Antiretroviral therapy and sexual behavior: a comparative study between antiretroviral- naive and -experienced patients at an urban HIV/AIDS care and research center in Kampala, Uganda

Consistent condom utilization among sexually active HIV positive individuals in Sub-Saharan Africa: systematic review and meta-analysis

This study aimed to ascertain the pooled prevalence and trend of consistent condom use in Sub-Saharan Africa, addressing the fragmented and inconsistent research on its role in preventing HIV transmission. In this meta-analysis, we systematically searched electronic databases such as PubMed, Embase, Scopus, Web of Science, Global Index Medicus, ScienceDirect, Africa-Wide Information (via EBSCOhost), as well as clinical trial registries, and the search engine Google Scholar. All necessary data were extracted using a standardized data extraction format. The data were analyzed using STATA 17 statistical software. Heterogeneity among the studies was assessed using the I2 test. A random-effect model was computed to estimate the pooled rate of consistent condom utilization. This meta-analysis, which included thirty-three full-text studies, found a pooled prevalence of 44.66% (95% CI 18.49-70.83; I2 = 0.00%) for consistent condom use in Sub-Saharan Africa. While the prevalence fluctuated between 2007 and 2022, the year-to-year variations were not statistically significant. The current study identified low rates of consistent condom use, with utilization fluctuating annually in the study area. Therefore, uncovering the underlying reasons and addressing barriers to consistent condom use is crucial in the region.

Lifetime Methamphetamine Use Disorder and Reported Sleep Quality in Adults Living with HIV

This study evaluated whether a history of lifetime methamphetamine (MA) use disorder increases risk for poor sleep quality in people with or without HIV infection (HIV+/HIV-). Participants (n = 313) were stratified into four groups based on HIV status and lifetime MA use disorder diagnosis [HIV+/MA+ (n = 84); HIV+/MA- (n = 141); HIV-/MA+ (n = 16); and HIV-/MA- (n = 72)] and compared on global sleep outcomes using the Pittsburgh Sleep Quality Index (PSQI). Significant differences on global sleep were observed between HIV+/MA+ and HIV+/MA- groups, but not between the HIV- groups. Follow-up multiple regression analyses within the HIV+ subgroups examined global sleep scores as a function of MA status and clinical covariates, including those related to HIV disease and demographics. HIV+ individuals with a history of MA use disorder evidenced significantly poorer sleep quality and were more likely to be classified as problematic sleepers than those without a lifetime disorder. This was independent of depressed mood, body mass index, and viral suppression while on treatment. Poorer reported sleep quality among HIV+/MA+ was associated also with multiple adverse functional outcomes, including greater objective cognitive impairment, unemployment, clinical ratings of functional impairment, and self-reported cognitive difficulties, decreased independence in activities of daily living, and poorer overall life quality. Interventions to avoid or curtail MA use in HIV+ individuals may help protect sleep quality and improve functioning.

Risky sexual behavior among patients on long-term antiretroviral therapy: a prospective cohort study in urban and rural Uganda

Background

While the effects of initiation of antiretroviral treatment (ART) on risky sexual behavior have been extensively studied, less is known about the long-term changes in risky sexual behavior over time in resource-poor settings.

Methods

We conducted a secondary longitudinal analysis of one rural and one urban cohort of patients who initiated ART in Uganda between April 2004 and July 2007 followed up-to 2016. Data on sexual behavior were collected every 6 months for 3.5 years in individuals on ART ≥ 4 years (baseline) when a behavioral questionnaire was introduced. Risky sexual behavior was defined as sexual intercourse with ≥ 2 partners or inconsistent or no condom use in previous 6 months. We report characteristics overall, and by cohort. We used multivariable generalized estimating equations logistic regression to assess the effects of time on ART on risky sexual behavior.

Results

Of 1012 participants, 402 (39.8%) were urban and 610 (60.2%) were rural residents. Mean age was 42.8 years (SD 8.5). Mean duration of follow-up was 51.3 months (SD 15.3), but longer for urban than rural participants (64.5 vs 36.4 months). Risky sexual behavior declined from 33.1% at baseline to 9.6% after 3.5 years of follow-up in the rural cohort (p ≤ 0.01 for the test of trend) and was unchanged from 9.7% at baseline to 9.9% after 3.5 years in the urban cohort (p = 0.51). Receiving care at a rural clinic (aOR 4.99, 95% CI 3.64–6.84); male gender (aOR 1.66, 95% CI 1.26–2.19) and being younger (aOR 5.60, 95% CI 3.80–8.25 for 18–34 years and aOR 2.34, 95% CI 1.74–3.14 for 35–44 years) were associated with increased odds of risky sexual behavior. Not being married (aOR 0.25; 95% CI 0.19–0.34), and longer time on ART (aOR 0.71 95% CI 0.67–0.76) were associated with reduced odds of risky sex.

Conclusions

We observed a decline in risky sexual behavior in rural people on long-term (≥ 4 years) ART. Rural, male and young individuals had higher odds of self-reported risky sexual behavior. ART programs should continue to emphasize risk reduction practices, especially among people receiving care in rural health facilities, males, younger individuals and those who are married.

Sexual Risk Behaviors of Patients with HIV/AIDS over the Course of Antiretroviral Treatment in Northern Vietnam

Antiretroviral therapy (ART) improves the health and well-being of people living with the human immunodeficiency virus (HIV, PLWH), and reduces their risk of transmitting the virus to sexual partners. However, patterns of sexual risk behavior among HIV-positive patients taking ART in Vietnam remain largely unknown. In this study, we sought to examine sexual risk behaviors and their associated factors among HIV-positive patients receiving ART in northern Vietnam. The socio-demographic characteristics, ART use, health status, and sexual behaviors of 1133 patients taking ART in the Hanoi and Nam Dinh provinces were explored through face-to-face interviews. There were 63.5% of patients who had one sex partner, while 3.6% and 5.6% of patients had sexual intercourse with casual partners or sex workers, respectively, in the previous 12 months. Most participants tended to use condoms more often with commercial sex partners (90.2%) and intimate partners (79.7%), and less often with casual partners (60.9%). Higher age (odds ratio, OR = 1.0; 95% CIs = 1.0, 1.1) or suffering pain/discomfort (OR = 1.7; 95% CIs = 1.2, 2.4) were factors more likely to be associated with multiple sex partners. Patients who were self-employed were more likely to have sexual intercourse with casual partners/sex workers (OR = 2.1; 95% CIs = 1.1, 4.0). Meanwhile, a higher score on the EuroQol visual analog scale (EQ-VAS), an unknown HIV stage, and a longer duration of ART were adversely associated with not using condoms with casual partners/sex workers. Patients with longer durations of ART had a lower likelihood of not using a condom with casual partners/sex workers (OR = 0.5; 95% CIs = 0.3, 0.8). Our study underscored a relatively high rate of unsafe sexual behaviors among HIV-positive patients. Continuing to improve the physical and psychological well-being of HIV-positive patients in Vietnam is important in reducing the spread of HIV via risky sexual behaviors. In addition, safe-sex education should be provided to older people, and to those who are self-employed.

Cross-sectional comparative study of risky sexual behaviours among HIV-infected persons initiated and waiting to start antiretroviral therapy in rural Rakai, Uganda

OBJECTIVES

To compare risky sexual behaviours between HIV-positive persons initiated on antiretroviral therapy (ART) (ART-experienced) and persons waiting to start on ART (ART-naive) and assess predictors of risky sexual behaviours among HIV-infected patients in rural Rakai district, Uganda.

STUDY DESIGN

This is a cross-sectional study that used data from the Rakai Community Cohort Study (RCCS) database between 2013 and 2014. A structured questionnaire was used for data collection. We used stepwise logistic regression as an index to estimate the adjusted ORs for the association between risky sexual behaviours and ART treatment status.

STUDY SETTING

This study was conducted in Rakai district, located in south-western Uganda. The data for this study were extracted from the RCCS. RCCS is an open prospective cohort of approximately 15 000 consenting participants aged 15-49 years.

PARTICIPANTS

HIV-positive participants aged 18-49 years who had sex at least once a month with any partner prior to the start of the study.

MAIN OUTCOME MEASURES

Inconsistent/no condom use in the last 12 months, alcohol use at last sexual encounter, and two or more sexual partners.

RESULTS

ART-naive participants were more likely to report inconsistent condom use (OR=1.74, 95% CI 1.11 to 2.73) and more likely to drink alcohol at last sexual encounter (OR=1.65, 95% CI 1.11 to 2.46), compared with ART-experienced patients. ART treatment status (p<0.001) was a significant predictor of risky sexual behaviours. Both marital status (p=0.016) and occupation level (p=0.009) were positively associated with inconsistent condom use, while sex (p<0.001) correlated with alcohol use at last sexual encounter.

CONCLUSION

ART-naive participants were more likely to exhibit risky sexual behaviours than the ART-experienced participants. The intensity of risk reduction counselling should be increased for HIV-positive persons waiting to start ART but already in HIV care.

