Individual Versus Community-Level Risk Compensation Following Preexposure Prophylaxis of HIV

Abstract

We analyzed the concept of risk compensation and how it has been applied in HIV prevention, paying particular attention to the strategy of HIV preexposure prophylaxis (PrEP). In risk compensation, reduced perceptions of risk after the introduction of a preventative intervention lead to more frequent risk-taking behavior. Such a change may undermine the intervention's protective benefits. We found that many studies purporting to investigate risk compensation do not assess or report changes in perceptions of risk, instead relying on behavioral measures. Our analysis suggests a complex and sometimes counterintuitive relationship between the introduction of a new prevention intervention, perceptions of HIV risk, and subsequent changes in behavior. As PrEP is introduced, we believe comprehensive assessment of community-level risk compensation-that is, changes in risk perceptions and behavior as a result of increased optimism about avoiding HIV among people not directly protected by PrEP-should not be omitted. We therefore suggest ways to assess prevention optimism and community-level risk compensation.

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

“…Because of ethical issues, this design is not a viable option . Other methodological considerations have been drawn : (1) studies are mostly focused on behavioural measures, failing to account for the possibility that changes in attitudes or risk perceptions (essential to the RC theory) may occur before behaviour change; (2) timing in the change of attitudes and behaviour is important but not always clear; condomless sex (CLS) can precede “optimistic attitudes” regarding HIV exposure; (3) some studies did not find that change in behaviour led to risk increase ; (4) even if changes in behaviour or risk perception are observed they will likely not undermine the high effectiveness of the prevention strategy ; (5) interventions are not considered from a community level, therefore are limited to an individual approach .…”

“…Recently, Holt and Murphy have introduced the concept of community‐level RC in the context of PrEP in which “changes in risk perceptions and behaviour (could occur) as a result of increased optimism about avoiding HIV among people not directly protected by PrEP.” However, due to increased PrEP uptake and consistent PrEP use among PrEP users, protection at the community‐level actually increased (reduction of HIV incidence). They propose monitoring changes in sexual behaviour in addition to attitudes to PrEP and perceived HIV risk.…”

“…They propose monitoring changes in sexual behaviour in addition to attitudes to PrEP and perceived HIV risk. This could measure HIV “prevention optimism” defined as “the belief that it is easier to avoid HIV infection or transmission because of PrEP and that it is more acceptable and safer to engage in condomless sex because the risk of HIV is perceived to be reduced” . Further research is needed to explore the impact of “optimism,” particularly among non‐PrEP users.…”

“…Although different BI for HIV prevention have shown their effectiveness (e.g. condoms, male circumcision, highly‐active antiretroviral treatment (HAART), post‐exposure prophylaxis (PEP), treatment as prevention (TasP) and pre‐exposure prophylaxis (PrEP)), each and every one has aroused concerns regarding “risk compensation” (RC) . The HIV/AIDS field has scarcely challenged the use of the RC concept at the expense of focusing on other positive aspects of BI such as increased quality of (sexual) life, empowerment to discuss safer sex and to disclose HIV status, reduced fear of transmitting or getting HIV, or the possibility to re‐engage in sexual activity after an HIV diagnosis, to name a few .…”

HIV Prioritization and Risk Perception Among an Online Sample of Men Who Have Sex With Men in the United States

“…HIV risk perception, particularly among young MSM, may be declining, partly due to “treatment optimism,” the awareness that antiretroviral treatments are highly effective in reducing HIV viremia ( Huebner, Rebchook, & Kegeles, 2004 ), along with the introduction of pre-exposure prophylaxis (PrEP), the use of antiretroviral medications among HIV to lower risk of HIV infection ( Chen, 2013 ; Kalichman et al, 2017 ). Studies have identified increases in condomless sex and higher rates of sexually transmitted infection among PrEP users, suggesting a potential association between prevention optimism and risk compensation related to PrEP ( Holt & Murphy, 2017 ; Traeger et al, 2018 ). In a recent study of sexually active MSM, one-third reported zero perceived risk of HIV, including nearly a quarter of men not in stable monogamous partnerships, and over half reported high confidence in remaining HIV uninfected ( Stephenson et al, 2015 ).…”