![]() ![]() ![]() 69,70Įven in the absence of substantive behavioral evidence for sexual risk compensation occurring, anticipated increases in sexual risk behavior among PrEP users may operate as a barrier to access in several ways. 48–60,62–66 Although predicted behavior may differ from actual behavior, 67 the variability of behavioral intentions expressed within PrEP acceptability research in combination with the limited existing insight about actual behavior among real-world PrEP users underscores the need for future research to accurately describe patterns of sexual behavior change outside of trial settings, 68 particularly in light of mathematical models that suggest that behavioral changes could affect PrEP’s population-level impact. 46,47 In addition, some participants in PrEP acceptability research have indicated that they or others may maintain or decrease their risk taking as a result of PrEP use, 48–60 perhaps adopting what has been called a “preventionist identity.” 41,61īy contrast, a small increase in condomless sex with nonprimary partners was noted in the open-label extension of the Partners PrEP Study, 44 increased condomless sex and participation in riskier sexual roles (e.g., receptive positioning during anal sex) have been documented among several PrEP users in demonstration project and hospital-based clinical settings, 46,47 and some participants in PrEP acceptability studies have predicted that they or others may engage in riskier sexual activity while using PrEP. 2 Likewise, preliminary reports from demonstration project and hospital-based clinical settings have indicated sustained or improved use of risk reduction strategies in conjunction with PrEP use among the majority of patients. 1–3,7,38–45 Many of these trials have even reported reduced risk-taking among participants over time, including reductions in risk associated with sexual behavior 1–3,7,38,41,45 and injection drug use. To date, double-blinded clinical trials and open-label studies have failed to yield substantive evidence of risk compensation occurring among participants. The prevalence and extent of sexual behavior change among oral PrEP users is currently under study. In light of continued controversy regarding the role of sexual pleasure in PrEP uptake, we aim here to briefly summarize the state of knowledge on sexual behavior change among PrEP users, to outline how concerns about user behavior (anticipation of sexual risk compensation) may limit access to PrEP regardless of actual behavior, to question increased risk behavior as grounds for restricting access to PrEP, and to recognize sexual pleasure as an underacknowledged benefit of PrEP and an acceptable incentive for-or consequence of-PrEP uptake. 33,37 To the extent that risk compensation fears bolster opposition to PrEP implementation, they pose a potential barrier to access for people who stand to benefit from PrEP. 12,32,33 The term “Truvada whore,” coined in a popular opinion piece condemning PrEP as a gateway to unsafe behavior, 34 captures the assumptions and negative sentiment associated with PrEP echoed by several public figures, including playwright and activist Larry Kramer, 35 actor Zachary Quinto, 36 and AIDS Healthcare Foundation president Michael Weinstein. ![]() 14–16 Risk compensation, or increased HIV risk behavior because of a perceived decrease in susceptibility to HIV (also referred to as offsetting, behavioral disinhibition, and condom migration 17–19), has been identified as a concern and potential deterrent to PrEP prescription among health care providers 20–31 and a key consideration among policymakers, health officials, and other stakeholders. Sexual pleasure-in terms of physical sensation or subjective enjoyment of sex-is less commonly acknowledged as a potential benefit within public health commentary surrounding PrEP, and several scholarly and popular press articles have framed the desire to engage in condomless sex as a dangerous and unacceptable motive for PrEP use. ![]() 1–7 Currently approved by the US Food and Drug Administration in once-daily pill form (emtricitabine and tenofovir disoproxil fumarate ), 8 PrEP has been praised for its multiple advantages as an adjunct to existing prevention methods (e.g., condoms) or in lieu of no protection, including its high efficacy among adherent users, 9,10 user-controlled and concealable administration, 11,12 and potential to support conception among serodiscordant heterosexual couples. Oral antiretroviral preexposure prophylaxis (PrEP) has received increasing recognition as a promising prevention strategy for people at risk for HIV because of sexual behavior, injection drug use, or both. ![]()
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