A Behavioral Economic Examination of Sexual Behaviors in the Era of Pre-exposure Prophylaxis via Explanatory Sequential Mixed Methods

Pre-exposure prophylaxis (PrEP) use may be associated with condom use decisions. The current investigation examined sexual decision-making in the context of PrEP among young adult men who have sex with men (MSM) between 18 and 30 years old, using an explanatory sequential mixed methods design. For the quantitative aim, 99 MSM currently taking PrEP (i.e., PrEP-experienced) and 140 MSM not currently taking PrEP (i.e., PrEP-naive) completed an online survey, including the Sexual Delay Discounting Task (SDDT), which captures likelihood of condom use. For the qualitative aim, 15 people from each group were interviewed about their (1) conceptualizations of risky sex and (2) ways they manage their sexual risk. Participants were, on average, 25.69 years old (SD = 3.07) and 64% White. Results from the quantitative aim revealed, controlling for covariates, PrEP-experienced participants exhibited significantly lower likelihood of (1) using an immediately available condom and (2) waiting for a delayed condom (i.e., sexual delay discounting) compared to PrEP-naive participants. Qualitative themes explaining what young adult MSM consider to be risky sex included: (1) any sex as risky sex, (2) risky sex as "sex without a conversation," and (3) risky sex as sex with risk for physical harm. Themes on ways young adult MSM manage sexual risk were classified as proactive, reactive, and passive. Results suggest that PrEP use is related to condom use decisions. Taken together, quantitative differences in sexual delay discounting, but qualitatively similar conceptualizations and management of risky sex, suggest that the SDDT may be a useful tool in sex research to capture processes (i.e., delay discounting) underlying sexual decision-making that may be missed by traditional self-reports. Implications of results, including potentially providing (good quality) condoms with every PrEP prescription, and future research topics are discussed.

Determinants of bicycle crashes at urban signalized intersections

PROBLEM

Bicycle volumes are increasing in many regions worldwide leading to higher relevance of an in-depth understanding of bicyclist safety mechanisms. Detailed studies on bicyclist safety that consider exposure and distinguish by intersection category and crash types are missing for urban signalized intersections, which are of particular relevance for bicyclist safety.

METHOD

Based on a comprehensive dataset of motorist and bicyclist volumes and infrastructure characteristics for a sample of 269 signalized intersections in two German cities, we utilize a top-down approach to analyze firstly, bicycle crashes of all types and secondly, bicycle crashes by type including turning, right-of-way and loss-of-control. A combination of descriptive statistics and Accident Prediction Models (APM) are applied as analysis methods.

RESULTS

Bicycle volumes are relevant for all types of intersections and crashes, whereas the effect of motor vehicle volumes differ between these different applications. The separation of bicyclists from motor vehicles in time and space increases their safety but also leads to behavioral adaption and risk compensation. The likelihood of right-of-way crashes even increases with more separation in the signaling scheme. The main predictor for loss-of-control crashes in terms of infrastructure are tram tracks.

SUMMARY

This study provides insights on relevant determinants of bicycle crashes at urban signalized intersections at several levels of detail. Exposure variables as well as the physical separation of bicyclists from motor vehicles show consistent effects on bicycle crash numbers whereas the effects of signaling differ between crash types.

PRACTICAL APPLICATIONS

The different types of intersections and crashes follow each specific mechanism of bicyclist safety. The separation of bicyclists and motorists in time and space are paramount at intersections with high bicycle volumes. Risk compensation such as red light running becomes more important as intersections get smaller and motor vehicle volumes decrease.

Applicability of risk compensation to the relationship between health behaviors and COVID-19 vaccination among inpatients in Taizhou, China

Aim

Based on the risk compensation theory, this study was designed to investigate the relationship between health behaviors of inpatients and COVID-19 vaccination during the epidemic with regard to the Omicron variant of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Taizhou, China.

Subject and methods

We conducted an online self-administered survey with a group of inpatients in a grade III, class A hospital in Taizhou, China, from February 27, 2022, to March 8, 2022. A total of 562 complete questionnaires were collected, and 18 questionnaires completed in under 180 seconds were rejected, leaving a total of 544 (96.8%) valid questionnaires collected. The participants who had received a COVID-19 vaccine were asked to describe the differences in their health behaviors before and after the vaccination, and the data were analyzed using SPSS Statistics version 22.0 software.

Results

There were significant differences in the percentage of individuals wearing masks (97.2% and 78.9%, P < 0.001) and the percentage of hand washing after taking off the mask (89.1% and 63.2%, P < 0.001) between the inoculated group and the uninoculated group; however, there were no significant differences in other health behaviors. The participants showed better health behaviors (handwashing and wearing a mask) after the vaccination than prior to it.

Conclusions

Our findings suggest that the Peltzman effect did not increase risk behaviors during the Omicron epidemic. There was no reduction in health behaviors among inpatients after the COVID-19 vaccine, which may have even improved their health behaviors.

An examination and extension of the Peltzman effect during the Covid-19 pandemic

Since the first COVID-19 case was confirmed in Germany, the German government has introduced various measures to counteract the pandemic. The implementation of safety measures can have counterproductive effects: people engage in risk compensatory behavior (fewer safety behaviors) after regulations are introduced and obligated by the government, which is known as the Peltzman effect (Peltzman, 1975). Based on the Peltzman effect, the researchers of this study hypothesized that people complied less with safety behaviors and took more health risks (e.g. keep less distance) after the implementation of more stringent COVID-19-related regulations (quarantine obligation and face mask duty) between the two measurement periods of this study. They also extended the Peltzman model by hypothesizing moderating roles of age, gender, and perceived COVID-19 threat. Results of the longitudinal survey study (N = 989, T1: 26 March - 31 March 2020 and T2: 27 April - 4 May 2020) confirm that people indeed complied less with safety recommendations over time associated with strengthened COVID-19-related regulations. Perceived COVID-19 threat to those in a person's surroundings (e.g. family, neighbors) had a positive impact on compliance, but age and gender had no effect. This extends the literature on the Peltzman effect by adding perceived COVID-19 threat as a new relevant construct, enabling the development of more effective safety preventions in the future.

Is self-reported depression, HIV status, COVID-19 health risk profile and SARS-CoV-2 exposure associated with difficulty in adhering to COVID-19 prevention measures among residents in West Africa?

BACKGROUND

The aim of this study was to determine whether self-reported depression, coronavirus disease of 2019 (COVID-19) health risk profile, HIV status, and SARS-CoV-2 exposure were associated with the use of COVID-19 prevention measures.

METHODS

This survey collected data electronically between June 29 and December 31, 2020 from a convenient sample of 5050 adults 18 years and above living in 12 West African countries. The dependent variables were: social distancing, working remotely, difficulty obtaining face masks and difficulty washing hands often. The independent variables were self-reported depression, having a health risk for COVID-19 (high, moderate and little/no risk), living with HIV and COVID-19 status (SARS-CoV-2 positive tests, having COVID-19 symptoms but not getting tested, having a close friend who tested positive for SARS-CoV-2 and knowing someone who died from COVID-19). Four binary logistic regression models were developed to model the associations between the dependent and independent variables, adjusting for socio-demographic variables (age, gender, educational status, employment status and living status).

