Abstract
Little is known about risk compensation among female sex workers (FSW) on HIV pre-exposure prophylaxis (PrEP), and self-report of sexual behaviors is subject to bias. Prospective observational PrEP demonstration study conducted among FSW in Cotonou, Benin. Over a period of 24 months, we assessed and compared trends in unprotected sex as measured by self-report (last 2 or 14 days), by detection of sexually transmitted infections (STIs), and by vaginal detection of prostate-specific antigen and Y-chromosomal DNA, 2 biomarkers of semen exposure in the last 2 or 14 days, respectively. Trends were assessed and compared using a log-binomial regression that was simultaneously fit for all unprotected sex measures. Of 255 participants, 120 (47.1%) completed their follow-up. Prevalence of STI decreased from 15.8% (95% confidence interval: 11.8% to 21.0%) at baseline to 2.1% (95% confidence interval: 0.4% to 10.2%) at 24 months of follow-up (P-trend = 0.04). However, we observed no trend in self-report of unprotected sex in the last 2 (P = 0.42) or 14 days (P = 0.49), nor in prostate-specific antigen (P = 0.53) or Y chromosomal DNA (P = 0.25) over the same period. We observed no statistically significant difference between trends in self-report of unprotected sex and trends in biomarkers of semen exposure in the last 2 days (P = 0.14) or in the last 14 days (P = 0.29). We observed no evidence of risk compensation, and a decrease in STI among FSW on PrEP. PrEP intervention may be an opportunity to control STI among FSW. Future studies should assess risk compensation with biomarkers of semen exposure when possible.
Highlights
Oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method that is strongly recommended by the World Health Organization as part of combination HIV prevention approaches for people at high risk of HIV infection.[1]
We observed no evidence of risk compensation, and a decrease in sexually transmitted infections (STIs) among female sex workers (FSW) on PrEP
The use of PrEP has raised a lot of concerns about potential risk compensation: increase in HIVrelated risk behaviors based on assumption of protection against HIV infection, which could lead to an increase in other sexually transmitted infections (STIs).[2]
Summary
Oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method that is strongly recommended by the World Health Organization as part of combination HIV prevention approaches for people at high risk of HIV infection.[1]. A review of 18 PrEP studies conducted among people who inject drugs, serodiscordant couples, men who have sex with men and transgender women, women, and heterosexual men has shown no association between PrEP use and changes in sexual risk behaviors as measured by self-report or STI. Incidence.[3] most of the included studies were randomized controlled trials, in which participants know they may be taking a placebo.[4] In another review restricted to open-labelled PrEP studies among men who have sex with men, most of the 16 included studies found evidence of an increase in condomless sex as measured by self-report or STI incidence among PrEP users.[4] Among female sex workers (FSW), one PrEP demonstration study conducted in South Africa has shown no clear change over time in self-reported consistent condom use, but a decrease in STI.[5]. Little is known about risk compensation among female sex workers (FSW) on HIV pre-exposure prophylaxis (PrEP), and self-report of sexual behaviors is subject to bias.
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