Behavioral Disinhibition and risk compensation with pre-exposure prophylaxis (PrEP) use among MSM in Kenya

Behavioral Disinhibition and risk compensation with pre-exposure prophylaxis (PrEP) use among MSM in Kenya

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The objective of Ombati’s project is to determine whether PrEP use among MSM may lead to neglect of traditional risk reduction practices through behavioural disinhibition or risk compensation. Pre-exposure prophylaxis represents a new biomedical approach to HIV prevention with the potential to become a powerful tool in the fight to reduce/prevent new HIV infections. As much as there is optimism about PrEP as a prevention strategy, many worry that the availability of PrEP may encourage reliance on “chemical prevention” in place of traditional risk reduction strategies such as condom use or reducing number of sexual partners. Some warn that such increases in high-risk behaviour may actually undermine the potential benefits of PrEP in reducing transmission rates.

There are two models describing mechanisms through which PrEP might increase risk taking; Behavioural Disinhibition argues that PrEP availability will increase risk taking by reducing self-imposed constraints on high-risk behaviour (focusing on effective and pleasure-driven aspects of risk taking and argues that individuals who desire condomless sex will view PrEP as a substitute for exercising behavioural control) while Risk Compensation suggests that PrEP availability will decrease condom use by decreasing individual’s perceptions of transmission risk (focuses on the cognitive aspects of risky decision making and argues that individuals who base decisions about condom use on the perceived risk of a given encounter will view unprotected sex as an acceptable risk in the context of PrEP).

Little evidence is available regarding the actual impact of PrEP on risk taking. However, increases in risk behaviour have been documented in the context of vaccine and microbicide trials, and among HIV-positive patients- those who believe that highly active antiretroviral therapy (HAART) protects against HIV transmission. As PrEP has been rolled out as a prevention strategy, there is need for better understanding of its implications for condom use and other risk reduction practices among MSM.

It is therefore critical that we understand the present awareness and attitudes toward PrEP among MSM, including perceptions of how it relates to traditional risk reduction efforts and also understand the psychosocial and behavioural factors that may enhance (or reduce) motivation for and maintenance of risk reduction practices in the context of ongoing PrEP use.