Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS

Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: the healthy living project randomized controlled study

CONTEXT

The US Centers for Disease Control and Prevention (CDC) strongly recommend comprehensive risk counceling and services for people living with HIV (PLH); yet, there are no evidence-based counseling protocols.

OBJECTIVE

To examine the effect of a 15-session, individually delivered, cognitive behavioral intervention on a diverse sample of PLH at risk of transmitting to others.

DESIGN

This was a multisite, 2-group, randomized, controlled trial.

PARTICIPANTS

Nine hundred thirty-six HIV-infected participants considered to be at risk of transmitting HIV of 3818 persons screened were randomized into the trial. Participants were recruited in Los Angeles, Milwaukee, New York, and San Francisco.

INTERVENTION

Fifteen 90-minute individually delivered intervention sessions were divided into 3 modules: stress, coping, and adjustment; safer behaviors; and health behaviors. The control group received no intervention until the trial was completed. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization.

MAIN OUTCOME MEASURE

Transmission risk, as measured by the number of unprotected sexual risk acts with persons of HIV-negative or unknown status, was the main outcome measure.

RESULTS

Overall, a significance difference in mean transmission risk acts was shown between the intervention and control arms over 5 to 25 months (chi2 = 16.0, degrees of freedom = 5; P = 0.007). The greatest reduction occurred at the 20-month follow-up, with a 36% reduction in the intervention group compared with the control group.

CONCLUSION

Cognitive behavioral intervention programs can effectively reduce the potential of HIV transmission to others among PLH who report significant transmission risk behavior.

Alcohol consumption, ART usage and high-risk sex among women infected with HIV

We examine the role of alcohol consumption on sexual risk behavior among a cohort of 187 sexually active HIV-infected women (aged 18-61) in care at an urban ambulatory clinic in New Orleans, Louisiana, U.S. Sexual risk behavior among women on and off antiretroviral therapy (ART) and the relationship between alcohol use, ART, and behavior was also explored. One-fourth of respondents were classified as binge drinkers and the average number of drinking occasions per week ranged from none to 10-12. Approximately 60% were prescribed ART and self-reported adherence was 90%. One-third of the women reported no condom use at last vaginal sex, 62% reported inconsistent condom use for vaginal sex, and 7% had multiple male sex partners in the last month. Binge alcohol users and women on ART were significantly more likely to participate in each sexual risk outcome examined. Partner refusal of condom use was also significantly associated with binge drinking patterns. Results lend strength to the equivocal literature on the relationship between both alcohol and prescription of ART and sexual behavior. Enhanced detection of alcohol abuse, coupled with risk reduction counseling especially among women prescribed ART are important clinical practices in treating women with HIV.

Oral contraception and unprotected sex with occasional partners of women HIV-infected through injection drug use

Among HIV-infected women, unprotected sex with the main sexual partner is common practice. Conversely, studies about condom use with sexual partners of unknown HIV sero-status are sparsely reported. We aimed to assess the impact of oral contraception on unsafe sexual behaviours with occasional partners in women HIV-infected through injection drug use. The analysis focused on 90 women, enrolled in the French cohort MANIF 2000 and reported having engaged in sexual relationships with occasional partners during a 48-month period. Visits where women reported unprotected sex with occasional partners in the prior 6 months were compared to visits where they reported protected sex using a logistic model based on Generalised Estimating Equations. Unprotected sex with occasional partners was independently associated with oral contraception (OR[95%CI] = 3.2[1.4-7.2]), reporting only one occasional partner (OR[95%CI] = 3.1[1.6-6.2]) and antiretroviral treatment receipt. No significant association was found between unprotected sex and CD4 level or plasma viral load. With the growing population of people living with HIV as a chronic infection, the development and evaluation of HIV-prevention interventions tailored toward women remain a public health priority. Risk reduction counselling and interventions are needed to promote either the use of dual contraception or, alternatively, that of female condom.

Communication of HIV viral load to guide sexual risk decisions with serodiscordant partners among San Francisco men who have sex with men

The objective of this study was to estimate frequency and correlates of discussing HIV viral load (VL) with serodiscordant sex partners to guide decisions about sexual activities among men who have sex with men (MSM). We conducted a cross-sectional survey of 573 San Francisco MSM. Among 507 who knew their HIV status, 397 (78%) were familiar with the term 'viral load', and half (n=199) had a serodiscordant partner in the prior year. These 199 respondents (n=130 [65%] HIV-positive; n=69 [35%] HIV-negative) were the focus of this analysis. A majority (n=111, 56%) discussed VL in the prior year with serodiscordant partners specifically to guide decisions about sexual risk behaviour. Discussion was more common among HIV-positive than HIV-negative participants (adjusted odds ratio [AOR], 3.5; 95% confidence interval [CI], 1.6-7.6), and African Americans compared to whites (AOR, 3.7; 95% CI, 1.5-9.5). HIV-negative men who discussed VL were more concerned about becoming infected, but also more willing to engage in risky behaviour with a partner whose VL is undetectable, than men not discussing VL. Some HIV-negative men may be discussing VL to engage in higher risk behaviour upon learning of an HIV-positive partner's undetectable VL. Interventions targeting MSM should explain that while risk of transmission is likely reduced with a low blood plasma VL, it is not necessarily eliminated.

Intoxication before intercourse and risky sexual behavior in male veterans with and without human immunodeficiency virus infection

BACKGROUND

Male veterans represent a large population at risk for acquiring or transmitting human immunodeficiency virus (HIV) infection. We sought to determine the prevalence of risky sexual behavior among veterans with and without HIV infection and to assess the relationship of intoxication before intercourse and other measures of drug and alcohol use to risky sexual behavior in this population.

METHODS

We analyzed baseline data on 1009 HIV-positive (mean age 49 years) and 710 HIV-negative male veterans (mean age 55 years) who were participating in the Veterans Aging Cohort 5-Site Study (VACS 5). Participants completed a written questionnaire that included measures of alcohol and drug use and risky sexual behavior.

RESULTS

Compared with HIV-negative veterans, HIV-positive veterans were more likely to report 5 or more sexual partners in the past year (14% vs. 4%, P < 0.01), less likely to report not using a condom at last intercourse (25% vs. 75%, P < 0.01), and similarly likely to report having 2 or more partners and inconsistent condom use (10% vs. 10%). Among sexually active HIV-positive veterans, intoxication before intercourse was significantly associated with having 5 or more sexual partners in the past year (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-2.8), inconsistent condom use (OR 1.8, 95% CI 1.2-2.7), and the combined measure of 2 or more partners and inconsistent condom use (OR 1.8, 95% CI 1.1-3.0). Intoxication before intercourse was not significantly associated with these behaviors in HIV-negative veterans, although similar trends were noted.