RESULTS

There were 2412 (47.8%) male participants and the mean (standard deviation) age was 36.94 (11.47) years. Respondents who reported depression had higher odds of working remotely (AOR: 1.341), and having difficulty obtaining face masks (AOR: 1.923;) and washing hands often (AOR: 1.263). People living with HIV had significantly lower odds of having difficulty washing hands often (AOR: 0.483). Respondents with moderate health risk for COVID-19 had significantly higher odds of social distancing (AOR: 1.144) and those with high health risk had difficulty obtaining face masks (AOR: 1.910). Respondents who had a close friend who tested positive for SARS-CoV-2 (AOR: 1.132) and knew someone who died of COVID-19 (AOR: 1.094) had significantly higher odds of social distancing. Those who tested positive for SARS-CoV-2 had significantly lower odds of social distancing (AOR: 0.629) and working remotely (AOR: 0.713). Those who had symptoms of COVID-19 but did not get tested had significantly lower odds of social distancing (AOR: 0.783) but significantly higher odds of working remotely (AOR: 1.277).

CONCLUSIONS

The study signifies a disparity in the access to and use of COVID-19 preventative measures that is allied to the health and COVID-19 status of residents in West Africa. Present findings point to risk compensation behaviours in explaining this outcome.

Playing defense? Health care in the era of Covid

Health workers have to balance their own welfare vs. that of their patients particularly when patients have a readily transmissible disease. These risks become more consequential during an outbreak, and especially so when the chance of severe illness or mortality is non-negligible. One way to reduce risk is by reducing contact with patients. Such changes could be along the intensive or extensive margins. Using data on primary care outpatient encounters during the early months of the Covid-19 pandemic, I document important changes in the intensity of provider-patient interactions. Significantly, I find that adherence to clinical guidelines, the probability that routine procedures such as physical examinations were completed, and even the quality of information given by health providers, all declined sharply. I present evidence that these effects likely reflect risk mitigation behavior by health providers.

Self-reported health behaviors and risk perceptions following the COVID-19 vaccination rollout in the USA: an online survey study

OBJECTIVES

Concerns have been raised that mass vaccination campaigns might lead to reduced engagement with other recommended health behaviors. We assessed self-reported behaviors and risk perceptions following the COVID-19 vaccine rollout in the USA.

STUDY DESIGN

Between December 2, 2020, and March 23, 2021, we conducted three online survey studies with US adult respondents.

METHODS

Respondents self-reported their COVID-19 vaccination status, their frequency of engaging in risk-increasing behaviors and wearing a mask when in public places, and their COVID-19 risk perceptions (i.e., perceived likelihood of getting COVID-19 and of being hospitalized if they got COVID-19).

RESULTS

Our analytical sample included 832 respondents who had completed the first and final surveys and had received either 0 or 2 doses of a COVID-19 vaccine. Most respondents were non-Hispanic White (75%), male (77%), and US Veterans (64%), with the median age between 55 and 74 years. Overall, respondents reported frequently wearing masks when in public and rarely engaging in risk-increasing behaviors. Regardless of vaccination status, respondents reported more frequently engaging in risk-increasing behaviors and lower risk perceptions in March 2021 than in December 2020. Mask wearing did not change over the study period, with vaccinated respondents consistently reporting more frequent mask wearing than unvaccinated respondents.

CONCLUSIONS

Taken together, our findings indicate that the COVID-19 vaccine rollout in the USA did not result in the rapid abandonment of protective behaviors or dramatic uptake of risk-increasing behaviors. Additional studies are needed to monitor how mass vaccination might impact public behaviors and risk perceptions as coverage widens.

Increased condom use among key populations using oral PrEP in Kenya: results from large scale programmatic surveillance

Background

Female sex workers (FSW) and men having sex with men (MSM) in Kenya have high rates of HIV infection. Following a 2015 WHO recommendation, Kenya initiated national scale-up of pre-exposure prophylaxis (PrEP) for all persons at high-risk. Concerns have been raised about PrEP users' potential changes in sexual behaviors such adopting condomless sex and multiple partners as a result of perceived reduction in HIV risk, a phenomenon known as risk compensation. Increased condomless sex may lead to unintended pregnancies and sexually transmitted infections and has been described in research contexts but not in the programmatic setting. This study looks at changes in condom use among FSW and MSM on PrEP through a national a scale-up program.

Methods

Routine program data collected between February 2017 and December 2019 were used to assess changes in condom use during the first three months of PrEP in 80 health facilities supported by a scale-up project, Jilinde. The primary outcome was self-reported condom use. Analyses were conducted separately for FSW and for MSM. Log-Binomial Regression with Generalized Estimating Equations was used to compare the incidence proportion (“risk”) of consistent condom use at the month 1, and month 3 visits relative to the initiation visit.

Results

At initiation, 69% of FSW and 65% of MSM reported consistent condom use. At month 3, this rose to 87% for FSW and 91% for MSM. MSM were 24% more likely to report consistent condom use at month 1 (Relative Risk [RR], 1.24, 95% Confidence Interval [CI], 1.18–1.30) and 40% more likely at month 3 (RR, 1.40, 95% CI, 1.33–1.47) compared to at initiation. FSW were 15% more likely to report consistent condom use at the month one visit (RR, 1.15, 95% CI, 1.13–1.17) and 27% more likely to report condom use on the month 3 visit (RR 1.27, 95% CI, 1.24–1.29).

Conclusion

Condom use increased substantially among both FSW and MSM. This may be because oral PrEP was provided as part of a combination prevention strategy that included counseling and condoms but could also be due to the low retention rates among those who initiated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12639-6.

Face mask use and physical distancing before and after mandatory masking: No evidence on risk compensation in public waiting lines

During the COVID-19 pandemic, the introduction of mandatory face mask usage triggered a heated debate. A major point of controversy is whether community use of masks creates a false sense of security that would diminish physical distancing, counteracting any potential direct benefit from masking. We conducted a randomized field experiment in Berlin, Germany, to investigate how masks affect distancing and whether the mask effect interacts with the introduction of an indoor mask mandate. Joining waiting lines in front of stores, we measured distances kept from the experimenter in two treatment conditions - the experimenter wore a mask in one and no face covering in the other - in two time spans - before and after mask use becoming mandatory in stores. We find no evidence that mandatory masking has a negative effect on distance kept toward a masked person. To the contrary, masks significantly increase distancing and the effect does not differ between the two periods. However, we show that after the mandate distances are shorter in locations where more non-essential stores, which were closed before the mandate, had reopened. We argue that the relaxations in general restrictions that coincided with the mask mandate led individuals to reduce other precautions, like keeping a safe distance.

"Like it's wrong, but it's not that wrong:" Exploring the normalization of risk-compensatory strategies among young drivers engaging in illegal smartphone use

INTRODUCTION

Young drivers are the most vulnerable road users and most likely to use a smartphone illegally while driving. Although when compared with drink-driving, attitudes to illegal smartphone risk are nearly identical, smartphone use among young drivers continues to increase.

METHOD

Four in-depth focus groups were conducted with 13 young (18-25 years) drivers to gain insight into their perceptions of the risks associated with the behavior. Our aim was to determine how drivers navigate that risk and if their behavior shapes and informs perceptions of norms.

RESULTS

Three key themes emerged: (a) participants perceived illegal smartphone use as commonplace, easy, and benign; (b) self-regulatory behaviors that compensate for risk are pervasive among illegal smartphone users; and (c) risk-compensation strategies rationalize risks and perceived norms, reducing the seriousness of transgression when compared with drink-driving. Young drivers rationalized their own use by comparing their selfregulatory smartphone and driving skills with those of "bad drivers," not law abiders. Practical Applications: These findings suggest that smartphone behaviors shape attitudes to risk, highlighting the importance for any countermeasure aimed at reducing illegal use to acknowledge how a young person's continued engagement in illegal smartphone use is justified by the dynamic composition of use, risk assessment and the perceived norms.

