Problematic risk perception: half of women acquiring HIV reported that they were not at risk

A descriptive analysis of perceptions of HIV risk and worry about acquiring HIV among FEM-PrEP participants who seroconverted in Bondo, Kenya, and Pretoria, South Africa.

Corneli AL, McKenna K, Headley J, Ahmed K, Odhiambo J, Skhosana J, Wang M, Agot K. J Int AIDS Soc. 2014 Sep 8;17(3 Suppl 2):19152. doi: 10.7448/IAS.17.3.19152. eCollection 2014.

Methods: FEM-PrEP was a phase III clinical trial of once-daily, oral emtricitabine and tenofovir disoproxil fumarate for HIV prevention among women in sub-Saharan Africa. We asked all participants about their perceived HIV risk in the next four weeks, prior to HIV testing, during a quantitative face-to-face interview at enrolment and at quarterly follow-up visits. Among participants who seroconverted, we calculated the frequencies of their responses from the visit conducted closest to, but before, HIV acquisition. Also among women who seroconverted, we conducted qualitative, semi-structured interviews (SSIs) at weeks 1, 4 and 8 after participants' HIV diagnosis visit to retrospectively explore feelings of HIV worry. Applied thematic analysis was used to analyse the SSI data.

Results: Among participants who seroconverted in Bondo and Pretoria, 52% reported in the quantitative interview that they had no chance of acquiring HIV in the next four weeks. We identified four processes of risk rationalization from the SSI narratives. In "protective behaviour," participants described at least one risk reduction behaviour they used to reduce their HIV risk; these actions made them feel not vulnerable to HIV, and therefore they did not worry about acquiring the virus. In "protective reasoning," participants considered their HIV risk but rationalized, based on certain events or beliefs, that they were not vulnerable and therefore did not worry about getting HIV. In "recognition of vulnerability," participants described reasons for being worried about getting HIV but said no or limited action was taken to reduce their perceived vulnerability. Participants with "no rationalization or action" did not describe any HIV worry or did not engage in HIV risk reduction behaviours.

Conclusions: Women who are at substantial risk of acquiring HIV may underestimate their actual risk. Yet, others who accurately understand their HIV risk may be unable to act on their concerns. Perceived HIV risk and risk rationalization are important concepts to explore in risk reduction counselling to increase the use of HIV prevention strategies among women at risk of HIV.

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Editor’s notes: Risk perception has been thought to be a significant driver of accessing and using HIV prevention methods. However, over the years, researchers have struggled to present a definitive argument as to the role risk perception plays in HIV prevention. While the FemPrEP study failed to show efficacy, or rather effectiveness of oral pre-exposure prophylaxis (PrEP) in preventing HIV acquisition in women in several sites in Africa, valuable data have been collected relating to risk perception. About half of the women who seroconverted to HIV during the trial and were interviewed, indicated that they did not perceive themselves to be at risk of contracting HIV. Interviews revealed different cognitive mechanisms by which women rationalised their perceptions and/or behaviours, some of which were outside their immediate control. A key finding was that women who were actually at significant risk of acquiring HIV did not accurately perceive their risk. While this analysis focused on risk perception, the narratives from some participants suggest that risk perception is only a small piece of the puzzle in understanding how and why women may access and use HIV prevention methods. While this study demonstrates that risk perception clearly plays an important role, it would be valuable to understand further the context within which the women are living and making decisions to fully comprehend HIV access and use. 

Kenya, South Africa
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