What will it change?
For each of these ten choices, both the precautionary and the risky behaviour has needs associated with doing it (or not doing it). If we are concerned only with the harm arising from sex we should try to minimise all sexual activity between MSM. This would mean being confident that the behaviour men should choose each and every time is the first option in each choice. However, sex also carries value, and for the majority of men that value warrants some risk. The second option in each choice carries potential value that varies for different people in different situations. The two options also carry risk, that is, the potential for harm. The amount of risk any sexual activity warrants cannot be decided by third parties, although most people have an opinion about what people should do sexually. With regard to the above choices, our strategic goal is for men to more frequently choose precautions than is currently the case.
Strategic Programme Goal: For men who have sex with men (MSM) to more frequently choose precaution across a range of 10 specified choices than is currently the case.
The following sections consider each of the ten choices and outline the range of factors influencing that choice. We identify those factors which we intend to influence, which we will refer to as needs. The needs are grouped by: useful knowledge (facts that we believe to be true that can help men form an attitude) and the opportunities, resources, and skills necessary to enact the choices. In the tables that accompany each choice, the needs are articulated as aims for interventions. These aims are also summarised in MiC aims, where they are subdivided into knowledge aims; opportunity and resource-related aims; and skills-related aims. The tables also outline benefits and costs associated with that choice (consequences that may or may not be of value to men); and social norms (who significant others may be and what they think about the choices).
Choice Zero: being involved in HIV transmission
Before considering the choices men make around any particular HIV risk or precautionary behaviour (for example, declining sex or using a condom for intercourse) there is the question of increasing their will or motivation to reduce HIV risks at all. The motivation to avoid HIV risk does not result in any single behavioural choice. For example, it is not the case that ‘unprotected intercourse = HIV’ and that ‘HIV prevention = condoms’. Men may react to knowledge of HIV in a variety of ways depending on their values and circumstances. However, all risk reduction choices can be motivated by increasing: knowledge of the existence of HIV; awareness of the consequences and impact of acquiring HIV; social norms for risk reduction; the knowledge and power to reduce risk. This section considers these generalised HIV prevention needs.
The motivation to avoid acquiring HIV
In order to lay the groundwork for any risk reduction promotion, we want men to have some basic knowledge of what HIV is, how common it is and what its general impact might be. This includes the following facts (the facts in this and the following sections have been agreed by the CHAPS partners as the knowledge base we wish to promote).
These are examples of the kinds of consequences men may be aware of. The consequences they actually consider are likely to be far more detailed and directly relevant to their lives. The consequences are founded on what men know and believe about HIV, and what they think they know may be incorrect. This does not prevent them from forming attitudes based on that incorrect knowledge.
People are more likely to choose an option that brings them greater benefits and fewer costs. In order to motivate men to reduce their risks of HIV infection, we want them in particular to be aware of the benefits of remaining HIV uninfected and the costs of acquiring HIV.
We do not believe many men seek to acquire HIV (belittled and caricatured as ‘bug-chasers’) or seek to pass HIV on (demonised as ‘gift-givers’), although some circumstances give rise to this desire and we acknowledge that some men are in this position.
The motivation to avoid passing on HIV
All people who acquire HIV are then at risk of passing it on. As with acquiring HIV, the consequences of passing it on are diverse. The following table illustrates some of the potential consequences that may be of value to MSM.
These are generic examples of the kinds of consequences people may have an understanding of. The broad groups of potential consequences of passing HIV are an extension of those of remaining uninfected or acquiring HIV but for someone else, plus further potential consequences for the person passing the infection.
The power to avoid or reduce the risk of acquiring and passing on HIV
Simply wanting to reduce HIV transmission risk is not enough. People need to know how to reduce or eliminate risk and be able to enact those decisions. In order to choose to reduce risk people require the knowledge of how to do so, the belief that they can carry out preventative actions and the opportunity for doing so, and the skills and resources required. The following table illustrates the range of factors involved.
We will therefore increase men’s knowledge of practical ways to reduce STI/HIV risk, including knowledge of how infectious agents are and are not transmitted. The scientific literature will be the basis for this education. We will also increase men’s real opportunities to reduce their risks through increasing the control they have over risk reduction.
