The Moral Hazard Paradox of PrEP and Condom Use

A recent study out of Australia now represents one of the strongest evidence bases for the association between PrEP and decreased condom use in men who have sex with men (MSM). How does a moral hazard framework impact stigma and harm reduction principles in HIV prevention?

When I was working in direct service for an HIV prevention/PrEP program, I was known to many in the office as the "condom guy". Half of my desk drawers were stuffed with condoms and sex supplies. I had a free, dual-variety condom dispenser mounted on my wall (though sometimes I went for a condom-lube display aesthetic). I had the condom delivery staff at the city health department on speed dial. I made sure every exam room and office were stocked with the widest array of condoms one could put together. And part of my counseling sessions often included a plug for the city's free, at-home condom delivery service. Condoms are great!

And yet, I lose absolutely zero sleep at night knowing that PrEP uptake leads to decreased condom use in MSM. Yes, even with the understanding that we are on the verge of an antibiotic-resistant gonorrhea crisis and syphilis epidemic. Here's why.

The moral hazard argument states that when people think they are protected from a certain consequence—taking PrEP to prevent HIV, in this case—they stop making an effort to alleviate risk—i.e, using condoms. And while this looks to be true for MSM, it should not be removed from certain contexts. Unlike gonorrhea, syphilis, HPV, and other serious sexually transmitted infections (STI), HIV has a long and deeply rooted history of fear and stigmatization in the MSM community. Condoms were a powerful and life-saving tool in the HIV prevention toolbox as the AIDS epidemic exploded in the 1980s. And for decades, that prevention toolbox only included condoms and abstinence (and to some degree, HIV testing once it became readily available). 

Today, however, the story is much different. HIV-negative people can now use PrEP and PEP for HIV prevention, and HIV-positive folks now have undeniable proof for undetectable equals untransmittable (U=U), or treatment as prevention. All of these drug-based options are excellent at preventing HIV transmission and are absolutely useless at preventing any other STI. For many MSM, they also happen to be much more sexually appealing than condoms or abstinence, which both have dramatic and undeniable effects on sexual experience.

While it was sometimes tempting to direct a patient's decision-making to my own ideal for health and prevention, I never felt as though it was my place. I was not there to manage an individual's sexual experience outside of setting and readjusting the stage for STI risk or other harm reduction in whatever combination that needed to look like.

If I believed that someone was at-risk for contracting HIV (which meant they were almost certainly at-risk for gonorrhea, syphilis and HPV, as well), a harm reduction approach would include the delivery of unbiased information that was not stigmatizing or fearful. This approach would also champion autonomy, promote a right to sexual liberation and choice, and empower medical decision-making. For example, a healthy exploration of resistance to condom use might have lead to potential quick-fixes—maybe there was some misunderstanding about condom application or what lubricant to use—but there also had to be validation of sexual choice, autonomy and liberation. These things are not really valued in medicalized approaches to risk reduction, especially in the context of HIV where gay sex is still stigmatized and criminalized.

If that day the plan did not include condoms but did include PrEP or treatment as prevention, that is still harm reduction from the scope of HIV prevention. That is still a success.

In the case of these drug-based prevention tools, I think it is so important to keep centered how powerful they are in relieving intergenerational anxiety about HIV/AIDS and gay sex in the MSM community. Although the implications for other equally concerning STIs are undeniably on the horizon, PrEP nor condoms are the enemy of the other. I welcome any and all advances in risk reduction for sexual health because they empower people to experience connection in their own way. 

Here are some other STI risk reduction strategies to consider:

  • Discuss more frequent and routine screening tests
  • Educate about systemic infections (syphilis), local infections (gonorrhea) and asymptomatic infections
  • Educate about emerging and drug-resistant infections and the roles of physical, behavioral and pharmaceutical protection
  • Role-play conversations (text and out-loud) about consent and testing history
  • Teach identification (self and other) of STI signs and symptoms
  • Provide harm reduction for other secondary risk factors, such as alcohol or drug use

For more on the recent study out of Australia, please see the original publication The Lancet: HIV here: https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(18)30072-9/fulltext

Image source: Austin Chronicle 2015