Significant rates of risky sexual behaviours among HIV-infected patients failing first-line ART: A sub-study of the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial

There are limited data on the prevalence of risky sexual behaviours in individuals failing first-line antiretroviral therapy (ART) and changes in sexual behaviour after switch to second-line ART. We undertook a sexual behaviour sub-study of Ugandan adults enrolled in the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial. A standardized questionnaire was used to collect sexual behaviour data and, in particular, risky sexual behaviours (defined as additional sexual partners to main sexual partner, inconsistent use of condoms, non-disclosure to sexual partners, and exchange of money for sex). Of the 79 participants enrolled in the sub-study, 62% were female, median age (IQR) was 37 (32-42) years, median CD4 cell count (IQR) was 79 (50-153) cells/µl, and median HIV viral load log was 4.9 copies/ml (IQR: 4.5-5.3) at enrolment. The majority were in long-term stable relationships; 69.6% had a main sexual partner and 87.3% of these had been sexually active in the preceding six months. At enrolment, around 20% reported other sexual partners, but this was higher among men than women (36% versus 6.7 %, p < 0.001). In 50% there was inconsistent condom use with their main sexual partner and a similar proportion with other sexual partners, both at baseline and follow-up. Forty-three per cent of participants had not disclosed their HIV status to their main sexual partner (73% with other sexual partners) at enrolment, which was similar in men and women. Overall, there was no significant change in these sexual behaviours over the 96 weeks following switch to second-line ART, but rate of non-disclosure of HIV status declined significantly (43.6% versus 19.6%, p <0.05). Among persons failing first-line ART, risky sexual behaviours were prevalent, which has implications for potential onward transmission of drug-resistant virus. There is need to intensify sexual risk reduction counselling and promotion of partner testing and disclosure, especially at diagnosis of treatment failure and following switch to second- or third-line ART.

The impact of HIV antiretroviral treatment perception on risky sexual behaviour in Botswana: a short report

The aim of this article is to investigate the impact of ART perception on risky sexual behaviours in Botswana. Using binary logistic regression analysis controlling for individual characteristics, the results tend to support the hypothesis that ART misconceptions do not necessarily increase risky sexual behaviours. In particular, the study findings suggest the belief that ARVs cure HIV and AIDS and that people on ARVs should not always use condoms do not necessarily lead to increased risky sexual behaviours, particularly among women. Gender differentials exist in the perceived sexual risk resulting from the use of ART. Risky sexual behaviours increase for women who, wrongly, believed that ARVs cure HIV and AIDS and people on ARVs should not always use condoms. Although there is evidence to suggest ART perceptions do not necessarily lead to increased risky sexual behaviours, HIV and AIDS prevention programmes are needed to strengthen their information, education and communication intervention component that can address misconceptions about ART treatment and provide correct information that is gender-appropriate.

Sexual risk behavior among HIV-positive persons in Jamaica

BACKGROUND

HIV/AIDS remains a global public health challenge, especially in sub-Saharan Africa and the Caribbean. Sexual risk behaviors among HIV-positive persons place their partners at risk for HIV transmission and other sexually transmitted infections. Stopping transmission acts among HIV-positive people is crucial in reversing HIV incidence.

OBJECTIVE

This study aimed to assess the prevalence and predictors of sexual risk behaviors among HIV-positive individuals in clinical care in Northwestern Jamaica.

METHODS

A cross-sectional survey of 118 (33 males and 85 females) HIV-positive individuals was used to assess demographic and health characteristics, HIV/AIDS knowledge, attitudes, and beliefs and sexual risk behaviors.

RESULTS

About 12% of the study population stated that they had unprotected anal or vaginal sex without disclosing their HIV status. Participants who agreed that condoms reduce the risk of HIV transmission were 13.1 times more likely to use condoms during their last sexual encounters(95% CI: 2.1-79.0) than those who disagreed. About 75% of participants reported using a condom every time they had sexual intercourse in the past year, while 25% used condoms irregularly. Participants who had unprotected anal or vaginal sex without disclosing their status were less likely to have used condoms during the last sexual encounter (OR=0.1; 95% CI: 0.02-0.5).

CONCLUSION

The prevalence of unsafe sex remains high among sexually active people living with HIV/AIDS in Jamaica. Study participants who engaged in unprotected sex without disclosing their HIV-positive status potentially place their partners at risk for HIV transmission and other sexually transmitted infections. The study findings highlight the need to promote safe sexual behaviors and a positive social environment for people living with HIV/AIDS in Jamaica.

Sexual risk related behaviour among youth living with HIV in central Uganda: implications for HIV prevention

INTRODUCTION

As young people living with HIV grow their sexual behaviour and it's implication on HIV prevention is of concern. This study describes the sexual risk related-behaviours and factors associated with abstinence among Youth Living with HIV in central Uganda.

METHODS

We conducted a cross-sectional study among 338 unmarried youth between 15 and 24 years accessing HIV care in central Uganda. Data was collected using interviewer administered structured questionnaires. Adjusted prevalence proportion ratios (adj. PPRs) of factors associated with sexual abstinence for at least six months were determined by multivariable log-binomial regression.

RESULTS

Overall, 79% (269/338) of respondents were abstaining from sexual intercourse for atleast six months, although, 45% (150/338) had ever been sexually active. Of the 283 respondents who desired to get married in future, 40% preferred negative marriage partners. Only 31% (39/126) of respondents in boy/girl relationships had disclosed their HIV status to their partners. Among those currently sexually active (n = 69), 57% did not consistently use condoms and 30% had more than one sexual partner in the past six months. The adj.PRR of abstinence was higher among youth between 15 and 19 years compared to those between 20 and 24 years (adj. PPR = 1.26, 95% CI; 1.08-1.46). The prevalence of abstinence was significantly lower among respondent who consumed alcohol (adj. PPR = 0.31, 95% CI 0.16-0.61).

CONCLUSION

Tailored interventions promoting disclosure, consistent condoms use and discouraging alcohol consumption among sero-positive youth could reduce HIV transmission risk.

Antiretroviral Treatment and Sexual Risk Behavior in South Africa

The sexual behavior of individuals living with HIV determines the onward transmission of HIV. With the understanding that antiretroviral therapy (ART) prevents transmission of HIV, the sexual behaviors of the individuals not on ART with unsuppressed viral loads becomes of the greatest importance in elucidating transmission. We assessed the association between being on ART and sexual risk behavior among those living with HIV in a nationally representative population-based cross-sectional survey of households in South Africa that was conducted in 2012. Of 2237 adults (aged 15-49) who tested HIV-seropositive, 667 (29.8 %) had detectable antiretroviral drugs in their blood specimens. Among males, 77.7 % of those on ART reported having had sex in the past year contrasted with 88.4 % of those not on ART (p = 0.001); among females, 72.2 % of those on ART reported having had sex in the past year while 80.3 % of those not on ART did (p < 0.001). For males and females, the odds of reporting consistent condom use and condom use at last sex were statistically significantly higher for individuals on ART compared to those not on ART (males: consistent condom use aOR 2.8, 95 % CI 1.6-4.9, condom use at last sex aOR 2.6, 95 % CI 1.5-4.6; females: consistent condom use aOR 2.3, 95 % CI 1.7-3.1, condom use at last sex aOR 2.3, 95 % CI 1.7-3.1), while there were no statistically significant differences in odds of reporting multiple sexual partners in the past year. In this nationally representative population-based survey of South African adults, we found evidence of less risky sexual risk behavior among people living with HIV on ART compared to those not on ART.

Sexual behaviour of people living with HIV attending a tertiary care government hospital in Kathmandu, Nepal: a cross sectional study

Background

Clinical improvements that follow antiretroviral therapy (ART) may lead to increase or resumption of high risk activities that could unintentionally result in HIV transmission. The objective was to investigate whether treatment status is a significant predictor of sexual risk behaviour (unprotected sex).

Methods

A cross sectional study was conducted among 160 people living with HIV (PLHIV) (89 ART experienced and 71 ART naïve) attending Sukraraj Tropical and Infectious Disease Hospital in Kathmandu, Nepal. A structured questionnaire was used for data collection. Logistic regression with stepwise modeling was used to obtain adjusted odds ratios (OR) with 95 % CI.

Results

In this study, 92 % of sexually active respondents reported sex with a regular partner. ART experienced PLHIV were significantly more likely to report consistent condom use with their regular partners compared to ART naïve PLHIV (83 vs. 53 %; P = 0.006) during the past six months. In multivariate analysis, sex (OR = 4.59, 95 % CI: 1.15–18.39), treatment status (OR = 4.76, 95 % CI: 1.29–17.52) and alcohol consumption during last sex with regular partners (OR = 14.75, 95 % CI: 2.75–79.29) were significantly associated with unprotected sex.

Conclusion

ART naïve PLHIV were five times more likely to exhibit sexual risk behaviour (have unprotected sex) than ART experienced PLHIV. Thus the study provided no evidence to suggest that ART experienced PLHIV exhibit greater sexual risk behaviour compared to ART naïve PLHIV. Prevention programmes need to emphasize on counselling to PLHIV and their regular partners with focused interventions such as couple counselling and education programmes.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1559-0) contains supplementary material, which is available to authorized users.

Changes in condom use during the first year of HIV treatment in Uganda and the relationship to depression

PURPOSE

We examined the effect of antiretroviral therapy (ART), and the predictive role of depression, on condom use with primary partners.