Men will not be prevented from acquiring or passing on HIV by reducing their opportunities to meet sexual partners who do (or do not have HIV). However, we will address men’s lack of motivation to avoid HIV because of feelings of worthlessness, hopelessness, or self-punishment. We will also enable men to choose precautionary choices by ensuring they have sufficient economic, interpersonal and psychological power to do so.
These power needs are not specific to any one method of risk reduction but are the generic needs to reduce risk. Since these needs lie at the root of all preventative actions, they are likely to hinder all precautionary choices if they are not met.
Drug and alcohol use
A major obstacle to men having power over their sexual choices can be the use of alcohol and other drugs. Intoxication can undermine motivation and can reduce interpersonal and motor skills. In extreme cases it can disable physical autonomy and leave people vulnerable to accident and assault.
All illicit drugs are used by a higher proportion of the MSM population than the general male population (Beddoes et al. 2010). Over the last ten year the prevalence of use of different drugs has changed, with use of amyl nitrite (poppers), cannabis, amphetamine and LSD becoming less common, and use of cocaine, ecstasy, ketamine and GHB increasing. However, cannabis and poppers remain the most commonly used drugs after alcohol. Polydrug use is common.
Awareness and uptake of drugs services is low among MSM. From the perspective of service users, good practice in drugs services means treatment and prevention programmes being aware of the specific needs of the LGBT population. Clinic-based support should include marketing in social venues accessed by MSM.
The extent of problematic alcohol and drug use in a local population of MSM (and the need for services to address them) should be included in HIV prevention needs assessments, including ensuring that MSM are explicitly addressed in drugs services needs assessments.
Choice One: STI screening before the next new sex partner, or not
For everyone who picks up HIV or another sexually transmitted infection (STI), someone passes it on. The first behavioural choice is about the risk of passing on sexually transmitted infections when men have new sexual partners, as well as reducing the impact of infections they pick up. If men have not been diagnosed with HIV we consider an HIV test part of an STI check-up.
Although some men currently have too many partners for it to be feasible to STI screen between each one, all men always have the choice of seeking an STI screen before their next partner by declining or deferring their next partner. It is not that having an STI screen between each partner is unfeasible but that many men consistently choose not to do so. In this case men will be unable to be 100% confident they are not contributing to HIV and STI risk.
Doctors recommend at least annual STI and HIV screening for MSM, and that a suspicion of symptoms should prompt immediate screening. The BHIVA / BASHH / BIS Guidelines on HIV Testing aim to ensure all MSM know that medical authorities think they should test for HIV early and often. We will aim to ensure men know that doctors think they should test for HIV.
The BHIVA Guidelines also intend for men to be aware of the benefits of HIV testing and the costs of not doing so, and are concordant with this framework. Swifter HIV diagnosis is one route to less harm both for the individual infected and potentially for those he has sex with.
Some social networks of HIV positive men organise ‘bareback orgies’ (closed spaces for multi-partner anal sexual contact without condoms). It has been claimed that these events do not contribute to the spread of HIV to those who are uninfected. However, the number of new HIV infections is related to the number of other STIs among men with HIV. HIV positive men can only be confident of not contributing to HIV incidence by having an STI screen before attending such events. Passing an STI to an HIV positive man means he is more infectious when he next has sex with uninfected men.
Population Target #1: Reduce the average length of time between HIV infection and HIV diagnosis in men who become infected.
This target is shared with other agencies concerned with HIV, in particular clinical sexual health services.
Choice Two: taking HIV treatment, or not (if diagnosed with HIV)
Virally suppressive anti-HIV treatment significantly reduces the risk of passing on HIV if a condom breaks or is not used. Although BHIVA treatment guidelines recommend that starting HIV treatment should be recommended to all people with a CD4 count of 350 cells/mm3 or below, one in five HIV-positive men who have sex with men with a CD4 count below this level are not taking treatment (see Health Protection Agency 2010).
While the decision to start treatment must primarily be determined by the clinical benefit for the individual, a decision to take effective treatment also potentially reduces harms to that person’s sexual partners and to public health. BHIVA guidelines recommend that reducing transmission may be a factor to consider in initiating anti-retroviral therapy when a person has a CD4 count above 350 cells/mm3.
The most relevant studies have been conducted with heterosexuals. While the reduction in infectiousness during anal sex cannot be quantified, it is likely to be substantial.
In a recent study conducted with 3,381 heterosexual couples in several African countries, the researchers calculated that treatment reduced the transmission risk by 92%. In each couple, one partner had HIV while the other did not. There were 103 HIV transmissions, but 102 of these were from a partner not taking HIV treatment (Donnell et al. 2010).
