It’s unhelpful to frame the use of pre-exposure prophylaxis (PrEP) in terms of ‘risky
behaviour’, Sarit Golub, professor of psychology at the City University of New
York told the HIV Research for Prevention conference (HIVR4P 2018) in Madrid last
week. Healthcare providers and those developing materials to educate on PrEP
should focus on reasons why people might want to take PrEP other than because
they are ‘high risk’, she argued.
It’s very common for PrEP programmes to use – or to try to
develop – risk assessment tools. They promise an objective means of identifying
the individuals who are most likely to benefit from PrEP. But they are not
helpful during conversations with potential PrEP users, she said.
The information gathered may not be accurate, due to less
than perfect relationships between clinicians and their patients. Significant
numbers of American gay and bisexual men say that they are not
comfortable talking to their primary care provider about their sexual
behaviour. Black men are
particularly likely to report that interactions with providers are
‘scripted’ in ways that don’t allow full disclosure.
The questions are confusing for people, she said. They tend
to focus on numbers – how many partners have you had in the past six months,
how many times did you have condomless receptive sex, and so on. This
communicates to people that the quantity is the most important factor, whereas
it’s clear for example that black gay men’s elevated risk for HIV acquisition
is not due to having more sexual partners. Questions about how many partners
were HIV positive reinforce the idea that it is easy to know a person’s HIV
status.
“There’s a huge data disconnect in risk assessment,” she
said. While having validity across a population, the tools are quite poor at
accurately predicting an individual’s risk of acquiring HIV. She gave the
example of a study of
young black men who have sex with men in Chicago, which found that men who acquired HIV were no
more likely to be eligible for PrEP – in three different guidelines – than men
who did not seroconvert.
Moreover, while it might be true that some individuals who
perceive themselves to be at risk of HIV are interested in PrEP, Golub said
that a person’s perception of being at risk is rarely an intervenable factor.
It’s probably not feasible to change it with the end goal of making them more
interested in PrEP.
Moreover, the language is stigmatising and alienating. “People
do not ‘engage in risk behaviour’, we ‘have sex’,” she said.
She argued that stigmatising diseases and behaviours is
unlikely to be helpful – it discourages people from acknowledging their
association with them. One
study found that in young South African women, there were no differences in
the risk perception of women who later became HIV positive and those who
remained HIV negative. However, women who expressed stigmatising beliefs about
HIV were more likely to acquire HIV.
One
of Golub’s own studies found that in American gay men, anticipated HIV
stigma (fear of the negative social and psychological consequences of acquiring
HIV) did not work as a motivating factor for men to take PrEP. In fact, men who
declined an offer of PrEP had higher levels of anticipated HIV stigma than men
who accepted the offer.
Sarit Golub argued that the public discussions about ‘risk
compensation’ and ‘behavioural disinhibition’ were particularly damaging. Healthcare providers who
have concerns about PrEP being associated with more condomless sex and
increases in sexually transmitted infections (STIs) are less willing to
prescribe PrEP than other clinicians. Some doctors are less
willing to prescribe PrEP to people who disclose non-condom use than people
who have less objective need for PrEP.
Moreover, it would be irrational to withhold this highly
effective HIV prevention tool in order to better control bacterial STIs. As
that is not a serious policy proposition, she asked why is the conversation
about PrEP being framed in terms of risk compensation?
“I believe that much of the risk compensation argument is an
attempt to reassert control over sexual expression, by substituting fear of STI
epidemics in place of fear of HIV,” she said. “PrEP allows us to control HIV
without controlling sex and that makes some people panic.”
Instead of conducting risk assessments, Golub said that healthcare
providers should ask patients about their own goals. She suggested three
questions:
- What are your biggest sexual health
concerns?
- What are your sexual health goals?
- What strategies and options can I
offer you to help with both?
And she said that providers should focus on the reasons why
people might want to take PrEP other than because they are ‘high risk’. These
including reducing anxiety, taking control over their own sexual health,
increasing sexual satisfaction and intimacy, staying safe and healthy, and
having a better future.