Face Mask Use Conditionally Decreases Compliance With Physical Distancing Rules Against COVID-19: Gender Differences in Risk Compensation Pattern

BACKGROUND

In the context of the COVID-19 emergency, the concern has been raised that people may compensate the reduction in risk ensured by mask use with an increase in risk induced by lower adherence to physical distancing rules.

PURPOSE

The paper investigates if people compensate risk in this manner when their interaction partner wears a face mask, examining if risk compensation further depends on gender, signaled social status and perceived race.

METHODS

An experiment was conducted in two waves (June, n = 1396 and September 2020, n = 1326) in front of the traffic lights of four busy roads in Paris. A confederate asked a randomly selected pedestrian for directions following a script and keeping the recommended distance. Confederates were locally recognizable as Blacks or Whites and alternatively presented themselves with a costume indicative of high or low social status. An observer recorded whether the pedestrian kept the recommended distance.

RESULTS

Both in June and September, men are less likely to comply with the distancing rule when the confederate wears the face mask, and particularly so when the confederate signals high status. When the confederate wears the mask, female pedestrians observe less the one-meter rule in September than in June.

CONCLUSIONS

Men's risk compensatory behavior is constant over time. In contrast, women's depends on the time period.

"We've Got Our Own Beliefs, Attitudes, Myths": A Mixed Methods Assessment of Rural South African Health Care Workers' Knowledge of and Attitudes Towards PrEP Implementation

South Africa maintains the world's largest HIV prevalence, accounting for 20.4% of people living with HIV internationally. HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy; however, there is limited data on PrEP implementation in South Africa, particularly in rural areas. Using grounded theory analysis of semi-structured interviews and exploratory factor analyses of structured surveys, this mixed methods study examines healthcare workers' (HCWs)' beliefs about their patients and the likelihood of PrEP uptake in their communities. The disproportionate burden of HIV among Black South Africans is linked to the legacy of apartheid and resulting disparities in wealth and employment. HCWs in our study emphasized the importance of addressing these structural barriers, including increased travel burden among men in the community looking for work, poor transportation infrastructure, and limited numbers of highly skilled clinical staff in their rural community. HCWs also espoused a vision of PrEP that prioritizes women due to perceived constraints on their sexual agency, and that minimizes the impact of HIV-related stigma on PrEP implementation. However, HCWs' additional concerns for risk compensation may reflect dominant social mores around sexual behavior. In recognition of HCWs' role as both informants and community members, implementation scientists should invite local HCWs to partner as early as the priority-setting stage for PrEP interventions. Inviting leadership from local HCWs may increase the likelihood of delivery plans that account for unique local context and structural barriers researchers may otherwise struggle to uncover.

Behavior Change and Sexually Transmitted Incidence in Relation to PREP Use Among Men Who Have Sex with Men in Kenya

We measured change in sexual practices and the incidence of C. trachomatis (CT) and N. gonorrhoeae (NG) within a prospective cohort of Kenyan MSM taking PrEP in Kenya. Over the one year of study participation, CT and NG were diagnosed in urine at baseline, 6- and 12- months. Multivariable Cox regression identified factors associated with incident infection. Sexual practices were assessed at baseline and every 3 months. We evaluated changes over time and in relation to PrEP adherence via generalized estimating equation analysis. From October 2017-January 2018, 158 participants initiated PrEP, having 10.3% baseline CT/NG prevalence (either or both). The incidence was 17.2 cases per 100 person-years (95% CI 11.7-25.5). Incident CT/NG increased with report of: transactional male sex partner (adjusted Hazard Ratio (aHR) = 2.46, p = 0.016, z = 2.40), regular female sex partner (aHR = 2.22, p = 0.051, z = 1.96), greater social support (highest vs. lowest quartile, aHR = 6.24, p = 0.012, z = 2.51), and CT/NG infection prior to enrollment (aHR = 2.90, p = 0.002, z = 3.03). Multiple sex partners, condomless sex, and transactional sex decreased over time and were not associated with PrEP adherence. Urethral CT/NG incidence remained high and there was no evidence of PrEP-related behavioral change. There is need for ongoing etiologic testing, improved understanding of risk from female sex partners, and development of more effective risk reduction interventions.

Elucidating reasons of COVID-19 re-infection and its management strategies

BACKGROUND AND AIMS

Reinfection is gradually being recognised after symptomatic or asymptomatic COVID-19 infection. We try to elucidate various explanations behind COVID-19 reinfection and suggest possible strategies to counteract this threat.

METHODS

We carried out a comprehensive review of the literature using suitable keywords such as 'COVID-19', 'Pandemics', 'Reinfection', 'Vaccines' and 'India' on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in March 2021 and first half of April 2021 during the current COVID-19 pandemic. Epidemiology, risk factors and trends of reinfection were assessed.

RESULTS

A multitude of factors have been associated with rising incidence of COVID-19 reinfection in India and across the world. Emergence of 'Variants of Concern (VOC)', pandemic fatigue and disregard of infection prevention strategies appear to be the most obvious reasons.

CONCLUSIONS

COVID-19 reinfection is an emerging concern amongst the worldwide population with newer mutant strains demonstrating increasing transmissibility and responsible for continuing waves of the pandemic. COVID Appropriate Behaviour (CAB), improvised vaccines and enhanced vaccination drives are necessary to mitigate global threat.

Examining driver distraction in the context of driving speed: An observational study using disruptive technology and naturalistic data

Considering the number of people who have been involved in crashes associated with driver distractions, it is important to understand the characteristics of distracted driving on public roadways. While experiments have indicated that driver distractions are associated with slower driving speeds, the methodologies tend to have limited external validity. Observational studies are often conducted under limited circumstances - be it time or location. Therefore, in order to better understand the nature of driver distractions, the authors investigated the relationships between driving speed, posted speed limits, and phone handling frequency through naturalistic driving data obtained (via disruptive technology) from 8,240 mobile application users on state-maintained highways throughout Texas. As a measure of manual distractions, a phone handling rate (PHR; times/hours driven) was calculated based on phone rotations. Within-subject comparisons were drawn for driving speed and posted speed limits under normal driving conditions and distracted conditions. The analysis revealed a strong negative correlation between PHR and driving speed (r_s = -0.87). Paired t-tests revealed significantly lower driving speeds (p = 0.000 < 0.01, d = -0.48, η = 0.69) and posted speed limits (p = 0.000 < 0.01, d = -0.20, η = 0.42) during phone handling events when compared to driving without phone handling. On average, users drove 3.26 mph slower in distracted conditions than in undistracted conditions. Driving speed had a larger effect size than posted speed limits. The findings were in line with existing theories and experiments as well as other observational studies conducted at fixed locations. Although this research did not reveal causal relations, it is noteworthy that speed reduction with manual distractions was observed under real road conditions. Spatial analyses are recommended to conduct in order to paint a more thorough picture of speed reduction, its relationship to space, and crash risks related to distracted driving.