A 92% reduction in risk is comparable to the reduction in risk given by consistent condom use (as a minority of condoms may break or otherwise fail). A combined strategy of consistent condom use and effective treatment is likely to be the most effective of all if men with diagnosed infection have intercourse with men without infection.
Population Target #2: increase the proportion of MSM with diagnosed HIV who are on fully suppressive anti-retroviral therapy.
Choice Three: declining or deferring a new sexual partner, or having a new partner (if men have an opportunity for a new partner)
Better sex is not the same as more sex partners. Saying ‘No, thanks!’, or ‘How about next week?’ or ‘How about going for a [something other than sex]?’ are all choices men have when an opportunity arises for sex with a new partner. Having sex with a new partner, particularly not having had an STI screen since the last partner, is a sexual health risk behaviour relative to choosing to do something other than having a new partner.
Consistently choosing not to have sex whenever presented with an opportunity for a new partner is sometimes called abstinence or celibacy. For some men this will be a preferred ‘sexual’ lifestyle, perhaps for an extended period of time. However, people do not have to make any one choice every time they are presented with it. Precautionary choices are not all or nothing choices and we are not advocating abstinence (that is, consistently choosing not to have a new sex partner) as a solution to HIV infection. However, declining, deferring or dating a potential sexual partner rather than having sex with him, and extending the length of time between new sexual partners can have beneficial impacts. Even in the absence of STI/HIV, there are benefits to declining sex. This is particularly the case where the sex utility was low (that is, bad sex).
We will promote choosing to do something other than have sex with a new partner by increasing men’s awareness of the benefits of doing so. For example, if men are looking for a close emotional relationship with another man, meeting as friends first rather than sex partners can lay a better foundation for a future together. We will also raise men’s awareness of the potential costs of having new partners.
We will not attempt to reduce men’s choosing to have new sex partners by undermining their opportunities for doing so. This means we will not attempt to close down or limit men’s places to meet sex partners (except within the law), nor to disable them from pursuing casual sex practices. Instead, we will increase men’s ability to decline or defer sex by increasing assertiveness, interpersonal skills and self-confidence. We recognise these also increase men’s ability to choose to have sex.
We recognise that some men in some situations will choose to take the risk of having sex with a new partner if the opportunity arises (with or without having tested for STIs since their last sex partner). Without attempting to limit the choice to have sex, we wish to influence the relative frequencies with which men acquired new sex partners and have STI screens.
Population Target #3: reduce the average number of sexual partners between STI screens.
Rather than aiming for men to have fewer sexual partners and/or specifying a length of time within which we aim for every man to have an STI screen (eg. every year), we are targeting the relationship between partners and sexual health screens. There are definitional issues with ‘sex’ and the range of tests that go toward an STI screen. However the intention is clear– we aim for men to have more STI screens per sexual partner (or fewer partners per STI screen) than is currently the case.
Choice Four: telling sexual partners about HIV and STI infections, or not (if men have sexual partners)
Sex between men occurs in a wide variety of contexts and with a varying amount of personal information exchanged before and after sex. Before (as well as after) sex people have the choice of talking about HIV and STIs, telling potential partner about any infections known about and bringing up the kind of sex (eg. anal intercourse or not, condom use or not) we are willing to have.
Knowledge and perception of their own and their sexual partners HIV status is central to the risks people are willing to take. Believing a partner to have the same HIV status means believing there is little risk of HIV infection. Many men who engage in HIV risk behaviour do so because they believe the sex they are having carries little or no risk. Both because of undiagnosed infection and because of other misreadings of HIV seroconcordancy, this choice (and what results from it) impacts on all other choices.
Expectation of HIV disclosure is very high among MSM although disclosure itself is relatively low. Expecting to be told that a person you are about to have sex with has HIV is a problem both because around a third of people with HIV do not know they have it and because many people who do know they have HIV will not tell sexual partners before sex.
Many men, especially with casual sexual partners, choose to not to bring up HIV and STIs because they either intend to have no anal intercourse or to have anal intercourse with a condom, and have decided this is a risk they are willing to take.
