate. Continuous variables were compared using Mann-Whitney U test. All p values were two tailed; p values less than 0.05 were considered statistically significant. Variables that were present at a significance level of p<0.20 in univariate analysis or had prior significance for low risk perception (age, gender, sexual orientation, education)^5,13
–15 and no interest in PrEP (education and income)^16,17 were entered into logistic regression models. These variables were subsequently removed from the models in backward stepwise fashion if their p values were >0.05 until the final model had reached. Adjusted odd ratios (aORs) and 95% confidence intervals (CIs) were determined for risk factors associated with low HIV risk perception and no interest in PrEP.

Results

Of 513 STI clinic attendees approached, 503 (98%) agreed to participate in this survey study. Nine of 503 were excluded due to known HIV-positive status. Characteristics of the remaining 494 participants were shown in Table 2. There were 409 high-risk participants and 85 participants with moderate or low risk. High-risk participants were more likely to report exchanging sex for money or drugs, using alcohol or drugs within 30 days, using alcohol or drugs with sex, injecting drugs with needles, having history of incarceration, having STIs within the past year, and having sexual partners who had STIs within the past year, used illicit drugs and been incarcerated.

Table 2.

Reported Characteristics of the Study Participants Stratified by HIV Risk

Characteristics	All (n=494)	High risk (n=409)	Moderate or low risk (n=85)	p^a
Age (years, median, interquartile range)	30 (26–40)	30 (26–38)	32 (26–45)	0.23
Gender				0.11
Male	311 (63)	264 (65)	47 (55)
Female	183 (37)	145 (35)	38 (45)
Race/ethnicity				0.26
Black	347 (70)	292 (71)	55 (65)
Latino	84 (17)	64 (16)	20 (24)
White	32 (7)	29 (7)	3 (3)
Asian	7 (1)	5 (1)	2 (2)
Others	24 (5)	19 (5)	5 (6)
Marital status				0.83
Single	352 (71)	291 (71)	61 (72)
Living with domestic partner	47 (10)	41 (10)	6 (6)
Married	38 (7)	31 (8)	7 (8)
Divorced	29 (6)	22 (5)	7 (8)
Separated	26 (5)	22 (5)	4 (5)
Widowed	2 (0.4)	2 (1)	0 (0)
Highest education level				0.73
Some high school or less	91 (18)	78 (19)	13 (15)
Completed high school/GED	288 (58)	239 (58)	49 (58)
Completed undergraduate	83 (17)	67 (16)	16 (19)
Completed graduate	32 (7)	26 (6)	7 (8)
Employed	182 (37)	151 (37)	31 (37)	0.94
Monthly household income				0.68
$0–499	225 (46)	186 (46)	39 (46)
$500–1,999	182 (37)	148 (36)	34 (40)
$2,000–4,999	73 (15)	62 (15)	11 (13)
$5,000 or more	14 (3)	13 (3)	1 (1)
Sexual orientation				0.07
Heterosexual	433 (88)	359 (88)	74 (87)
Homosexual	31 (6)	22 (5)	9 (11)
Bisexual	30 (6)	28 (7)	2 (2)
Exchanging sex for money or drugs	43 (9)	43 (11)	0 (0)	<0.001
Drinking alcohol within 30 days	312 (63)	270 (66)	42 (49)	0.004
Drinking alcohol with sex				<0.001
Never	76/312 (24)	54/270 (20)	22/42 (52)
Sometimes	131/312 (42)	111/270 (41)	20/42 (48)
About a half of time	40/312 (13)	40/270 (15)	0/42 (0)
Most of the time	43/312 (14)	43/270 (16)	0/42 (0)
Always	22/312 (7)	22/270 (8)	0/42 (0)
Using drugs within 30 days	160 (32)	148 (36)	12 (14)	<0.001
Marijuana	139 (28)	128 (31)	11 (13)	0.001
Cocaine	33 (7)	32 (8)	1 (1)	0.03
Heroin	13 (3)	13 (3)	0 (0)	0.14
Psychedelics	13 (3)	13 (3)	0 (0)	0.14
Methamphetamine	4 (1)	4 (1)	0 (0)	1.00
Using drugs with sex				0.03
Never	37/160 (23)	34/148 (23)	3/12 (25)
Sometimes	58/160 (36)	49/148 (33)	9/12 (75)
About a half of time	21/160 (13)	21/148 (14)	0/12 (0)
Most of the time	23/160 (14)	23/148 (16)	0/12 (0)
Always	21/160 (13)	21/148 (14)	0/12 (0)
Ever injected drug with needles	23 (5)	23 (6)	0 (0)	0.03
Ever shared needles				0.28
Never	482 (98)	397 (97)	85 (100)
Sometimes	11 (2)	11 (3)	0 (0)
About a half of time	1 (0.2)	1 (0.2)	0 (0)
Most of the time	0 (0)	0 (0)	0 (0)
Always	0 (0)	0 (0)	0 (0)
Ever been in a jail or a prison	176 (36)	176 (43)	0 (0)	<0.001
Having STIs within the past year	152 (31)	152 (37)	0 (0)	<0.001
STIs in sexual partner within the past year	112 (23)	112 (27)	0 (0)	<0.001
Sexual partner exchanged sex for money or drugs within 30 days	8 (2)	8 (2)	0 (0)	0.36
Sexual partner used drugs within 30 days	64 (13)	64 (16)	0 (0)	<0.001
Sexual partner ever been in a jail or a prison	79 (16)	79 (19)	0 (0)	<0.001
Would take a pill for PrEP				0.31
Yes	411 (83)	345 (84)	66 (78)
No	42 (9)	32 (8)	10 (12)
Do not know	41 (8)	32 (8)	9 (11)