Development and Psychometric Evaluation of the PrEP Sexual Expectancies (PSEXS) Scale

The goal of this study was to develop and evaluate psychometric properties of the PrEP Sexual Expectancies Scale (PSEXS). The PSEXS represents a range of expectations for how PrEP use will affect one's sexual experience. The scale was developed to understand perceived reinforcements of PrEP use among men who have sex with men (MSM), including sexual risk-taking. The study builds upon Expectancy Theory to develop a measure of sex-related PrEP expectancies with a representative sample of 1155 MSM participants from Ukraine and 408 MSM participants from the U.S. Expectancy items represented two domains: increased sexual risk-taking and enhancement of sexual experience. Confirmatory analyses showed that a two-factor model provided a good fit to the data. The PSEXS scale had a high internal reliability in both samples (Ukraine α = 0.88, U.S. α = 0.83), and the identified factor structure explains a large amount of variance in both samples. Recent studies suggest that expectations of intimacy and better sexual experience can be a significant deciding factor for PrEP uptake. The PSEXS provides researchers with a useful measure for examining MSM's expectancy beliefs about the impact of PrEP use on their sexual life.

Greater Levels of Self-Reported Adherence to Pre-Exposure Prophylaxis (PrEP) are Associated with Increased Condomless Sex Among Men Who Have Sex with Men

The effectiveness of pre-exposure prophylaxis (PrEP) against HIV acquisition depends on treatment adherence; however, within-person associations between levels of PrEP adherence and engagement in condomless sex have not been well studied. In the context of a demonstration project, 372 men who have sex with men received once-daily PrEP and completed six study visits over 48 weeks. Two-part growth mixture modeling was used to examine the longitudinal trajectory of condomless anal intercourse (CAI) and self-reports of PrEP adherence, controlling for relevant covariates. Over time, greater PrEP adherence was contemporaneously associated with both a higher likelihood of engaging in any CAI and with a greater number of CAI acts. Substance use was also associated with a higher likelihood of engaging in CAI. Contemporaneous associations between self-reported PrEP adherence and CAI suggest that adherence behaviors may be motivated by the desire to mitigate risk of HIV infection; however, exact directionality is unknown.

Free and perfectly safe but only partially effective vaccines can harm everyone

Risk compensation can undermine the ability of partially-effective vaccines to curb epidemics: Vaccinated agents may optimally choose to engage in more risky interactions and, as a result, may increase everyone's infection probability. We show that-in contrast to the prediction of standard models-things can be worse than that: Free and perfectly safe but only partially effective vaccines can reduce everyone's welfare, and hence fail to satisfy-in a strong sense-the fundamental principle of "first, do no harm." Our main departure from standard economic epidemiological models is that we allow agents to strategically choose their partners, which we show creates strategic complementarities in risky interactions. As a result, the introduction of a partially-effective vaccine can lead to a much denser interaction structure-whose negative welfare effects overwhelm the beneficial direct welfare effects of this intervention.

Scaling up screening and treatment for elimination of hepatitis C among men who have sex with men in the era of HIV pre-exposure prophylaxis

BACKGROUND

Routine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown.

METHODS

An HCV/HIV transmission model was calibrated to UK prevalence of HIV among MSM (4·7%) and chronic HCV infection among HIV-positive MSM (9·9%) and HIV-negative MSM (1.2%). Assuming 12·5% coverage of PrEP among HIV-negative MSM, we evaluated the relative reduction in overall HCV incidence by 2030 (compared to 2018 levels) of HCV screening every 12/6-months (alongside completing direct acting antiviral treatment within 6-months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We estimated the additional screening required among HIV-negative non-PrEP users to reduce overall incidence by 90% by 2030. The effect of 50% reduction in condom use among PrEP users (risk compensation) was estimated.

RESULTS

Screening and treating PrEP users for HCV every 12 or 6-months decreases HCV incidence by 67·3% (uncertainty range 52·7-79·2%) or 70·2% (57·1-80·8%), respectively, increasing to 75·4% (59·0-88·6%) or 78·8% (63·9-90·4%) if HIV-diagnosed MSM are also screened at same frequencies. Risk compensation reduces these latter projections by <10%. To reduce HCV incidence by 90% by 2030 without risk compensation, HIV-negative non-PrEP users require screening every 5·6 (3·8-9·2) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, shortening to 4·4 (3·1-6·6) years with risk compensation. For 25·0% PrEP coverage, the HCV elimination target can be reached without screening HIV-negative MSM not on PrEP, irrespective of risk compensation.

INTERPRETATION

At low PrEP coverage, increased screening of all MSM is required to achieve the WHO HCV-elimination targets for MSM in the UK, whereas at higher PrEP coverage this is possible through just screening HIV-diagnosed MSM and PrEP users.

An assessment of risk compensation and spillover behavioural adaptions associated with the use of vaccines in animal disease management

This paper analyses farmers' behavioural responses to Government attempts to reduce the risk of disease transmission from badgers to cattle through badger vaccination. Evidence for two opposing behavioural adaptions is examined in response to the vaccination of badgers to reduce the risk of transmission to farmed cattle. Risk compensation theory suggests that interventions that reduce risk, such as vaccination, are counterbalanced by negative behavioural adaptions. By contrast, the spillover effect suggests that interventions can prompt further positive behaviours. The paper uses data from a longitudinal mixed methods study of farmers' attitudes to badger vaccination to prevent the spread of bovine tuberculosis, their reports of biosecurity practices, and cattle movement data in 5 areas of England, one of which experienced badger vaccination. Analysis finds limited evidence of spillover behaviours following vaccination. Lack of spillover is attributed to farmers' beliefs in the effectiveness of biosecurity and the lack of similarity between badger vaccination and vaccination for other animal diseases. Risk compensation behaviours are associated with farmers' beliefs as to who should manage animal disease. Rather than farmers' belief in vaccine effectiveness, it is more likely that farmers' low sense of being able to do anything to prevent disease influences their apparent risk compensation behaviours. These findings address the gap in the literature relating to farmers' behavioural adaptions to vaccine use in the management of animal disease.

Stigma, the Media, and Pre-exposure Prophylaxis for HIV Prevention: Observations for Enhancing Knowledge Translation and Resisting Stigma in the Canadian Context

Pre-Exposure Prophylaxis (PrEP) is an effective, though sometimes stigmatized, strategy for HIV prevention. With the goal of examining how PrEP stigma can be addressed, this study examined the media's handling of stigma related to PrEP by searching the Canadian Newsstream and Daily Xtra news databases for key terms related to PrEP. Overall, 101 media articles were thematically coded in triplicate; 36.3% of which included mentions of PrEP stigma. LGBT media sources were more likely than mainstream sources to have included content coded as relating to PrEP stigma (p = 0.02). In these articles, uncertainty regarding PrEP, and neo-liberal attitudes towards sexual responsibility were major factors associated with media discussion of PrEP stigma. We discuss the role that heuristics play in shaping lay readers perceptions and interpretation of PrEP media coverage and discuss methods for overcoming stigma using evidence-based communication strategies.

