Modelling the effect of market forces on the impact of introducing human immunodeficiency virus pre‐exposure prophylaxis among female sex workers

Matthew Quaife, Fern Terris‐Prestholt, Zindoga Mukandavire, Peter Vickerman

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    2 Citations (Scopus)
    60 Downloads (Pure)


    Pre-exposure prophylaxis (PrEP) to prevent human immunodeficiency virus (HIV) enables female sex workers (FSWs) to protect themselves from HIV without relying on clients using condoms. Yet, because PrEP reduces HIV risk, financial incentives to not use condoms may lead to risk compensation: reductions in condom use and/or increases in commercial sex, and may reduce the price of unprotected sex. In this analysis, we integrate market forces into a dynamic HIV transmission model to assess how risk compensation could change the impact of PrEP among FSWs and clients. We parameterise how sexual behavior may change with PrEP use among FSWs using stated preference data combined with economic theory. Our projections suggest the impact of PrEP is sensitive to risk compensatory behaviors driven by changes in the economics of sex work. Condom substitution could reduce the impact of PrEP on HIV incidence by 55%, while increases in the frequency of commercial sex to counter decreases in the price charged for unprotected sex among PrEP users could entirely mitigate the impact of PrEP. Accounting for competition between PrEP users and nonusers exacerbates this further. Alternative scenarios where increases in unprotected sex among PrEP users are balanced by decreases in non-PrEP users have the opposite effect, resulting in PrEP having much greater impact. Intervention studies need to determine how HIV prevention products may change the economics of sex work and provision of unprotected sex to enable a better understanding of their impact.

    Original languageEnglish
    Pages (from-to)659-679
    Number of pages21
    JournalHealth Economics
    Issue number3
    Early online date29 Dec 2020
    Publication statusPublished - Mar 2021

    Bibliographical note

    This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.


    • HIV prevention
    • South Africa
    • economics of sex work
    • pre-exposure prophylaxis
    • transmission model

    ASJC Scopus subject areas

    • Health Policy


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