CONCLUSION

Risky sexual behavior was common among male veterans attending outpatient clinics and is more common among HIV-positive veterans who use alcohol and drugs in sexual situations. Asking HIV-positive men a single question about intoxication before intercourse could help to identify men at increased risk of engaging in risky sexual behavior, and specific advice to avoid intoxication in sexual situations could help to reduce risky sexual behavior.

Commercial sex venues: a closer look at their impact on the syphilis and HIV epidemics among men who have sex with men

OBJECTIVE

To provide insight into the role of commercial sex venues in the spread of syphilis and HIV among men who have sex with men (MSM).

STUDY

A cross sectional study of 1351 MSM who were diagnosed with early syphilis who did and did not encounter sexual partners at commercial sex venues.

RESULTS

Overall, 26% MSM diagnosed with syphilis had sexual encounters at commercial sex venues. Of these, 74% were HIV positive, 94% reported anonymous sex, and 66% did not use a condom. Compared to those who did not have a sexual encounter at these venues, they were twice as likely to be HIV positive (OR = 1.91, 95% CI 1.36 to 2.68), six times more likely to have anonymous sex (OR = 6.18, 95% CI 3.37 to 11.32), twice as likely not to use condom (OR = 2.02, 95% CI 1.71 to 2.38), and twice as likely to use non-injecting drugs (OR = 1.65, 95% CI 1.21 to 2.37).

CONCLUSIONS

MSM diagnosed with syphilis who frequent commercial sex venues are engaging in high risk behaviours for syphilis and HIV transmission and acquisition. Thus commercial sex venues are one of the focal points of syphilis and HIV transmission and acquisition.

Analysis of the influence of therapy and viral suppression on high-risk sexual behaviour and sexually transmitted infections among patients infected with human immunodeficiency virus in Taiwan

This study examined the effects of certain characteristics of human immunodeficiency virus (HIV)-infected patients related to the risks of practising unprotected sex (UPS) among 919 HIV-infected patients who attended the sexually transmitted disease (STD) clinic of the Taipei City STD Control Center, Taiwan, during the period January-July 2004. After learning that they were HIV-positive, 517 (56%) subjects had practised UPS, 476 (52%) had a new STD diagnosis, and 106 (12%) had used some form of injected drug. UPS was reported by 76% of homosexual/bisexual males, 19% of heterosexual males and 5% of females, and was reported more often by those individuals with casual sexual partners (p < 0.001). According to multivariate logistic regression analyses, UPS was associated with male-to-male sexual intercourse (OR 2.46; 95% CI 1.26-4.86, p < 0.001), with casual sexual partners (OR 2.82; 95% CI 1.62-4.88, p < 0.001), and with an individual's knowledge of his/her HIV status for > 11 years (OR 2.06; 95% CI 1.02-4.18, p < 0.05). Although using anti-retroviral therapy to prevent sexual transmission of HIV is rational, the avoidance of at-risk sexual behaviour should also be a priority among HIV-seropositive individuals. Ongoing risk-reduction counselling related to HIV transmission is needed to reduce certain sexual behaviours associated with HIV transmission.

Acceptability of male circumcision for prevention of HIV infection in Malawi

Numerous epidemiological and biological studies report male circumcision (MC) to have a significant protective effect against HIV-1 acquisition. This study assesses the acceptability of MC in four districts in Malawi, a country with high HIV-1 prevalence and low prevalence of MC. Thirty-two focus group discussions were conducted with 159 men and 159 women ages 16-80 years. Acceptability was lower in the north where the practice was little known, higher in younger participants and higher in central and southern districts where MC is practiced by a minority Muslim group (Yao). Barriers to circumcision included fear of infection and bleeding, cost, and pain. Facilitators included hygiene, reduced risk of STI, religion, medical conditions, and enhanced sexual pleasure. If MC services are introduced in Malawi, acceptance is likely to vary by region, but many parents and young men would use the services if they were safe, affordable and confidential.

Sexually Transmitted Infection Services as a Component of HIV Care

OBJECTIVES

As Thailand scales up its antiretroviral treatment program, the role of sexually transmitted infection (STI) services to prevent HIV transmission has not been addressed. We provided STI services for HIV-infected women as a component of HIV care and assessed STI prevalence and risk behaviors.

METHODS

HIV-infected women attending an infectious disease clinic and an STI clinic in Bangkok were screened for the presence of genital ulcers by visual inspection, for gonorrhea and chlamydial infection by polymerase chain reaction, for trichomoniasis by wet mount, and for syphilis by serology. Women were asked about sexual risk behavior and use of antiretroviral treatment. Risk-reduction counseling, condoms, and STI treatment were provided.

RESULTS

Two-hundred ten HIV-infected women at an infectious disease clinic (n = 150) and an STI clinic (n = 60) received STI services from July 2003 through February 2004. The prevalence for any STI was 8.0% at the infectious disease clinic and 30.0% at the STI clinic (P < 0.01). Of the 116 (55.2%) sexually active women, 42 (36.2%) reported sex without a condom during the last 3 months. Women receiving antiretroviral treatment reported condom use during last sex more often compared with those not receiving antiretroviral treatment (82.2% vs. 58.8%; P = 0.03).

CONCLUSION

STIs and sexual risk behavior were common among these HIV-infected women, and STI services for HIV-infected persons have been expanded to more clinics in Thailand. Further analysis of HIV transmission risk is necessary for developing a national strategy for prevention of HIV transmission among HIV-infected persons.

Risk factors for HIV infection among men who have sex with men

OBJECTIVES

Risk factors for HIV acquisition were examined in a recent cohort of men who have sex with men (MSM).

DESIGN

A longitudinal analysis of 4295 HIV-negative MSM enrolled in a randomized behavioral intervention trial conducted in six US cities.

METHODS

MSM were enrolled and assessed for HIV infection and risk behaviors semi-annually, up to 48 months.

RESULTS

In multivariate analysis, men reporting four or more male sex partners, unprotected receptive anal intercourse with any HIV serostatus partners and unprotected insertive anal intercourse with HIV-positive partners were at increased risk of HIV infection, as were those reporting amphetamine or heavy alcohol use and alcohol or drug use before sex. Some depression symptoms and occurrence of gonorrhea also were independently associated with HIV infection. The attributable fractions of high number of male partners, use of alcohol or drugs before sex, and unprotected receptive anal intercourse with unknown status partners and the same with presumed negative partners accounted for 32.3, 29.0, 28.4 and 21.6% of infections, respectively.

CONCLUSIONS

The challenge is to develop strategies to identify men in need. Interventions are needed to help men reduce their number of sexual partners, occurrences of unprotected anal intercourse, alcohol or drug use before sex and address other mental health issues.