The Context of Sexual Risk Behaviour Among Men Who Have Sex with Men Seeking PrEP, and the Impact of PrEP on Sexual Behaviour

There are still important gaps in our understanding of how people will incorporate PrEP into their existing HIV prevention strategies. In this paper, we explore how PrEP use impacted existing sexual risk behaviours and risk reduction strategies using qualitative data from the PROUD study. From February 2014 to January 2016, we conducted 41 in-depth interviews with gay, bisexual and other men who have sex with men (GBMSM) enrolled in the PROUD PrEP study at sexual health clinics in England. The interviews were conducted in English and were audio-recorded. The recordings were transcribed, coded and analysed using framework analysis. In the interviews, we explored participants’ sexual behaviour before joining the study and among those using or who had used PrEP, changes to sexual behaviour after starting PrEP. Participants described the risk behaviour and management strategies before using PrEP, which included irregular condom use, sero-sorting, and strategic positioning. Participants described their sexual risk taking before initiating PrEP in the context of the sexualised use of drugs, geographical spaces linked with higher risk sexual norms, and digitised sexual networking, as well as problematic psychological factors that exacerbated risk taking. The findings highlight that in the main, individuals who were already having frequent condomless sex, added PrEP to the existing range of risk management strategies, influencing the boundaries of the ‘rules’ for some but not all. While approximately half the participants reduced other risk reduction strategies after starting PrEP, the other half did not alter their behaviours. PrEP provided an additional HIV prevention option to a cohort of GBMSM at high risk of HIV due to inconsistent use of other prevention options. In summary, PrEP provides a critical and necessary additional HIV prevention option that individuals can add to existing strategies in order to enhance protection, at least from HIV. As a daily pill, PrEP offers protection in the context of the sex cultures associated with sexualised drug use, digitised sexual applications and shifting social norms around sexual fulfilment and risk taking. PrEP can offer short or longer-term options for individuals as their sexual desires change over their life course offering protection from HIV during periods of heightened risk. PrEP should not be perceived or positioned in opposition to the existing HIV prevention toolkit, but rather as additive and as a tool that can and is having a substantial impact on HIV.

Update on HIV Preexposure Prophylaxis: Effectiveness, Drug Resistance, and Risk Compensation

PURPOSE OF REVIEW

In 2019, the US government launched an initiative to decrease new HIV infections by 90% over the next decade. Studies have demonstrated the efficacy of HIV preexposure prophylaxis (PrEP) for high-risk populations, and the United States Preventative Services Task Force has issued a grade A recommendation for PrEP, indicating substantial net benefit. However, questions have been raised about the effectiveness of PrEP in clinical settings and whether PrEP use might promote antiretroviral drug resistance and increased sexual risk behaviors, which could increase transmission of bacterial sexually transmitted infections. In this narrative review, we summarize recent evidence of the effectiveness of PrEP when provided in clinical and community settings, the emergence of antiretroviral drug resistance during PrEP use, and associations between PrEP use and increased sexual risk behaviors. We also review novel PrEP modalities that are being developed to optimize PrEP acceptability, adherence, and effectiveness.

RECENT FINDINGS

Studies suggest that PrEP is effective when provided in clinical settings. However, PrEP uptake and impact have been limited in the USA thus far, and major disparities in access to PrEP exist. In addition, there is evidence that drug resistance can occur with PrEP use, particularly with inadvertent PrEP use during undiagnosed acute HIV infection. Risk compensation can also occur with PrEP use and has been associated with increased sexually transmitted infections. Promising new modalities for PrEP could expand options. PrEP has strong potential to decrease HIV incidence. However, disparities in access must be addressed to ensure equity and impact for PrEP. While drug resistance and risk compensation can occur with PrEP use, these are not valid reasons to withhold PrEP from patients given its substantial protective benefits.

Behavioral intention to perform risk compensation behaviors after receiving HPV vaccination among men who have sex with men in China

Men who have sex with men (MSM) are recommended to take up human papillomavirus (HPV) vaccination. There are concerns that MSM would increase sexual risk behaviors after taking up HPV vaccination, a phenomenon known as risk compensation. This study investigated the prevalence of and factors associated with behavioral intention to reduce the frequency of condom use with men after receiving the HPV vaccination. The study was based on the baseline sample of an ongoing randomized controlled trial promoting HPV vaccination among MSM in Hong Kong. Hong Kong Chinese-speaking MSM who have never vaccinated against HPV were recruited from multiple sources. A total of 624 participants completed the baseline survey during July to December 2017. The prevalence of behavior intention to reduce the frequency of condom use with regular and non-regular male sex partners after receiving HPV vaccination was 6.9% and 4.0%; 8.0% of them intended to reduce condom use with either type of male partners after receiving the HPV vaccination. Adjusting for significant background variables (education level and condomless anal intercourse with men in the last six months), two constructs of the pre-intentional phase of Health Action Process Approach model were significantly associated with the dependent variable in the expected direction. They were (1) positive outcome expectancies of condomless anal intercourse after receiving HPV vaccination (adjusted odds ratios [AOR]: 1.29, 95% confidence interval [CI]: 1.12, 1.48, p < 0.001) and (2) perceived self-efficacy of consistent condom use after receiving HPV vaccination (AOR: 0.83, 95% CI: 0.70, 0.92, p = 0.001). Risk compensation may not be a major concern when promoting HPV vaccination among MSM. The results should be assuring health-care providers and policymakers.

Rebound in Sexually Transmitted Infections Following the Success of Antiretrovirals for HIV/AIDS

Nearly 1 million people become infected every day with any of the four major curable sexually transmitted infections (STIs), namely trichomoniasis, chlamydia, gonorrhea, and syphilis. Despite huge global incidence, STIs remain as neglected diseases. The success of antiretrovirals for halting progression to AIDS in HIV-infected individuals and for stopping HIV transmission to uninfected contacts, either as pre- or post-exposure -prophylaxis, has to lead to increased risky sexual behaviors through risk compensation. Recent epidemics and outbreaks of STIs among men having sex with men reflect the global loss of fear to HIV/AIDS. The -alarming rising rates of STIs worldwide have been fueled by: (1) rapid spread of drug resistance, that is, for Neisseria gonorrhoeae and Mycoplasma genitalium; (2) unprecedented impact of recreational drugs (chemsex) and internet (apps, websites) for facilitating exposure to multiple sex partners; and (3) growing rates of sexual violence and commercial sex, associated with wars, refugees, migrations, traveling, and sexual tourism. Moreover, there is an increasing appreciation of sexual transmission for other agents, -including human T-lymphotropic virus type 1, hepatitis A and C viruses, Zika, and Ebola. For addressing this new scenario for STIs, an expert panel workshop was arranged in Madrid, Spain in May 2018. This review summarizes the discussions at the meeting.

"Mate! I'm running 10 min late": An investigation into the self-regulation of mobile phone tasks while driving

The adaptive behaviour of mobile phone distracted drivers has been a topic of much discussion in the recent literature, but the mechanisms of behavioural adaptation are still unclear. This study investigated the influence of driving demands, secondary task characteristics, and personal characteristics on behavioural adaptation of mobile phone distracted drivers. In particular, distracted drivers' self-regulation at strategic, tactical, and operational levels was investigated through a driving simulator experiment. In a high-fidelity driving simulator, participants driving through various driving conditions (e.g. interactions with pedestrian crossings, signalized intersections, merging ramps, roundabouts, etc.) needed to decide where and how to perform the following four mobile phone tasks: (a) ring a doctor and cancel an appointment, (b) text a friend and tell him/her that the participant will be arriving 10 min late, (c) share the doctor's phone number with a friend, and (d) take a 'selfie'. At a strategic level, the decision to pull over was modelled as a function of self-reported personal/attitudinal characteristics with a logistic regression model. Similarly, tactical self-regulation (decision to engage in a task while driving in a specific situation) and operational self-regulation (decision to temporarily stop the mobile phone task) were modelled as a function of driving demands and personal/attitudinal characteristics using a random-effects logistic regression model, which accounts for correlations resulting from multiple observations of a driver. Results suggest that tactical self-regulation is more common among distracted drivers followed by operational and strategic self-regulation. Personal beliefs regarding how safe it is to use the mobile phone for texting/browsing while driving were predictors of self-regulation for all levels. Drivers were observed to use the mobile phone more when the driving demands are low, e.g. while stopped at an intersection. This research suggests that distracted drivers engage in various levels of self-regulation, and future research could be focused on further theoretical refinement and development of technology-based interventions.

