HIV Pre-Exposure Prophylaxis, Condoms, or Both? Insights on Risk Compensation Through a Discrete Choice Experiment and Latent Class Analysis Among Men Who Have Sex With Men

Rayner Kay Jin Tan,Yi Wang,Kiesha Prem,Jack Harrison-Quintana,Alvin Kuo Jing Teo,Nashwinder Kaur,Alex R Cook,Mark I-Cheng Chen,Chen Seong Wong

doi:10.1016/j.jval.2020.11.023

Abstract

ObjectivesWe considered how decision making around human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) among gay, bisexual, and other men who have sex with men (GBMSM) is made in the context of one’s perceived risk of HIV acquisition and the availability of condoms. MethodsWe recruited 648 GBMSM aged 18 years old and residing in Singapore through Grindr. Participants were given information on PrEP and participated in a discrete choice experiment requiring them to choose between 2 baskets of PrEP attributes and compare the chosen “PrEP only” option to default options of “condoms only” or “PrEP with condoms.” Generalized multinomial logit model was used to examine the scaling effect and preference heterogeneity. Latent class analysis was conducted to examine preference heterogeneity in the sample. ResultsLatent class analysis revealed 3 classes of GBMSM: PrEP conservatives (53.9%), moderates (31.1%), and liberals (14.9%). PrEP conservatives were more likely to report greater utility when using condoms only compared with PrEP only, as well as PrEP with condoms, compared with PrEP only, and more likely to report the lowest utility for PrEP as perceived HIV risk increased. PrEP liberals were more likely to report greatest utilities for PrEP only compared with condoms only, as well as PrEP only compared with PrEP with condoms. The utility for PrEP was not affected by perceived risk of HIV or sexually transmitted infections when risks were low. ConclusionThis study provides some evidence for risk compensation among a class of GBMSM who already perceived themselves to be good candidates for PrEP before the discrete choice experiment.

Highlights

Gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) in many settings
A systematic review and meta-analysis of earlier studies of oral pre-exposure prophylaxis (PrEP) among atrisk populations for HIV acquisition found no evidence for any increase in sexual risk behaviors or compensation,[7] but a more recent meta-analysis of open-label studies found that PrEP use was associated with increased condomless sex and incidence of STIs, these increases were most prominent in GBMSM who reported such behaviors at baseline.[8]
This study advances our understanding for risk compensation beyond prior studies that use behavioral indicators by showing how one’s utility for condom use in lieu of PrEP, or utility for PrEP with condoms, was associated with changes in one’s perception of HIV or STI acquisition risk

Summary

Introduction

Bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) in many settings. There is unequivocal evidence for the effectiveness of PrEP for HIV prevention among GBMSM, concerns around risk compensation and the normative aspects of PrEP have surfaced. A systematic review and meta-analysis of earlier studies of oral PrEP among atrisk populations for HIV acquisition found no evidence for any increase in sexual risk behaviors or compensation,[7] but a more recent meta-analysis of open-label studies found that PrEP use was associated with increased condomless sex and incidence of STIs, these increases were most prominent in GBMSM who reported such behaviors at baseline.[8] Another recently published systematic review found a high burden of other STIs among individuals who were initiating PrEP, or who have been taking PrEP.[9]

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