Improving adherence and risk reduction
In the era of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and treatment as prevention, behavioural methods of risk reduction – including condom use, clean injecting equipment, HIV serosorting, strategic positioning, and negotiated safe practices with sexual partners– retain
their importance in preventing HIV transmission (Box 11.1). However, some vulnerable individuals, particularly some cis-gender and transgender women, may be unable to effectively negotiate use of these prevention strategies, especially condoms, with their regular, or casual partners. The initiation of PrEP is straightforward, but on occasion it may be appropriate to refer some particularly vulnerable people with complex needs to health professionals with expertise in HIV prevention and sexual health.
PrEP’s efficacy relates directly to the patient’s adherence to PrEP medication not to whether the patient is using condoms in tandem with PrEP (1,2). Individuals should be supported with ongoing information about the role that condoms and other practices play in preventing HIV when PrEP adherence is sub-optimal as well as the role that condoms play in sexually transmissible infection (STI) prevention.
Box 11.1 Discussion points on behavioural reduction of HIV and STI risk.
Provide feedback on HIV risk factors identified during sexual and substance use history taking:
• Elicit barriers to, and facilitators of consistent condom use and other safer sex and substance use practices
• Elicit barriers to, and facilitators of, reducing injecting drug use
• Discuss with patients the barriers to, and facilitators of, evidence-based drug treatment where indicated and requested.
Support risk-reduction efforts:
• Help patients identify one or two feasible, acceptable, incremental steps toward risk reduction
• Identify and address anticipated barriers to accomplishing planned actions to reduce risk.
Monitor medication adherence in a non-judgmental manner:
• Acknowledge the effort required for behavioural change
• Reinforce success.
If not fully successful, assess factors interfering with completion of planned actions and help patient identify the next steps (including consideration of commencing PrEP).
- de Visser RO, Badcock PB, Rissel C, et al. Safer sex and condom use: findings from the Second Australian Study of Health and Relationships. Sex Health 2014;11:495-504.
- Nasrullah M, Oraka E, Chavez PR, Johnson CH, DiNenno E. Factors associated with condom use among sexually active US adults, National Survey of Family Growth, 2006-2010 and 2011-2013. J Sex Med 2017;14:541-50.