Revisiting the ABC strategy: HIV prevention in Uganda in the era of antiretroviral therapy

The ABC strategy is credited for bringing the HIV/AIDS epidemic under control in Uganda. By promoting abstinence, being faithful, and condom use, safe(r) behaviours have been identified that are applicable to people in different circumstances. However, scaling-up of antiretroviral therapy in the country raised concerns that HIV prevention messages targeting the uninfected population are not taking sufficient account of inherent complexities. Furthermore, there is debate in the country over relative importance of abstinence in reduction of HIV incidence as well as over the morality and effectiveness of condoms. The purpose of this paper is to examine each component of ABC in light of current developments. It is argued that there is still a strong justification for condom use to complement abstinence and being faithful. There is an urgent need to update and relaunch Uganda's ABC strategy--its three elements are complementary, synergistic, and inseparable in the national HIV prevention programme.

Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda

BACKGROUND

The impact of antiretroviral therapy (ART) on sexual risk behavior and HIV transmission among HIV-infected persons in Africa is unknown.

OBJECTIVE

To assess changes in risky sexual behavior and estimated HIV transmission from HIV-infected adults after 6 months of ART.

DESIGN AND METHODS

A prospective cohort study was performed in rural Uganda. Between May 2003 and December 2004 a total of 926 HIV-infected adults were enrolled and followed in a home-based ART program that included prevention counselling, voluntary counseling and testing (VCT) for cohabitating partners and condom provision. At baseline and follow-up, participants' HIV plasma viral load and partner-specific sexual behaviors were assessed. Risky sex was defined as inconsistent or no condom use with partners of HIV-negative or unknown serostatus in the previous 3 months. The rates of risky sex were compared using a Poisson regression model and transmission risk per partner was estimated, based on established viral load-specific transmission rates.

RESULTS

Six months after initiating ART, risky sexual behavior reduced by 70% [adjusted risk ratio, 0.3; 95% confidence interval (CI), 0.2-0.7; P = 0.0017]. Over 85% of risky sexual acts occurred within married couples. At baseline, median viral load among those reporting risky sex was 122 500 copies/ml, and at follow-up, < 50 copies/ml. Estimated risk of HIV transmission from cohort members declined by 98%, from 45.7 to 0.9 per 1000 person years.

CONCLUSIONS

Providing ART, prevention counseling, and partner VCT was associated with reduced sexual risk behavior and estimated risk of HIV transmission among HIV-infected Ugandan adults during the first 6 months of therapy. Integrated ART and prevention programs may reduce HIV transmission in Africa.

The Public Health Response to Epidemic Syphilis, San Francisco, 1999–2004

In 1999, the Centers for Disease Control and Prevention launched the National Plan to Eliminate Syphilis. From 1999 to 2003 in San Francisco, early syphilis was epidemic, increasing from 44 cases to 522 cases a year. Syphilis cases were more likely to be in gay or bisexual men, those with human immunodeficiency virus (HIV) infection, those who had anonymous partners, and those who met sex partners on the Internet. Increases in sexual activity and sexual risk behavior in men who have sex with men during this period have been attributed to the improved physical health of HIV-infected men on highly active antiretroviral therapy, HIV treatment optimism, increases in methamphetamine use, and the use of Viagra. The San Francisco Department of Public Health's response to the epidemic included enhanced surveillance, expanded clinical and testing services, provider and community mobilization and sexual health education, and risk factor identification and abatement through investigations, public health advocacy, and treatment. Collaborations with community-based organizations and local businesses were key to the successful implementation of disease-control efforts. A multitude of converging risk factors and new environments contributed to the syphilis epidemic, requiring a comprehensive, innovative, and flexible disease-control strategy.

Predictors of serostatus disclosure to partners among young people living with HIV in the pre- and post-HAART eras

Predictors of serostatus disclosure were identified among youth living with HIV pre- and post-introduction of highly active antiretroviral therapy (HAART). Two cohorts of HIV-positive youth, aged 13-24, in 1994-1996 (n = 351) and 1999-2000 (n = 253) in Los Angeles, New York, San Francisco, and Miami were sampled through medical providers and a variety of social service agencies. Data were collected on demographic, social, medical, and behavioral topics. Men who had sex with men were more likely to disclose serostatus to their partners. Moreover, a positive association with length of time since diagnosis and the likelihood of disclosure exists; across time, youth were less likely to disclose serostatus to casual partners or HIV-negative partners. Post-HAART, number of sex acts with a partner was associated with increased likelihood of disclosure. Interventions for HIV-positive youth must improve disclosure to casual and serodiscordant sexual partners.

Sexually transmitted disease testing protocols, sexually transmitted disease testing, and discussion of sexual behaviors in HIV clinics in Los Angeles County

OBJECTIVE/GOAL

The objective of this study was to evaluate the use of written protocols for sexually transmitted disease (STD) screening, the frequency and types of STD tests performed, and the occurrence and frequency of obtaining sexual risk assessments among HIV clinics.

STUDY

A survey was administered to 36 medical directors, clinic directors, and HIV providers representing 48 HIV healthcare clinics in Los Angeles.

RESULTS

The use of a written or electronic protocol for STD testing was reported by 50% of clinics. Clinics with written or electronic STD protocols were significantly more likely to report questioning patients at each visit regarding their sexual practices (prevalence ratio, 2.2; 95% confidence interval, 1.4-3.4). Clinics with written or electronic protocols were not more likely to report more frequent STD testing.

CONCLUSIONS

Written or electronic protocols for STD testing may promote sexual risk assessment questioning among HIV healthcare providers and may help to ensure STD testing per Centers for Disease Control and Prevention/IDSA guidelines for HIV-positive persons at sexual risk.

Syphilis, chlamydia, and gonorrhea screening in HIV-infected patients in primary care, San Francisco, California, 2003

The Centers for Disease Control (CDC) recommends sexually transmitted disease (STD) screening among HIV-infected persons in order to reduce HIV transmission. We evaluated the results of routine screening for syphilis and for urogenital, pharyngeal, and rectal gonorrhea (GC) and chlamydia (CT) among asymptomatic HIV-infected patients at an HIV primary care clinic in San Francisco, California. We found 15 new syphilis infections of 814 tested (1.8%) and 60 new cases of CT or GC infection of 586 tested (10.2%), with 88% of GC and CT infections occurring at nonurethral sites. Our study reveals a high rate of asymptomatic STDs among HIV-infected patients in primary care and supports the CDC recommendations to screen HIV-infected patients for STDs at all relevant anatomic sites.

Social Marketing Campaign Significantly Associated With Increases in Syphilis Testing Among Gay and Bisexual Men in San Francisco

BACKGROUND

Between 1999 and 2002, San Francisco experienced a sharp increase in early syphilis among gay and bisexual men. In response, the San Francisco Department of Public Health launched a social marketing campaign to increase testing for syphilis, and awareness and knowledge about syphilis among gay and bisexual men.

METHODS

A convenience sample of 244 gay and bisexual men (18-60 years of age) were surveyed to evaluate the effectiveness of the campaign. Respondents were interviewed to elicit unaided and aided awareness about the campaign, knowledge about syphilis, recent sexual behaviors, and syphilis testing behavior.