METHODS

Data from three studies in Uganda were combined into a sample of 750 patients with a primary sex partner, with 502 starting ART and 248 entering HIV care, and followed for 12 months. Random-effects logistic regression models were used to examine the impact of ART, and the influence of baseline level and change in depression, on condom use with primary partners.

RESULTS

At month 12, 61 % ART and 67 % non-ART patients were consistent condom users, compared to 44 and 41 % at baseline, respectively. Multivariate analysis revealed that consistent condom use increased similarly for ART and non-ART patients, and that minor depression at baseline and increased depression over time predicted inconsistent condom use.

CONCLUSIONS

Improved depression diagnosis and treatment could benefit HIV prevention.

The Impact of Visual Aids and Enhanced Training on the Delivery of Positive Health, Dignity, and Prevention Messages to Adult Patients Living with HIV in Rural North Central Mozambique

Introduction

Positive health, dignity, and prevention (PHDP) interventions target people living with HIV and AIDS (PLHIV) to promote well-being and prevent onward transmission. Concern that increased life expectancy and improved well-being would lead to increased risky sexual behaviour and subsequent HIV transmission motivated researchers to test novel strategies to support treatment adherence, encourage safer sex, STI treatment and partner testing, prevention of mother to child transmission, and support uptake of family planning.

Methods

We assessed the number and type of PHDP messages delivered to PLHIV before and after the implementation of an educational intervention for health providers combined with the distribution of visual job aids and monthly technical assistance.

Results

From April 21, 2013 to March 20, 2014, we documented 54,731 clinical encounters at three rural health centres in Zambézia province, Mozambique from 9,248 unique patients. The percentage of patients who received all seven PHDP messages during their last three visits was 1.9% pre-intervention vs. 13.6% post- intervention (p=<0.001). Younger patients (25 years vs. 35) and those with a recent HIV diagnosis (two weeks vs. two years) had higher odds of receiving any PHDP message (Odds Ratio [OR]: 1.22 and 2.79, respectively). Patients >59 days late collecting medications were not more likely to receive adherence messages than adherent patients (p=0.17).

Discussion

Targeting HIV prevention efforts to PLHIV is an effective HIV prevention approach to eliminate HIV transmission. Despite intensive training and support, PHDP message delivery remained unacceptably low in rural Mozambique. Patients at high risk for treatment abandonment were not more likely to be counselled about adherence and support measures, something that needs to be addressed.

Conclusions

We need to develop novel strategies to motivate health care providers to deliver these messages more consistently to all patients and develop a system that assists counsellors and clinicians to quickly and effectively determine which messages should be delivered.

Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behavior: a systematic review and meta-analysis

BACKGROUND

Increased global access and use of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) has been postulated to undermine HIV prevention efforts by changing individual risk-taking behavior. This review aims to determine whether ART use is associated with changes in sexual or injecting risk-taking behavior or diagnosis of sexually transmitted infections (STIs).

METHODS

A systematic review and meta-analysis was conducted of HIV-seropositive participants receiving ART compared with no ART use in experimental or observational studies. Primary outcomes included (1) any unprotected sexual intercourse, (2) STI diagnoses, and (3) any unsafe injecting behavior.

RESULTS

Fifty-eight studies met the selection criteria. Fifty-six studies containing 32 857 participants reported unprotected sex; 11 studies containing 16 138 participants reported STI diagnoses; and 4 studies containing 1600 participants reported unsafe injecting behavior. All included studies were observational. Unprotected sex was lower in participants receiving ART than in those not receiving ART (odds ratio [OR], 0.73; 95% confidence interval [CI], .64-.83; P < .001; heterogeneity I(2) = 79%) in both high-income (n = 38) and low-/middle-income country (n = 18) settings, without any evidence of publication bias. STI diagnoses were also lower among individuals on ART (OR, 0.58; 95% CI, .33-1.01; P = .053; I(2) = 92%); however, there was no difference in injecting risk-taking behavior with antiretroviral use (OR, 0.90; 95% CI, .60-1.35; P = .6; I(2) = 0%).

CONCLUSIONS

Despite concerns that use of ART might increase sexual or injecting risk-taking, available research suggests that unprotected sex is reduced among HIV-infected individuals on treatment. The reasons for this are not yet clear, although self-selection and mutually reinforcing effects of HIV treatment and prevention messages among people on ART are likely.

Sexual behavior among persons living with HIV in Uganda: implications for policy and practice

Introduction

HIV epidemics are sustained and propagated by new cases of infection which result from transmission from infected persons to uninfected susceptible individuals. People living with HIV (PLHIV) play a critical role in prevention if they adopt safer sexual behaviors. This study estimated the prevalence of and factors associated with safer sexual behaviors among PLHIV seeking care from civil society organizations (CSOs).

Methods

In a cross sectional study PLHIV were interviewed about their sexual practices, use of alcohol, HIV status of their regular sexual partners, desire for more children and about their socio-demographic characteristics. We calculated the proportion of PLHIV who abstained and consistently used condoms in the previous twelve months. Independent associations between safer sex and other variables were estimated using adjusted prevalence ratios (aPR) and their 95% confidence intervals (CI).

Results

Of the 939 PLHIV, 54% (508) were either abstaining or using condoms consistently and 291 (31%) desired more children. The prevalence of consistent condom use among the sexually active was 41.3% (300/731). Consistent condom use was higher among PLHIV who: didn't use alcohol (aPR 1.30, CI 1.03–1.63); were educated about re-infection with a new strain of HIV (aPR 1.84, CI 1.08–3.12) and had regular sexual partner who was HIV negative (aPR 1.29, CI 1.05–1.57). Prevalence of abstinence was 22.2% (208/939). Abstinence increased with age from 9.4% among PLHIV <25 years to 40.5% among those >50 years. Abstinence was extremely low (2.5%) among PLHIV who were married.

Conclusions

Effective interventions that reduce alcohol consumption among PLHIV are needed to avert HIV transmission, prevent acquisition of new HIV strains and STIs. In addition, strategies are needed to address needs of PLHIV who desire more children.

Impact of antidepressant therapy on cognitive aspects of work, condom use, and psychosocial well-being among HIV clients in Uganda

OBJECTIVE

Depression has been found to impede several health outcomes among people living with HIV, but little research has examined whether depression treatment mitigates this influence. We assessed the impact of antidepressant therapy on measures of work, condom use, and psychosocial well-being among depressed HIV clients in Uganda.

METHODS

Paired t-tests and McNemar tests were used to assess change in survey data collected from participants at initiation of antidepressant therapy (baseline) and 6 months later.

RESULTS

Ninety-five participants completed the 6-month assessment, of whom 82 (86%) responded to treatment (defined as Patient Health Questionnaire-9 score < 5). Among study completers, work functioning improved significantly, as did measures of self-efficacy related to condom use and work (as well as general self-efficacy), and internalized HIV stigma declined; however, actual engagement in work activity and consistent condom use did not show significant change. Similar findings were observed among treatment responders.

CONCLUSIONS

Antidepressant treatment benefits functional capacity, psychological well-being, and cognitive intermediary factors that may be essential for behavioral change related to work and condom use, but supplementary therapeutic strategies may be needed to impact more direct behavioral change.

Risky behaviours among young people living with HIV attending care and treatment clinics in Dar Es Salaam, Tanzania: implications for prevention with a positive approach

INTRODUCTION

Prevention with a positive approach has been advocated as one of the main strategies to reduce new instances of HIV infection. Risky sexual behaviours among people living with HIV/AIDS are the cornerstone for this approach. Understanding the extent to which infected individuals practice risky behaviours is fundamental in designing appropriate population-specific interventions. With the HIV infection transmission rates remaining high among young people in sub-Saharan Africa, continued prevention among them remains a priority. This study therefore seeks to describe the magnitude and determinants of risky sexual behaviours among young people living with HIV.

METHODS

A cross-sectional study was conducted between June and July 2010 in selected Care and Treatment Clinics (CTCs) in Dar Es Salaam, Tanzania. A total of 282 HIV-positive patients aged 15-24 were interviewed about their sexual behaviours using a questionnaire.

RESULTS

Prevalence of unprotected sex was 40.0% among young males and 37.5% among young females (p<0.001). Multiple sexual partnerships were reported by 10.6% of males and 15.9% of females (p<0.005). More than 50% of the participants did not know about the HIV status of their sexual partners. A large proportion of participants had minimal knowledge of transmission (46.7% males vs. 60.4% females) and prevention (65.3% males vs. 73.4% females) of sexually transmitted infections (STIs). Independent predictors of condom use included non-use of alcohol [adjusted odds ratio (AOR), 0.40 95% confidence interval (CI); 0.17-0.84] and younger age (15-19 years) (AOR, 2.76, 95% CI: 1.05-7.27). Being on antiretroviral therapy (AOR, 0.38, 95% CI: 0.17-0.85) and not knowing partners' HIV sero-status (AOR, 2.62, 95% CI: 1.14-5.10) predicted the practice of multiple sexual partnership.

CONCLUSIONS

Unprotected sex and multiple sexual partnerships were prevalent among young people living with HIV. Less knowledge on STI and lack of HIV disclosure increased the vulnerability and risk for HIV transmission among young people. Specific intervention measures addressing alcohol consumption, risky sexual behaviours, and STI transmission and prevention knowledge should be integrated in the routine HIV/AIDS care and treatment offered to this age group.

