How Can Providers Deal With Concerns About Risk Compensation in PrEP Users?
Pre-exposure prophylaxis (PrEP) remains an underutilized method of HIV prevention, with growing evidence that the most important barriers to wider use do not lie with patients but with health care professionals, who act as gatekeepers and conduits to this prescription medicine.
Some health care providers may have concerns or misgivings about PrEP, including fears that some PrEP users may increase their sexual risk-taking behavior because they feel less susceptible to HIV while taking PrEP. This may be referred to as "risk compensation" or "behavioral disinhibition" and refers to individuals using condoms less often, having more sexual partners, or otherwise having riskier behavior while taking PrEP. No study has identified a consistent pattern of risk compensation in PrEP users, although it may describe the behavior of a minority of PrEP users.
How do other health care providers manage and think about this issue? Sarah Calabrese, Ph.D., and colleagues conducted in-depth interviews with 18 "early adopter" PrEP providers in order to find out. Most were infectious disease or HIV specialists, working in university-affiliated medical centers or hospitals, in the northeast or the south of the United States. Key findings were published in the April 2017 issue of AIDS Patient Care and STDs.
Most interviewees' role as a provider was to support patients in making informed choices about their sexual health. The providers emphasized the benefits of using condoms together with PrEP (particularly in relation to sexually transmitted infections), but recognized that patients may not always follow these recommendations. Some providers valued a patient-centered approach to care, in which they aimed to support each client "at the space that they are in," as one provider put it.
Another interviewee explained a more situational-based approach: "When I talk about whether taking PrEP may change people's behavior... as a provider it's not my business. My job, as a provider, is making sure that I use the methods that I have available to minimize negative outcomes. So I spend less time into trying to change people in society, but to give them information so they can make better decisions when they are in x, y, z situations."
Some providers recognized their knowledge of patients' sexual behaviors is incomplete because, as one put it, "there's always this thing about seeing a doctor and saying the right thing in front of them." And many felt that patients had insights into their own sexual behavior that health care providers inevitably lacked. Many providers felt that, in general, "people know what's best for themselves" and so patients must be actively involved in making choices about their own health.
Many of the providers interviewed were skeptical that "risk compensation" would offset the protective benefit of PrEP, and it may not in fact be a new behavior in response to PrEP. "I don't think people really change their behaviors. The people who are not using condoms with PrEP never used condoms without PrEP," one interviewee explained, summarizing the feeling that it would not be possible for some patients' behaviors to become any riskier.
Several providers also expressed confidence that even if patients did increase their risk behavior, the high level of protection against HIV that PrEP affords would more than offset that increase. One noted that the best evidence for the efficacy of condoms during vaginal sex is around 80%, but that people who adhere to PrEP have close to 100% protection.
"So now you have this medication you can take every day that appears, possibly, certainly as effective, if not more effective, than condoms. So there's no way that I would ever not give PrEP out to someone, even if their condom use went to zero."
The providers also felt that PrEP-related risk compensation was unduly stigmatized by health care professionals and in wider society. "You should just view it like you view treating high cholesterol," one provider said. "You know, sometimes people who are taking statin drugs might eat steaks now and then because they feel like they can 'cause they're on this drug ... "
Others drew parallels with family planning: Women using hormonal contraception often stop using condoms. Appropriately, that behavior is not stigmatized, providers said. But they shared multiple anecdotes of their patients being discouraged when initially seeking PrEP from other providers.
"The biggest clinical challenges for me have been supply side," one health care professional shared. "What I mean by that is primary care doctors or primary care providers or even other HIV specialists who are not supportive of PrEP use, and shaming patients."
Some believe that prescribing PrEP is a professional obligation when it was clinically indicated. To withhold PrEP due to concerns about changes in a patient's condom use or partner numbers would constitute an imposition of the provider's personal values and preferences rather than an evidence-based clinical decision.
Finally, several interviewees said that their own thinking and attitudes had evolved, from initial ambivalence to greater acceptance of PrEP and PrEP-related behavior change. The researchers hope that sharing their insights will help other health care providers develop their own thinking on this issue.