Publications & Reports

Effects of Pre-exposure Prophylaxis for the Prevention of HIV Infection on Sexual Risk Behavior in Men Who Have Sex with Men: A Systematic Review and Meta-analysis.

Traeger MW, Schroeder SE, Wright EJ, Hellard ME, Cornelisse VJ, Doyle JS, Stoové MA
Burnet Institute, Disease Elimination Program, Public Health Discipline, Melbourne, Victoria, Australia.

Abstract

Background: HIV pre-exposure prophylaxis (PrEP) is effective in reducing HIV risk in men who have sex with men (MSM). However concerns remain that risk compensation in PrEP users may lead to decreased condom use and increased incidence of sexually transmitted infections (STIs). We assessed the impact of PrEP on sexual risk outcomes in MSM. Methods: We conducted a systematic review of open-label trials and observational studies published to August 2017 reporting sexual risk outcomes (STI diagnoses, condom use, number of sexual partners) in the context of daily oral PrEP use in HIV-negative MSM and transgender women. Pooled effect estimates were calculated using random-effects meta-analysis and a qualitative review and risk of bias assessment were performed. Results: Sixteen observational studies and one open-label trial met selection criteria. Eight studies with 4388 participants reported STI prevalence and 13 studies with 5008 participants reported change in condom use. PrEP use was associated with a significant increase in rectal chlamydia (odds ratio [OR]=1.59; 95%CI 1.19-2.13; p=0.002; heterogeneity I 2=23%) and an increase in any STI diagnosis (OR=1.24; 95%CI 0.99-1.54; p=0.059; I 2=50%). The association of PrEP use with STI diagnoses was stronger in later studies. Most studies showed evidence of an increase in condomless sex among PrEP users. Conclusion: Findings highlight the importance of efforts to minimize STIs among PrEP users and their sexual partners. Monitoring of risk compensation among MSM in the context of PrEP scale-up is needed to assess the impact of PrEP on the sexual health of MSM and to inform preventive strategies.

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Burnet Institute acknowledges support from the Victorian Government Operational Infrastructure Fund. EJW, MEH, JSD and MAS acknowledge fellowship support from the National Health and Medical Research Council. VJC receives a stipend from the Research Training Program of the Australian Government’s Department of Education and Training.