The need to reemphasize behavior change for HIV prevention in Uganda: a qualitative study

Uganda has long been considered an AIDS success story, although in recent years declines in prevalence and incidence appear to have stalled or even reversed. During the early stages of Uganda's AIDS prevention program, health messages emphasized behavior change, especially fidelity. Ugandans were made to fear AIDS and feel personally at risk of dying from a new, poorly understood disease. In this research, six focus group discussions with 64 participants in peri-urban and rural areas outside Kampala suggest that HIV prevention messages have shifted in the direction of risk reduction: condoms, testing, and drugs. Ugandans now seem less afraid of becoming infected with HIV, at least in part because antiretroviral therapy is available, and this diminished fear may be having a disinhibiting effect on sexual behavior. Participants believe that HIV rates are on the rise, that more individuals are engaged in multiple and concurrent sexual partnerships, and that sexual behavior is less restrained than a generation ago. These findings suggest that AIDS-prevention programs in Uganda would benefit from refocusing on the content that yielded success previously-sexual behavior change strategies.

Does integrating family planning into HIV care and treatment impact intention to use contraception? Patient perspectives from HIV-infected individuals in Nyanza Province, Kenya

OBJECTIVE

To evaluate whether HIV-infected women and men in HIV care and not using highly effective methods of contraception thought they would be more likely to use contraception if it were available at the HIV clinic.

METHODS

A face-to-face survey assessing family-planning knowledge, attitudes, and practices was conducted among 976 HIV-infected women and men at 18 public-sector HIV clinics in Nyanza, Kenya. Data were analyzed using logistic regression and generalized estimating equations.

RESULTS

The majority of women (73%) and men (71%) thought that they or their partner would be more likely to use family planning if it were offered at the HIV clinic. In multivariable analysis, women who reported making family-planning decisions with their partner (adjusted odds ratio [aOR] 3.22; 95% confidence interval [CI], 1.53-6.80) and women aged 18-25 years who were not currently using family planning (aOR 4.76; 95% CI, 2.28-9.95) were more likely to think they would use contraception if integrated services were available. Women who perceived themselves to be infertile (aOR 0.07; 95% CI, 0.02-0.31) and had access to a cell phone (aOR 0.40; 95% CI, 0.25-0.63) were less likely to think that integrated services would change their contraceptive use. Men who were not taking antiretroviral medications (aOR 3.30; 95% CI, 1.49-7.29) were more likely, and men who were unsure of their partner's desired number of children (aOR 0.36; 95% CI, 0.17-0.76), were not currently using family planning (aOR 0.40; 95% CI, 0.22-0.73), and were living in a peri-urban setting (aOR 0.46; 95% CI, 0.21-0.99) were less likely to think their partner would use contraception if available at the HIV clinic.

CONCLUSIONS

Integrating family planning into HIV care would probably have a broad impact on the majority of women and men accessing HIV care and treatment. Integrated services would offer the opportunity to involve men more actively in the contraceptive decision-making process, potentially addressing 2 barriers to family planning: access to contraception and partner uncertainty or opposition.

Disinhibition in risky sexual behavior in men, but not women, during four years of antiretroviral therapy in rural, southwestern Uganda

BACKGROUND

In resource-rich areas, risky sexual behavior (RSB) largely diminishes after initiation of anti-retroviral therapy, with notable exceptions among some populations who perceive a protected benefit from anti-retroviral therapy (ART). Yet, there is limited data about long-term trends in risky sexual behavior among HIV-infected people in sub-Saharan Africa after initiation of anti-retroviral therapy.

METHODS

We administered questionnaires every three months to collect sexual behavior data among patients taking ART in southwestern Uganda over four years of follow-up time. We defined RSB as having unprotected sex with an HIV-negative or unknown status partner, or unprotected sex with a casual partner. We fit logistic regression models to estimate changes in RSB by time on ART, with and without adjustment for calendar year and CD4 count.

RESULTS

506 participants were enrolled between 2005 and 2011 and contributed a median of 13 visits and 3.5 years of observation time. The majority were female (70%) and median age was 34 years (interquartile range 29-39). There was a decrease in the proportion of men reporting RSB from the pre-ART visit to the first post-ART visit (16.2 to 4.3%, p<0.01) but not women (14.1 to 13.3%, p = 0.80). With each year of ART, women reported decreasing RSB (OR 0.85 per year, 95%CI 0.74-0.98, p = 0.03). In contrast, men had increasing odds of reporting RSB with each year of ART to near pre-treatment rates (OR 1.41, 95%CI 1.14-1.74, p = 0.001), which was partially confounded by changes in calendar time and CD4 count (AOR = 1.24, 95%CI 0.92-1.67, p = 0.16).

CONCLUSIONS

Men in southwestern Uganda reported increasing RSB over four years on ART, to levels approaching pre-treatment rates. Strategies to promote long-term safe sex practices targeted to HIV-infected men on ART might have a significant impact on preventing HIV transmission in this setting.

Sexual risk behaviour, marriage and ART: a study of HIV-positive people in Papua New Guinea

Background

The prevention of intimate partner transmission of HIV remains an important component of comprehensive HIV prevention strategies. In this paper we examine the sexual practices of people living with HIV on antiretroviral therapy (ART) in Papua New Guinea (PNG).

Method

In 2008, a total of 374 HIV-positive people over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. This accounted for around 18% of adults on ART at the time. A further 36 people participated in semi-structured interviews. All interviews were thematically analysed using NVivo qualitative data analysis software.

Results

Less than forty per cent (38%) of participants reported having had sexual intercourse in the six months prior to the survey. Marital status was by far the most important factor in determining sexual activity, but consistent condom use during vaginal intercourse with a regular partner was low. Only 46% reported consistent condom use during vaginal intercourse with a regular partner in the last six months, despite 77% of all participants reporting that consistent condom use can prevent HIV transmission. Consistent condom use was lowest amongst married couples and those in seroconcordant relationships. The vast majority (91.8%) of all participants with a regular heterosexual partner had disclosed their status to their partner. Qualitative data reinforced low rates of sexual activity and provided important insights into sexual abstinence and condom use.

Conclusions

Considering the importance of intimate partner transmission of HIV, these results on the sexual practices of people with HIV on ART in PNG suggest that one-dimensional HIV prevention messages focussing solely on condom use fail to account for the current practices and needs of HIV-positive people, especially those who are married and know their partners’ HIV status.

Knowing a sexual partner is HIV-1-uninfected is associated with higher condom use among HIV-1-infected adults in Kenya

The relation between awareness of sexual partner's HIV serostatus and unprotected sex was examined in HIV clinic enrollees. Increased condom use was associated with knowing that a partner was HIV-negative (adjusted odds ratio = 5.99; P < 0.001) versus not knowing partner's status. Partner testing may increase condom use in discordant couples.

Living with HIV postdiagnosis: a qualitative study of the experiences of Nairobi slum residents

OBJECTIVES

To characterise the experiences of heterosexual men and women living with HIV postdiagnosis and explain these experiences in relation to their identity and sexuality.

DESIGN

Qualitative study using in-depth interviews and a theoretically informed biographic disruption theory.

SETTING

Interviews were conducted in two Nairobi slums (Kenya).

PARTICIPANTS

41 HIV-infected heterosexual men and women aged 18 years or older.

RESULTS

People living with HIV have divergent experiences surrounding HIV diagnosis. Postdiagnosis, there are multiple phases of identity transition, including status (non-)disclosure, and attempts at identity repair and normalcy. For some people, this process involves a transition to a new self-identity, incorporating both HIV and antiretroviral treatment (ART) into their lives. For others, it involves a partial transition, with some aspects of their prediagnosis identity persisting, and for others it involves a rejection of HIV identity. Those people who were able to incorporate HIV/AIDS in their identity, without it being disruptive to their biography, were pursuing safer sexual and reproductive lives. By contrast, those people with a more continuous biography continued to reflect their prediagnosis identity and sexual behaviour.

CONCLUSIONS

People living with HIV/AIDS (PLWHA) had to rework their sense of identity following diagnosis in the context of living in a slum setting. Men and women living with HIV in slums are poorly supported by health systems and services as they attempt to cope with a diagnosis of HIV. Given the availability of ART, health services and professionals need to support the rights of PLWHA to be sexually active if they want to and achieve their fertility goals, while minimising HIV transmission risk.

Susceptibility to transmitting HIV in patients initiating antiretroviral therapy in rural district hospitals in Cameroon (Stratall ANRS 12110/ESTHER Trial)

OBJECTIVES

Using cohort data nested in a randomized trial conducted in Cameroon, this study aimed to investigate time trends and predictors of the susceptibility to transmitting HIV during the first 24 months of treatment.

METHODS

The outcome, susceptibility to transmitting HIV, was defined as reporting inconsistent condom use and experiencing incomplete virological suppression. Mixed logistic regressions were performed to identify predictors of this outcome among 250 patients reporting to have had sexual relationships either with HIV-negative or unknown HIV status partner(s).

