Abstract
Recent studies among men who have sex with men suggest that sexual behaviors associated with risk of sexually transmitted infections increase following initiation of pre-exposure prophylaxis (PrEP) for HIV prevention. We used longitudinal data from HIV-uninfected participants (n = 1013) enrolled in an open-label study of PrEP delivered to Ugandan and Kenyan heterosexual HIV serodiscordant couples to understand the association between PrEP initiation and HIV risk-related sexual behaviors among these couples. In the month following PrEP initiation, the mean number of monthly sex acts within couples decreased from 7.9 to 6.9 (mean difference: − 1.1; 95% CI − 1.5, − 0.7) and the proportion of couples having condomless sex decreased from 65% to 32% (percentage point change: − 33%; 95% CI − 37%, − 30%); these behaviors then remained relatively constant over 2 years. We found no evidence of sexual risk compensation following PrEP initiation within African serodiscordant couples. However, roughly a third of couples continued to engage in condomless sex during follow up, emphasizing the importance of continued PrEP use to sustain HIV protection.
Highlights
Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection [1,2,3,4], but concerns remain that sexual risk compensation following PrEP initiation may be associated with increased incidence of sexually transmitted infections (STIs) or HIV due to higher rates of condomless sex and a higher number of sexual partners [5]
Even though we observed no evidence of sexual risk compensation among serodiscordant couples in this study, many couples continued to engage in condomless sex within the couple throughout the 2-year study period, emphasizing the important prevention gap filled by PrEP
The use of condoms for HIV protection has been engrained in HIV prevention counseling for the past three decades [28,29,30], more research would enable better understanding of how this message could be appropriately modified to best suit the needs of HIV serodiscordant couples on PrEP, especially as the partner living with HIV achieves suppressed HIV viremia with consistent antiretroviral treatment (ART) use and is no longer infectious [31]
Summary
Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection [1,2,3,4], but concerns remain that sexual risk compensation following PrEP initiation may be associated with increased incidence of sexually transmitted infections (STIs) or HIV (if PrEP adherence is low) due to higher rates of condomless sex and a higher number of sexual partners [5]. Primarily from cohorts of MSM on PrEP, have shown that PrEP initiation increases the frequency of condomless sex [7,8,9, 12, 13], number of sexual partners [8, 9, 11], and the incidence of STIs [10], among members of HIV at-risk populations.
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