Data are in number (%) unless otherwise indicated.

Compare between high-and moderate- or low-risk groups.

PrEP, preexposure prophylaxis; STIs, sexually-transmitted infections.

Characteristics, risk behaviors, and environmental risks of the high-risk heterosexual participants by gender (Table 3)

When compared to female participants, males reported having higher numbers of different sexual partners (median 2 versus 1; p=0.04), new sexual partners (median 1 versus 0; p=0.03) within 30 days and alcohol drinking days (median 7 versus 4; p=0.001) than females. Males were more likely to report participating in oral sex and using condoms for vaginal sex more consistently than females (83% versus 70% and 17% versus 12%, respectively). The reported rates of consistent condom use for oral sex and anal sex were all low and did not differ significantly between males and females (6% versus 10% and 19% versus 11%, respectively). Males reported history of incarceration more than females (55% versus 23%) while females reported having sexual partner who had history of incarceration more than males (40% versus 9%). Females were more likely to report exchanging sex for money or drugs than males. There were no significant differences in age, race/ethnicity, marital status, education level, employment status, household income and drug use between genders.

Table 3.

Reported Demographics, Risk Behaviors, and Environmental Risks of the 359 High-Risk Heterosexual Participants, Stratified by Gender

Characteristics	All (n=359)	Male (n=234)	Female (n=125)	p^a
Age (years, median, interquartile range)	30 (26–38)	31 (26–38)	29 (26–39)	0.36
Race/ethnicity				0.39
Black	269 (75)	173 (74)	96 (77)
Latino	52 (15)	39 (17)	13 (10)
White	19 (5)	12 (5)	7 (6)
Asian	5 (1)	2 (1)	3 (2)
Others	14 (4)	8 (3)	6 (5)
Marital status				0.42
Single	259 (72)	171 (73)	88 (70)
Living with domestic partner	32 (9)	19 (8)	13 (10)
Married	30 (8)	22 (9)	8 (6)
Separated	21 (6)	14 (6)	7 (6)
Divorced	16 (5)	8 (3)	8 (6)
Widowed	1 (0.3)	0 (0)	1 (1)
Highest education level				0.82
Some high school or less	67 (19)	43 (18)	24 (19)
Completed high school or GED	215 (60)	144 (62)	71 (57)
Completed undergraduate	57 (16)	35 (15)	22 (18)
Completed graduate	20 (6)	12 (5)	8 (6)
Employed	130 (36)	81 (35)	49 (39)	0.39
Monthly household income				0.62
$0–499	164 (46)	112 (48)	52 (42)
$500–1,999	131 (37)	80 (34)	51 (41)
$2,000–4,999	51 (14)	34 (15)	17 (14)
$5,000 or more	13 (4)	8 (3)	5 (4)
Number of different sexual partner within 30 days (median, interquartile range)	2 (1–2)	2 (1–2)	1 (1–2)	0.04
Number of new sexual partner within 30 days (median, interquartile range)	1 (0–1)	1 (0–1)	0 (0–1)	0.03
Having vaginal sex	333 (93)	211 (90)	122 (98)	0.009
Using condom with vaginal sex				0.005
Never	66/333 (20)	34/211 (16)	32/122 (26)
Sometimes	123/333 (37)	83/211 (39)	40/122 (33)
About a half of time	23/333 (7)	14/211 (7)	9/122 (7)
Most of the time	71/333 (21)	45/211 (21)	26/122 (21)
Always	50/333 (15)	35/211 (17)	15/122 (12)
Having oral sex	284 (79)	195 (83)	89 (70)	0.007
Using condom with oral sex				0.36