RESULTS

Despite an initial decrease from 76% at M0 to 50% at M6, the rate of inconsistent condom use significantly increased from M12 (59%) to M24 (66%) (p = 0.017). However, the proportion of patients susceptible to transmitting HIV significantly decreased over follow-up from 76% at M0, to 50% at M6, 31% at M12 and 27% at M24 (p<0.001). After controlling for age, gender and intervention group, we found that perceiving healthcare staff's readiness to listen as poor (adjusted odds ratios (AOR) [95% Confidence Interval (CI)] = 1.87 [1.01-3.46]), reporting to have sexual relationships more than once per week (AOR [95%CI] = 2.52 [1.29-4.93]), having more than one sexual partner (AOR [95%CI] = 2.53 [1.21-5.30]) and desiring a/another child (AOR [95%CI] = 2.07 [1.10-3.87]) were all associated with a higher risk of being susceptible to transmitting HIV. Conversely, time since ART initiation (AOR [95%CI] = 0.66 [0.53-0.83] for an extra 6 months and ART adherence (AOR [95%CI] = 0.33 [0.15-0.72]) were significantly associated with a lower risk of being susceptible to transmitting HIV.

CONCLUSIONS

The decrease observed in the susceptibility to transmitting HIV suggests that fear of behavioural disinhibition should not be a barrier to universal access to ART. However, developing adequate preventive interventions matching patients' expectations -like the desire to have children- and strengthening healthcare staff's counselling skills are urgently needed to maximize the impact of ART in slowing the HIV epidemic.

Is the Sexual Behaviour of HIV Patients on Antiretroviral therapy safe or risky in Sub-Saharan Africa? Meta-Analysis and Meta-Regression

Background

Reports on the sexual behavior of people on antiretroviral therapy (ART) are inconsistent. We selected 14 articles that compared the sexual behavior of people with and without ART for this analysis.

Methods

We included both cross-sectional studies that compared different ART-naïve and ART-experienced participants and longitudinal studies examining the behavior of the same individuals pre- and post-ART start. Meta-analyses were performed both stratified by type of study and combined. Outcome variables assessed for association with ART experience were any sexual activity, unprotected sex and having multiple sexual partners. Random-effect models were applied to determine the overall odds ratios. Sub-group analyses and meta-regression analyses were performed to examine sources of heterogeneity among the studies. Sensitivity analysis was also conducted to evaluate the stability of the overall odds ratio in the presence of outliers.

Results

The meta-analysis failed to show a statistically significant association of any sexual activity with ART experience. It did, however, show an overall statistically significant reduction of any unprotected sex, having multiple sexual partners and unprotected sex with HIV negative or unknown HIV status with ART experience. Meta-regression showed no interaction between duration of ART use or recall period of sexual behavior with the sexual activity variables. However, there was an association between the percentage of married or cohabiting participants included in a study and reductions in the practice of unprotected sex with ART.

Conclusion

In general, this meta-analysis demonstrated a significant reduction in risky sexual behavior among people on ART in sub-Saharan Africa. Future studies should investigate the reproducibility and continuity of the observed positive behavioural changes as the duration of ART lasts a decade or more.

Patterns of condom use and associated factors among adult HIV positive clients in North Western Ethiopia: a comparative cross sectional study

BACKGROUND

The introduction of antiretroviral therapy (ART) has sharply decreased morbidity and mortality rates among HIV infected patients. Due to this, more and more people with HIV live longer and healthier lives. Yet if they practice sex without condom, those with high viral load have the potential to infect their sero-negative sexual partner or at risk of acquiring drug resistant viral strains from their sexual partner who are already infected. Hence, we aimed to assess practice of condom use and associated factors among HIV positive clients at Felege Hiwot Referral Hospital in North Western Ethiopia.

METHODS

Hospital based comparative cross sectional study was conducted at Felege Hiwot Referral Hospital in northwest Ethiopia. Systematic random sampling technique was used to select 466 study participants from the ART and pre ART clinic of the Hospital. A structured interview administered questionnaire first prepared in English then translated into Amharic was used to collect data. Nurses who were working in the hospital but not in the HIV clinic were recruited and trained as data collectors.

RESULTS

A total of 454 (224 respondents from ART naive and 230 ART experienced groups) were included in the study. Females constitute 151 (67.4%) and 133 (57.8%) of pre ART and ART group respectively. The ages of the participants ranged from 18 to 72 years. The average age was 31.7 years for women and 36.6 years for the men. About half of the participants (47.4% of ART group and 50.4% of the pre ART group) were sexually active. Inconsistent condom use was reported by 61(56%) ART and 50 (44.2%) of the pre ART sexually active study participants.

CONCLUSIONS

The study found that those who are on ART were at lower risk of using condom inconsistently as compared to the ART naïve patients living with HIV. Therefore, these results are of high importance in order to design tailored interventions.

Sexual behavior of HIV-positive adults not accessing HIV treatment in Mombasa, Kenya: Defining their prevention needs

BACKGROUND

HIV spread continues at high rates from infected persons to their sexual partners. In 2009, an estimated 2.6 million new infections occurred globally. People living with HIV (PLHIV) receiving treatment are in contact with health workers and therefore exposed to prevention messages. By contrast, PLHIV not receiving ART often fall outside the ambit of prevention programs. There is little information on their sexual risk behaviors. This study in Mombasa Kenya therefore explored sexual behaviors of PLHIV not receiving any HIV treatment.

RESULTS

Using modified targeted snowball sampling, 698 PLHIV were recruited through community health workers and HIV-positive peer counsellors. Of the 59.2% sexually-active PLHIV, 24.5% reported multiple sexual partners. Of all sexual partners, 10.2% were HIV negative, while 74.5% were of unknown HIV status. Overall, unprotected sex occurred in 52% of sexual partnerships; notably with 32% of HIV-negative partners and 54% of partners of unknown HIV status in the last 6 months. Multivariate analysis, controlling for intra-client clustering, showed non-disclosure of HIV status (AOR: 2.38, 95%CI: 1.47-3.84, p < 0.001); experiencing moderate levels of perceived stigma (AOR: 2.94, 95%CI: 1.50-5.75, p = 0.002); and believing condoms reduce sexual pleasure (AOR: 2.81, 95%CI: 1.60-4.91, p < 0.001) were independently associated with unsafe sex. Unsafe sex was also higher in those using contraceptive methods other than condoms (AOR: 5.47, 95%CI: 2.57-11.65, p < 0.001); or no method (AOR: 3.99, 95%CI: 2.06-7.75, p < 0.001), compared to condom users.

CONCLUSIONS

High-risk sexual behaviors are common among PLHIV not accessing treatment services, raising the risk of HIV transmission to discordant partners. This population can be identified and reached in the community. Prevention programs need to urgently bring this population into the ambit of prevention and care services. Moreover, beginning HIV treatment earlier might assist in bringing this group into contact with providers and HIV prevention services, and in reducing risk behaviors.

Sexual risk behaviors among HIV-infected South African men and women with their partners in a primary care program: implications for couples-based prevention

We studied 1163 sexually-active HIV-infected South African men and women in an urban primary care program to understand patterns of sexual behaviors and whether these behaviors differed by partner HIV status. Overall, 40% reported a HIV-positive partner and 60% a HIV-negative or status unknown partner; and 17.5% reported >2 sex acts in the last 2 weeks, 16.4% unprotected sex in the last 6 months, and 3.7% >1 sex partner in the last 6 months. Antiretroviral therapy (ART) was consistently associated with decreased sexual risk behaviors, as well as with reporting a HIV-negative or status unknown partner. The odds of sexual risk behaviors differed by sex; and were generally higher among participants reporting a HIV-positive partner, but continued among those with a HIV-negative or status unknown partner. These data support ART as a means of HIV prevention. Engaging in sexual risk behaviors primarily with HIV-positive partners was not widely practiced in this setting, emphasizing the need for couples-based prevention.

HIV treatment as prevention: systematic comparison of mathematical models of the potential impact of antiretroviral therapy on HIV incidence in South Africa

BACKGROUND

Many mathematical models have investigated the impact of expanding access to antiretroviral therapy (ART) on new HIV infections. Comparing results and conclusions across models is challenging because models have addressed slightly different questions and have reported different outcome metrics. This study compares the predictions of several mathematical models simulating the same ART intervention programmes to determine the extent to which models agree about the epidemiological impact of expanded ART.

METHODS AND FINDINGS

Twelve independent mathematical models evaluated a set of standardised ART intervention scenarios in South Africa and reported a common set of outputs. Intervention scenarios systematically varied the CD4 count threshold for treatment eligibility, access to treatment, and programme retention. For a scenario in which 80% of HIV-infected individuals start treatment on average 1 y after their CD4 count drops below 350 cells/µl and 85% remain on treatment after 3 y, the models projected that HIV incidence would be 35% to 54% lower 8 y after the introduction of ART, compared to a counterfactual scenario in which there is no ART. More variation existed in the estimated long-term (38 y) reductions in incidence. The impact of optimistic interventions including immediate ART initiation varied widely across models, maintaining substantial uncertainty about the theoretical prospect for elimination of HIV from the population using ART alone over the next four decades. The number of person-years of ART per infection averted over 8 y ranged between 5.8 and 18.7. Considering the actual scale-up of ART in South Africa, seven models estimated that current HIV incidence is 17% to 32% lower than it would have been in the absence of ART. Differences between model assumptions about CD4 decline and HIV transmissibility over the course of infection explained only a modest amount of the variation in model results.