Some men with diagnosed HIV infection attempt to limit HIV risk behaviours to other men with HIV by ‘choosing partners carefully’ or ‘sero-sorting’. This should be easier for men who know they have HIV than for those who do not, and should be able to reduce HIV transmission risk compared to infected men engaging in risk behaviours with no regard for the HIV status of partners. However, in practice many HIV positive men make optimistic judgements that their sexual partners in casual or anonymous settings also have HIV without making verbal confirmation (Bourne et al. 2009). Similarly, some men who believe themselves uninfected attempt to limit sexual risk behaviours to men they think also do not have HIV, but again with extensive assumptions. Limited to one partner this has been labelled ‘negotiating safety’ (ensuring mutual HIV uninfected statuses by testing together before engaging in intercourse and agreeing on avoiding risk behaviours with third parties) and can reduce the risk of HIV acquisition substantially compared with engaging in unprotected intercourse with no recourse to tests or sharing information (Kippax et al. 1993). It does not eliminate risk because of the possibility of a partner not sticking to the agreement, picking up HIV and passing it to their partner (eg. HIV incidence among men in negotiated safety arrangements in Sydney has been measured at 0.55%, see Jin et al. 2009).
Attempting to limit risk behaviours to men without HIV when doing so with more than one partner (‘choosing partners carefully’ or ‘sero-sorting’) is less likely to be successful than limiting them to one partner, but is still able to reduce HIV acquisition risk compared to engaging in risk behaviours with no regard for the HIV status of partners. The majority of MSM with undiagnosed infection in England have previously tested HIV negative and still believe they are HIV uninfected (Williamson et al. 2008). Uninfected men are unable to successfully reject all infected partners because of the extent of undiagnosed infection. Engaging in risk acts with men whose HIV status is unknown may be more likely to result in infection than doing so with a man known to be HIV infected due to differences in viral load (and therefore infectivity) between diagnosed and undiagnosed men with HIV (Butler & Smith 2007).
Knowing who infection was acquired from can result in greater sharing of understanding in the future. Although some people react unpleasantly (or violently) to knowing who they got an infection from, not knowing is more likely to result in also withholding understanding. Greater certainty about who men had contracted HIV from is associated with disclosure of positive HIV status to new partners, while greater uncertainty is associated with not disclosing HIV serostatus to new partners (Moskowitz & Roloff 2008).
Prosecutions for harm associated with transmitting STIs are not limited to HIV. All men are at risk of prosecution if they, for example, attend sex venues in the knowledge of having an STI and having sex without ensuring their partners know about their infection beforehand.
We recognise that some men who know they have an infection, in some situations, choose to take the risk of having sex without disclosing their infection. Without removing that choice we want to influence the proportion who do so.
Population Target #4: reduce the frequency with which men have unprotected anal intercourse without knowing whether or not they and their partner are HIV sero-concordant.
This target concerns what men know about the risks they take, not whether they take the risks or not. Later targets concern the risks men take. Here we are concerned that, whenever risks are taken with UAI, men know what the risk they are taking. The target is change in the profile of the population.
Choice Five: monogamy or open relationship (if men have a regular sexual partner)
If men have a regular sexual partner they can choose whether to have sex with that partner only, or to also have sex with other people. The regular partner has the same choice. Sexual exclusivity is not normative among gay and bisexual men and many couples choose to have open relationships. Others choose to have sex only with each other, but one or both may not stick to this agreement. The potential consequences of these choices for both the relationship and the sexual health of both partners are extensive.
HIV positive men (who have no other STIs) in monogamous relationships with uninfected men are at small risk of transmission during sex (of any kind) if the positive partners viral load is undetectable. Non-monogamous relationships are at risk of other STIs (brought in by either partner) and therefore viral load spikes which can make HIV transmission much more likely.
As well as increasing knowledge of the STI implications of different relationship configurations, we will attempt to influence men’s choice of relationships by increasing awareness of the benefits of monogamous relationships and the costs of open-relationships. We will not attempt to disable or prevent men from implementing open relationships if that is what they and their partner choose.
Even in the absence of STI/HIV there are benefits to monogamy. However, we recognise that some men in sexual relationships with other men choose to also have sex with third parties, and that some men have multiple on-going sexual relationships. While making no attempt to remove that choice, we wish to reduce the extent of concurrent (that is sexually open or overlapping) partnerships in the MSM population.
Population Target #5: increase the length of time since having an extra-relational sex partner, among men with a regular male sex partner.
