Discussion
In spite of the lack of public information or regulation on PrEP in Italy at the time of this study, 38% of the participants were aware of PrEP, 24% knew the results of the studies demonstrating a risk reduction through the use of ARVs, 22% had discussed PrEP with their peers or doctors, 9% had people in their close circle who used PrEP, and 1% had shared their personal ARVs for PrEP with someone.
Though the study was conducted in Italy 2 years after the PREVIC Study, after FDA approved Truvada® for PrEP in adults at high risk for contracting HIV infection, and after the launch of two well-publicized PrEP studies in Europe, these proportions are very similar to those observed in France [
12].
However, only some similarities were observed in the two PLWHA populations (French and Italian) regarding factors associated with a greater likelihood of discussing PrEP with peers or having PrEP experience: among males, HIV association membership and non-heterosexual route of HIV transmission; and among females, having multiple partners. Actually, in Italy, HIV association membership was the strongest predictor of discussing and having a personal or a close experience of PrEP across the whole patient population (males, females and transgender persons), thereby confirming the crucial role that associations play in the spread of information [
13]. Indeed, in our study, factors predictive of either discussion or experience regarding PrEP seem mostly related to having access to information on this issue, especially among females. Other factors seem to be related with the possibility of transmitting the infection, i.e., having multiple partners among all genders, route of HIV transmission among males, and having a detectable viral load among females, though in a previous study, the fear of infecting the partner among women living with HIV in Italy was unrelated with virological control in plasma [
14].
Also very similar were the proportions of French and Italian HIV physicians aware of PrEP, knowing the dosage schedule, and having actually prescribed PrEP. Data on PrEP knowledge, though not further assessed, are consistent with previous results among Italian HIV specialists [
15]. Among patients, discussion with their HIV physician was reported by 15%, though we excluded this item from the MLR analysis as in Italy we had observed conflicting results regarding attitudes towards PrEP prescription among HIV physicians [
15,
16].
These results cannot be considered fully representative of the whole population on ARVs in Italy, even if the centres which contributed are among those which treat the highest proportion of PLWHA. However, our results are in line with those of the “Flash PrEP” survey conducted almost contemporarily to characterize informal PrEP use in France [
17]. Moreover, a significant increase in awareness and attitude is likely to have occurred after the widely publicized appearance of the results from IPERGAY [
5] and PROUD [
6], the international guidelines, and the EMA approval, so that any further delay in incorporating PrEP in national prevention protocols might result in dangerous practices. HIV seroconversion while using non-prescribed ARVs for PrEP has been reported, and uncontrolled use might undermine the protective benefits of PrEP [
18].
As a biomedical HIV prevention technology, PrEP opens up opportunities for expanded autonomy in managing one’s own sexual health, and might re-balance structural asymmetries through shifting the control of sexual risk from the HIV-positive to the HIV-negative partner, a fact especially important for women [
19]. PrEP also prefigures a different kind of user of sexual health services, one more mobile and active than the traditional idea of patient allows [
20]. Therefore, it should not be unexpected that 45.6% of PLWHA were somehow aware, discussed or had direct or indirect experience of PrEP at a time and place where there were neither information nor proposals or interventions to guide public policies in this regard. This underlines that the temporal rhythms of connection between affected communities and public health systems should be synchronized to avoid uncontrolled procurement practices and self-administration of ARVs amongst HIV-exposed persons.
Acknowledgements
Group authorship: Members of the PrEPventHIV Italy Study Group.
Nicoletta, Ladisa (AO Policlinico - Bari).
Franco, Maggiolo; Marco, Rizzi (Ospedale Papa Giovanni XXIII - Bergamo).
Leonardo, Calza; Vincenzo, Colangeli; Nicolò, Girometti (Malattie Infettive S. Orsola Malpighi - Bologna).
Alice, Ferraresi; Emanuele, Focà; Pier Francesco, Giorgetti; Maria Chiara, Pezzoli (AO Spedali Civili Università degli Studi di Brescia - Brescia).
Benedetto Maurizio, Celesia; Marilia Rita, Pinzone (Unità Operativa di Malattie Infettive, ARNAS Garibaldi Nesima - Catania).
Tiziana, Bruno; Alberto, Viada; Davide, Vitullo (AOS Croce e Carle SC Malattie Infettive e Tropicali - Cuneo).
Viola, Guardigni; Laura, Sighinolfi (AOU Ferrara - Ferrara).
Silvia, Ambu; Dario, Bartolozzi; Irene, Campolmi; Massimo, Meli; Marco, Pozzi; Gaetana, Sterrantino (AOU Careggi - Firenze).
Filippo, Matarazzo; Francesco, Purificato (ASL LATINA - UOSD Malattie Infettive - Formia).
