{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T04:35:54Z","timestamp":1791434154817,"version":"4.3.3"},"update-to":[{"DOI":"10.1371\/journal.pmed.1004458","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,9,3]],"date-time":"2025-09-03T00:00:00Z","timestamp":1756857600000}}],"reference-count":31,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2025,8,18]],"date-time":"2025-08-18T00:00:00Z","timestamp":1755475200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000265","name":"Medical Research Council","doi-asserted-by":"publisher","award":["MR\/T00262X\/1"],"award-info":[{"award-number":["MR\/T00262X\/1"]}],"id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100005797","name":"Vereniging Trustfonds Erasmus Universiteit Rotterdam","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100005797","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>HIV prevention through pre-exposure prophylaxis (PrEP) may encourage riskier sexual behaviours that undermine the protection afforded by PrEP and generate negative spillovers through sexually transmitted infections (STIs). Tests for such risk compensatory behaviour in high-risk populations, such as female sex workers (FSWs), are lacking. This study aims to assess whether risk compensatory behaviours were observed among FSWs in Senegal after the rollout of PrEP.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods and findings<\/jats:title>\n<jats:p>In a randomised controlled trial with a Zelen design, we stratified FSWs in Dakar (Senegal) by self-reported sexual risk-taking and prior PrEP experience and randomly assigned them to immediate referral for oral PrEP (Treatment) from 7 September 2021 to end January 2022 or delayed PrEP referral (Control). We compared outcomes 3\u20138 months after the referral of the treatment group and before the referral of the control group. Primary outcomes were self-reported condom use with clients and perceived HIV\/STI risks from sex with clients with and without a condom. The analysis is a modified intention-to-treat analysis. We estimated effects of PrEP referral as well as effects of oral PrEP use induced by randomised assignment to active PrEP referral. Out of 500 individuals randomised, 308 (61.6%) were included in the analysis (Treatment: 182\/300\u2009=\u200960.7%; Control: 126\/200\u2009=\u200963%). PrEP referral increased the probability of using oral PrEP by 34.5 percentage points (pp) (95% CI [25.4, 43.6]; <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001). Estimated effects of PrEP referral and PrEP use on condom use with the last client were positive but not statistically significantly different from zero. PrEP referral was estimated to increase the probability of condom use with all of the last three clients by 11.0 pp (95% CI [0.8, 21.2]; <jats:italic>p<\/jats:italic>\u2009=\u20090.034). PrEP use was estimated to increase this probability by 25.8 pp (95% CI [5.2, 46.4]; <jats:italic>p<\/jats:italic>\u2009=\u20090.014). Main limitations were low power, high attrition, self-reported outcomes and a limited follow-up period.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>This study, conducted in one location, did not find evidence that PrEP referral or oral PrEP use increased self-reported risky sex behaviours of FSWs within 3\u20138 months. The robustness of this finding needs to be tested with larger cohorts followed for longer periods in other settings, and using survey instruments that allow further examination of whether PrEP users are more likely to overreport condom use.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Trial Registration<\/jats:title>\n<jats:p>ISRCTN\u2014The UK\u2019s Clinical Study Registry, ISRCTN16445862 <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/www.isrctn.com\/ISRCTN16445862\" xlink:type=\"simple\">https:\/\/www.isrctn.com\/ISRCTN16445862<\/jats:ext-link><\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pmed.1004458","type":"journal-article","created":{"date-parts":[[2025,8,18]],"date-time":"2025-08-18T18:05:04Z","timestamp":1755540304000},"page":"e1004458","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Effect of pre-exposure prophylaxis on risky sexual behaviour of female sex workers in Dakar, Senegal: A randomised controlled trial"],"prefix":"10.1371","volume":"22","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7980-050X","authenticated-orcid":true,"given":"Wally","family":"Toh","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9237-2914","authenticated-orcid":true,"given":"Aur\u00e9lia","family":"L\u00e9pine","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khady","family":"Gueye","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mame Mor","family":"Fall","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdou Khoudia","family":"Diop","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"El Hadj Alioune","family":"Mbaye","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cheikh Tidiane","family":"Ndour","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6289-1924","authenticated-orcid":true,"given":"Owen","family":"O\u2019Donnell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,8,18]]},"reference":[{"issue":"6","key":"pmed.1004458.ref001","doi-asserted-by":"crossref","DOI":"10.1016\/S2468-2667(22)00106-2","article-title":"Real-world