RESULTS

After controlling for other potential confounders, unaided campaign awareness was a significant correlate of having a syphilis test in the last 6 months (odds ratio, 3.21; 95% confidence interval, 1.30-7.97) compared with no awareness of the campaign. A comparison of respondents aware of the campaign with those not aware also revealed significant increases in awareness and knowledge about syphilis.

CONCLUSIONS

The Healthy Penis 2002 campaign achieved its primary objective of increasing syphilis testing, and awareness and knowledge about syphilis among gay and bisexual men in San Francisco.

Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya

Numerous epidemiologic studies report significant associations between lack of male circumcision and HIV-1 infection, leading some to suggest that male circumcision be added to the limited armamentarium of HIV prevention strategies in areas where HIV prevalence is high and the mode of transmission is primarily heterosexual. This cross-sectional survey of 107 men and 110 women in Nyanza Province, Kenya, assesses the attitudes, beliefs, and predictors of circumcision preference among men and women in a traditionally non-circumcising region. Sixty per cent (n=64) of uncircumcised men and 69% (n=68) of women who had uncircumcised regular partners reported that they would prefer to be circumcised or their partners to be circumcised. Men's circumcision preference was associated with the belief that it is easier for uncircumcised men to get penile cancer, sexually transmitted diseases, and HIV/AIDS, and that circumcised men have more feeling in their penises, enjoy sex more, and confer more pleasure to their partners. Women with nine or more years of school were more likely to prefer circumcised partners. Men who preferred to remain uncircumcised were concerned about the pain and cost of the procedure, and pain was a significant deterrent for women to agree to circumcision for their sons. If clinical trials prove circumcision to be efficacious in reducing risk of HIV infection, it is likely that the procedure will be sought by a significant proportion of the population, especially if it is affordable and minimally painful.

Estimates of Primary and Secondary Syphilis Rates in Persons With HIV in the United States, 2002

BACKGROUND

In the United States, there is a high rate of HIV coinfection in persons with syphilis.

GOAL

The goal of this study was to estimate the rate of primary and secondary (P&S) syphilis in persons living with HIV in the United States in 2002.

STUDY

We approximated the number of new cases of P&S syphilis in HIV-infected persons and divided this by the estimated number of persons living with HIV. Values for the calculations were obtained from national syphilis and HIV/AIDS surveillance reports and other published sources.

RESULTS

We estimated the rate of new cases of P&S syphilis at 186 per 100,000 persons living with HIV in 2002, 25 per 100,000 HIV-infected women, 60 per 100,000 HIV-infected men who have sex with women only, and 336 per 100,000 HIV-infected men who have sex with men. Of the 6862 reported cases of P&S syphilis in 2002, an estimated 1718 (25%) occurred in persons coinfected with HIV.

CONCLUSIONS

The estimated rate of P&S syphilis in persons with HIV is considerably higher than that of the general population. These findings highlight the importance of providing sexually transmitted disease prevention and control services to HIV-infected persons.

Cost-effectiveness of a behavioral intervention for seropositive youth

An intervention for young people living with HIV (YPLH) was effective in reducing the number of partners of unknown serostatus and the number of unprotected sexual risk acts. In this article, we outline new methods to assess the cost-effectiveness of this intervention. Over a period of 3 months, the intervention would avert an estimated 2.02 new infections per 1,000 YPLH. The cost of mounting the intervention was estimated at US 522 dollars/YPLH, with the cost-effectiveness over a 1-year period being US 103,366 dollars/infection averted. Based on standardized estimates of the cost of treating HIV-positive persons and the adjusted quality of life years lost (10.23 for partners of a mean age of 29 years), the cost utility estimate shows that the treatment costs averted exceed the cost of the intervention. Both the methodology of calculating cost-effectiveness and the cost utility of interventions are important for focusing policy makers, clinicians, community providers, and researchers on prevention for persons living with HIV.

Risk behaviors of youth living with HIV: pre- and post-HAART

OBJECTIVE

To examine the transmission behavior among youth living with HIV (YLH), pre- and post-HAART.

METHODS

Two cohorts were recruited: (1) 349 YLH during 1994 to 1996 and (2) 175 YLH during 1999 to 2000, after the wide availability of HAART. Differences in sexual and substance-use risk acts and quality of life were examined.

RESULTS

Post-HAART YLH were more likely to engage in unprotected sex and substance use, to be more emotionally distressed, and to have lower quality of life than were pre-HAART YLH.

CONCLUSIONS

Targeted interventions for YLH that address reductions in transmission acts and aim to improve quality of life are still needed.

The antiretroviral rollout and drug-resistant HIV in Africa: insights from empirical data and theoretical models

The U.S. Government has pledged to spend $15 billion in Africa and the Caribbean on AIDS. A central focus of this plan is to provide antiretroviral treatment (ART) to millions. Here, we evaluate whether the plan to rollout ART in Africa is likely to generate an epidemic of drug-resistant strains of HIV. We review what has occurred as a result of high usage of ART in developed countries in terms of changes in risky behavior, and the emergence and transmission of drug-resistant HIV. We also review how mathematical models have been used to predict the evolution of drug-resistant HIV epidemics. We then show how models can be used to predict the likely impact of the ART rollout on the evolution of drug-resistant HIV in Africa. At currently planned levels of treatment coverage, we predict that (over the next decade) in Africa: (i) the impact of ART on reducing HIV transmission (and prevalence) is likely to be undetectable (unless accompanied by substantial changes in behavior), (ii) the transmission rate of drug-resistant HIV will be below the WHO surveillance threshold of 5%, and (ii) the majority of cases of drug-resistant HIV that will occur will be due to acquired (and not transmitted) resistance. For the next decade, large-scale surveillance for detecting transmitted resistance in Africa is unnecessary. Instead, we recommend that patients should be closely monitored for acquired resistance, and sentinel surveillance (in a few urban centers) should be used to monitor transmitted resistance.

Challenges for HIV vaccine dissemination and clinical trial recruitment: if we build it, will they come?

HIV vaccine availability does not guarantee uptake. Given suboptimal uptake of highly efficacious and already accessible vaccines in the United States, low vaccine coverage in the developing world, and the expectation that initial HIV vaccines will be only partially efficacious, the public health community will face formidable challenges in disseminating U.S. Food and Drug Administration (FDA)-approved HIV vaccines. HIV/AIDS stigma, fear of vaccine- induced HIV infection, social side effects of testing HIV-positive, and mistrust of government and research present additional obstacles to HIV vaccine dissemination. Increased risk behaviors because of HIV vaccine availability can undermine the effectiveness of partially efficacious vaccines in reducing HIV incidence. HIV vaccine efficacy trials also face significant challenges in recruitment of sufficient volunteers and possible increases in risk behaviors due to trial participation. Planning and designing interventions to facilitate successful recruitment for large-scale phase 3 efficacy trials is a vital step towards U.S. FDA-approved HIV vaccines. Rather than despair in the face of momentous HIV vaccine dissemination challenges, or presume unrealistically that vaccine uptake will ensue automatically and that risk behavior increases will not occur, let us deem the estimated 10-year window to an approved HIV vaccine as an opportunity to investigate and confront these challenges. A consumer research agenda founded on social marketing principles is needed to facilitate the design of empirically-based interventions tailored to the unique needs and preferences of specific segments of consumers. Social marketing interventions may increase future HIV vaccine uptake and clinical trial participation, and mitigate increases in HIV risk behaviors.

