HIV pre-exposure prophylaxis (PrEP) and the required tests (e.g. for HIV, STIs) before and during PrEP use are currently not covered by health insurances in Germany. Generic PrEP can be purchased with private prescriptions through pharmacies since October 2017. Before, non-prescription PrEP use with drugs obtained through informal sources was common. The objective of this study is to estimate the extent of continued informal PrEP use in a sample of German PrEP users and to identify possible risk factors associated with non-prescription PrEP use.
From 24th July to 3rd September 2018 we recruited PrEP users on geolocation dating apps for MSM, community-based HIV testing sites, and a community website in Germany for an anonymous online survey. Prescription PrEP use was defined as use of PrEP drugs obtained through German pharmacies and clinical trials; other sources were classified as non-prescription drug use. Risk factors associated with non-prescription PrEP use were assessed with logistic regression models adjusting for age, country of origin, and annual gross income.
We recruited 2,005 current PrEP users into our study, 78.7% of which completed the survey. The median age of the participants was 38 years (IQR: 31–45). 95.4% of the participants obtained medical tests before starting PrEP and 86.9% receive medical tests during PrEP use. 80.4% of the participants obtained PrEP through prescriptions, whereas 19.6% used non-prescription sources (Table 1). PrEP users with non-prescription drug use tended to have used PrEP longer than PrEP users with prescription drug use (median: 7-12 months vs 3-6 months, p<0.001) and were more likely to use PrEP intermittently or on demand (OR = 4.4, 95% CI 3.2, 5.9). PrEP users with non-prescription use were at higher risk of not obtaining medical tests before starting PrEP (OR = 8.1, 95% CI 4.5, 14.5) or during PrEP use (OR = 5.8, 95% CI 4.1, 8.3). We found that among daily PrEP users, non-prescription users were more likely to take PrEP fewer than 26 days per month on average than prescription PrEP users (OR =3.7, 95% CI 1.5, 8.7).
Non-prescription PrEP users were less likely to use PrEP according to current guidelines. This could increase the risk for undetected HIV and STI infections in this group. Our findings highlight the need for patients to access PrEP through healthcare systems in order to allow safe use.