Skip to main content

Advertisement

Springer Nature Link
Log in

Sexual Behavior, Risk Compensation, and HIV Prevention Strategies Among Participants in the San Francisco PrEP Demonstration Project: A Qualitative Analysis of Counseling Notes

  • Original Paper
  • Published:
AIDS and Behavior Aims and scope Submit manuscript

Abstract

Pre-exposure prophylaxis (PrEP) is a viable HIV prevention strategy but risk compensation could undermine potential benefits. There are limited data that examine this phenomenon outside of clinical trials. We conducted a qualitative analysis of counseling notes from the San Francisco site of the US PrEP demonstration project to assess how men who have sex with men used PrEP as a prevention strategy and its impact on their sexual practices. Four major themes emerged from our analysis of 130 distinct notes associated with 26 participants. Prevention strategy decision-making was dynamic, often influenced by the context and perceived risk of a sexual encounter. Counselors noted that participants used PrEP in conjunction with other health promotion strategies like condoms, asking about HIV status of their sex partners, and seroadaptation. With few exceptions, existing risk reduction strategies were not abandoned upon initiation of PrEP. Risk-taking behavior was ‘seasonal’ and fluctuations were influenced by various personal, psychosocial, and health-related factors. PrEP also helped relieve anxiety regarding sex and HIV, particularly among serodiscordant partners. Understanding sexual decision-making and how PrEP is incorporated into existing prevention strategies can help inform future PrEP implementation efforts.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Canada)

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. US Food and Drug Administration. FDA approves first drug for reducing the risk of sexually acquired HIV infection (2012). Accessed 24 Oct 2007.

  2. US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2014: a clinical practice guideline (2014). Accessed May 14 2014.

  3. Okwundu CI, Uthman OA, Okoromah CA. Antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV in high-risk individuals. Cochrane Database syst Rev. 2012;7:CD007189.

  4. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367(5):423–34.

    Article  CAS  PubMed  Google Scholar 

  6. Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083–90.

    Article  PubMed  Google Scholar 

  8. Baeten JM, Haberer JE, Liu AY, Sista N. Preexposure prophylaxis for HIV prevention: where have we been and where are we going? J Acquir Immune Defic Syndr. 2013;63(Suppl 2):S122–9.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Donnell D, Baeten JM, Bumpus NN, Brantley J, Bangsberg DR, Haberer JE, et al. HIV protective efficacy and correlates of tenofovir blood concentrations in a clinical trial of PrEP for HIV prevention. J Acquir Immune Defic Syndr. 2014;66(3):340–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Anderson PL, Glidden DV, Liu A, Buchbinder S, Lama JR, Guanira JV, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 2012;4(151):151ra125–5.

  11. Cassels S, Menza TW, Goodreau SM, Golden MR. HIV serosorting as a harm reduction strategy: evidence from Seattle, Washington. AIDS. 2009;23(18):2497–506.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Eaton LA, Kalichman S. Risk compensation in HIV prevention: implications for vaccines, microbicides, and other biomedical HIV prevention technologies. Curr HIV/AIDS Rep. 2007;4(4):165–72.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Grant RM, Wainberg MA. Chemoprophylaxis of HIV infection: moving forward with caution. J Infect Dis. 2006;194(7):874–6.

    Article  CAS  PubMed  Google Scholar 

  14. Liu AY, Grant RM, Buchbinder SP. Preexposure prophylaxis for HIV: unproven promise and potential pitfalls. JAMA. 2006;296(7):863–5.

    Article  CAS  PubMed  Google Scholar 

  15. Desai K, Sansom SL, Ackers ML, Stewart SR, Hall HI, Hu DJ, et al. Modeling the impact of HIV chemoprophylaxis strategies among men who have sex with men in the United States: HIV infections prevented and cost-effectiveness. AIDS. 2008;22(14):1829–39.

    Article  PubMed  Google Scholar 

  16. Vissers DCJ, Voeten HACM, Nagelkerke NJD, Habbema JDF, de Vlas SJ. The impact of pre-exposure prophylaxis (PrEP) on HIV epidemics in Africa and India: a simulation study. Maartens G, editor. PloS One. 2008 May 7;3(5):e2077.

  17. Hogben M, Liddon N. Disinhibition and risk compensation: scope, definitions, and perspective. Sex Transm Dis. 2008;35(12):1009–10.

    PubMed  Google Scholar 

  18. Golub SA, Kowalczyk W, Weinberger CL, Parsons JT. Preexposure prophylaxis and predicted condom use among high-risk men who have sex with men. J Acquir Immune Defic Syndr. 2010;54(5):548–55.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Chesney MA, Chambers DB, Kahn JO. Risk behavior for HIV infection in participants in preventive HIV vaccine trials: a cautionary note. J Acquir Immune Defic Syndr Hum Retrovirol. 1997;16(4):266–71.

    Article  CAS  PubMed  Google Scholar 

  20. Roddy RE, Zekeng L, Ryan KA, Tamoufé U, Tweedy KG. Effect of nonoxynol-9 gel on urogenital gonorrhea and chlamydial infection: a randomized controlled trial. JAMA. 2002;287(9):1117–22.

    Article  CAS  PubMed  Google Scholar 

  21. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review. JAMA. 2004;292(2):224–36.

    Article  CAS  PubMed  Google Scholar 

  22. Liu AY, Vittinghoff E, Chillag K, Mayer K, Thompson M, Grohskopf L, et al. Sexual risk behavior among HIV-uninfected men who have sex with men participating in a tenofovir preexposure prophylaxis randomized trial in the United States. J Acquir Immune Defic Syndr. 2013;64(1):87–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Guest G, Shattuck D, Johnson L, Akumatey B, Clarke EEK, Chen P-L, et al. Changes in sexual risk behavior among participants in a PrEP HIV prevention trial. Sex Transm Dis. 2008;35(12):1002–8.