Crystal methamphetamine use predicts incident STD infection among men who have sex with men recruited online: a nested case-control study

BACKGROUND

Among men who have sex with men (MSM), the number of newly diagnosed human immunodeficiency virus (HIV) infections has increased by approximately 60% since 1999. Factors that may be contributing to this resurgence include a widely reported increase in bacterial sexually transmitted diseases (STDs) among HIV-positive and HIV-negative MSM, as well as unsafe sexual practices.

OBJECTIVE

This research was undertaken to learn more about risk behaviors associated with an incident STD among MSM.

METHODS

A nested case-control study was conducted, using data from a cross-sectional Internet survey of MSM (N=2643), which investigated risk behaviors during a 6-month period in 2001. Chi-square and logistic regression methods were used to estimate the likelihood of acquiring an incident STD versus no STD.

RESULTS

Eighty-five percent of the respondents were white, 46% were under age 30, and 80% had met sex partners online; 7% were HIV-positive. Men with an incident STD were more likely than men without an STD to report drug use (crystal methamphetamine odds ratio 3.8; 95% confidence interval 2.1-6.7; cocaine OR 2.3; 95% CI 1.2-4.2; ecstasy OR 2.2; 95% CI 1.3-3.8; Viagra OR 2.1; 95% CI 1.2-3.7), alcohol before or during sex (OR 1.9; 95% CI 1.2-2.9), and high-risk sexual behavior (unprotected anal intercourse OR 5.0; 95% CI 2.8-8.9; multiple sex partners OR 5.9; 95% CI 2.5-13.8). In the multivariate analysis, significant independent predictors associated with an incident STD were crystal methamphetamine use (adjusted OR 2.0; 95% CI 1.1-3.8), unprotected anal intercourse (adjusted OR 3.4; 95% CI 1.9-6.3), and 6 or more sex partners during the study period (adjusted OR 3.3; 95% CI 1.4-7.8).

CONCLUSION

Identifying and treating MSM who have STDs, or who are at increased risk for acquiring STDs, is crucial in preventing the further spread of disease. In addition, there is a need to integrate HIV/STD and substance use prevention and education into Web-based and community-based venues.

A Case–Control Study of Syphilis Among Men Who Have Sex With Men in New York City

OBJECTIVE

The objective of this study was to determine factors associated with syphilis among men who report sex with other men in New York City. DESIGN, SETTING AND STUDY SUBJECTS: We conducted a case-control study among 88 men who reported sex with men in the previous year, 18 to 55 years old and diagnosed with primary or secondary syphilis during 2001; and 176 control subjects frequently matched by age and type of health provider.

RESULTS

HIV prevalence among syphilis cases was 48% compared with 15% among control subjects (P <0.001). Variables associated with syphilis in a multivariate model were HIV infection (odds ratio [OR], 7.3; 95% confidence interval [CI], 3.5-15.4), income >$30,000 per year (OR, 2.7; CI, 1.4-5.2), and barebacking (OR, 2.6; CI, 1.4-4.8). The median time since HIV diagnosis for HIV-positive was 6 years for cases and 7 years for control subjects (P = 0.70). Among HIV-infected participants, syphilis cases were more likely than control subjects to report being on antiretroviral therapy (69% vs. 44%, P = 0.05) and to report having undetectable viral load (58% vs. 24%, P = 0.02).

CONCLUSION

HIV infection was strongly associated with syphilis in this study. High-risk behavior reported by both cases and control subjects indicates the potential for increased HIV transmission.

Perceived viral load, but not actual HIV-1-RNA load, is associated with sexual risk behaviour among HIV-infected homosexual men

BACKGROUND

Increases in sexual risk behaviour and sexually transmitted infections among HIV-infected homosexual men after the introduction of highly active antiretroviral therapy (HAART) confirm the need for innovative prevention activities. The present study focused on time trends in sexual risk behaviour and predictors for unprotected anal intercourse in the HAART era among HIV-infected homosexual men.

METHODS

In 2000-2003, 57 HIV-infected homosexual men (mean age 45 years) were interviewed in three serial data waves. Logistic regression, correcting for repeated measurements, was used to assess time trends in risky sex, and the association between HAART-related beliefs, and both the perceived and actual viral load level and CD4 cell counts and subsequent risky sex.

RESULTS

Risky sex with casual partners increased from 10.5% in 2000 to 27.8% in 2003 (P < 0.01), and with steady partners of negative or unknown HIV status from 5.3% to 10.7% (P = 0.6). Homosexual men with a favourable perception of their viral load were more likely to engage in subsequent risky sex with steady partners of negative or unknown HIV status than men with a less favourable perception of their viral load; this association was independent of the actual HIV-1-RNA load and CD4 cell counts.

CONCLUSION

Risky sex increased in this group of HIV-infected homosexual men. The perceived viral load, but not the actual load, is associated with subsequent risky sex with steady partners of negative or unknown HIV status. Care givers should discuss with patients not only their actual viral load and CD4 cell count but also their perceived viral load.

Perfil epidemiológico dos usuários de um Centro de Testagem e Aconselhamento para DST/HIV da Rede Municipal de São Paulo, com sorologia positiva para o HIV

Centros de Testagem e Aconselhamento em DST/HIV (CTA) oferecem, entre outras atividades, a realização de testes sorológicos anti-HIV e VDRL. Estes serviços dispõem de coleta sistemática de dados permitindo conhecer o perfil epidemiológico dos indivíduos infectados. O presente estudo descreve o perfil epidemiológico das pessoas com sorologia positiva que utilizaram um dos maiores CTA do país, durante os anos de 2001 e 2002. Foram utilizados dados de sorologia positiva e das entrevistas (pré e pós teste) realizadas de rotina. Obsevou-se 470 (4%) resultados positivos entre 10657 testes sorológicos realizados, sendo que grande parte (81,4%) dos usuários com sorologia positiva são do sexo masculino. A idade média dos indivíduos estudados foi 32,3 anos, sem diferencial para sexo (p=0,968); 75% trabalham; 41% dos usuários do sexo feminino e 77% do sexo masculino são solteiros (p<0,001); 43% possuem segundo grau (completo e incompleto). Quanto à categoria de exposição, 36% são homossexuais, 34% são heterossexuais e 27% bissexuais. Alto percentual refere ter parceiros múltiplos (82%); 32% referem utilizar preservativo sempre.