Risk Compensation Following Medical Male Circumcision: Results from a 1-Year Prospective Cohort Study of Young School-Going Men in KwaZulu-Natal, South Africa

PURPOSE

This study sought to assess risk compensation following voluntary medical male circumcision of young school-going men. Risk compensation is defined as an inadvertent increase in sexual risk behaviors and a corresponding decrease in self-perceived risk for contracting HIV following the application of a risk reduction technology.

METHODS

This study documented the sexual practices of circumcised (n = 485) and uncircumcised (n = 496) young men in 42 secondary schools at three time points (baseline and 6 and 12 months) in a sub-district of KwaZulu-Natal, South Africa. Study participants were aged from 16 to 24 years old.

RESULTS

At the end of the study period, there was no significant difference between the two cohorts concerning learners' perceptions of being at risk of contracting HIV (interaction effect: b = -0.12, p = 0.40). There was also no significant difference in the number of sexual partners in the previous month (interaction effect: b = -0.23, p = 0.15). The proportion of learners who have never used a condom decreased significantly over time (time effect: b = -0.27, p = 0.01), and there was no difference between the circumcised and uncircumcised learners (interaction effect: b = -0.09, p = 0.91).

CONCLUSIONS

Risk compensation, as evidenced in this study over a 1-year period, was not associated with undergoing voluntary medical male circumcision (VMMC) in our sample of young school-going men. However, it is of concern that at the end of this study, less than half of the sexually active sample in a high-HIV-prevalence community used condoms consistently in the previous month (39% for both study cohorts). The latter underscores the need to view VMMC as a potential entry point for planned HIV and sexuality education interventions targeting young men in this community.

HIV pre-exposure prophylaxis in South East Asia: A focused review on present situation

Pre-exposure prophylaxis (PrEP) with the use of antiretrovirals has been approved for HIV prevention in many western countries and internationally. PrEP is however not yet widely available in South East Asia. Awareness of PrEP among MSM in the region is very variable in different countries. While willingness of PrEP uptake is closely related to the extent of awareness, it is largely affected by factors at the individual level, e.g. financial consideration, risk perception, understanding of PrEP and convenience. Removal of social stigmata and secure data confidentiality can improve willingness of uptake. The diverse religious beliefs in South East Asia could have potential influence on PrEP uptake but there was very limited data in the region. There is no strong evidence suggesting substantial risk compensation among MSM who are on PrEP. As in other parts of the world, education on condom use to prevent other sexually transmitted diseases (STD) should be properly addressed rather than blaming PrEP as a sole cause of rise in STD among MSM.

Distracting behaviors among teenagers and young, middle-aged, and older adult drivers when driving without and with warnings from an integrated vehicle safety system

INTRODUCTION

Negative reinforcement from crash warnings may reduce the likelihood that drivers engage in distracted driving. Alternatively, drivers may compensate for the perceived safety benefit of crash warnings by engaging in distractions more frequently, especially at higher speeds. The purpose of this study was to examine whether warning feedback from an integrated vehicle-based safety system affected the likelihood that various secondary behaviors were present among drivers ages 16-17, 20-30, 40-50, and 60-70.

METHOD

Participants drove an instrumented sedan with various collision warning systems for an extended period. Ten 5-second video clips were randomly sampled from driving periods at speeds above 25mph and below 5mph each week for each driver and coded for the presence of 11 secondary behaviors.

RESULTS

At least one secondary behavior was present in 46% of video clips; conversing with a passenger (17%), personal grooming (9%), and cellphone conversation (6%) were the most common. The likelihood that at least one secondary behavior was present was not significantly different during periods when drivers received warnings relative to periods without warnings. At least one secondary behavior was 21% more likely to be present at speeds below 5mph relative to speeds above 25mph; however, the effect of vehicle speed was not significantly affected by warning presence. Separate models for each of the five most common secondary behaviors also indicated that warnings had no significant effect on the likelihood that each behavior was present.

CONCLUSIONS

Collision warnings were not associated with significant increases or decreases in the overall likelihood that teen and adult drivers engaged in secondary behaviors or the likelihood of the behaviors at speeds above 25mph or below 5mph.

PRACTICAL APPLICATIONS

There was no evidence that forward collision warning and other technologies like those in this study will increase or decrease distracted driving.

Exploring evidence for behavioral risk compensation among participants in an HIV vaccine clinical trial

BACKGROUND

HIV vaccine trial participants may engage in behavioral risk compensation due to a false sense of protection. We conducted an ancillary study of an HIV Vaccine Trials Network (HVTN) vaccine efficacy trial to explore risk compensation among trial participants compared to persons who were willing to participate but ineligible based on previous exposure to the Ad5 virus (Ad5+) across three timepoints.

METHODS

Participants were drawn from the Atlanta, GA site of the HVTN 505 vaccine trial. From 2011-2013, all persons who met prescreening criteria for the clinical trial and presented for Ad5 antibody testing were invited to participate in the ancillary study. Data were collected from vaccine trial participants (n=51) and Ad5+ participants (n=60) via online surveys across three timepoints: baseline, T2 (after trial participants received 2/4 injections) and T3 (after trial participants received 4/4 injections). Data analyses assessed demographic, psychosocial, and behavioral differences at baseline and changes at each timepoint.

RESULTS

At baseline, Ad5+ participants were less likely to have some college education (p=0.024) or health insurance (p=0.008), and were more likely to want to participate in the vaccine trial "to feel safer having unprotected sex" (p=0.005). Among vaccine trial participants, unprotected anal sex with a casual partner (p=0.05), HIV transmission worry (p=0.033), and perceived chance of getting HIV (p=0.027), decreased across timepoints.

CONCLUSIONS

Study findings suggest that persons with previous exposure to Ad5 may be systematically different from their Ad5-negative peers. Unprotected anal sex with a casual partner significantly decreased among HIV vaccine trial participants, as did HIV worry and perceived chance of getting HIV. Findings did not support evidence of risk compensation among HIV vaccine trial participants compared to Ad5+ participants.

Correlates of willingness to initiate pre-exposure prophylaxis and anticipation of practicing safer drug- and sex-related behaviors among high-risk drug users on methadone treatment

BACKGROUND

Although people who use drugs (PWUD) are key populations recommended to receive pre-exposure prophylaxis (PrEP) to prevent HIV, few data are available to guide PrEP delivery in this underserved group. We therefore examined the willingness to initiate PrEP and the anticipation of HIV risk reduction while on PrEP among high-risk PWUD.

METHODS

In a cross-sectional study of 400 HIV-negative, opioid dependent persons enrolled in a methadone program and reporting recent risk behaviors, we examined independent correlates of being willing to initiate PrEP.

RESULTS

While only 72 (18%) were aware of PrEP, after being given a description of it, 251 (62.7%) were willing to initiate PrEP. This outcome was associated with having neurocognitive impairment (aOR=3.184, p=0.004) and higher perceived HIV risk (aOR=8.044, p<0.001). Among those willing to initiate PrEP, only 12.5% and 28.2%, respectively, indicated that they would always use condoms and not share injection equipment while on PrEP. Consistent condom use was associated with higher income (aOR=8.315, p=0.016), always using condoms with casual partners (aOR=6.597, p=0.001), and inversely associated with ongoing drug injection (aOR=0.323, p=0.027). Consistent safe injection, however, was inversely associated with age (aOR=0.948, p=0.035), ongoing drug injection (aOR=0.342, p<0.001), and perceived HIV risk (aOR=0.191, p=0.019).