Never	159/284 (56)	106/195 (54)	53/89 (60)
Sometimes	77/284 (27)	59/195 (30)	18/89 (20)
About a half of time	15/284 (5)	10/195 (5)	5/89 (6)
Most of the time	13/284 (5)	9/195 (5)	4/89 (5)
Always	20/284 (7)	11/195 (6)	9/89 (10)
Having anal sex	74 (21)	48 (21)	26 (21)	0.95
Using condom with anal sex				0.73
Never	22/74 (30)	12/48 (25)	10/26 (39)
Sometimes	30/74 (41)	21/48 (44)	9/26 (35)
About a half of time	5/74 (7)	3/48 (6)	2/26 (8)
Most of the time	5/74 (7)	3/48 (6)	2/26 (8)
Always	12/74 (16)	9/48 (19)	3/26 (11)
Exchanging sex for money or drugs	33 (9)	14 (6)	19 (15)	0.004
Drinking alcohol within 30 days	237 (66)	158 (68)	79 (63)	0.41
Number of alcohol drinking days within 30 days (median, interquartile range)	5 (3–10)	7 (3–12)	4 (2–7)	0.001
Number of drinks per day within 30 days (median, interquartile range)	2 (1–4)	3 (1–4)	2 (1–3)	0.24
Drinking alcohol with sex				0.20
Never	48/237 (20)	26/158 (17)	22/79 (28)
Sometimes	99/237 (42)	69/158 (44)	30/79 (38)
About a half of time	34/237 (14)	24/158 (15)	10/79 (13)
Most of the time	37/237 (16)	28/158 (18)	9/79 (11)
Always	19/237 (8)	11/158 (7)	8/79 (10)
Using drugs within 30 days	121 (34)	86 (37)	35 (28)	0.10
Marijuana	106 (30)	75 (32)	31 (25)	0.18
Cocaine	23 (6)	16 (7)	7 (6)	0.86
Heroin	11 (3)	8 (3)	3 (2)	1.00
Psychedelics	9 (3)	8 (3)	1 (1)	0.45
Methamphetamine	3 (1)	3 (1)	0 (0)	0.56
Using drug with sex				0.55
Never	25/121 (21)	17/86 (20)	8/35 (23)
Sometimes	41/121 (34)	33/86 (38)	8/35 (23)
About a half of time	20/121 (17)	14/86 (16)	6/35 (17)
Most of the time	19/121 (16)	12/86 (14)	7/35 (20)
Always	16/121 (13)	10/86 (12)	6/35 (17)
Ever injected drug with needles	16 (5)	12 (5)	4 (3)	0.59
Ever shared needles				0.72
Never	351 (98)	228 (97)	123 (98)
Sometimes	7 (2)	5 (2)	2 (2)
About a half of time	1 (0.3)	1 (0.4)	0 (0)
Most of the time	0 (0)	0 (0)	0 (0)
Always	0 (0)	0 (0)	0 (0)
Ever been in a jail or a prison	158 (44)	129 (55)	29 (23)	<0.001
Having STIs within the past year				0.16
Yes	133 (37)	82 (35)	51 (41)
No	168 (47)	108 (46)	60 (48)
Do not know	58 (16)	44 (19)	14 (11)
Type of STIs
Chlamydia	64/133 (48)	42/82 (51)	22/51 (43)	0.38
Trichomonas	47/133 (35)	20/82 (24)	27/51 (53)	0.001
Gonorrhea	34/133 (26)	26/82 (32)	8/51 (16)	0.04
HSV	15/133 (11)	11/82 (13)	4/51 (8)	0.41
Syphilis	3/133 (2)	2/82 (2)	1/51 (2)	1.00
STIs in sexual partner within the past year	97 (27)	60 (26)	37 (30)	0.46
Type of STIs in the partner
Chlamydia	46/97 (47)	28/60 (47)	18/37 (49)	1.00
Trichomonas	36/97 (37)	21/60 (35)	15/37 (41)	0.67
Gonorrhea	19/97 (20)	12/60 (20)	7/31 (19)	1.00
HSV	7/97 (7)	5/60 (8)	2/31 (5)	0.71
Syphilis	1/97 (1)	1/60 (2)	0/31 (0)	1.00
Sexual partner exchanged sex for money or drugs within 30 days				0.18
Yes	7 (2)	6 (3)	1 (1)
No	241 (67)	150 (64)	91 (73)
Do not know	111 (31)	78 (33)	33 (26)
Sexual partner used drug within 30 days				0.03
Yes	51 (14)	34 (15)	17 (13)
No	189 (53)	112 (48)	77 (62)
Do not know	119 (33)	88 (38)	31 (25)
Sexual partner ever been in a jail or a prison				<0.001
Yes	72 (20)	22 (9)	50 (40)
No	225 (63)	166 (71)	59 (47)
Do not know	62 (17)	46 (20)	16 (13)

