PrEP User Adherence to Regular HIV Testing Recommendations

In Germany, HIV pre-exposure prophylaxis users are recommended to receive regular HIV, STI, and renal function testing. How frequently are PrEP users getting tested?

HIV pre-exposure prophylaxis (PrEP) is a preventative medication, taken orally daily or injected as infrequently as 6 times a year. PrEP uptake has been attributed as one of the greatest reducers of HIV infections worldwide.

Just taking PrEP is not sufficient HIV prevention, however. German guidelines call for PrEP users to regularly get tested for HIV, sexually transmitted infections (STIs), and renal function. Notably, German PrEP users had to cover treatment and appointment costs themselves before September 2019. One study, published in Eurosurveillance, examined testing frequencies among German PrEP users during this self-funded period.

The investigators recruited German PrEP users from July-October 2018 and April-June 2019. Participants were identified via men who have sex with men (MSM) dating apps (Grindr, Romeo, Hornet), a German PrEP community website, and anonymous HIV/STI testing locations. Participants were also asked to recruit friends who fit the study criteria. After consenting to the study, participants completed an anonymous survey about their PREP use, testing practices, and STI history.

Participants were identified as cisgender male, cisgender female, or gender diverse (including transgender, nonbinary, or intersex gender identity). Source of current PrEP usage was classified as either “medical prescription” or “informal” (if they received the medication from internet platforms, dealers, or friends). Anyone who responded that they did not pay for tests was considered “cost coverage,” while those who paid any amount for their testing were “self-payment.” Testing locations included “testing only at the physician's,” “testing at the physician's and other locations,” and “only using checkpoints, self-tests or other locations”; checkpoints are anonymous testing sites in Germany.

A total of 2118 current and former PrEP users were included during wave 1 of the survey, and 2730 were included in wave 2. The average age of the sample was 37 years and 88.7% were cisgender men.

The results showed 22.0% of participants had received at least 1 gonorrhea diagnosis, 21.4% received 1 or more chlamydia diagnoses, and 13.0% received at least 1 syphilis diagnosis during their PrEP use. Among all study participants, 3.4% indicated they had not received any medical testing before starting PrEP, and 8.0% said they were not getting tested during their current PrEP use.

Germany recommends PrEP for people at “substantial” risk of HIV infection. Specific recommendations call for potential PrEP users to first be screened for HIV, hepatitis B virus (HBV), and impaired kidney function. After initiating PrEP, users should receive medical supervision during PrEP use, be tested at least every 3 months to ensure they are still HIV-negative, be screened for syphilis every 3 months, be screened for gonorrhea and chlamydia every 3-6 months, and have kidney function monitored regularly.

Most participants said they were receiving HIV and renal function testing at least every 3 months and STI testing at least every 6 months. Participants who obtained PrEP from informal sources had much lower rates of testing before and during PrEP usage. The strongest factor associated with inadequate HIV testing frequencies was not receiving any testing before initiating PrEP.

Overall, PrEP users reported testing frequencies below the German recommendations for regular HIV (26.3%), STI (20.9%), and renal function (29.2%) testing. Participants who frequently tested for STIs had had a higher proportion of self-reported STI diagnoses during their PrEP use. Those with the least frequent HIV, STI and renal function testing commonly reported not having any testing before starting PrEP, obtaining PrEP from informal sources, and on-demand or intermittent PrEP use.

HIV and STI testing rates in this German study were higher than in the US. The investigators noted that stigma around PrEP may be preventing some people from seeking medical care and regular testing. “We will investigate barriers to regular testing in future surveys,” the investigators concluded.