    PubMed  Google Scholar 

  24. Marcus JL, Glidden DV, Mayer KH, Liu AY, Buchbinder SP, Amico KR, et al. No evidence of sexual risk compensation in the iPrEx trial of daily oral HIV preexposure prophylaxis. PLoS One. 2013;8(12):e81997.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Mugwanya KK, Donnell D, Celum C, Thomas KK, Ndase P, Mugo N, et al. Sexual behaviour of heterosexual men and women receiving antiretroviral pre-exposure prophylaxis for HIV prevention: a longitudinal analysis. Lancet Infect Dis. 2013;13(12):1021–8.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Grace D, Chown SA, Jollimore J, Parry R, Kwag M, Steinberg M, et al. HIV-negative gay men’s accounts of using context-dependent sero-adaptive strategies. Cult Health Sex. 2014 [Epub ahead of print].

  28. Halkitis PN, Moeller RW, Pollock JA. Sexual practices of gay, bisexual, and other nonidentified MSM attending New York City gyms: patterns of serosorting, strategic positioning, and context selection. J Sex Res. 2008;45(3):253–61.

    Article  PubMed  Google Scholar 

  29. Van de Ven P, Kippax S, Crawford J, Rawstorne P, Prestage G, Grulich A, et al. In a minority of gay men, sexual risk practice indicates strategic positioning for perceived risk reduction rather than unbridled sex. AIDS Care. 2002;14(4):471–80.

    Article  PubMed  Google Scholar 

  30. Gilmore H, Koester K, Liu A, Amico KR, McMahan V, Goicochea P, et al. To PrEP or not to PrEP: Perspectives from US iPrEx Open Label Extension (OLE) participants. Abstract presented at: 9th International Conference on HIV Treatment and Prevention Adherence; 2014 Jun 8–10; Miami, FL.

  31. Buchbinder SP, Liu A. Pre-exposure prophylaxis and the promise of combination prevention approaches. AIDS Behav. 2011;15(Suppl 1):S72–9.

    Article  PubMed  Google Scholar 

  32. Persson A. Reflections on the Swiss Consensus Statement in the context of qualitative interviews with heterosexuals living with HIV. AIDS Care. 2010;22(12):1487–92.

    Article  CAS  PubMed  Google Scholar 

  33. Bauermeister JA, Carballo-Diéguez A, Ventuneac A, Dolezal C. Assessing motivations to engage in intentional condomless anal intercourse in HIV risk contexts (“Bareback Sex”) among men who have sex with men. AIDS Educ Prev. 2009;21(2):156–68.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Pines HA, Gorbach PM, Weiss RE, Shoptaw S, Landovitz RJ, Javanbakht M, et al. Sexual Risk Trajectories Among MSM in the United States: implications for Pre-exposure Prophylaxis Delivery. J Acquir Immune Defic Syndr. 2014;65(5):579–86.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Brooks RA, Kaplan RL, Lieber E, Landovitz RJ, Lee S-J, Leibowitz AA. Motivators, concerns, and barriers to adoption of preexposure prophylaxis for HIV prevention among gay and bisexual men in HIV-serodiscordant male relationships. AIDS care. 2011;23(9):1136–45.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Rosser BR, Metz ME, Bockting WO, Buroker T. Sexual difficulties, concerns, and satisfaction in homosexual men: an empirical study with implications for HIV prevention. J Sex Marital Ther. 1997;23(1):61–73.

    Article  CAS  PubMed  Google Scholar 

  37. Hoff CC, Chakravarty D, Beougher SC, Neilands TB, Darbes LA. Relationship characteristics associated with sexual risk behavior among MSM in committed relationships. AIDS Patient Care STDS. 2012;26(12):738–45.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

We are grateful to the San Francisco study counselors (Zoë Lehman, Amanda Jernstrom, and Robert Wilder Blue) and to the participants for allowing us to share their experiences. This work was supported in part by the National Institute of General Medical Sciences (R25 GM56847) and the National Institute of Drug Abuse (R01 DA033854-02S1). Support for the parent study was provided by the Division of AIDS, National Institute of Allergy and Infectious Diseases (DAIDS ID: #11879). Pharmaceutical support for the parent study was provided by Gilead Sciences, Inc. (IND: #71,859).

Author information

Authors and Affiliations

  1. Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N505, San Francisco, CA, 94143, USA

    J. Carlo Hojilla

  2. Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, USA

    Kimberly A. Koester

  3. Disease Prevention and Control, San Francisco Department of Public Health, San Francisco, CA, USA

    Stephanie E. Cohen

  4. Division of Infectious Diseases, University of California, San Francisco, San Francisco, CA, USA

    Stephanie E. Cohen

  5. Bridge HIV, San Francisco Department of Public Health, San Francisco, CA, USA

    Susan Buchbinder & Albert Y. Liu

  6. San Francisco Department of Public Health, San Francisco, CA, USA

    Deawodi Ladzekpo & Tim Matheson

Authors
  1. J. Carlo Hojilla
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kimberly A. Koester
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stephanie E. Cohen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Susan Buchbinder
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Deawodi Ladzekpo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Tim Matheson
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Albert Y. Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. Carlo Hojilla.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Carlo Hojilla, J., Koester, K.A., Cohen, S.E. et al. Sexual Behavior, Risk Compensation, and HIV Prevention Strategies Among Participants in the San Francisco PrEP Demonstration Project: A Qualitative Analysis of Counseling Notes. AIDS Behav 20, 1461–1469 (2016). https://doi.org/10.1007/s10461-015-1055-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10461-015-1055-5

Keywords

Search

Navigation