Data are in number (%) unless otherwise indicated.

Compare between male and female groups.

HSV, herpes simplex virus; STIs, sexually transmitted infections.

HIV risk perception and knowledge about HIV transmission risks (Table 4)

Despite having behaviors that placed them at increased risk for HIV acquisition, 301 of 359 (84%) participants perceived themselves at no or low risk. The perception of risk was not significantly different between males and females. Most of the participants (>80%) correctly stated that “You can get HIV from vaginal sex, anal sex, oral sex, tattoo needles, and sharing needles,” “Having multiple sexual partners increases risk of HIV,” “Condom use decreases risk of HIV,” and “Exchanging sex for money or drugs increases risk of HIV.” A lower proportion of the participants (59%) correctly stated that “Getting high increases risk of HIV.” There were no significant differences in the knowledge about HIV transmission risks between genders, except that males were less-likely to correctly state that “You can get HIV from anal sex” than females (92% versus 99%; p=0.02).

Table 4.

HIV Risk Perception and Knowledge About HIV Transmission Risks of the 359 High-Risk Heterosexual Participants, Stratified by Gender

Characteristics	All (n=359)	Male (n=234)	Female (n=125)	p^a
HIV risk perception				0.25
No risk at all	205 (57)	130 (65)	75 (60)
Little risk	96 (27)	68 (29)	28 (22)
More than little risk	36 (10)	25 (11)	11 (9)
A lot risk	22 (6)	11 (5)	11 (9)
Answer for “You can get HIV from vaginal sex”				0.23
True	337 (94)	216 (92)	121 (97)
False	7 (2)	6 (3)	1 (1)
Do not know	15 (4)	12 (5)	3 (2)
Answer for “You can get HIV from anal sex”				0.02
True	340 (95)	216 (92)	124 (99)
False	8 (2)	8 (3)	0 (0)
Do not know	11 (3)	10 (4)	1 (1)
Answer for “You can get HIV from oral sex”				0.14
True	308 (86)	198 (85)	110 (88)
False	24 (7)	20 (9)	4 (3)
Do not know	27 (7)	16 (7)	11 (9)
Answer for “Having multiple sexual partners increases risk of HIV”				0.63
True	348 (97)	226 (97)	122 (98)
False	5 (1)	3 (1)	2 (2)
Do not know	6 (2)	5 (2)	1 (1)
Answer for “Condom use decreases risk of HIV”				0.50
True	315 (88)	202 (86)	113 (90)
False	35 (10)	25 (11)	10 (8)
Do not know	9 (3)	7 (3)	2 (2)
Answer for “Exchanging sex for money or drugs increases risk of HIV”				0.25
True	297 (83)	199 (85)	98 (78)
False	37 (10)	20 (9)	17 (14)
Do not know	25 (7)	15 (6)	10 (8)
Answer for “Getting high increases risk of HIV”				0.21
True	210 (59)	131 (56)	79 (63)
False	95 (26)	69 (30)	26 (21)
Do not know	54 (15)	34 (15)	20 (16)
Answer for “you can get HIV from tattoo needles”				0.07
True	314 (87)	211 (90)	103 (82)
False	13 (4)	8 (3)	5 (4)
Do not know	32 (9)	15 (6)	17 (14)
Answer for “you can get HIV from sharing needles”				0.42
True	348 (97)	226 (97)	122 (98)
False	4 (1)	2 (1)	2 (2)
Do not know	7 (2)	6 (3)	1 (1)

Data are in number (%).