CONCLUSIONS

While willingness to initiate PrEP was high and correlated with being at elevated risk for HIV, anticipated higher risk behaviors in this group even while on PrEP suggests that the next generation of HIV prevention approaches may need to combine biomedical and behavioral components to sustain HIV risk reduction over time.

Differences in cervical cancer screening knowledge, practices, and beliefs: An examination of survey responses

Among the identified barriers to HPV vaccination is the concern that women may compensate for their reduced susceptibility to cervical cancers by reducing cervical cancer screening. This exploratory study examined the relationship between cervical cancer screening rates and HPV vaccination. We conducted a cross-sectional survey using a convenience sample of women aged 21–35 attending a local minority health fair in July 2015. Data were analyzed in 2015–2016. Outcomes assessed were: receiving a Pap test within the last three years, awareness and comfort with current Pap test recommendations, and knowledge regarding the purpose of a Pap test. A total of 291 women were included in the analyses. Mean age was 28.5 years and 62% were non-Hispanic black. 84% had received a Pap test in the last three years and 33% had received at least one HPV vaccine. Logistic regression results showed that women who had been vaccinated did not have lower odds of having a Pap test in the past three years (OR = 1.32; 95% CI = 0.66–2.65). In an adjusted regression model controlling for age and race, vaccinated women were significantly more likely to have had a Pap test (AOR = 3.06; 95% CI = 1.37–6.83). Yet only 26% of women knew the purpose of a Pap test and the proportion who answered correctly was higher among non-Hispanic white women. Women who have been vaccinated for HPV are more likely to have been screened for cervical cancer. These results suggest areas for more robust studies examining pro-health attitudes, behaviors, and communication regarding vaccination and preventive screening.

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A comparison of cervical cancer screening practices among mostly minority women

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HPV vaccinated participants didn't have lower rates of cervical cancer screening.

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Knowledge about the purpose of a Pap test was low especially among minority women.

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Current recommendations and screening purpose are areas for future interventions.

Needs Assessment and Theory-Based Promotion of Voluntary Medical Male Circumcision (VMMC) Among Male Sexually Transmitted Diseases Patients (MSTDP) in China

Voluntary medical male circumcision (VMMC) is an evidence-based biomedical HIV prevention method. It is under-utilized in countries outside Africa, including China. The present single-arm, non-blinded test-of-concept trial was designed to promote VMMC among 179 male sexually transmitted diseases patients (MSTDP) in Shenzhen, China. It was based on behavioral health theories and results of a formative survey. At month 4, 45.5 % of the MSTDP responded positively to the intervention (19.9 % had taken up VMMC and 25.6 % intended to do so in the next 6 months). Adjusted analysis showed that cognitive variables measured at baseline (perceived self-efficacy, subjective norm and behavioral intention) significantly predicted adoption of VMMC during the 4-month follow-up period. Process evaluation involving clinicians of the STD clinics was positive. At month 6, 36.0 % of the circumcised participants used condom less frequently with their regular sex partner. We recommend scaling up the intervention, taking prevention of risk compensation into account.

Decisions and actions of distracted drivers at the onset of yellow lights

Driving on an approach to a signalized intersection while distracted is relatively risky, as potential vehicular conflicts and resulting angle collisions tend to be relatively more severe compared to other locations. Given the prevalence and importance of this particular scenario, the objective of this study was to examine the decisions and actions of distracted drivers during the onset of yellow lights. Driving simulator data were obtained from a sample of 69 drivers under baseline and handheld cell phone conditions at the University of Iowa - National Advanced Driving Simulator. Explanatory variables included age, gender, cell phone use, distance to stop-line, and speed. Although there is extensive research on drivers' responses to yellow traffic signals, the examinations have been conducted from a traditional regression-based approach, which do not necessary provide the underlying relations and patterns among the sampled data. In this paper, we exploit the benefits of both classical statistical inference and data mining techniques to identify the a priori relationships among main effects, non-linearities, and interaction effects. Results suggest that the probability of yellow light running increases with the increase in driving speed at the onset of yellow. Both young (18-25 years) and middle-aged (30-45 years) drivers reveal reduced propensity for yellow light running whilst distracted across the entire speed range, exhibiting possible risk compensation during this critical driving situation. The propensity for yellow light running for both distracted male and female older (50-60 years) drivers is significantly higher. Driver experience captured by age interacts with distraction, resulting in their combined effect having slower physiological response and being distracted particularly risky.

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

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.

Willingness to Take PrEP and Potential for Risk Compensation Among Highly Sexually Active Gay and Bisexual Men

Once-daily Truvada (Emtricitabine/Tenofovir) as a method of pre-exposure prophylaxis (PrEP) is one of the most promising biomedical interventions to eliminate new HIV infections; however, uptake among gay, bisexual, and other men who have sex with men has been slow amidst growing concern in popular/social media that PrEP use will result in reduced condom use (i.e., risk compensation). We investigated demographic, behavioral, and psychosocial differences in willingness to use PrEP as well as the perceived impact of PrEP on participants' condom use in a sample of 206 highly sexually active HIV-negative gay and bisexual men. Nearly half (46.1 %) said they would be willing to take PrEP if it were provided at no cost. Although men willing to take PrEP (vs. others) reported similar numbers of recent casual male partners (<6 weeks), they had higher odds of recent receptive condomless anal sex (CAS)-i.e., those already at high risk of contracting HIV were more willing to take PrEP. Neither age, race/ethnicity, nor income were associated with willingness to take PrEP, suggesting equal acceptability among subpopulations that are experiencing disparities in HIV incidence. There was limited evidence to suggest men would risk compensate. Only 10 % of men who had not engaged in recent CAS felt that PrEP would result in them starting to have CAS. Men who had not tested for HIV recently were also significantly more likely than others to indicate willingness to take PrEP. Offering PrEP to men who test infrequently may serve to engage them more in routine HIV/STI testing and create a continued dialogue around sexual health between patient and provider in order to prevent HIV infection.

Impact of mobile phone use on car-following behaviour of young drivers

Multitasking, such as the concurrent use of a mobile phone and operating a motor vehicle, is a significant distraction that impairs driving performance and is becoming a leading cause of motor vehicle crashes. This study investigates the impact of mobile phone conversations on car-following behaviour. The CARRS-Q Advanced Driving Simulator was used to test a group of young Australian drivers aged 18-26 years on a car-following task in three randomised phone conditions: baseline (no phone conversation), hands-free and handheld. Repeated measure ANOVA was applied to examine the effect of mobile phone distraction on selected car-following variables such as driving speed, spacing, and time headway. Overall, drivers tended to select slower driving speeds, larger vehicle spacings, and longer time headways when they were engaged in either hands-free or handheld phone conversations, suggesting possible risk compensatory behaviour. In addition, phone conversations while driving influenced car-following behaviour such that variability was increased in driving speeds, vehicle spacings, and acceleration and decelerations. To further investigate car-following behaviour of distracted drivers, driver time headways were modelled using Generalized Estimation Equation (GEE). After controlling for various exogenous factors, the model predicts an increase of 0.33s in time headway when a driver is engaged in hands-free phone conversation and a 0.75s increase for handheld phone conversation. The findings will improve the collective understanding of distraction on driving performance, in particular car following behaviour which is most critical in the determination of rear-end crashes.

Increased patterns of risky behaviours among helmet wearers in skiing and snowboarding

BACKGROUND

There has been an ongoing debate as to whether wearing helmets in skiing and snowboarding increases the risk tolerance of participants.

