Grant, H., Mukandavire, Z., Eakle, R., et al. Journal of the International AIDS Society (September 2017), 20: 2174, doi:10.7448/IAS.21.1.21744.
This modeling study assessed the possible outcomes of behavioral disinhibition (specifically, reduced use of condoms) related to the use of pre-exposure prophylaxis (PrEP) among female sex workers (FSWs) in South Africa. The authors modeled outcomes of PrEP and condom use based on three scenarios: 1) an FSW and her clients; 2) an FSW and her clients while accounting for exposure to sexually transmitted infection (STI); and 3) an FSW, her clients, and regular partners while accounting for STI exposure. Analysis of interactions with clients showed that if the effectiveness of PrEP use equaled or exceeded that of condom use, the FSW could stop using condoms without increasing HIV risk. FSWs who used condoms less than half the time (and thus had greater exposure to STIs) had reduced HIV risk if their adherence to PrEP was high. Analysis of the "clients and regular partners" scenario showed that FSWs with low baseline condom use, or with high PrEP effectiveness, had minimal HIV risk when reducing condom use. However, the authors cautioned that their study did not address the potential for developing resistance, or the effects of different stages of disease. Programmers should prioritize reaching FSWs who have high condom use and limited expected PrEP adherence, and provide support for PrEP adherence and continued condom use.