Compare between male and female groups.

PrEP interest and its various administration options (Table 5)

Two hundred and ninety-nine (83%) participants were interested in PrEP. There was no difference in the willingness to take a pill for PrEP between genders. However, females were more likely to be uncertain about taking PrEP than males. When given alternatives for the timing of oral administration of PrEP, taking it 1 h before sex (77%), taking it once a week (76%), and 1 day before sex (75%) are comparably acceptable, while taking PrEP once a day was the least acceptable (63%). There were no differences in the acceptance of the PrEP administration options between genders. The main reasons why the participants would not take a pill for PrEP were that they practice safe sex already (37%), a pill makes them sick (32%), and they forget taking pills easily (27%). The responses were similar between genders.

Table 5.

Acceptance of Preexposure Prophylaxis (PrEP) and Potential Impact on Safe Sex Behaviors of the 359 High-Risk Heterosexual Participants, Stratified by Gender

Characteristics	All (n=359)	Male (n=234)	Female (n=125)	p^a
Would take a pill for PrEP				0.04
Yes	299 (83)	197 (84)	102 (82)
No	30 (8)	23 (10)	7 (6)
Do not know	30 (8)	14 (6)	16 (13)
Would take it once a week				0.50
Yes	274 (76)	176 (75)	98 (78)
No	85 (24)	58 (25)	27 (22)
Would take it once a day				0.76
Yes	226 (63)	146 (62)	80 (64)
No	133 (37)	88 (38)	45 (36)
Would take it 1 day before sex				0.39
Yes	269 (75)	172 (74)	97 (78)
No	90 (25)	62 (26)	28 (22)
Would take it 1 h before sex				0.98
Yes	276 (77)	180 (77)	96 (77)
No	83 (23)	54 (23)	29 (23)
Reasons for not taking a pill^b				0.49
I practice safe sex already	100/268 (37)	71/170 (42)	29/98 (30)
Pill makes me sick	85/268 (32)	49/170 (29)	36/98 (37)
I forget easily	73/268 (27)	43/170 (25)	30/98 (31)
I have no risk	55/268 (21)	34/170 (20)	21/98 (21)
I do not like taking pills	38/268 (14)	24/170 (14)	14/98 (14)
Unspecified reasons	15/268 (6)	9/170 (5)	6/98 (6)
If taking the pill, I will use condom				0.09
Less	71 (20)	54 (23)	17 (14)
More	81 (23)	55 (24)	26 (21)
The same	183 (51)	109 (47)	74 (59)
I do not use condom	24 (7)	16 (7)	8 (6)
If taking the pill, the number of my sexual partners will be				<0.001
Less	68 (19)	44 (19)	24 (19)
More	61 (17)	54 (23)	7 (6)
The same	230 (64)	136 (58)	94 (75)

Data are in number (%).

Compare between male and female groups.

All participants can choose to answer this question regardless of PrEP interest and can choose for more than one reason.

Impact of PrEP on risk behaviors (Table 4)

When asked if they thought taking PrEP would change their behaviors, 51% of the participants would not change their condom use and 64% would have the same number of sexual partners. However, 20% of the participants would use condoms less, while 7% would not use condoms at all if taking PrEP. The change in condom use practice if taking PrEP was not different between genders. Sixty-one participants (17%) would have more sexual partners if taking PrEP. Males were more likely than females to have more sexual partners if taking PrEP (23% versus 6%).

Risk factors for low HIV risk perception

Characteristics of the participants who perceived themselves at low risk and high risk were similar with regard to age, gender, race/ethnicity, marital status, education level, employment status, household income, substance use, history of incarceration, STIs within the past year, and rates of consistent condom use for vaginal, oral, and anal sex. However, the participants who perceived themselves at high risk were more likely to report exchanging sex for money or drugs (p=0.02) and using cocaine (p=0.02). There was a trend suggesting that participants who perceived themselves at low risk were less likely to be interested in PrEP (p=0.13).