effectiveness of pre-exposure prophylaxis in men at high risk of HIV infection in France: a nested case-control study","volume":"7","author":"H Jourdain","year":"2022","journal-title":"Lancet Public Health"},{"issue":"5","key":"pmed.1004458.ref002","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-048478","article-title":"Oral pre-exposure prophylaxis (PrEP) to prevent HIV: a systematic review and meta-analysis of clinical effectiveness, safety, adherence and risk compensation in all populations","volume":"12","author":"E O Murchu","year":"2022","journal-title":"BMJ Open"},{"key":"pmed.1004458.ref003","article-title":"Give PrEP a chance: moving on from the \u201crisk compensation\u201d concept","author":"D Rojas Castro","year":"2019","journal-title":"J Int AIDS Soc"},{"issue":"4","key":"pmed.1004458.ref004","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1086\/260352","article-title":"The effects of automobile safety regulation","volume":"83","author":"S Peltzman","year":"1975","journal-title":"J Pol Econ"},{"key":"pmed.1004458.ref005","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/j.jdeveco.2013.08.012","article-title":"Is sex like driving? HIV prevention and risk compensation","volume":"106","author":"NL Wilson","year":"2014","journal-title":"J Dev Econ"},{"issue":"7","key":"pmed.1004458.ref006","doi-asserted-by":"crossref","first-page":"1461","DOI":"10.1007\/s10461-015-1055-5","article-title":"Sexual behavior, risk compensation, and HIV prevention strategies among participants in the San Francisco PrEP demonstration project: a qualitative analysis of counseling notes","volume":"20","author":"J Carlo Hojilla","year":"2016","journal-title":"AIDS Behav"},{"issue":"3","key":"pmed.1004458.ref007","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1097\/QAI.0000000000002134","article-title":"PrEP use among female sex workers: no evidence for risk compensation","volume":"82","author":"K Gigu\u00e8re","year":"2019","journal-title":"J Acquir Immune Defic Syndr"},{"issue":"8","key":"pmed.1004458.ref008","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1007\/s11908-019-0685-6","article-title":"Update on HIV preexposure prophylaxis: effectiveness, drug resistance, and risk compensation","volume":"21","author":"VE Powell","year":"2019","journal-title":"Curr Infect Dis Rep"},{"issue":"5","key":"pmed.1004458.ref009","doi-asserted-by":"crossref","first-page":"676","DOI":"10.1093\/cid\/ciy182","article-title":"Effects of pre-exposure prophylaxis for the prevention of human immunodeficiency virus infection on sexual risk behavior in men who have sex with men: a systematic review and meta-analysis","volume":"67","author":"MW Traeger","year":"2018","journal-title":"Clin Infect Dis"},{"issue":"4","key":"pmed.1004458.ref010","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1016\/S1473-3099(22)00151-7","article-title":"Evaluating the risk compensation of HIV\/AIDS prevention measures","volume":"22","author":"X Yan","year":"2022","journal-title":"Lancet Infect Dis"},{"issue":"10","key":"pmed.1004458.ref011","doi-asserted-by":"crossref","first-page":"1550","DOI":"10.1002\/hec.3784","article-title":"The effect of HIV prevention products on incentives to supply condomless commercial sex among female sex workers in South Africa","volume":"27","author":"M Quaife","year":"2018","journal-title":"Health Econ"},{"issue":"2","key":"pmed.1004458.ref012","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.25442","article-title":"HIV pre-exposure prophylaxis for female sex workers: ensuring women\u2019s family planning needs are not left behind","volume":"23","author":"AL Bowring","year":"2020","journal-title":"J Int AIDS Soc"},{"issue":"11","key":"pmed.1004458.ref013","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.25208","article-title":"Early antiretroviral therapy and daily pre-exposure prophylaxis for HIV prevention among female sex workers in Cotonou, Benin: a prospective observational demonstration study","volume":"21","author":"A Mboup","year":"2018","journal-title":"J Int AIDS Soc"},{"issue":"12","key":"pmed.1004458.ref014","doi-asserted-by":"crossref","first-page":"1002","DOI":"10.1097\/OLQ.0b013e3181812939","article-title":"Changes in sexual risk behavior among participants in a PrEP HIV prevention trial","volume":"35","author":"G Guest","year":"2008","journal-title":"Sex Transm Dis"},{"issue":"9","key":"pmed.1004458.ref015","doi-asserted-by":"crossref","first-page":"820","DOI":"10.1016\/S1473-3099(14)70847-3","article-title":"Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study","volume":"14","author":"RM Grant","year":"2014","journal-title":"Lancet Infect Dis"},{"issue":"1","key":"pmed.1004458.ref016","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1186\/s12905-022-02018-z","article-title":"Uptake of and adherence to oral pre-exposure prophylaxis among adolescent girls and young women at high risk of HIV-infection in Kampala, Uganda: a qualitative study of experiences, facilitators and barriers","volume":"22","author":"I Kayesu","year":"2022","journal-title":"BMC Womens Health"},{"key":"pmed.1004458.ref017","unstructured":"UNAIDS. 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