Sexual exclusivity in male-male relationships varies with length of relationship, age of partners, social setting and other factors. However, in opportunistic samples of gay men about half of the men with a regular partner also have sex with other men. There are distinctions to be made between explicit and implicit expectations and agreements, and actual behaviour, as well as definitional issues about ‘relationships’ and ‘sex’.
The target is a profile in the population, not a proportion. Considering only those men with a regular partner, we wish to increase the average length of time since those men had sex with someone else.
Choice Six: sex without or with anal intercourse (if men have sex)
Sex between men is not equal to anal intercourse and men do not need to have anal intercourse to be gay. Even in the absence of HIV and STIs, there are benefits to not having intercourse when having sex.
Avoiding anal intercourse and instead having non-penetrative sex is a highly effective way of reducing HIV risk. Avoiding both insertive and receptive intercourse with all partners reduces the vast majority of HIV acquisition risk. Risk is not eliminated because HIV can be acquired orally.
Gay men are surrounded by messages that suggest gay sex equals anal intercourse. We will promote the notion of satisfying gay sex without intercourse in order to give men real choices about their sexual behaviour. We will also promote the notion that different sexual sessions with the same partner can include different sexual choices.
In order to choose sex other than intercourse men need to have physical autonomy, that is being free from physical force and rape. Men also require a location to have sex in and we will promote safe spaces for men who have sex. We will not attempt to reduce men’s ability to engage in intercourse by removing locations in which they can have it. Similarly, sexual competencies (for example, assertiveness, interpersonal sensitivity and skills, physical techniques) are required for all sex and we will promote these in order for men to make more precautionary choices.
Sex without intercourse can be erotic, intimate and satisfying. However, some pairs of men choose to have anal intercourse.
Population Target #6: decrease the proportion of sexual sessions between men that feature anal intercourse.
A surrogate marker for this target may be the average length of time since anal intercourse. This target may be distinguished by partner type or context of sex, for example, the proportion of sexual sessions with new partners that feature anal intercourse.
Choice Seven: using condoms and lubricant, or not (if men have anal intercourse)
During anal intercourse the pre-cum from the penis of the insertive partner and the mucus (and possibly blood) from the anus of the receptive partner are transferred to each other. The insertive partner has the receptive partner’s anal mucus on his penis and the receptive partner has the insertive partner’s pre-cum in his rectum. Both of these fluids can transmit HIV if either partner has HIV. This section considers the choice of having protected anal intercourse or not – the choice and implications of ejaculation into the rectum if anal intercourse occurs is in the withdrawal section.
We will aim to ensure men have accurate knowledge about the consequences of using a condom or not if they have intercourse. We will not assume that men will have intercourse and will acknowledge that intercourse with a condom is a greater HIV risk than no intercourse.
We will promote condoms if intercourse is chosen by ensuring men are aware of the benefits of condom use and the risks of non-use. The benefits of condom use is always present and does not require men to be HIV sero-discordant to be present. In all situations, condom use has benefits to both partners.
For uninfected men, attempting to avoid Act 1 (being receptive in anal intercourse with HIV infected men) without a condom but not attempting to avoid engaging in Act 2 (being insertive) without a condom has been named ‘strategic positioning’: uninfected men can reduce their HIV acquisition risk by not engaging in RUAI even if they continue to engage in IUAI (Jin et al. 2009). This tactic has major problems unless men are testing for HIV in between each risk. The risk of infection through IUAI remains substantial. Those men who rely on strategic positioning without testing for HIV between risk events who do become infected are very likely to pass their infection on when they continue to engage in IUAI thinking they are reducing the risk to themselves while in fact they are now increasing the risk to their partners because they have HIV.
Similarly, for HIV positive men attempting to avoid Act 1 (being insertive in anal intercourse with uninfected men) without a condom but not avoiding Act 2 (receptive intercourse) has also been labelled ‘strategic positioning’ under the belief that infected men are more likely to pass on their infection if they engage in insertive rather than receptive UAI49. However, the risk of passing on HIV through RUAI remains substantial, particularly in the presence of a rectal co-infection. Positive men who rely on strategic positioning without testing for STIs between risk episodes who become co-infected become more likely to pass-on their infection when they continue to engage in RUAI.
Avoiding Act 1 and Act 2 without a condom by using condoms for all occasions of intercourse with all partners reduces the majority of HIV risk. Risk is not eliminated because condom failure occurs, and because HIV can be acquired orally. Knowledge of HIV status is not required to employ this tactic.