Risk factors for no interest in PrEP

The participants with no interest in PrEP had lower education level than those with interest in or uncertain about PrEP. In multivariate logistic regression analysis, the final model variables included education level, low HIV risk perception, male gender, and psychedelics use. Some high school education level or less was independently associated with no interest in PrEP (aOR 4.97; 95% CI 1.26–19.67; p=0.02) while there was a trend that low HIV risk perception was associated with no interest in PrEP, but this did not reach statistical significance (p=0.10).

Discussion

Our study population primarily consisted of black, single, heterosexuals with high school education or less who presented for care at an urban STI clinic. This population has been shown to be at higher risk for HIV acquisition and should be the focus for preventive strategies to reduce HIV transmission.^1,3,18 Although STI clinic clients are at higher than average risk for HIV acquisition, we believe that the use of a risk categorization tool based on the participants' behavior and environmental risk characteristics in this study helped us clearly differentiate high-risk participants from moderate to low-risk participants. This strategy allows us to accurately assess perception of risk in the population with the highest measurable risk.

We focused our analyses among the high-risk heterosexual participants. Overall participants' knowledge about HIV transmission risks was high (>80% correctly stated about the relationship of common risk behaviors and increase in HIV risk). Nonetheless, 84% of these participants perceived themselves at low risk and the overall consistent condom use rates were low (<20%) for vaginal, oral, and anal sex. The high rates of low risk perception have been reported in other settings including 40% of injection drug users (IDUs) and more than 50% of MSM from the United States,^19,20 more than 67% of the callers to AIDS Help-Line in Italy,¹³ and 81% of a sample population in the United Kingdom.⁵ Some factors that may contribute to lower perception of risk among black heterosexuals include beliefs that associate HIV risk with particular groups, e.g., MSM, drug users, etc. rather than risk behaviors. Blacks have been shown to have higher HIV infection rates in their partner pools than other ethnicities and frequently have closed sexual networks (only within black population).¹⁸ Thus, even while engaging in normative heterosexual behaviors, blacks could still be at higher risk for HIV acquisition but they may not recognize their risks.²¹ Furthermore, blacks may use cognitive coping mechanisms, such as denial and suppression so that they would not change their behaviors despite having the knowledge about HIV transmission risks and correctly perceiving the risks.¹⁹ In this study, the low rates of consistent condom use despite high levels of knowledge about HIV transmission risks support this suggestion. Factors associated with low risk perception in other studies included heterosexual orientation, young age and high school education level.^5,13,14 An anonymous survey study conducted among predominantly heterosexual STI clinic attendees in South Carolina suggests that age 40–49 years, male gender, and having more than one sexual partner within 3 months were associated with low risk perception.¹⁵ Although the overall design and setting of this study were similar to our study, differences included use of a risk categorization tool and more detailed assessment of the participants' knowledge about HIV transmission risks, risk characteristics, condom use and PrEP interest in our study.

Importantly, there was some evidence in our study that the participants who reported having exchanged sex for money or drugs and using cocaine were more likely to perceive themselves at high risk (perceive their risks correctly). This association between antecedent high-risk behaviors and correct perception of risk was also evident in other studies for alcohol use,¹⁴ marijuana use,¹³ high number of sexual partners,^22

–25 and history of treated STIs in the past year.²⁵ Nonetheless, the risks associated with normative heterosexual sex in communities with high HIV prevalence may not be as widely perceived and understood as the risks associated with these traditional risk behaviors.²¹

We also explored the impact of risk perception on condom use. Although a previous study suggested that correct perception of risk was positively associated with condom use,²⁶ we found no differences in reported rates of consistent condom use for vaginal, oral, and anal sex between participants who perceived themselves at low risk and high risk. The inconsistency of the results may be due to the differences in some aspects between the two studies that influenced the condom use. First, the study populations and the prevalence of HIV are different in these two studies. Second, heterosexuals are perceived at lower risk in the United States while this group makes up the largest proportion of HIV-infected persons in Mozambique.

