This article is available in: PDF HTML EPUB XML

When are declines in condom use while using PrEP a concern? Modelling insights from a Hillbrow, South Africa case study

Hannah Grant, Zindoga Mukandavire, Robyn Eakle, Holly Prudden, Gabriela B. Gomez, Helen Rees, Charlotte Watts



Introduction: Oral pre-exposure prophylaxis (PrEP) is a promising new prevention approach for those most at risk of HIV infection. However, there are concerns that behavioural disinhibition, specifically reductions in condom use, might limit PrEP’s protective effect. This study uses the case of female sex workers (FSWs) in Johannesburg, South Africa, to assess whether decreased levels of condom use following the introduction of PrEP may limit HIV risk reduction.

Methods: We developed a static model of HIV risk and compared HIV-risk estimates before and after the introduction of PrEP to determine the maximum tolerated reductions in condom use with regular partners and clients for HIV risk not to change. The model incorporated the effects of increased STI exposure owing to decreased condom use. Noting that condom use with regular partners is generally low, we also estimated the change in condom use tolerated with clients only, to still achieve 50 and 90% risk reduction on PrEP. The model was parameterized using data from Hillbrow, Johannesburg. Sensitivity analyses were performed to ascertain the robustness of our results.

Results: Reductions in condom use could be tolerated by FSWs with lower baseline condom use (65%). For scenarios where 75% PrEP effectiveness is attained, 50% HIV-risk reduction on PrEP would be possible even with 100% reduction in condom use from consistent condom use as high as 70% with clients. Increased exposure to STIs through reductions in condom use had limited effect on the reductions in condom use tolerated for HIV risk not to increase on PrEP.

Conclusions: PrEP is likely to be of benefit in reducing HIV risk, even if reductions in condom use do occur. Efforts to promote consistent condom use will be critical for FSWs with high initial levels of condom use, but with challenges in adhering to PrEP.

Keywords HIV; pre-exposure prophylaxis; sexually transmitted infections; mathematical models; behaviour change; risk compensation; condom migration

(Published: 20 September 2017)

Grant H et al. Journal of the International AIDS Society 2017, 20:21744 |

Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.

Journal of the International AIDS Society | eISSN 1758-2652 | Editors-in-Chief: Susan Kippax and Kenneth Mayer

*2016 Journal Citation Reports® Science Edition - a Clarivate Analytics product.

Disclaimer: The Journal of the International AIDS Society is an official journal of and is published by the International AIDS Society. The costs of the Journal of the International AIDS Society are secured by the International AIDS Society. This support does not in any way affect the editorial independency of the Journal of the International AIDS Society. Material published in the journal is entirely independent of the opinion of external sponsors and the society.