CONCLUSIONS

Mathematical models evaluating the impact of ART vary substantially in structure, complexity, and parameter choices, but all suggest that ART, at high levels of access and with high adherence, has the potential to substantially reduce new HIV infections. There was broad agreement regarding the short-term epidemiologic impact of ambitious treatment scale-up, but more variation in longer term projections and in the efficiency with which treatment can reduce new infections. Differences between model predictions could not be explained by differences in model structure or parameterization that were hypothesized to affect intervention impact.

What works to meet the sexual and reproductive health needs of women living with HIV/AIDS

It is critical to include a sexual and reproductive health lens in HIV programming as most HIV transmission occurs through sexual intercourse. As global attention is focusing on the sexual and reproductive health needs of women living with HIV, identifying which interventions work becomes vitally important. What evidence exists to support sexual and reproductive health programming related to HIV programmes?

This article reviews the evidence of what works to meet the sexual and reproductive health needs of women living with HIV in developing countries and includes 35 studies and evaluations of eight general interventions using various methods of implementation science from 15 countries. Data are primarily from 2000-2009. Searches to identify effective evaluations used SCOPUS, Popline, Medline, websites and consultations with experts. Evidence was ranked using the Gray Scale.

A range of successful and promising interventions to improve the sexual and reproductive health and rights of women living with HIV include: providing contraceptives and family planning counselling as part of HIV services; ensuring early postpartum visits providing family planning and HIV information and services; providing youth-friendly services; supporting information and skills building; supporting disclosure; providing cervical cancer screening; and promoting condom use for dual protection against pregnancy and HIV. Provision of antiretrovirals can also increase protective behaviours, including condom use.

While many gaps in programming and research remain, much can be done now to operationalize evidence-based effective interventions to meet the sexual and reproductive health needs of women living with HIV.

Is expanded HIV treatment preventing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the developing world

There have been dramatic increases in access to antiretroviral therapy (ART) across the developing world, and growing public health attention has focused on the possibility of utilizing ART as a means of slowing the global HIV epidemic. The preventive impact of ART will likely depend on decreasing levels of sexual risk behaviors following treatment initiation. The current review study examines the impact of wider access to ART on sexual risk behaviors among HIV-infected individuals in the developing world. The observational studies to date demonstrate that ART is associated with a significant reduction in unprotected sex following treatment initiation. Although data on the impact of ART on possible risk compensation are rapidly expanding across the developing world, more evidence is still needed before we can safely conclude expanded treatment will result in durable decreases in sexual risk behaviors.

Sexual behaviors over a 3-year period among individuals with advanced HIV/AIDS receiving antiretroviral therapy in an urban HIV clinic in Kampala, Uganda

BACKGROUND

Few studies have prospectively examined sexual behaviors of HIV-infected person on antiretroviral therapy (ART) in sub-Saharan Africa.

METHODS

Between 2004 and 2005, 559 HIV-infected, ART-naïve individuals initiating ART at an HIV clinic in Kampala, Uganda, were enrolled into a prospective study and followed to 2008. Clinical and sexual behavior information was assessed at enrollment and semiannually for 3 years after ART initiation. Using log-binomial regression models, we estimated prevalence ratios (PRs) to determine factors associated with being sexually active and having unprotected sex over 3 years after initiating ART.

RESULTS

Five hundred fifty-nine adults contributed 2594 person-visits of follow-up. At the time of ART initiation, 323 (57.9%) were sexually active of which 176 (54.5%) had unprotected sex at last sexual intercourse. The majority (63.4%) of married individuals were unaware of their partner's HIV status. Female gender (PR, 2.97; 95% confidence interval, 1.85-4.79), being married (PR, 1.48; 95% confidence interval, 1.06-2.06), and reporting unprotected sex before ART (PR, 1.68; 95% confidence interval, 1.16-2.42) were among the factors independently associated with unprotected sex while on ART. Overall, 7.3% of visit intervals of unprotected sex, 1.0% of intervals of sexual activity, occurred when plasma viral load greater than 1500 copies/mL, representing periods of greater HIV transmission risk.

CONCLUSIONS

Although unprotected sex reduced over time, women reported unprotected sex more often than men. Disclosure of HIV status was low. Integration of comprehensive prevention programs into HIV care is needed, particularly ones specific for women.

Changes in sexual desires and behaviours of people living with HIV after initiation of ART: implications for HIV prevention and health promotion

BACKGROUND

As immune compromised HIV sero-positive people regain health after initiating antiretroviral treatment (ART), they may seek a return to an active 'normal' life, including sexual activity. The aim of the paper is to explore the changing sexual desires and behaviour of people on ART in Uganda over a 30 month period.

METHODS

This study employed longitudinal qualitative interviews with forty people starting ART. The participants received their ART, adherence education and counselling support from The AIDS Support Organisation (TASO). The participants were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic or home-based) and HIV progression stage (early or advanced) and interviewed at enrolment, 3, 6, 18 and 30 months of their ART use.

RESULTS

Sexual desire changed over time with many reporting diminished desire at 3 and 6 months on ART compared to 18 and 30 months of use. The reasons for remaining abstinent included fear of superinfection or infecting others, fear that engaging in sex would awaken the virus and weaken them and a desire to adhere to the counsellors' health advice to remain abstinent. The motivations for resumption of sexual activity were: for companionship, to obtain material support, social norms around marriage, desire to bear children as well as to satisfy sexual desires. The challenges for most of the participants were using condoms consistently and finding a suitable sexual partner (preferably someone with a similar HIV serostatus) who could agree to have a sexual relationship with them and provide for their material needs.

CONCLUSIONS

These findings point to the importance of tailoring counselling messages to the changing realities of the ART users' cultural expectations around child bearing, marriage and sexual desire. People taking ART require support so they feel comfortable to disclose their HIV status to sexual partners.

Understanding the context of HIV risk behavior among HIV-positive and HIV-negative female sex workers and male bar clients following antiretroviral therapy rollout in Mombasa, Kenya

This study explored perceptions of HIV following local introduction of antiretroviral therapy (ART), among 30 HIV-positive and -negative female sex workers (FSWs) and 10 male bar patrons in Mombasa, Kenya. Semi-structured interviews were analyzed qualitatively to identify determinants of sexual risk behaviors. ART was not perceived as a barrier to safer sex and in some cases led to decreased high-risk behaviors. Barriers to safer sex included economic pressure and sexual partnership types. Many women reported that negotiating condom use is more difficult in long-term partnerships. These women favored short-term partnerships to minimize risk through consistent condom use. For women living with HIV, concern about maintaining health and avoiding HIV superinfection was a strong motivator of protective behaviors. For HIV-negative women, a negative HIV test was a powerful motivator. Incorporation of context- and serostatus-specific factors (e.g., self-protection for HIV-positive women) into tailored prevention counseling may support high-risk women to reduce risk behaviors.

Attitudes and beliefs about anti-retroviral therapy are associated with high risk sexual behaviors among the general population of Kisumu, Kenya

Attitudes and beliefs about antiretroviral therapy (ART) may affect sexual risk behaviors among the general population in sub-Saharan Africa. We performed a cross-sectional population-based study in Kisumu, Kenya to test this hypothesis in October 2006. A total of 1655 participants were interviewed regarding attitudes and beliefs about ART and their sexual risk behaviors. The majority of participants, (71%) men and (70%) women, had heard of ART. Of these, 20% of men and 29% of women believed ART cures HIV. Among women, an attitude that "HIV is more controllable now that ART is available" was associated with sex with a non-spousal partner, increased lifetime number of sexual partners as well as a younger age at sexual debut. No significant associations with this factor were found among men. The belief that "ART cures HIV" was associated with younger age of sexual debut among women. The same belief was associated with an increased likelihood of exchanging sex for money/gifts and decreased likelihood of condom use at last sex among men. These findings were most significant for people aged 15-29 years. In high HIV seroprevalence populations with expanding access to ART, prevention programs must ensure their content counteracts misconceptions of ART in order to reduce high risk sexual behaviors, especially among youth.

Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery

The current study examines sexual behaviors among HIV-infected Indians in primary care, where access to highly active antiretroviral therapy (HAART) has recently increased. Between January and April 2008, we assessed the sexual behaviors of 247 HIV-infected South Indians in care. Multivariable logistic regression models were used to determine predictors of being in a HIV-seroconcordant primary relationship, being sexually active, and reporting unprotected sex. Over three-fourths (80%) of participants were HAART-experienced. Among the 58% of participants who were currently in a seroconcordant relationship, one-third were serodiscordant when enrolling into care. Approximately two-thirds (63.2%) of participants were sexually active; 9.0% reported unprotected sex. In the multivariable analyses, participants who were in a seroconcordant primary relationship were more likely to have children, use alcohol, report unprotected sex, and have been enrolled in care for >12 months. Sexually active participants were more likely to be on HAART, have a prior tuberculosis diagnosis, test Herpes simplex type 2 antibody seropositive, and have low general health perceptions. Participants who reported unprotected sex were more likely to be in a seroconcordant relationship, be childless, want to have a child, and use alcohol. We did not document an association between HAART and unprotected sex. Among HIV-infected Indians in primary care, predictors of unprotected sex included alcohol use and desire for children. Prevention interventions for Indian couples should integrate reproductive health and alcohol use counseling at entry into care.

