14 June 2018 

Study finds high burden of psychosocial issues among PEP users

  • An Ontario study examined issues facing post-exposure prophylaxis (PEP) users.
  • At least one psychosocial issue was identified in 74% of participants.
  • Researchers suggest screening PEP-seeking patients for depression and other issues.

In cases of possible exposure to HIV through condomless sex, needlestick injuries or other means, the use of PEP (post-exposure prophylaxis) is a highly effective means of reducing the risk of HIV infection. PEP consists of a combination of anti-HIV drugs and needs to be initiated within 72 hours of possible exposure. It needs to be taken every day exactly as prescribed and directed for 28 consecutive days.

Research has found that many people who seek PEP in Canada tend to be disproportionately gay, bisexual or other men who have sex with men (MSM). To gain a better understanding of the psychosocial issues that underpin the vulnerability of some MSM to HIV, researchers at three leading HIV clinics in Toronto and Ottawa conducted a study. In analysing the information collected from 186 MSM enrolled in the study, researchers found that 74% had at least one psychosocial issue, including depression and/or problematic drug or alcohol use. Furthermore, nearly half (47%) of participants had more than one issue.

Based on their findings, the Ontario research team encouraged doctors and nurses to routinely screen their PEP-seeking patients for psychosocial issues. Should screening uncover these issues, the researchers recommended that healthcare practitioners refer their patients to specialists who can intervene to address depression and other issues. Such interventions can improve overall health and decrease future vulnerability to HIV.

Study details

Researchers in Toronto (St. Michael’s Hospital and Toronto General Hospital) and Ottawa (Ottawa General Hospital) collected health-related information from 186 participants who sought PEP between June 2013 and August 2016. This information was gathered from questionnaires (self-administered by participants) and medical records. The questionnaires incorporated information from what the researchers stated were “previously published, validated screening tools” for the following issues:

  • depression
  • harmful alcohol use
  • problematic drug use

The researchers also sought to assess what they termed “sexual compulsivity” (this term was not defined in their report) using validated screening tools.

Bear in mind that the researchers did not use what they called “formal diagnostic tests,” as such testing would have gone beyond a self-administered questionnaire and would have made the study more complex and expensive.

During the study, commonly used regimens for PEP included a combination of the drugs tenofovir DF + FTC with one of the following other drugs:

  • raltegravir (Isentress)
  • lopinavir-ritonavir (Kaletra)

The average profile of participants upon entering the study was as follows:

  • age – 31 years
  • 88% had a college degree
  • number of male partners in the past six months – six


The researchers used validated questions to assess the HIV risk of participants. According to the researchers, over half of the participants (56%) sought PEP because of condomless anal intercourse. Despite this route of possible exposure, the researchers found that many participants “perceived themselves to be at no/low risk as opposed to moderate/high overall HIV risk.” The researchers found that, overall, based on what participants disclosed, 81% of all participants “met the cutoff for high objective HIV risk.”

Underlying issues

Researchers found that many participants (74%) had at least one of the following issues:

  • depression – 53%
  • harmful alcohol use – 34%
  • problematic drug use – 30%
  • “sexual compulsivity” – 16%

The researchers found the burden of psychosocial issues among MSM to be “alarmingly high.” In contrast, in other studies done in Canada, the distribution of psychological issues among the average Canadian was as follows:

  • depression – 5%
  • harmful alcohol use – 3%
  • problematic drug use – 1%
  • “sexual compulsivity” – 3% to 6% (the researchers noted that “rates among MSM have been up to 19%”)

In context

The researchers found statistical associations suggesting that MSM in their study who had depression tended to engage in harmful alcohol use. They also found associations suggesting that MSM who engaged in problematic substance use tended to also engage in harmful use of alcohol. The researchers stated that these associations suggested that some psychosocial issues “frequently clustered together in individuals.”

The findings from the Ontario study with PEP users are broadly similar to findings from a previous study in Boston. In the Boston study, researchers analysed data collected between 1997 and 2013 and also found a high burden of psychosocial issues among people who sought PEP at a major clinic. The Ontario researchers noted that the findings from the present PEP study are similar to findings from a study they previously did with MSM who were considering or using PrEP (pre-exposure prophylaxis).

What to do?

The Ontario researchers stated that the findings from their studies as well as the study from Boston suggest that some psychosocial issues are common among MSM using PEP. They therefore stated that “measures to systematically assess and provide onward referrals for [psychosocial issues] may be warranted in this population.” They stated that such assessments are important for the following reasons:

  • Depression and/or harmful substance use can cause illness and contribute to an increased risk of death and “it is ethically and clinically important to link patients with unmet health needs into appropriate care.”
  • Previous research has found that the psychosocial issues mentioned in the present study have been linked to acquiring HIV infection.

The Ontario researchers hope that as healthcare providers identify psychosocial issues and refer affected patients into care “…HIV risk could be reduced over the longer term.”

As mentioned previously in this report, the researchers found a large disparity between the self-perceived risk for HIV among participants who sought PEP and objective measures of HIV risk. The researchers made the following statement: “This disparity parallels the misconceptions regarding HIV risk that we and others have observed in studies among MSM. Clinical encounters for PEP [in cases of possible sexual exposure] may be an ideal setting in which to counsel patients in greater detail about how they perceive their HIV risk, given that these patients have identified themselves as being concerned about this issue.”

PEP access

Note that subsidized access to PEP varies greatly across Canada. In British Columbia and Quebec, PEP is broadly subsidized. In Ontario, the province subsidizes the cost of PEP in some cases. Check with your local HIV or sexual health clinic and pharmacist to find out if subsidies are available in your region.


—Sean R. Hosein


  1. Morrison SA, Yoong D, Hart TA, et al. High prevalence of syndemic health problems in patients seeking post-exposure prophylaxis for sexual exposures to HIV. PLoS One. 2018 May 23;13(5):e0197998.
  2. Jain S, Oldenburg CE, Mimiaga MJ, et al. High levels of concomitant behavioral health disorders among patients presenting for HIV non-occupational post-exposure prophylaxis at a Boston community health center between 1997 and 2013. AIDS and Behavior. 2016 Jul;20(7):1556-63.