Factors affecting HIV-related sexual risk-taking in people living with HIV

For many people with HIV, the post-test counselling session at which they are told about their HIV-positive test result also serves as an introduction to what they need to know about preventing onward transmission of HIV. Post-test counselling, in fact, can be viewed as an important HIV prevention opportunity.

However, a newly diagnosed individual may be unable to take in more than a small fraction of the HIV prevention information provided in a single post-test counselling session. Furthermore, the quality of post-test counselling may vary widely from one health care setting to another.¹

Something else that may limit the effectiveness of post-test counselling as an HIV prevention tool is its focus on the newly diagnosed person’s full range of needs. Whilst a discussion of HIV-related risk reduction strategies and disclosure of HIV-positive status to sexual partner(s) may seem like it ought to be a post-test counselling priority, many other issues vie for attention, including concerns about HIV treatment; interpersonal relationships; employment; financial security; pregnancy and parenting; and other fears and anxieties about the future.

Other than post-test counselling, structured opportunities for HIV-positive people to learn more about HIV-related risk reduction strategies may not be widely available. Most health care systems only provide such services on an ad-hoc basis. Few countries have developed policies regarding what used to be known as “positive prevention” (see ‘Positive prevention’ and its implications for responsibility) and there is often divergent advice on the riskiness of specific sexual practices.

For more on the impact of treatment and/or maintaining an undetectable viral load on the risk of HIV exposure, see the chapter: Risk.

For example, in Switzerland, people with HIV are now counselled that under certain circumstances – on antiretroviral treatment, with an undetectable viral load for six months, and with no other sexually transmitted infections – unprotected sex with their primary partner does not risk HIV exposure.² In contrast, although the United States Centers for Disease Control and Prevention (CDC) acknowledges the Swiss approach, it notes that the risk of transmission on successful treatment is not zero and re-emphasises its long-standing advice that people living with HIV who are sexually active should use condoms with all sexual partners.³

Immediately following their diagnosis, many HIV-positive people are in a state of shock that can lead to confusion and depression. Studies from a wide variety of settings have found that some individuals go on to experience a period of denial.^4,5,6,7 It takes time to adjust to living with HIV, the length of which depends on an individual’s situation.^8,9,10

Denial is an important and complex psychological concept commonly encountered in clinical practice for those dealing with serious illnesses.¹¹ Denial may mean that HIV-positive individuals:

• Do not accept their diagnosis or are oblivious to it;

• Minimise or ignore the full implications of their diagnosis, including their potential infectiousness to others; and/or

• Avoid, delay or comply poorly with treatment.¹²

In several recent cases that have come before the courts (and reported in English-language newspapers), defendants have raised the defence of being in denial – including in Scotland, 2010;¹³ Australia, 2008;¹⁴ and Canada 2008¹⁵ – but have nevertheless been found to be criminally liable for their actions. In another Canadian case from 2008 the judge pointed out during sentencing that the defendant, "seem[ed] to be living in a state of mind of denial," but nevertheless said that having unprotected sex with a stranger without disclosing his HIV status was "an act of extreme callous insensitivity that must be deplored" and that the five-year prison sentence sent a message "that this type of behaviour won't be tolerated".¹⁶

Denial is not to be confused with HIV denialism – a movement that does not believe that HIV causes AIDS, and therefore that HIV exposure or transmission is not harmful.¹⁷ This argument was attempted on appeal to the Supreme Court following a criminal HIV exposure conviction in South Australia, and was rejected.¹⁸

Compared to uninfected individuals, people living with HIV have disproportionately high rates of psychiatric disorders, with mood and anxiety disorders being the most common.¹⁹ Evidence also suggests that posttraumatic stress and bipolar disorders are also more prevalent in HIV-positive individuals relative to the general population.^20,21 Studies have also found that people with psychiatric disorders, including depression and substance use, are more likely to engage in HIV-related risk-taking behaviours, despite knowing their HIV status.^22,23,24 Evidence is emerging that effective mental health interventions can help people reduce HIV-related risk-taking behaviour.^25,26 However, there is a marked lack of structured opportunities within HIV treatment and care settings,²⁷ and the public health system more generally,²⁸ that could help individuals with such a dual diagnosis.

