PrEP Use Doesn’t Lead to Risky Sex, Researchers
Researchers seek to dispel the idea that a Pre-Exposure Prophylaxis (PrEP) prescription will lead to risky sexual behavior among patients, according to a recent study published in the journal AIDS Patient Care and STDs.
Only about 80,000 people—less than seven percent of those who are eligible for PrEP—have filled a prescription in the past four years in America, according to numbers released by Gilead, the manufacturer of Truvada, the most common brand version of PrEP.
One reason for the lack of prescription numbers is that doctors have been hesitant to prescribe PrEP, according to Douglas Krakower and Kenneth Mayer, Harvard Medical School researchers who have studied PrEP-prescription behaviors of clinicians.
Until very recently, only HIV specialists as part of HIV infection treatment regimens usually prescribed Truvada. However, the majority of patients in need of PrEP do not consult HIV specialists, but general physicians, who are far less experienced with the drug and therefore less likely to prescribe it.
In addition to feeling potentially inexperienced with the drug, another reason that general physicians have been hesitant to prescribe PrEP has to do with an idea called “risk compensation.” In the past, many social circles raised concerns that taking PrEP might lead to less condom usage and riskier sexual behavior due to a perceived decrease in HIV risk, which could then potentially increase rates of sexually transmitted infections (STIs).
In a study published last September in the journal AIDS Care, 78 percent of HIV clinicians said they were very likely to prescribe PrEP to gay men in monogamous relationships, while only 60 percent were very likely to prescribe it to men who didn't use condoms, didn't know the status of their partner, or had a history of STIs. Even though the CDC's PrEP guidelines recommend PrEP for all of these other groups, clinicians worried that men who weren’t in monogamous relationships were likely to engage in riskier sexual behavior while on PrEP.
Study after study has shown that PrEP does not lead to riskier sexual behavior. One 2013 study showed that sexual risk behavior remained steady or decreased after patients were prescribed PrEP.
“We found no evidence of risk compensation among at-risk MSM [men who have sex with men] initiating PrEP,” wrote the authors of the 2013 study. “Mean numbers of partners and the proportion of men reporting UAS [unprotected anal sex] decreased significantly from baseline during 24 months of follow-up.”
Even though evidence shows that PrEP will not lead to an increase in risky sexual behavior, the idea of risk compensation still persists, which discourages doctors to prescribe PrEP.
“Overcoming the barrier of risk compensation is essential to supporting PrEP access and uptake among people at risk for HIV,” wrote the authors of the current study.
In order to explore and dispel the idea of risk compensation, researchers sought to explore the attitude of clinicians who had firsthand experience prescribing PrEP.
In their study, researchers interviewed 18 medical providers who prescribed Truvada as PrEP to their patients. Almost all of the clinicians had prescribed PrEP in either their clinical practice or as part of a research study. Ninety-four percent of the clinicians had prescribed PrEP as part of their clinical practice to a median six patients, ranging between two and 56 patients. Thirty-nine percent had prescribed PrEP as a part of a research study to a median of 145 patients, ranging of one to 300 patients.
The study clinicians reported that their patients’ behavior patterns with regard to condoms tended to remain consistent after starting PrEP, especially if they were already consistent about never or always opting to use them, rather than using them sporadically.
While the clinicians they interviewed did not relay data about any changes in sexually transmitted infection rates among their patients after starting PrEP, a potential indication of shifts in sexual risk taking, they believed that the HIV risk reduction gained from taking PrEP outweighed any potential increase in sexual risk taking among their patients.
“The providers acknowledged that they had evolved in their own thinking about PrEP over time,” the authors of the study wrote. “They overcame their ambivalence about prescribing it and ultimately looking more favorably on the risk reduction method and its potential relationship with shifting sexual risk-taking.”
The clinicians they interviewed also acknowledged that individuals both within and outside of the health care community unduly stigmatized PrEP. For example, excess risk-taking relating to starting cholesterol-lowering statins, which results from eating a poorer diet, is not similarly stigmatized.
"As public awareness about PrEP increases and more at-risk individuals actively seek out PrEP from their healthcare providers, there is an urgent need to prepare providers to respond appropriately," the authors wrote. "This includes not only enhancing providers' comfort and competence prescribing PrEP or referring patients elsewhere for PrEP care but also educating providers about reacting to patient inquiries in a sensitive and professional way."