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Re-Thinking Risk Compensation: A Conversation with Kim Koester

, by Emily Newman

What changes when people start taking pre-exposure prophylaxis (PrEP) to prevent HIV? Does it change how people have sex?

That’s a question that Kim Koester, a cultural anthropologist and director of qualitative research in the AIDS Policy Research Center at the Center for AIDS Prevention Studies at the University of California, San Francisco, has been studying for the past few years. As part of the iPrEx OLE study in 2012, she conducted in-depth interviews with 60 men who have sex with men to find out what changed when they started taking PrEP during the study. In the following Q&A, she shares the study’s findings and her current thoughts about sex on PrEP with BETA.

One thing you set out to study was risk compensation: the theory that people on PrEP might actually place themselves at higher risk by engaging in more frequent or riskier sexual behaviors. Did you find evidence of this?

This is something that many people are concerned about. We were trying to find out what was happening in men’s sexual and social lives once they began taking PrEP. We were also interested in adherence and men’s experiences more generally in the study. So the interviews covered a lot of ground. There’s an a priori assumption that once you go on PrEP, you’re going to stop using condoms. Note that this assumes that people are using condoms in the first place.

What we found was that this was not true at all. There were a host of things that were going on for guys—and for those men who were regularly using condoms—they did not stop using condoms simply because PrEP entered their lives. In fact, some men started using condoms more often as a result of taking PrEP and because of their involvement in the iPrEx study.  And yes, in the classic definition of risk compensation, some men told us that they were using condoms less often. However, they were in the minority. The language around “added safety” came up all the time in interviews. What we found significant evidence for was that PrEP added to—and was not necessarily a replacement for—other HIV prevention strategies.

Sex is a relational act and some amount of negotiation between partners takes place either verbally or non-verbally.  Deciding whether or not to use a condom may take place well ahead of time through verbal agreement, may be pre-determined based on prior sex with that particular partner (e.g., condomless sex with boyfriend or friends) or the decision may happen in the moment. These types of agreements or ways of negotiating are in play whether people use PrEP or not. PrEP use may or may not cause these negotiations to shift.  The point is—it’s not always just up to you. There are other people involved who have thoughts, feelings and ways of going about having sex. A good example is when we noted that for some men in magnetic or serodiscordant relationships, the partner living with HIV was not necessarily comfortable making any changes to the ways in which they had sex.

Is there a chance your interview subjects over-stated how much they used condoms? In other words, is there a chance the answers you got were biased?

We didn’t get the sense that people felt like they had to impress upon us that they were “being good” and still using condoms. Nobody tried to say, ‘I was using condoms every time.’ I think the men were clear about when they were using condoms and when they were not.

The presumption with PrEP is that condoms are going to go away. But they aren’t—they just get deployed strategically. They were before PrEP was a part of their lives and they were afterwards. What I find to be really helpful and really useful, as a sex researcher, is understanding when and how condoms get deployed.

What have you found about when condoms are or aren’t used?

There may be times when a person might not feel completely, 100% comfortable having condomless sex—it could be that they just met or that they’re not attracted to the person enough that they’re going to go without a condom. Maybe they’re concerned about cleanliness. There really are some practical reasons why a person might want to wear a condom.

As more and more people start to use PrEP, how does the way researchers approach the question of whether or not people are putting themselves at greater risk have to change?

We really need to re-think—what does risk compensation even mean, in the context of PrEP? And let’s be specific. You’re not at risk of getting HIV if you’re taking PrEP with good adherence. For those who have already given up on condoms, and then started taking PrEP there is no risk compensation related to HIV. There’s only benefit. But we don’t talk about measuring the protective aspects of going on PrEP. In the various meetings or conferences that I attend people in the audience, primarily my fellow researchers, are very focused on risk compensation. I would say overly focused on risk compensation. When we fixate on risk compensation, which assumes that PrEP replaces or substitutes prior protective behaviors it undermines or marginalizes a far more pervasive reality and that is that men are gravitating towards PrEP as an additive element. Men are seeking additional reassurance and protection from HIV. From the perspective of men who see themselves as adopting safer ways of having sex, in terms of HIV prevention, the notion of risk compensation is offensive and confusing.

I wouldn’t talk about risk compensation without giving equal attention to what PrEP users are personally experiencing—a tremendous relief from the threat of HIV. I’d advocate strongly for measuring the social and emotional benefits that gay men are experiencing as a result of PrEP use. I would not limit the research to men who are uninfected with HIV, but we can extend our curiosity towards men who are infected with HIV to understand the benefits they perceive to be related to PrEP. And finally, I would encourage us to think about PrEP in the context of discussions about, ‘having the sex you want.’ This foregrounds an attitude that is respectful and supportive of people’s decisions to use or not use PrEP.

This makes me think of how we’ve had to re-think how we’re using terms like “unprotected sex” and “protected sex” with the advent of PrEP.

I was just at a PrEP forum with more than 50 audience members and witnessed a discussion between two people—one person who asked a question about “unprotected” sex among participants in a large scale PrEP demonstration project (all participants were on PrEP) and the researcher answering the question nonchalantly corrected the audience member just by responding to the question using the term “condomless” sex.  It’s great to see how quickly some people have adopted PrEP-specific terminology. It will be interesting to watch the evolution and development of the conversation. It’s very early in the development of how we’re going to talk about sexual practices in the context of PrEP. The discourse is definitely changing. Language inevitably shifts people’s attitudes.  And attitudes about PrEP are rapidly shifting as more people learn about it.

So how does sex change when you add PrEP in the mix?

Well, it wasn’t so much that the physical act of sex changed very much—as we talked about earlier—men by and large continued to do what they were doing before they were on PrEP. The main finding of our study was that PrEP use created feelings of security and decreased feelings of anxiety. We saw men had this tremendous sense of relief. So for us, we thought deeply about the feelings of relief.  Perhaps, this is intuitive to gay men, but I can tell you that the rest of the world needs to know what we learned in the context of our study and that is HIV was this thing that hung over men in our study—all the time. These strong, unconscious feelings of fear and threat around HIV were lifted with the addition of PrEP.

Interested in reading more about risk compensation? Check out the following articles.

Liu, A. Y. and colleagues. Sexual risk behavior among HIV-uninfected men who have sex with men participating in a tenofovir preexposure prophylaxis randomized trial in the United States. Epidemiology and Prevention, 64(1), 87-94. September 1, 2013.

Marcus, J. L. and colleagues. No evidence of sexual risk compensation in the iPrEx trial of daily oral HIV preexposure prophylaxis. PLOS One, 8(12). December 18, 2013.



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