Give PrEP a chance: moving on from the “risk compensation” concept

Abstract

Introduction While bio‐behavioural interventions (BIs) for sexually transmitted infections (STIs) and HIV prevention have shown their effectiveness (e.g. treatment for syphilis, HPV vaccination or pre‐exposure prophylaxis [PrEP]), they have also aroused major concerns regarding behavioural changes that could counteract their benefit. Risk compensation (RC) fears concerning BIs in the HIV/STIs prevention field are intimately linked to representations, judgements and social control on sexual behaviour. With an increasing number of PrEP studies describing a rise in STIs due to RC, this paper argues for a shift away from the focus on RC and proposes a more constructive approach to respond to the needs of people living with HIV and populations most at risk. Discussion The concept of RC, stemming from road safety and derived from economic theory, relies on rational theoretical models of human behaviour. Although widely applied in several contexts its use has been reasonably questioned. Major methodological issues regarding RC have been raised within HIV/AIDS literature. Although behavioural changes (e.g. condomless sex and number of sexual partners) are often erroneously assimilated with RC, there is no evidence that behavioural changes have undermined the effectiveness of previous and current BIs. Still, PrEP has not escaped RC concerns. Increases in condomless sex within the context of growing uptake of PrEP signals a continued need for integrated and innovative HIV and STI prevention strategies and a comprehensive sexual health approach. Routine HIV/STI testing, peer‐led counselling, and identification of sexual health needs within the PrEP model of care could become a gold standard in the sexual health field for all populations. Conclusions RC remains a frequent argument against the availability and provision of prevention methods for vulnerable populations. Individuals should be able to benefit from the full panel of BIs options available, to find and adapt methods according to their needs. Current, past and future PrEP users, with other stakeholders, may provide valuable insight into innovative solutions and programmes to control HIV and other STIs.

Face Masks Against COVID-19: An Evidence Review

“…This involves neglecting other important preventative measures like physical distancing and hand hygiene based on overvaluing the protection a surgical mask may offer due to an exaggerated or false sense of security (103). Similar arguments have previously been made for HIV prevention strategies (104,105) motorcycle helmet laws (106), seat-belts (107) and alpine skiing helmets (108). However, contrary to predictions, risk compensation behaviors have not been significant on population level, being out-weighed by increased safety in each case (107,(109)(110)(111).…”

Face Masks Against COVID-19: An Evidence Review

“…This involves fear that public would neglect other measures like physical distancing and hand hygiene, based on overvaluing the protection a mask may offer due to an exaggerated or false sense of security (102). Similar arguments have previously been made for HIV prevention strategies (103,104), motorcycle helmet laws (105), seat-belts (106) and alpine skiing helmets (107). However, contrary to predictions, risk compensation behaviors have not been significant at a population level, being out-weighed by increased safety in each case (106,(108)(109)(110)(111).…”

Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review

“…Even if risk compensation does occur in some individuals or populations, related concerns do not justify withholding PrEP from people at risk for HIV infection [ 56 ]. Consistent with this notion, it has been proposed that PrEP be viewed as an opportunity for improved STI control [ 124 , 129 ], whereby an increase in detection rates due to more frequent STI testing, with potentially earlier diagnosis and treatment, may counteract or surpass any negative effects of risk compensation [ 130 ]. Nevertheless, patients receiving PrEP should be provided with support for risk-reduction behaviors [ 33 ].…”