Is unsafe sexual behaviour increasing among HIV-infected individuals?

BACKGROUND

The number of new diagnoses of HIV infection is rising in the northwestern hemisphere and it is becoming increasingly important to understand the mechanisms behind this trend.

OBJECTIVE

To evaluate whether reported unsafe sexual behaviour among HIV- infected individuals is changing over time.

DESIGN

Participants in the Swiss HIV Cohort Study were asked about their sexual practices every 6 months for 3 years during regular follow-up of the cohort beginning on 1 April 2000.

METHODS

: Logistic regression models were fit using generalized estimating equations assuming a constant correlation between responses from the same individual.

RESULTS

At least one sexual behaviour questionnaire was obtained for 6545 HIV-infected individuals and the median number of questionnaires completed per individual was five. There was no evidence of an increase in reported unsafe sex over time in this population [odds ratio (OR), 1.0; 95% confidence interval (CI), 0.96-1.05]. Females (OR, 1.38; 95% CI, 1.19-1.60), 15-30 year olds (OR, 1.26; 95% CI, 1.09-1.47), those with HIV-positive partners (OR, 12.58; 95% CI, 10.84-14.07) and those with occasional partners (OR, 3.25; 95% CI, 2.87-3.67) were more likely to report unsafe sex. There was no evidence of a response bias over time, but individuals were less willing to leave questions about their sexual behaviour unanswered or ambiguous (OR, 0.93; 95% CI, 0.90-0.97).

CONCLUSIONS

There was no evidence of a trend in unsafe sex behaviour over time. However, several subgroups were identified as being more likely to report unsafe sex and should be targeted for specific interventions.

Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study

BACKGROUND

Effective interventions are needed to prevent acquisition of HIV infection in men who have sex with men. To date, no behavioural interventions specifically for this risk group have been tested with HIV infection as the primary outcome.

METHODS

This multisite two-group randomised controlled phase IIb trial tested the efficacy of a behavioural intervention in preventing HIV infection among 4295 men who have sex with men. The experimental intervention consisted of ten one-on-one counselling sessions followed by maintenance sessions every 3 months. The standard condition was twice-yearly Project RESPECT individual counselling. Twice-yearly follow-up visits included testing for HIV antibody and assessment of behavioural outcomes.

FINDINGS

The rate of acquisition of HIV infection was 18.2% (95% CI -4.7 to 36.0) lower in the intervention group than the standard group. Adjustment for baseline covariates attenuated the intervention effect to 15.7% (-8.4 to 34.4). The effect was more favourable in the first 12-18 months of follow-up. The occurrence of unprotected receptive anal intercourse with HIV-positive and unknown-status partners was 20.5% (10.9 to 29.0) lower in the intervention than in the standard group.

INTERPRETATION

The results from the primary analyses allow us to rule out that the experimental intervention is associated with a 35% lower rate of HIV acquisition than in the standard group. The overall estimate of a difference of 18.2%, more favourable estimates of effect in the first 12-18 months, and similar effects on risk behaviours suggest that prevention of HIV infection among men who have sex with men by a behavioural intervention is feasible. Further work should be done to develop more effective interventions.

Impact of HAART-related side effects on unsafe sexual behaviours in HIV-infected injecting drug users: 7-year follow up

OBJECTIVE

To investigate the impact of non-lipodystrophy HAART-related side effects on unprotected sexual behaviours among HIV-infected drug users. DESIGNAND PARTICIPANTS: HAART-treated patients who reported having occasional partners during the follow-up period after HAART initiation were selected among patients of the MANIF 2000 cohort of HIV-infected drug users.

METHODS

Visits where patients reported unsafe sexual behaviours with occasional partners were compared to visits where they reported safe sexual behaviours using a logistic model based on Generalized Estimating Equations.

RESULTS

One-hundred and ninety-two HAART-treated patients reported occasional sexual partners at least once during follow-up, accounting for a total of 464 visits. Among these 192 patients, 134 (70%) declared at least once unsafe sexual behaviours with occasional partners. During follow-up, three or more HAART-related side effects were reported in 273 of the 464 visits. When comparing visits where patients reported unsafe sexual behaviours with occasional partners (n = 249) with those where they reported safe sexual behaviours (n = 215), experiencing three or more HAART-related side effects was significantly associated with unsafe sex after adjustment for cofactors such as injecting drug status, reporting more than two sexual partners and having sex more than once a week.

CONCLUSIONS

Perceived side effects play a role in determining unsafe sexual behaviours. HIV prevention interventions must consider the negative impact of HAART-related side effects on sexual risk-taking behaviours. Drug maintenance programs contribute to sexual risk reduction among drug injecting patients.

HIV risk and prevention in a post-vaccine context

Initial HIV vaccines are likely to be only partially efficacious; increased risk behaviors in response to future HIV vaccine availability have the potential to subvert the effectiveness of vaccines in controlling the AIDS epidemic. To assess attitudes, beliefs and behavioral intentions in response to hypothetical availability of FDA-approved HIV vaccines, we conducted 9 focus groups among participants (N = 99; median age = 33 years; 48% female; 22% African American, 44% Latino, 28% White) recruited from STD clinics, needle exchange programs, and Latino community based health organizations, using purposive, venue-based sampling, and interviewed 9 key informant service providers. Data were analyzed using narrative thematic analysis and Ethnograph qualitative software. Participants predicted a "lightening up" of safer sex behaviors among at least half of their peers and, to a lesser extent, a relaxing of safer needle use practices in response to HIV vaccine availability. Both participants and providers urged HIV preventive interventions that: (1) provide education and awareness regarding partial efficacy vaccines, (2) combat the belief in an HIV vaccine as a "magic bullet," and (3) stressed the need for sustained behavioral risk reduction interventions in the face of continued HIV risk and other STDs.

Importance of Sex Partner HIV Status in HIV Risk Assessment Among Men Who have Sex With Men

Clinical HIV risk assessments have not typically integrated questions about sex partners' HIV status with questions about condom use and type of sex. Since 2001, we have asked all men who have sex with men (MSM) evaluated in an urban sexually transmitted disease (STD) clinic how often in the preceding 12 months they used condoms for anal sex with partners who were HIV-positive, HIV-negative, and of unknown HIV status. Overall, MSM displayed a pattern of assortative mixing by HIV status, particularly for unprotected anal intercourse (UAI). Nevertheless, 433 (27%) of 1580 MSM who denied knowing they were HIV-positive and 93 (43%) of 217 HIV-positive MSM reported having UAI with a partner of opposite or unknown HIV status. Among men who denied previously knowing they were HIV-positive, 24 (9.6%) of 251 MSM who reported having UAI with an HIV-positive partner or partner of unknown HIV status compared with 11 (1.7%) of 620 MSM who denied such exposure tested HIV-positive (odds ratio=5.8, 95% confidence interval: 2.8-12.1). UAI with an HIV-positive partner or partner with unknown HIV status was 69% sensitive and 73% specific in identifying men with previously undiagnosed HIV infection; UAI regardless of partner HIV status was 80% sensitive but only 45% specific. The positive predictive value was highest for risk assessments that included partner HIV status. Integrating questions about anal sex partner HIV status and condom use identifies MSM at greatest risk for HIV acquisition and transmission. These risk criteria might be effectively used to triage MSM into more intensive prevention interventions.