Change in sexual activity 12 months after ART initiation among HIV-positive Mozambicans

We assessed sexual behaviors before and 12-months after ART initiation among 277 Mozambicans attending an HIV clinic. Measured behaviors included the number of sexual partners, condom use, concurrent relationships, disclosure of HIV status, alcohol use, and partners' serostatus. Compared to before ART initiation, increases were seen 12 months after ART in the proportion of participants who were sexually active (48% vs. 64% respondents, P < 0.001) and the proportion of participants with HIV-negative or unknown serostatus partners (45% vs. 80%, P < 0.001). Almost all (96%) concurrent partnerships reported at 12 months formed after ART initiation. Although reported correct and consist condom use increased, the number of unprotected sexual relationships remained the same (n = 45). Non-disclosure of HIV-serostatus to sexual partners was the only significant predictor of practicing unprotected sex with partners of HIV-negative or unknown serostatus. Sexual activity among HIV-positive persons on ART increased 12 months after ART initiation. Ongoing secondary transmission prevention programs addressing sexual activity with multiple partners, disclosure to partners and consistent condom use with serodisconcordant partners must be incorporated throughout HIV care programs.

Association between participant self-report and biological outcomes used to measure sexual risk behavior in human immunodeficiency virus-1-seropositive female sex workers in Mombasa, Kenya

BACKGROUND

Few studies have examined the association between self-reported sexual risk behaviors and biologic outcomes in human immunodeficiency virus (HIV)-1-seropositive African adults.

METHODS

We conducted a prospective cohort study in 898 HIV-1-seropositive women who reported engaging in transactional sex in Mombasa, Kenya. Primary outcome measures included detection of sperm in genital secretions, pregnancy, and sexually transmitted infections. Because 3 outcomes were evaluated, data are presented with odds ratios [OR] and 96.7% confidence intervals [CI] to reflect that we would reject a null hypothesis if a P-value was ≤0.033 (Simes' methodology).

RESULTS

During 2404 person-years of follow-up, self-reported unprotected intercourse was associated with significantly higher likelihood of detecting sperm in genital secretions (OR: 2.32, 96.7% CI: 1.93, 2.81), and pregnancy (OR: 2.78, 96.7% CI: 1.57, 4.92), but not with detection of sexually transmitted infections (OR: 1.20, 96.7% CI: 0.98, 1.48). At visits where women reported being sexually active, having >1 sex partner in the past week was associated with lower likelihood of detecting sperm in genital secretions (OR: 0.74, 96.7% CI: 0.56, 0.98). This association became nonsignificant after adjustment for reported condom use (adjusted OR: 0.81, 96.7% CI: 0.60, 1.08).

CONCLUSIONS

Combining behavioral and biologic outcomes, which provide complementary information, is advantageous for understanding sexual risk behavior in populations at risk for transmitting HIV-1. The paradoxical relationship between higher numbers of sex partners and less frequent identification of sperm in genital secretions highlights the potential importance of context-specific behavior, such as condom use dependent on partner type, when evaluating sexual risk behavior.

Decreased sexual risk behavior in the era of HAART among HIV-infected urban and rural South Africans attending primary care clinics

OBJECTIVE

In light of increasing access to HAART in sub-Saharan Africa, we conducted a longitudinal study to assess the impact of HAART on sexual risk behaviors among HIV-infected South Africans in urban and rural primary care clinics.

DESIGN

Prospective observational cohort.

METHODS

We conducted a cohort study at rural and urban primary care HIV clinics in South Africa consisting of 1544 men and 4719 women enrolled from 2003 to 2010, representing 19703 clinic visits. The primary outcomes were being sexually active, unprotected sex, and more than one sex partner and were evaluated at 6 monthly intervals. Generalized estimated equations assessed the impact of HAART on sexual risk behaviors.

RESULTS

Among 6263 HIV-infected men and women, over a third (37.2%) initiated HAART during study follow-up. In comparison to pre-HAART follow-up, visits while receiving HAART were associated with a decrease in those reporting being sexually active [adjusted odds ratio: 0.86 (95% confidence interval: 0.78-0.95)]. Unprotected sex and having more than one sex partner were reduced at visits following HAART initiation compared to pre-HAART visits [adjusted odds ratio: 0.40 (95% confidence interval: 0.34-0.46) and adjusted odds ratio: 0.20 (95% confidence interval: 0.14-0.29), respectively].

CONCLUSION

Sexual risk behavior significantly decreased following HAART initiation among HIV-infected South African men and women in primary care programs. The further expansion of antiretroviral treatment programs could enhance HIV prevention efforts in Africa.

Antiretroviral therapy as HIV prevention: status and prospects

As antiretroviral treatment of HIV infection has become increasingly accessible, attention has focused on whether these drugs can used for prevention because of increased tolerability of newer medications, decreased cost, and the limitations of other approaches. We review the status of antiretroviral HIV prevention, including chemoprophylaxis, as well as the effects of treatment of infected individuals on prevention. It is possible that the life-saving agents that have transformed the natural history of AIDS can be a critical component of HIV prevention efforts, but their ultimate role in affecting HIV transmission dynamics remains to be defined.

An overview of the relative risks of different sexual behaviours on HIV transmission

PURPOSE OF REVIEW

Sexual intercourse represents the majority of HIV transmission and is preventable. Overall, the risk of HIV transmission following a single sexual exposure is low especially in comparison with other sexually transmitted infections (STIs), with estimates of the average probability of male-to-female HIV transmission only 0.0005-0.0026 per coital act. The risk of acquiring HIV from a single contact varies enormously and is dependant upon the infectiousness of the HIV-positive individual and the susceptibility to HIV of their sexual partner.

RECENT FINDINGS

Of concern, unprotected sex among men who have sex with men (MSM) has increased in recent years and HIV incidence in both MSM and heterosexuals remains a considerable public health concern. Sexual practices and health optimism about HIV have changed, which have significantly impacted HIV risk behaviour.

SUMMARY

In this review article we summarize the current evidence regarding the observed relative risks of HIV transmission for each different types of sex act, relationship type and the strategies that have been tested to interrupt transmission.

Antiretroviral therapy and reproductive life projects: mitigating the stigma of AIDS in Nigeria

As millions of people infected with HIV in Africa are increasingly able to live longer and healthier lives because of access to antiretroviral therapy, concerns have emerged that people might eschew protective practices after their health improves. Extending beyond the notion of sexual "disinhibition," researchers have begun to analyze the sexual behavior of people in treatment through the perspective of their marital and childbearing aspirations. This article explores the reproductive life projects of HIV-positive men and women in southeastern Nigeria, showing how actions that contradict medical advice are understandable in the context of patients' socially normative desires for marriage and children. Based on in-depth interviews and observations (June-December 2004; June-July 2006; June-July 2007) of people enrolled in the region's oldest treatment program, we argue that broadly held social expectations with regard to reproduction are experienced even more acutely by HIV-positive people. This is because in Nigeria the stigma associated with AIDS is closely tied to widespread perceptions of social and moral crisis, such that AIDS itself is seen as both a cause and a symptom of anxiety-producing forms of social change. Specifically, in an era of rapid societal transformation, Nigerians see sexual promiscuity and the alienation of young people from traditional obligations to kin and community as indicative of threatened social reproduction. For people who are HIV-positive, marrying and having children offer not only the opportunity to lead normal lives, but also a means to mitigate the stigma associated with the disease. Four ethnographic case studies are provided to exemplify how and why social and personal life projects can trump or complicate medical and public health priorities. These examples suggest that treatment programs must openly address and proactively support the life projects of people on antiretroviral therapy if the full benefits of expanded access to treatment are to be realized.

Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis

BACKGROUND

High plasma HIV-1 RNA concentrations are associated with increased risk of HIV-1 transmission. Initiation of antiretroviral therapy (ART) reduces plasma HIV-1 concentrations. We aimed to assess the effect of ART use by patients infected with HIV-1 on risk of transmission to their uninfected partners.

METHODS

Participants in our prospective cohort analysis were from a randomised placebo-controlled trial that enrolled heterosexual African adults who were seropositive for both HIV-1 and herpes simplex virus type 2, and their HIV-1 seronegative partners. At enrolment, HIV-1 infected participants had CD4 counts of 250 cells per microL or greater and did not meet national guidelines for ART initiation; during 24 months of follow-up, CD4 counts were measured every 6 months and ART was initiated in accordance with national guidelines. Uninfected partners were tested for HIV-1 every 3 months. The primary outcome was genetically-linked HIV-1 transmission within the study partnership. We assessed rates of HIV-1 transmission by ART status of infected participants.

FINDINGS

3381 couples were eligible for analysis. 349 (10%) participants with HIV-1 initiated ART during the study, at a median CD4 cell count of 198 (IQR 161-265) cells per microL. Only one of 103 genetically-linked HIV-1 transmissions was from an infected participant who had started ART, corresponding to transmission rates of 0.37 (95% CI 0.09-2.04) per 100 person-years in those who had initiated treatment and 2.24 (1.84-2.72) per 100 person-years in those who had not-a 92% reduction (adjusted incidence rate ratio 0.08, 95% CI 0.00-0.57, p=0.004). In participants not on ART, the highest HIV-1 transmission rate (8.79 per 100 person-years) was from those with CD4 cell counts lower than 200 cells per microL. In couples in whom the untreated HIV-1 infected partner had a CD4 cell count greater than 200 cells per microL, 66 (70%) of 94 transmissions occurred when plasma HIV-1 concentrations exceeded 50 000 copies per mL.