OBJECTIVE

To investigate the roles of demographic and personality variables, and helmet usage in predicting risk taking behaviours in a cross-sectional sample of intermediate and proficient skiers and snowboarders.

METHODS

Risk taking in skiing was measured using a validated 10-item self-report measure which was designated as the outcome variable in a three step hierarchical regression. Independent predictors included age, sex, education, sport, ability, helmet usage, and personality traits that have been associated with risk taking: impulsivity and sensation seeking.

RESULTS

In the final regression model, helmet use significantly predicted variance in risk taking (standardized β=.10, p=.024), and the relationship remained after accounting for variance due to demographic variables and general trait measures. The partial relationship between risk taking and sex, ability, impulsivity, and sensation seeking were also significant (p<.05).

CONCLUSION

High sensation seeking, high impulsivity, male sex, and proficiency were associated with increased patterns of risky behaviours in skiers and snowboarders, and after accounting for these factors, helmet use was a significant predictor of risk taking. The relationship between helmet use and risk taking was modest suggesting that the costs of increased risk taking is not likely to outweigh the protective benefits of a helmet.

Human papillomavirus (HPV) vaccination and subsequent sexual behaviour: evidence from a large survey of Nordic women

OBJECTIVE

To assess whether recipients and non-recipients of the human papillomavirus (HPV) vaccine subsequently differ in terms of sexual risk taking behaviour.

DESIGN

Cross-sectional survey. Sequential analyses constructed from self-reported age at vaccination, age at first intercourse and age at response.

SETTING

A random selection of women aged 18-46 years living in Denmark, Norway and Sweden in 2011-2012, eligible for opportunistic or organized catch-up HPV vaccination.

PARTICIPANTS

A total of 3805 women reported to have received the HPV vaccine and 40,247 reported not to have received it. Among vaccinees, 1539 received the HPV vaccine before or at the same age as sexual debut, of which 476 and 1063 were eligible for organized catch-up and opportunistic vaccination, respectively.

MAIN OUTCOME MEASURES

Self-reported sexual behaviour, compared by hazard ratios and odds ratios for women who received the HPV vaccine before or at the same age as sexual debut versus women who did not receive the HPV vaccine.

RESULTS

HPV vaccination did not result in younger age at first intercourse. Women who received the HPV vaccine before or at the same age as sexual debut did not have more sexual partners than did non-vaccinees. Non-use of contraception during first intercourse was more common among non-vaccinees than among HPV vaccinees. The results were similar for organized catch-up and opportunistic vaccinees.

CONCLUSION

Women who received the HPV vaccine before or at the same age as sexual debut did not subsequently engage more in sexual risk taking behaviour than women who did not receive the HPV vaccine.

Development of an HIV vaccine attitudes scale to predict HIV vaccine acceptability among vulnerable populations: L.A. VOICES

BACKGROUND

Decade-long delays in successful implementation of Hepatitis B vaccines and ongoing obstacles in HPV vaccine roll-out suggest the importance of an implementation science approach to prepare for the effective translation of future HIV vaccines from clinical trials into routine practice. The objective of this study was to test HIV vaccine attitude items to develop reliable scales and to examine their association with HIV vaccine acceptability.

METHODS

HIV vaccine attitude items were assessed as part of the L.A. VOICES survey, a large-scale study conducted among underserved residents of Los Angeles, to identify factors that may influence HIV vaccine acceptability. Participants (n=1225) were randomly selected from public STD clinics, needle exchange sites and Latino community clinics using three-stage, venue-based time space sampling.

RESULTS

Exploratory factor analysis across 20 items revealed four distinct factors - mistrust, HIV vaccine social concerns, risk compensation, and altruistic vaccination - with acceptable reliability coefficients for each subscale (Cronbach's α range 0.61-0.84). We found no significant differences in reliability by gender or by vaccine acceptability. Risk compensation (odds ratio (OR)=1.49; 95% CI=[1.18, 1.89]; p=0.001) and altruistic vaccination (OR=1.40; 95% CI=[1.14, 1.71]; p=0.001) were significantly and positively associated with HIV vaccine acceptability.

CONCLUSIONS

We identified four HIV vaccine attitude scales with sound internal reliability parameters. In the aftermath of the first candidate vaccine to demonstrate efficacy against HIV infection, these scales may be helpful in bridging expectable research-to-practice gaps in future HIV vaccine dissemination among populations at risk. As HIV vaccine trials progress in the United States and globally, these measures also may be useful as a tool to assess and facilitate effective responses to community concerns about HIV vaccine trials and to target interventions to support recruitment and mitigate risk compensation.

Study designs for identifying risk compensation behavior among users of biomedical HIV prevention technologies: balancing methodological rigor and research ethics

The growing evidence base for biomedical HIV prevention interventions - such as oral pre-exposure prophylaxis, microbicides, male circumcision, treatment as prevention, and eventually prevention vaccines - has given rise to concerns about the ways in which users of these biomedical products may adjust their HIV risk behaviors based on the perception that they are prevented from infection. Known as risk compensation, this behavioral adjustment draws on the theory of "risk homeostasis," which has previously been applied to phenomena as diverse as Lyme disease vaccination, insurance mandates, and automobile safety. Little rigorous evidence exists to answer risk compensation concerns in the biomedical HIV prevention literature, in part because the field has not systematically evaluated the study designs available for testing these behaviors. The goals of this Commentary are to explain the origins of risk compensation behavior in risk homeostasis theory, to reframe risk compensation as a testable response to the perception of reduced risk, and to assess the methodological rigor and ethical justification of study designs aiming to isolate risk compensation responses. Although the most rigorous methodological designs for assessing risk compensation behavior may be unavailable due to ethical flaws, several strategies can help investigators identify potential risk compensation behavior during Phase II, Phase III, and Phase IV testing of new technologies. Where concerns arise regarding risk compensation behavior, empirical evidence about the incidence, types, and extent of these behavioral changes can illuminate opportunities to better support the users of new HIV prevention strategies. This Commentary concludes by suggesting a new way to conceptualize risk compensation behavior in the HIV prevention context.

Risk compensation in children's activities: A pilot study

BACKGROUND

The intent of protective equipment (PE) in sports and leisure activities is to reduce injuries. However, some postulate that any safety measure prompts riskier behaviour, a phenomenon known as 'risk homeostasis' or 'risk compensation.' This study explores one approach to examining this in children. The rationale for this pilot study was to establish if children between six and 16 years old could answer questions about risk-taking sensibly and which questions, if any, could be eliminated; to establish the reliability of response; and to determine the numbers needed for a definitive study.

METHODS

Sixty-three children with nonsevere injuries, ages six to 16 years, were interviewed while waiting to be seen at the Montreal Children's Hospital emergency department. An interviewer administered a questionnaire comprising three sections. The first part only applied to those who were injured in an activity for which some form of PE was available (n=19). The second part examined customary risk-taking behaviour using the thrill and adventure seeking scales of a standardized questionnaire (Zuckerman) (n=63). The third section posed hypothetical questions about likely risk-taking when using PE to those who had engaged in such activities (n=58).

RESULTS

The approach and questionnaire proved feasible with this age group. The responses suggest that children wearing PE were more likely to report increased risk-taking than those who did not wear PE. For most of the hypothetical questions, the majority also reported changes toward riskier behaviour when using PE. However, those wearing PE scored lower on the thrill and adventure seeking scale, suggesting that they are, by nature, less venturesome.

CONCLUSION

The results indicate that risk compensation may modify the effectiveness of PE for children engaged in sports and leisure activities. Conversely, the findings also suggest that those wearing PE may be a cautious subgroup.