Enza, Anzalone; Luciano, Sarracino (Ospedale «F. Spaziani» Div. Malattie Infettive - Frosinone).
Miriam, Lichtner; Raffaella, Marocco; Vito Sante, Mercurio (Ospedale Santa Maria Goretti Università Sapienza Polo Pontino - Latina).
Paula, Castelli; Lorena, Paoli Martorelli (Ospedale di Macerata ASUR Marche ZT9 - Macerata).
Angela, Linzalone (Ospedale Madonna delle Grazie, UO Malattie Infettive - Matera).
Franklyn Esoka, Eseme; Enzo, Raise (Ospedale dell’Angelo - Mestre (VE)).
Simona, Bossolasco; Antonella, Castagna; Massimo, Cernuschi; Paola, Cinque; Luca, Fumagalli; Giovanni, Gaiera; Nicola, Gianotti; Monica, Guffanti; Miriam, Maillard; Silvia, Nozza; Vincenzo, Spagnuolo; Caterina, Uberti-Foppa (Ospedale San Raffaele IRCCS - Milano).
Vanni, Borghi; Cristina, Mussini (AOU Modena Malattie Infettive - Modena).
Luchino, Chessa; Laura, Matta; Maria Cristina, Pasetto (Dipartimento di Scienze Mediche “M. Aresu” Università di Cagliari - Monserrato (CA)).
Giuseppe, D’Esposito; Alfredo, Franco; Crescenzo Maria, Izzo; Elio, Manzillo; Alessandro, Marocco; Raffaele, Micillo; Teresa, Pizzella;(AORN «Ospedali dei Colli» - Napoli).
Salvatore, Martini (Seconda Università degli studi di Napoli UOC Diagnosi e Terapia AIDS e Patologie Infettive Correlate - Napoli).
Maria Vittoria, Moretti; Elisabetta, Schiaroli (Azienda Ospedaliera, Ospedale S. Maria della Misericordia, Clinica Malattie Infettive - Perugia).
Corrado, Catalani; Marina, Giorgi; Beatrice, Menichini; Michele, Trezzi (Ospedale San Jacopo - AUSL 3 Pistoia - U.O. Malattie Infettive - Pistoia).
Simona, Migliore (UOC Malattie Infettive - Ospedale Civile - Ragusa).
Giuseppe, Ballardini (AUSL Ravenna UO Malattie Infettive - Ravenna).
Enrico, Barchi; Elisa, Garlassi; Giacomo, Magnani; Francesca, Prati; Lucia, Testa; Maria Alessandra, Ursitti; Giuliana, Zoboli (Arcispedale Santa Maria Nuova IRCCS - Reggio Emilia).
Elisabetta, Teti (AOU Sant’Andrea - Roma).
Anna Rita, Buonomini; Carlotta, Cerva; Giovanni, D’Anna; Barbara, Ilari; Vincenzo, Malagnino; Loredana, Sarmati (Fondazione Policlinico Università Tor Vergata - Roma).
Adriana, Ammassari; Rita, Bellagamba; Evangelo, Boumis; Stefania, Cicalini; Giuseppina, Liuzzi; Laura, Loiacono; Paolo, Migliorisi; Emanuele, Nicastri; Carmela, Pinnetti; Alessandro, Sampaolesi; Chiara, Tommasi; Mauro, Zaccarelli (Istituto Nazionale per le Malattie Infettive «Lazzaro Spallanzani», IRCCS - Roma).
Rosalia, Angileri; Maria, Coscia; Gabriella, d’Ettorre; Alessandra, Fantauzzi; Giancarlo, Iaiani; Ivano, Mezzaroma; Francesca, Paoletti; Maria, Zaccaria (Azienda Policlinico Umberto I - DAI Malattie Infettive e Tropicali - Roma).
Andrea, De Luca; Barbara, Rossetti; Manola, Pomi (AOU Senese, UOC Malattie Infettive Universitarie - Siena).
Nicoletta, Carnicelli; Angela, Gonnelli; Daniele, Marri; Lucia, Toscano (AOU Senese, UOC Malattie Infettive ed Epatologia - Siena).
Orlando, Armignacco; Anna Rita, Capino; Antonio Luciano, Caterini; Barbara, Di Filippo; Anna Maria, Ialungo; Elena, Rastrelli; Rita, Sabatini (UOC Malattie Infettive - Complesso Ospedaliero Belcolle-AUSL - Viterbo).
Coordinating centre:
Gabriella, De Carli; Antonio, Palummieri; Vincenzo, Puro (Istituto Nazionale per le Malattie Infettive «Lazzaro Spallanzani», IRCCS - Roma).