INTERPRETATION

Low CD4 cell counts and high plasma HIV-1 concentrations might guide use of ART to achieve an HIV-1 prevention benefit. Provision of ART to HIV-1 infected patients could be an effective strategy to achieve population-level reductions in HIV-1 transmission.

FUNDING

Bill & Melinda Gates Foundation; US National Institutes of Health.

Treatment to prevent transmission of HIV-1

Antiretroviral therapy (ART) has the potential to prevent human immunodeficiency virus (HIV) transmission by reducing the concentration of HIV in blood and genital secretions. Indeed, mathematical models with favorable assumptions suggest the potential of ART to stop the spread of HIV infection. Empirical results from ecological and population-based studies and from several short-term observational studies involving HIV status-discordant heterosexual couples suggest that ART reduces the rate of HIV transmission. A multinational, randomized, controlled trial (National Institutes of Health HPTN052) examining the reliability and durability of ART as prevention of transmission in HIV status-discordant couples is under way. The latter and other studies also consider sexual risk-taking behavior and transmission of HIV-resistant variants when ART is used as prevention. Early HIV detection and treatment (ie, test and treat) are being considered as an important prevention strategy. In this article, we review the data supporting the use of ART to prevent HIV transmission and critically examine the public health implications of this strategy.

Health services utilization among South African women living with HIV and reporting sexual and substance-use risk behaviors

HIV health services are critical in sub-Saharan African where the burden of the HIV pandemic is devastating. Existing studies suggest that HIV-infected individuals from marginalized populations who know their status do not seek health services because they are unaware of available treatment and care options, may not understand how to access services, or have poor access to and utilization of health care services. This study examined factors associated with health service utilization in a sample of poor, underserved recently diagnosed HIV-positive South African women with sexual and substance use risk behaviors. The data were collected between June 2004 and May 2008. Primary outcomes included consultation with a medical professional and utilization of any health services since learning of HIV status at 3- and 6-month follow-up assessments. The study findings suggest that denial of HIV status may be a barrier to care, leading study participants to avoid utilizing health services specific to their disease and to prefer more general medical care services. In multivariate analyses, prior use of health services, financially supporting others, and sex trading were strongly associated with health service use at follow-up assessments. The study findings suggest a reduced likelihood of health services utilization among participants who met DSM-IV criteria for drug abuse as well as participants with greater numbers of poor physical health symptoms. As an important preliminary step in examining the issue of health services utilization in sub-Saharan Africa, the findings suggest an urgent need to promote HIV prevention and early testing, to strengthen long-term HIV care services, and to increase access to services.

Treatment with antiretroviral therapy is not associated with increased sexual risk behavior in Kenyan female sex workers

OBJECTIVE

The objective of this study was to test the hypothesis that sexual risk behavior would increase following initiation of antiretroviral therapy (ART) in Kenyan female sex workers (FSWs).

DESIGN

Prospective cohort study.

SETTING

FSW cohort in Mombasa, Kenya, 1993-2008.

SUBJECTS

Eight hundred and ninety-eight women contributed HIV-1-seropositive follow-up visits, of whom 129 initiated ART.

INTERVENTION

Beginning in March 2004, ART was provided to women qualifying for treatment according to Kenyan National Guidelines. Participants received sexual risk reduction education and free condoms at every visit.

MAIN OUTCOME MEASURES

Main outcome measures included unprotected intercourse, abstinence, 100% condom use, number of sexual partners, and frequency of sex. Outcomes were evaluated at monthly follow-up visits using a 1-week recall interval.

RESULTS

Compared with non-ART-exposed follow-up, visits following ART initiation were not associated with an increase in unprotected sex [adjusted odds ratio (AOR) 0.86, 95% confidence interval (CI) 0.62-1.19, P = 0.4]. There was a nonsignificant decrease in abstinence (AOR 0.81, 95% CI 0.65-1.01, P = 0.07), which was offset by a substantial increase in 100% condom use (AOR 1.54, 95% CI 1.07-2.20, P = 0.02). Numbers of sex partners and frequency of sex were similar before versus after starting ART. A trend for decreased sexually transmitted infections following ART initiation provides additional support for the validity of the self-reported behavioral outcomes (AOR 0.67, 95% CI 0.44-1.02, P = 0.06).

CONCLUSION

In the setting of ongoing risk reduction education and provision of free condoms, initiation of ART was not associated with increased sexual risk behavior in this cohort of Kenyan FSWs.

Couples at risk for HIV infection in Southern India: characteristics of HIV-infected patients in concordant and discordant heterosexual relationships

The aim of the article is to compare the clinical and behavioural characteristics of HIV-infected South Indian patients in concordant and discordant heterosexual relationships. A cross-sectional analysis of married couples in concordant and discordant relationships was carried out. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were assessed. A total of 839 concordant patients and 996 discordant patients were included in this analysis. Significantly more men were in discordant than concordant relationships (97% versus 59%; P = 0.002). More discordant patients had never initiated highly active antiretroviral treatment (HAART) than concordant patients (14.1% versus 8.5%; P = 0.004). Concordant patients had significantly higher CD4 cell counts than discordant patients at the time of enrolling to care (205 versus 139 cells/μL; P = 0.001). Discordant patients had significantly higher plasma viral loads than concordant patients (100,000 copies/mL versus 89,154 copies/mL; P = 0.002). Discordant patients were more likely to use condoms with their spouses than concordant patients (49% versus 28.8%; P = 0.01).

In conclusion, couples-based interventions and the provision of HAART could substantially decrease behavioural and clinical correlates of HIV transmission among discordant South Indian married couples. The spouses of HIV-infected index patients are at increased risk for HIV infection, and further preventive measures are needed.

Initial outcomes of provider-initiated routine HIV testing and counseling during outpatient care at a rural Ugandan hospital: risky sexual behavior, partner HIV testing, disclosure, and HIV care seeking

Provider-initiated routine HIV testing is being scaled up throughout the world, however, little is known about the outcomes of routine HIV testing on subsequent behavior. This study examined the initial outcomes of provider-initiated routine HIV testing at a rural Ugandan hospital regarding partner HIV testing, sexual risk behavior, disclosure, and HIV care seeking. In a prospective cohort study, 245 outpatients receiving routine HIV testing completed baseline and 3-month follow-up interviews. After receiving routine HIV testing the percentage of participants engaging in risky sex decreased from 70.1% to 50.3% among HIV-negative and from 75.0% to 53.5% among HIV-positive participants, the percentage knowing their partner(s)' HIV status increased from 18.7% to 34.3% of HIV-negative and from 14.3% to 35.7% of HIV-positive participants. Among those reporting risky sex at baseline, HIV-positive participants were more likely to eliminate risky sex in general and specifically to become abstinent at follow-up than were HIV-negative participants. Similarly, unmarried participants who were risky at baseline were more likely to become safe in general, become abstinent, and start 100% condom use than were married/cohabitating participants. Rates of disclosure were high. Over 85% of those who tested HIV positive enrolled in care. Routine HIV testing in this setting may promote earlier HIV diagnosis and access to care but leads to only modest reductions in risky sexual behavior. To fully realize the potential HIV prevention benefits of routine HIV testing an emphasis on tailored risk-reduction counseling may be necessary.

Higher risk of unsafe sex and impaired quality of life among patients not receiving antiretroviral therapy in Cameroon: results from the EVAL survey (ANRS 12-116)

OBJECTIVE

Cameroon has initiated a national programme of HIV care decentralization providing access to antiretroviral therapy (ART) for patients with CD4 cell counts less than 200 cells/microl or AIDS stage. Current clinical research suggests these criteria may be too stringent. This study aimed at evaluating the effect of not receiving ART on patients' psychosocial outcomes.

DESIGN

The national cross-sectional survey EVAL (ANRS 12-116) collected psychosocial and clinical data for 3151 patients attending HIV services (September 2006 to March 2007).

METHODS

Propensity score matching was used to control for demographic/clinical-immunological differences between patients receiving ART and those who did not. Generalized linear models were used to assess the impact, for different CD4 cell levels, of "not receiving" ART on health-related quality of life (HRQoL) inconsistent condom use with a sexual partner either serodiscordant or of unknown HIV status, self-reported symptoms and disclosure of HIV status to relatives or friends.

RESULTS

Seventy-eight per cent of patients included in the survey were receiving ART. Non-treated patient breakdown was as follows: 8% (CD4<200 or AIDS stage), 5% (200<or=CD4<or=350) and 8% (CD4>350). In the multivariate matched-pairs analysis, impaired physical HRQoL, more frequent inconsistent condom use, more self-reported symptoms and less frequent disclosure of HIV status were all significantly associated (P < 0.0001) with not receiving ART, irrespective of the CD4 cell level.

CONCLUSION

In addition to increasing clinical effectiveness, earlier initiation of ART at less severe immune-depression levels than previously recommended by World Health Organization guidelines for low-resource settings may be justified for improving subjective health and positive prevention among people living with HIV.