We will also promote choosing condoms and lubricant through making them widely available. We will not attempt to reduce intercourse without condoms by reducing men’s contact with other men (who want unprotected intercourse) or by limiting their access to locations for doing so.
Condoms are health protective in all cases of anal intercourse, irrespective of the HIV status of the two partners – there are always benefits to using condoms for intercourse. However we recognise that some men choose to engage in unprotected intercourse.
Population Target #7: increase the proportion of anal intercourse events that feature condoms from the beginning of intercourse.
This target can be distinguished in different contexts, for example, the proportion of anal intercourse events with casual partners that feature condoms.
Choice Eight: ejaculating outside or inside the body (if men have anal or oral intercourse)
Anal intercourse and fellation need not end with ejaculation into the rectum or mouth. As with all sexual behaviours, whether or not men are attracted to ejaculation in the body is very personal. It is also the medium through which infections can be carried if present.
The gap between intention and behaviour may be particularly large for withdrawal as ejaculation can take men by surprise and approaching orgasm is a time when many men feel out of control.
Unprotected intercourse without ejaculation (between partners not mutually known to be STI clear) is a risk for STI transmission. We do not ‘advocate’ that men engage in unprotected intercourse with withdrawal as this would promote risk. However, we do advocate that men know that ejaculation during unprotected intercourse greatly increases the chances STIs will be passed if the insertive partner has an infection. It is also important that men known that the gap between intention and behaviour may be particularly large around withdrawal. Despite the risk involved, some men choose to take ejaculate into their mouth or rectum because of the benefits it brings to them.
Population Target #8: reduce the frequency with which ejaculation occurs into a mouth or rectum without a condom.
The amount of semen transferred from HIV infected men to HIV uninfected men is a major determinant of transmission. An indicator for this target could be the length of time since men ejaculated into a mouth or rectum without a condom.
Choice Nine: avoiding poppers, or using poppers, during receptive anal intercourse (if men have receptive anal intercourse)
Poppers are a very common part of gay life in the UK. They are widely advertised in the press and are on sale in shops and at clubs and are given away in commercial promotions. The widespread availability of poppers means that they are widely used.
No skills are required to use poppers, however they do require access to them, including finance. Because we value men making their own choices, we will not seek to reduce the widespread use of poppers by reducing men’s access to them. We attempt to promote men’s choosing not to use poppers by ensuring they are knowledgeable about them, and are aware of the benefits of avoiding them and the costs of using them.
It has not been demonstrated that poppers increase the transmission of other STIs although the potential health harms of poppers are clear. However, some men choose to use poppers during receptive anal intercourse.
Population Target #9: reduce the frequency with which men use poppers during receptive anal intercourse.
This target can be distinguished by partner and context, for example, with new or casual sexual partners. An indicator of the target could be how recently men had used poppers during unprotected receptive anal intercourse. The target is the profile of use in the population.
Choice Ten: seeking Post-Exposure Prophylaxis, or not (if HIV uninfected men are sexually exposed to HIV)
Having intercourse without a condom with new partners is the riskiest thing an MSM can do as far as HIV / STIs go, particularly if ejaculation into the rectum occurs. Even at this late stage, choices make a difference to whether people get HIV or not. We do not advocate the use of post-exposure prophylaxis (PEP) as a sustainable risk reduction tactic; it is not. However, for men who are exposed to HIV, using PEP or not can make the difference between acquiring an incurable infection or not.
Taking anti-HIV drugs as soon as possible following sex with a risk of HIV exposure can reduce the risk of HIV acquisition. This framework supports the recently updated UK Guideline for the use of PEP for HIV following sexual exposure, by the British Association for Sexual Health & HIV (BASSH). This new Guidleine on PEP is summarised and contextualised in a recent Making it Count Briefing Sheet on PEP.
We will promote seeking PEP for men may have been sexually exposed to HIV as a personal health service, not a public health intervention. We will seek to ensure men know about PEP, its uses and limitations and how to access it.
We will seek to ensure PEP assessment and prescription services are available in all areas of the country and that men know about them and feel able to access them without judgement.
There is no population level target associated with choice ten as we are not seeking for PEP to be a public health intervention, but a personal health intervention that should be available to men who have sex with men.
Page last updated: 5 July 2013