Our study sought to evaluate interest in PrEP and the factors that contribute to it in this population. Previous studies have reported rates of PrEP interest that ranged from 43% to 83% in MSM populations from different settings, including a Gay Pride Event, a STI clinic, clinical trials and a host of others.^{16,17,27

–30} These rates were generally lower than the rate of PrEP interest in our study (83%). This may be due to the fact that people who came to a STI clinic were motivated or open to preventive strategies. This statement is supported by a previous study that reported higher rates of PrEP interest in attendees of a STI clinic in comparison to those of a Gay Pride Event.³⁰ Despite the overall high rate of PrEP interest, there was a trend that participants with low risk perception had lower rate of PrEP interest than those with high risk perception. In a further analysis, we found that high school education level or less was independently associated with no interest in PrEP. A previous study also suggested that persons with some college education, in comparison to those with bachelor degree or higher, were less likely to be interested in PrEP.¹⁶ However, another study among MSM demonstrated than intent-to-use PrEP was associated with less education, moderate income, no perceived side effects from taking PrEP, and not having to pay for PrEP.¹⁷ Altogether, these findings suggested the potential of educational interventions in increasing knowledge and PrEP interest that need to be tailored to different populations.

Options for oral administration of PrEP that were preferred in our study participants included once a week, 1 day before sex, and 1 hour before sex, while the once-daily option was less preferred. This finding was consistent with the low rate of compliance (32% with drug-level detection) of once-daily PrEP regimen in the previous clinical trial.⁹ Given that only an oral PrEP regimen with once-daily dosing has been shown to be effective,^9
–11,31 if PrEP is implemented, counseling and education about a daily dosing regimen is needed along with monitoring of adherence and short- and long-term side effects.³¹ A new PrEP drug with a longer half-life and more convenient way and frequency of administration may increase compliance and success in HIV prevention in the near future.

We asked the participants to predict the effect of PrEP on their behaviors. The results revealed that 20% of the participants would use condoms less and 17% would have more sexual partners if taking PrEP. A previous study also reported that more than 35% of MSM stated that they would use condoms less after taking PrEP.²⁸ In addition, males were more-likely than females to report that they would have more sexual partners if they were taking PrEP in our study. These findings suggest a potential for increased risk behavior among PrEP users because they believe they would be protected (risk compensation). Risk-reduction counseling along with a comprehensive package of prevention was shown to reduce the number of sexual partners and increase condom use among MSM in a clinical trial of PrEP.⁹ However, this finding needs to be evaluated when PrEP is used outside clinical trials. Since PrEP is not currently proved to be 100% effective in prevention of HIV acquisition,⁶ concurrent use of other preventive methods, such as condoms, risk behavior assessment and risk reduction counseling are recommended for PrEP users.^31

–34

There were notable limitations in our study. First, the results may have limited generalizability given that our study population consisted of primarily black, single, heterosexuals with high school education or less. Second, the small sample size for non-black race/ethnicities may limit our ability to detect the differences in the study outcomes including risk perception, condom use and PrEP interest between black and nonblack participants. Third, given a cross-sectional design of this study, we could not determine whether the participants' characteristics preceded low risk perception and no interest in PrEP. Fourth, using a convenient sample may preclude generalizability of the results. However, due to a large sample size and acceptance rate of 98% of the participants in this study, this limitation should be minimal. Fifth, although our survey had fifth-grade reading level, self-administration of a survey could still be problematic to a low literacy population in this study. Lastly, our survey asked several hypothetical questions about what participants would do if taking PrEP. As is true of most questions about future actions, participants could only speculate as to what their behavior would be. We cannot report on what it would actually be.

In conclusion, perception of HIV risk and the rates of condom use among heterosexual high-risk individuals in this study were low despite their knowledge of HIV transmission risks. Underlying mechanisms that cause the dissociation between individual's knowledge, risk perception and ongoing risk behaviors need to be identified in further studies. Pre-exposure prophylaxis may be an attractive method for HIV prevention as an adjunct to currently available preventive strategies. However, since low risk perception and low education level may affect PrEP interest, enhanced interventions that improve HIV risk perception, knowledge about PrEP and safer sex practices are necessary for successful PrEP implementation and HIV transmission prevention among this high-risk population.

Footnotes

Acknowledgment

We thank Dr. Judith A. Levy for her critical and thoughtful review of the manuscript. This research was supported in part by the Chicago Developmental Center for AIDS Research (D-cFAR).

Author Disclosure Statement

Dr. Kimberly Smith is a consultant for Gilead. No competing financial interests exist.

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