Risk compensation: the Achilles' heel of innovations in HIV prevention?

doi:10.1136/bmj.332.7541.605

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Michael M Cassell, senior prevention adviser (mcassell@usaid.gov)1,
Daniel T Halperin, regional prevention and behaviour change adviser3,
James D Shelton, senior medical adviser2,
David Stanton, division chief, technical leadership and research1

¹ Office of HIV/AIDS, United States Agency for International Development, Washington, DC 20523-3700, USA
² Office of Population and Reproductive Health, United States Agency for International Development, Washington, DC
³ Southern African Regional HIV-AIDS Program, United States Agency for International Development, Mbabane, Swaziland

Correspondence to: M M Cassell

Accepted 2 February 2006

The benefits of new methods of prevention of HIV could be jeopardised if they are not accompanied by efforts to change risky behaviour

The recent finding that circumcision of men substantially reduces the risk of HIV infection is one of the most exciting developments in the history of HIV prevention.1 ^{w1 w2} Nevertheless, this finding has quickly been clouded by concerns that risk compensation—increases in risky behaviour sparked by decreases in perceived risk—could undermine circumcision's protective benefits. Similar concerns might also be raised with regard to other promising innovations for HIV prevention. Microbicides, pre-exposure antiretroviral prophylaxis, and vaccines all have the potential to help combat the global spread of HIV but may also inhibit the uptake of safer behaviours by reducing people's perceptions of their risk of infection.

Potential innovations in HIV prevention

New approaches to combat the pandemic are particularly welcome in light of United Nations' estimates that almost five million people become infected with HIV, and more than three million people die of AIDS, each year.^w3 Innovations in antiretroviral drug treatment have invigorated international efforts to curb the annual burden of AIDS deaths, but preventing new infections remains the key to breaking the back of the epidemic and curtailing the expanding need for treatment.^{w3 w4}

Raising risk awareness in San Francisco nightclubs

Credit: STOPAIDS

Several innovations show promise for reducing the efficiency of HIV transmission (table).^w5 However, for any of these approaches to reduce the rate of new infections, they must reach sufficient numbers of people who are likely to transmit or acquire infection, and their protective benefits must not be offset by increased riskier behaviour in the targeted community.6 7 Of particular concern is the possibility that the introduction of new methods of prevention could reduce perceptions of risk among a broader set of people who …