Individual HIV Risk versus Population Impact of Risk Compensation after HIV Preexposure Prophylaxis Initiation among Men Who Have Sex with Men

• Type of Material: Article
• Authors: Samuel Jenness, Emory University; Akshay Sharma, Emory University; Steven M. Goodreau, University of Washington; Eli Rosenberg, Emory University; Kevin M. Weiss, Emory University; Karen W. Hoover, Centers for Disease Control and Prevention; Dawn K. Smith, Centers for Disease Control and Prevention; Patrick Sullivan, Emory University
• Language: English
• Date: 2017-01-06
• Publisher: Public Library of Science
• Publication Version: Final Published Version
• Copyright Statement: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose.
• License: Creative Commons Creative Commons CC0 1.0 Universal
• Final Published Version (URL): http://dx.doi.org/10.1371/journal.pone.0169484
• Title of Journal or Parent Work: PLoS ONE
• ISSN: 1932-6203
• Volume: 12
• Issue: 1
• Start Page: e0169484
• End Page: e0169484
• Grant/Funding Information: National Institute of Allergy and Infectious Diseases P30 AI027757.; Eunice Kennedy Shriver National Institute of Child Health and Human Development R21 HD075662 to Steven M. Goodreau.; National Institute of Allergy and Infectious Diseases P30 AI050409.; This work was supported by Centers for Disease Control [grant: U38 PS004646], the National Institutes of Health [R21 HD075662], the Center for AIDS Research at Emory [grant: P30 AI050409] and the University of Washington [grant: P30 AI027757].; National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention U38 PS004646 to Patrick Sullivan.
• Keywords: CONTINUUM; Multidisciplinary Sciences; ATLANTA; COHORT; Behavior; CHALLENGES; WHITE MEN; HIV; INFECTIONS; HIV infections; Sexually transmitted infections; HIV epidemiology; RESISTANCE; Science & Technology - Other Topics; Pre-exposure prophylaxis; PREVENTION; UNITED-STATES; Science & Technology; DISPARITIES; HIV prevention
• Research Categories: Health Sciences, Public Health; Health Sciences, Epidemiology

Abstract

Objectives: Risk compensation (RC) could reduce or offset the biological prevention benefits of HIV pre-exposure prophylaxis (PrEP) among those at substantial risk of infection, including men who have sex with men (MSM). We investigated the potential extent and causal mechanisms through which RC could impact HIV transmission at the population and individual levels. Methods: Using a stochastic network-based mathematical model of HIV transmission dynamics among MSM in the United States, we simulated RC as a reduction in the probability of condom use after initiating PrEP, with heterogeneity by PrEP adherence profiles and partnership type in which RC occurred. Outcomes were changes to population-level HIV incidence and individual-level acquisition risk. Results: When RC was limited to MSM highly/moderately adherent to PrEP, 100% RC (full replacement of condoms) resulted in a 2% relative decline in incidence compared to no RC, but an 8% relative increase in infection risk for MSM on PrEP. This resulted from confounding by indication: RC increased the number of MSM indicated for PrEP as a function of more condomless anal intercourse among men otherwise not indicated for PrEP; this led to an increased PrEP uptake and subsequent decline in incidence. Conclusions: RC is unlikely to decrease the prevention impact of PrEP, and in some cases RC may be counterintuitively beneficial at the population level. This depended on PrEP uptake scaling with behavioral indications. Due to the increased acquisition risk associated with RC, however, clinicians should continue to support PrEP as a supplement rather than replacement of condoms.