In addition, there appears to be a lack of capacity by the criminal justice system to recognise and deal effectively with mental health issues in the context of potential or actual HIV exposure or transmission.²⁸ "[P]eople with psychiatric illness and intellectual disability are now expected by the courts to possess understanding of and perform according to wider societal norms for sexual behavior," write New Zealand social scientists Alistair MacDonald and Heather Worth in an assessment of how people with a dual diagnosis of mental illness and HIV can be viewed by the criminal justice system. "And while psychiatrists may assert that mental illness does not preclude individuals from knowing right from wrong, perhaps the context, or the world in which those living with the condition exist, does."²⁸

Case studies involving individuals with mental illness on trial for actual or potential HIV exposure or transmission highlight such difficulties. A 26 year-old HIV-positive gay man in Canada was recently sentenced to eight months in prison for not disclosing his HIV status before unprotected sex whilst experiencing an episode of schizophrenia.²⁹ Although the judge told the man that the case was "unusual. . . because you suffered from a mental illness that affected your judgment and because you have expressed genuine remorse" he was told he still deserved a custodial sentence because he "selfishly and recklessly had unprotected sex with [another man, who was not infected] and exposed him to a deadly virus... [It is ] essential that others who are HIV positive understand that if they fail to disclose their condition and engage in unprotected sex with men or women who are not infected, they will go to jail."²⁹ And in the United States, a 28 year-old HIV-positive female sex worker, who was also "diagnosed with a neurological disorder and mental problems" was told she faced between three and 15 years in prison for "aggravated prostitution" because she continued to offer her sexual services following her HIV-positive diagnosis.³⁰

Just like their HIV-negative counterparts, HIV-positive individuals may have a variety of reasons not to use condoms.³¹ These include:

• Being concerned that condom use signals lack of trust or infidelity.

• Conforming to social norms that create social pressure to have unprotected sex.

• Feeling that condoms reduce sexual pleasure or intimacy.

• Participating in sexual cultures where non-condom sex is the norm and it is reasonable to believe anyone entering and taking part knows this.

• Wanting to be free of worry about HIV during sex.

Consequently, people living with HIV may try to prevent transmission to partners by employing strategies other than 100% condom use and direct disclosure of known HIV-positive status.¹ In a 2009 article discussing this phenomenon, researchers from the CDC provide several examples of what they term “moral” behaviour that may still risk HIV exposure.³¹

These include:

• Receiving treatment and/or maintaining an undetectable viral load in the belief these will mean one is no longer infectious. However, as examined in the chapter: Risk, data are still being collected regarding the individual per-act risk of HIV transmission in all circumstances in HIV-positive individuals who are receiving treatment and/or maintaining an undetectable viral load. Courts in Geneva, Switzerland,³² have taken notice of the data on treatment, viral load and extremely low risk of infectiousness, even overturning a previous HIV-related conviction; however other courts currently do not accept that this reduces the risk of HIV exposure enough to remove liability in the absence of disclosure (although with an appeal based on this issue currently before the courts in Canada,³³ this may soon change in other countries).

• A belief that being the receptive partner in sexual intercourse minimises or eliminates risk of HIV transmission to the insertive partner. However, although the relative risk of HIV transmission may well be lower from a woman to a man, or from a receptive partner in anal sex to an insertive partner, a certain amount of risk remains. See the chapter: Risk.

• Choosing partners who are (or assumed to be) of the same HIV status in order to have unprotected sex. To reduce HIV-related risk-taking this requires both partners to be aware of each other's current HIV status. Social scientists have termed this 'serosorting', although when both parties assume they have the same HIV status but one, in fact, has HIV (and either doesn't know it, or has not explicity disclosed this) this has been called "seroguessing".³⁴

1. An excellent review of the changes in gay men’s sexual risk-taking behaviour between 1996 and 2006 can be found in Elford J Changing patterns of sexual behaviour in the era of highly active antiretroviral therapy. Curr Opin Infect Dis 19:26–32, 2006.