Transmission of HIV-1 drug resistance

BACKGROUND

The use of highly-active anti-retroviral therapy (HAART) for treating HIV infections is increasing. Recent studies have demonstrated that HAART is improving both the length and quality of life in HIV-infected patients. Resistant strains of HIV arise when drug adherence is poor. This can lead to the transmission of drug-resistant strains of HIV to susceptible individuals. This can lead to suboptimal first-line therapy, if the resistance profile of the transmitted virus is unknown.

OBJECTIVES

To review the mechanisms of how drug resistance arises; the methods used to characterise drug resistance; the problems arising with compliance leading to the development of drug-resistant HIV strains; the evidence for the incidence, prevalence and trends in the transmission of resistant HIV strains in different risk groups; and the evidence of suboptimal response to first-line therapy where transmission of a resistant HIV strain has occurred. On the basis of this, a case is presented for the routine resistance testing of all newly diagnosed HIV-infected individuals.

STUDY DESIGN

Literature review.

RESULTS AND CONCLUSIONS

There is evidence, though limited at present, that transmission of drug-resistant HIV strains can lead to suboptimal response to first-line therapy in newly diagnosed HIV-infected individuals. As the use of HAART can only increase in the future, and compliance will always be a problem in such HAART-treated patients, baseline resistance testing should become a routine part of their management.

Justice and HIV care in Africa--antiretrovirals in perspective

The immense burden of HIV disease in sub-Saharan Africa has focused international interest on HIV care, especially on the lack of access to antiretroviral therapy (ART). Difficulties in implementing ART in Africa include drug costs, adequate long-term funding sources, assurance of drug quality, and rapid development of the human resources and healthcare infrastructure needed to deliver ART. Important questions requiring study are the minimum level of laboratory monitoring and clinical support consistent with good treatment outcomes, the impact of antiretroviral drug resistance on treated individuals and communities, and the effect of ART on transmission at a community level. There are some concerns and risks. First, a focus on treatment could compromise the commitment of individuals to risk-reduction, and of governments to prevention. Second, health equity could be reduced, by diverting scarce public funds from basic care for the poorest, to costly disease-suppressive care for a small and probably elite group. In conclusion, while prevention must be the first priority, care is also essential. The vast prevailing economic inequity between the world's rich and poor is the fundamental determinant of inequities in health and healthcare, including care for HIV. The global community of healthcare workers must focus its substantial influence on changing political and economic policies that foster injustice and AIDS.

Gay Asian men in San Francisco follow the international trend: increases in rates of unprotected anal intercourse and sexually transmitted diseases, 1999-2002

Worldwide, studies of men who have sex with men (MSM) report increases in HIV risk-related behavior. Less is known about trends within minority subpopulations of MSM, particularly those of Asian and Pacific Islander (A&PI) ethnicity. A&PI MSM are underrepresented among AIDS cases (2.7%) with respect to their estimated makeup in the gay community of San Francisco (4.5%). However, recent trends in unprotected anal intercourse (UAI) and sexually transmitted diseases suggest a reversal in the relative risk for HIV among A&PI MSM compared with White MSM. Starting from lower levels in 1999, UAI with multiple partners, UAI with multiple partners of unknown HIV serostatus, the incidence of male rectal gonorrhea, and the incidence of early syphilis among A&PI MSM surpassed levels among White MSM by 2002. A window of opportunity to prevent further spread of HIV among A&PI MSM may be closing.

Epidemiología de la infección por el VIH/sida y su relación con otras infecciones de transmisión sexual. Perspectivas de futuro

Over the last decade, different cross-sectional and case-control studies have shown the relationship between HIV and Sexually Transmitted infections (STI). In this sense, different reasons are found: a modification of the clinical manifestations of some STI as well as an increase of HIV infectiousness and susceptibility to HIV. The main objective of HIV/AIDS and STI surveillance includes: to assess its temporal trends, to define high risk groups and high-risk behaviours and to plan and to evaluate public health programmes. Nevertheless, classical surveillance systems are not enough to describe the real situation of HIV/AIDS and STI. Thus, an enhanced surveillance system which includes complementary resources should be implemented.

[Economic and socio-behavioural issues related to highly active antiretroviral therapies for HIV infection: the contribution of social science research]

This article presents a synthesis of the main topics covered by social science research (SSR) on HIV/AIDS, since the advent of highly active antiretroviral therapies (HAART) in 1996. SSR has shown that non-adherence cannot be reliably <<predicted>> on the sole basis of a few a priori patient characteristics that clinicians could easily identify before initiation of HAART, and that a dynamic approach to adherence, continuously monitoring the impact of patients' subjective experience with HAART is needed. In relationship with the evolution of HIV infection toward a <<chronic disease>>, SSR has dealt with the impact of HAART on all aspects of patients' daily lives (from employment and professional status to sexuality). It has also emphasised the potential contradictions between the hopes generated by these cost-effective therapeutic advances, on the one hand, and the high social vulnerability of a growing proportion of people living with HIV-AIDS, on the other hand. Finally, SSR suggests recommendations for <<normalising>> AIDS public policies without losing the potential for innovations that the fight against this epidemic has introduced in health care and <<Social Security>> systems, as well as physician-patient's relationships.

Sexual risk reduction among HIV-positive drug-using men who have sex with men

According to the US Centers for Disease Control, the majority of new HIV infections are the direct result of unprotected sexual relations between serodiscordant individuals. Thus, the development of behavioral interventions to increase the safer sex practices of HIV-positive individuals has the potential to reduce the number of new infections. Currently, less than 1% of the total US population is infected with HIV. Targeting behavioral interventions to this smaller group of HIV-positive individuals has the potential for making cost-effective reductions in the number of new infections. Despite reports that some HIV-positive individuals continue to engage in high-risk behaviors, interventions designed to prevent secondary transmission of HIV are rare. In this era of highly active antiretroviral therapy (HAART), interventions for HIV-positive individuals are more critical than ever to address the unique challenges and issues they face regarding disclosure and partner notification, use of HAART and sexual risk behavior, and HIV-related stigma. Although a growing number of reports document the efficacy of sexual risk reduction interventions for HIV-positive individuals, to date none of these studies have focused on drug-using populations. This article focuses on sexual risk reduction interventions for HIV-positive men who have sex with men (MSM), the largest group of HIV-positive individuals in the United States. It reviews factors associated with high-risk behaviors and discusses some findings from research with HIV-positive methamphetamine users, including (1) data from a small qualitative study and its implications for the development of new interventions, and (2) baseline data from an ongoing large-scale study of the efficacy of a theory-based sexual risk reduction intervention for HIV-positive methamphetamine-using MSM. The article concludes with a discussion of future research issues, including, for example: Can sexual risks be reduced in the context of active drug use? Are different patterns of drug use, or specific drugs, associated with increased risk behavior? How do gender, race, and culture relate to the efficacy of specific interventions?

