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

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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.

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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).

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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

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  1. J. Carlo Hojilla
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  2. Kimberly A. Koester
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  3. Stephanie E. Cohen
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  7. Albert Y. Liu
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Correspondence to J. Carlo Hojilla.

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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

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