Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. OPINION Using preexposure prophylaxis, losing condoms? Preexposure prophylaxis promotion may undermine safe sex Kamair Alaei a,b , Christopher A. Paynter a,b , Shao-Chiu Juan a,b and Arash Alaei a,b AIDS 2016, 30:2753–2756 Keywords: condoms, preexposure prophylaxis, risk-taking, sexually transmitted diseases, unsafe sex Preexposure prophylaxis (PrEP) has emerged as a powerful new tool in the fight against HIV [1–3]. However, the expanding use of PrEP has been accompanied by increases in other sexually transmitted infections (STIs) previously under control. Between 2013 and 2014, there was a 15% increase in the number of reported primary and secondary syphilis cases nationwide [4]. Among the 2014 cases, 83% were among MSM, an important target group for PrEP [4]. One concern about PrEP is the idea of risk compensation, namely that individuals taking PrEP may increase their risky sex behaviors and thereby increase the spread of STIs other than HIV [5]. Risk compensation has often been ignored on the basis of a few high-profile clinical trials that failed to find evidence for increased risk behaviors [1,2,6–8]. However, new evidence from real-world applications of PrEP suggests that increased risk behavior may indeed be a problem [3,9]. PrEP is definitely still valuable as a tool for lowering the likelihood of HIV transmission, but it must be accompanied by clear messages that vulnerable populations should continue practicing safe sex. Given that PrEP is becoming more widely available, public health advocates need to be even more active in ensuring that condom promotion is not neglected. A landmark study demonstrating the effectiveness of PrEP for reducing HIV incidence was the iniciativa profilaxis pre-exposicion (iPrEX) double-blind clinical trial [1]. One of the major arguments for lack of risk compensation comes from data from this study [6,7]. The researchers collected data on sexual risk behaviors and STIs, including gonorrhea, chlamydia, and syphilis in addition to HIV. The researchers concluded that risk compen- sation did not occur because there was either no change or a decrease in risk behaviors [7]. However, the data on risk behaviors relied entirely on self-report, which may have been skewed by desire to give the socially acceptable response. The researchers also noted that syphilis incidence did not differ as a function of whether people believed they were in the treatment or control group [7]. Surprisingly though, the researchers did not analyze or discuss incidence for gonorrhea or chlamydia, even though data were apparently available for these STIs in addition to syphilis [1]. The original studies on the impact of PrEP on HIV incidence used the standard practice of double-blind procedures to look at the biological effect on HIV incidence, so participants were not aware of whether they were actually taking PrEP or not [1,6,7]. This research a Global Institute for Health and Human Rights, and b Department of Public Administration and Policy, Rockefeller College, University at Albany, State University of New York, Albany, New York, USA. Correspondence to Christopher A. Paynter, PhD, Global Institute for Health and Human Rights, 1400 Washington Ave., Albany, NY 12222, USA; Department of Public Administration and Policy, Rockefeller College, University at Albany, State University of New York, 135 Western Ave., Albany, NY 12222, USA. Tel: +1 518 442 3300; e-mail: cpaynter.neuro@gmail.com Received: 1 August 2016; accepted: 11 August 2016. DOI:10.1097/QAD.0000000000001262 ISSN 0269-9370 Copyright Q 2016 Wolters Kluwer Health, Inc. All rights reserved. 2753