Attitudes about combination HIV therapies: the next generation of gay men at risk

This study examined awareness of and attitudes about highly active antiretroviral therapies (HAARTs) among adolescent and young men who have sex with men (MSM). As part of the multisite Young Men's Survey, 813 MSM aged 15-22 years who attended public venues in two cities were questioned about HAART in 1997-1998. Overall, 45.1% had heard of HAART, 61.6% in Seattle, Washington, and 35.0% in New York City. MSM in New York City who were the youngest, men of color, men who were human immunodeficiency virus (HIV) antibody negative, and men who resided in New Jersey were significantly less likely to be aware of HAART. Attitudes about HAART were not associated with sexual risk behaviors. Prevention efforts among young MSM should focus on other determinants of risk, but also include information on the changing nature of HIV therapies.

Prevalence of unsafe sexual behavior among HIV-infected individuals: the Swiss HIV Cohort Study

Sexual contact is the major mode of HIV transmission. Increased sexual risk taking has been described in HIV-infected individuals receiving potent antiretroviral therapy. A new questionnaire on sexual behavior was introduced into the Swiss HIV Cohort Study on April 1, 2000. We evaluated sexual behavior in all individuals who completed the questionnaire for the first time within 1 year after its introduction. Our primary hypothesis was that self-reported unsafe sexual behavior would be more prevalent among individuals with optimal viral suppression. On April 1, 2000, 4948 individuals were registered in the study, and 4723 (95%) completed the questionnaire. Of these individuals, 12% reported unsafe sex, 78% received antiretroviral therapy, and 25% had optimal viral suppression (HIV RNA level always <50 copies/mL during the preceding 12 months). During the preceding 6 months, 55% of individuals had stable and 19% had occasional partners, and 6% had both types of partners. Sexual intercourse was reported by 82% of individuals with stable and 87% of individuals with occasional partners, and of those reporting sexual intercourse in each group, 76% and 86%, respectively, said that they always used condoms. After adjustment for covariates, reported unsafe sex was not associated with optimal viral suppression (odds ratio, 1.04; 95% confidence interval, 0.81-1.33) or antiretroviral therapy (odds ratio, 0.83; 95% confidence interval, 0.65-1.07), but it was associated with gender, age, ethnicity, HIV transmission group, HIV status of partner, having occasional partners, and living alone. There is no evidence that self-reported unsafe sexual behavior is more prevalent among HIV-infected individuals with optimal viral suppression. However, unsafe sex is associated with other factors.

Increases in gonorrhea and sexual risk behaviors among men who have sex with men: a 12-year trend analysis at the Denver Metro Health Clinic

BACKGROUND

Recent increases in rates of sexually transmitted diseases (STDs) and decreases in safe sex behaviors among men who have sex with men (MSM) in several American and European cities have been noted by researchers. It has been suggested that these trends are the result of perceptions that HIV/AIDS is less serious because of the availability of highly active antiretroviral therapy (HAART).

GOAL

The goal of the study was to examine trends in STD rates and risk behaviors among MSM and men who have sex with women (MSW) visiting a public STD clinic in Denver and to determine whether there is an ecological association with the availability of HAART.

STUDY DESIGN

This is a two-part retrospective analysis of male visits to the Denver Metro Health Clinic (DMHC). The first part describes gonorrhea and early (primary and secondary) syphilis trends among MSM between 1982 and 2001. For the second part, data were grouped into two 6-year time periods to represent pre-HAART and post-HAART time frames, 1990 to 1995 and 1996 to 2001.

RESULTS

Gonorrhea and early syphilis cases among MSM declined precipitously between 1982 and 1988 and then stabilized at low rates. The proportion of male visits to the clinic made by MSM decreased from 14.1% in 1990 to 7.2% in 1995 and then increased to 13.0% in 2001. Gonorrhea positivity rates among MSM increased after 1995 and were significantly higher in the period 1996 to 2001 (12.9%) than in the period 1990 to 1995 (8.1%; P<0.0001). Conversely, gonorrhea rates among MSW dropped from 11.2% in the first period to 6.9% in the second (P<0.0001). Among MSM known to be HIV-infected, gonorrhea rates increased from 11.6% in the first time period to 24.0% in the second period (P<0.0001). Reports of anal sex among MSM increased from 64.4% to 70.9% (P<0.0001). Reporting more than one sex partner increased for MSM from 65.2% to 70.3% (P<0.0001), but it significantly decreased from 52.6% to 46.2% for MSW (P<0.0001). No or inconsistent condom use increased from 60.9% to 63.0% for MSM (P=NS) and decreased from 85.1% to 82.4% among MSW (P<0.0001).

CONCLUSIONS

These trends appear to reflect a change toward higher risk-taking behaviors among MSM but not MSW since the time HAART became available and raise concerns about the potential for increased HIV transmission in this group.

AIDS mortality may have contributed to the decline in syphilis rates in the United States in the 1990s

BACKGROUND

The mortality associated with AIDS among men may have had an influence on primary and secondary syphilis trends among men in the United States, through the loss of men at high risk for acquisition or transmission of syphilis in this population and/or by prompting safer sexual behaviors in response to the threat of AIDS.

GOAL

The goal of this study was to examine the association between AIDS mortality rates and primary and secondary syphilis incidence rates among men in the United States from 1984 to 1997.

STUDY DESIGN

We used a fixed-effects regression analysis of state-level AIDS mortality rates and primary and secondary syphilis incidence rates for men.

RESULTS

Our analysis showed a significant association between higher AIDS mortality and lower rates of syphilis incidence, after we controlled for confounding factors. Our model estimates suggested that every 20 AIDS deaths per 100,000 adult men are associated with declines of about 7% to 12% in syphilis incidence rates among men.

CONCLUSION

Increases in AIDS-associated mortality may have accounted for one-third to one-half of the decline in syphilis rates among men in the early 1990s. Recent declines in AIDS mortality in the United States may have contributed to the recent outbreaks of syphilis, particularly among men who have sex with men. Our findings underscore the importance of providing STD prevention services to men with HIV infection and the need for STD surveillance in communities at risk for syphilis outbreaks.