Re-Thinking Risk Compensation: A Conversation with Kim Koester

Published: December 18, 2014

Emily Newman
Original Article:

What changes when people start taking pre-exposure prophylaxis (PrEP) to prevent HIV? Does it change how people have sex?

That’s a question that Kim Koester, a cultural anthropologist and director of qualitative research in the AIDS Policy Research Center at the Center for AIDS Prevention Studies at the University of California, San Francisco, has been studying for the past few years. As part of the iPrEx OLE study in 2012, she conducted in-depth interviews with 60 men who have sex with men to find out what changed when they started taking PrEP during the study. In the following Q&A, she shares the study’s findings and her current thoughts about sex on PrEP with BETA.

One thing you set out to study was risk compensation: the theory that people on PrEP might actually place themselves at higher risk by engaging in more frequent or riskier sexual behaviors. Did you find evidence of this?

This is something that many people are concerned about. We were trying to find out what was happening in men’s sexual and social lives once they began taking PrEP. We were also interested in adherence and men’s experiences more generally in the study. So the interviews covered a lot of ground. There’s an a priori assumption that once you go on PrEP, you’re going to stop using condoms. Note that this assumes that people are using condoms in the first place.

What we found was that this was not true at all. There were a host of things that were going on for guys—and for those men who were regularly using condoms—they did not stop using condoms simply because PrEP entered their lives. In fact, some men started using condoms more often as a result of taking PrEP and because of their involvement in the iPrEx study.  And yes, in the classic definition of risk compensation, some men told us that they were using condoms less often. However, they were in the minority. The language around “added safety” came up all the time in interviews. What we found significant evidence for was that PrEP added to—and was not necessarily a replacement for—other HIV prevention strategies.

Sex is a relational act and some amount of negotiation between partners takes place either verbally or non-verbally.  Deciding whether or not to use a condom may take place well ahead of time through verbal agreement, may be pre-determined based on prior sex with that particular partner (e.g., condomless sex with boyfriend or friends) or the decision may happen in the moment. These types of agreements or ways of negotiating are in play whether people use PrEP or not. PrEP use may or may not cause these negotiations to shift.  The point is—it’s not always just up to you. There are other people involved who have thoughts, feelings and ways of going about having sex. A good example is when we noted that for some men in magnetic or serodiscordant relationships, the partner living with HIV was not necessarily comfortable making any changes to the ways in which they had sex.

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