The debate over whether PrEP usage leads to risk compensation -- increased risk-taking behavior as a result of feeling more protected from negative outcomes -- should not prevent clinicians from offering PrEP to all people at risk for HIV infection, according to a multidisciplinary team of authors writing in the New England Journal of Medicine.
The authors draw a parallel to the clinical discussion about oral contraceptives for women in the mid-1900s, stating that despite the concerns of some that hormonal contraceptive use would lead to sexual risk compensation, modern guidelines don't require people to commit to using condoms before being prescribed an oral contraceptive. They also advocate for the psychological benefits of improved sexual health as a result of PrEP uptake. "Disease prevention doesn't always trump other priorities for patients, for whom consistent condom use may not be realistic or desired," they write. "The same reasoning applies to PrEP."
The article is intended in part as a response to sentiments like those expressed in a June 2018 New York Times op-ed entitled "The End of Safe Gay Sex," said Julia Marcus, Ph.D., the lead author of the NEJM article, in an interview. Marcus was frustrated to read a perspective in mainstream media that was "moralizing PrEP and demonizing PrEP" -- and equally frustrated at "how persistent that is, even in scientific literature." The NEJM article's authors, a group that includes an HIV-focused epidemiologist, infectious disease physician, dermatologist, and clinical psychologist, counter that perceived bias with a call for normalizing PrEP across medical fields.
"[Contraception] was this really hard thing at the beginning -- lots of stigma, lots of questions about risk compensation -- and then it just became totally routine and totally normal," Marcus said. "If we can bring awareness of PrEP -- and routinize sexual history taking -- into primary care, this will go the way of contraception."