No Evidence of Risk Compensation on Pre-Exposure Prophylaxis (PrEP) for HIV Prevention in a Longitudinal Analysis of Men Who Have Sex with Men (MSM) in South Africa Open Access

Abstract

Objective: To assess evidence of changes in sexual risk behavior associated with pre-exposure prophylaxis (PrEP) among a cohort of men who have sex with men (MSM) in South Africa.

Design: This analysis uses data from a longitudinal, prospective cohort pilot study that sought to assess the feasibility of providing a tailored combination HIV prevention package to MSM in South Africa. Conducted in two cities, participants in the pilot were able to initiate PrEP as part of the intervention package at either month 1 or month 4 if clinically and behaviorally eligible.

Methods: Of the 202 MSM prospectively enrolled, 167 were HIV-negative and retained for follow-up. Using computer-assisted self-interview (CASI), sexual risk behaviors were assessed at baseline and post-enrollment at months 3, 6, and 12. We analyzed the longitudinal data to estimate the association between PrEP use and sexual behaviors using logistic regression and Generalized Estimating Equations (GEEs) adjusted for age, income, marital status, and partner’s HIV status.

Results: Among all participants during follow-up we observed decreases in reported condomless sex and the total number of sexual partners. Persons who initiated PrEP reported lower levels of unprotected sex relative to those who did not initiate PrEP. A non-significant trend was observed for lower numbers of reported sexual partners for those initiating PrEP. There were no significant differences in baseline characteristics, including sexual behaviors, between groups.

Conclusions: We found no evidence of sexual risk compensation among HIV-negative MSM in South Africa. Instead we found PrEP initiation to be protective against additional risk. In this study that provided PrEP in the context of a comprehensive HIV prevention package with regular HIV/STI testing, counseling, and condom provision, PrEP initiation did not lead to increases in reported sexual risk behavior among MSM. Future studies should consider the impact of combination HIV prevention services on PrEP-related risk compensation.

Table of Contents

INTRODUCTION ………………………………………………………………………………..1

METHODS………………………………………………………………………………………..3

RESULTS…………………………………………………………………………………………9

DISCUSSION……………………………………………………………………………………11

REFERENCES…………………………………………………………………………………..14

TABLES…………………………………………………………………………………………18

           Table 1. Baseline demographics…………………………………………………………18

           Table 2. Baseline sexual health & behavior characteristics …………………………….19

           Table 3. Logistic regressions ……………………………………………………………20

FIGURES ………………………………………………………………………………………..21

           Figure 1. Directed acyclic graph…………………………………………………………21

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health
Keyword	risk compensation pre-exposure prophylaxis PrEP sexual risk behavior men who have sex with men MSM HIV
Committee Chair / Thesis Advisor	Siegler, Aaron, Emory University
Committee Members	Jones, Jeb, Emory University

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