Unprotected sex reported by the majority of sexually active adolescents infected with HIV since birth

Close to two-thirds of sexually active adolescents infected with HIV at birth have had unprotected sex, US investigators report in the online edition of Clinical Infectious Diseases. Many of those initiating sexual activity had a high viral load and harboured drug-resistant strains of virus, potentially placing “their partners at risk for infection with HIV, including infection with drug-resistant virus”.

“Sexual intercourse, while a normal developmental milestone, presents special challenges for PHIV+ (perinatal HIV-positive) youth,” comment the investigators. 

Improvements in HIV treatment and care have lead to significant improvements in the prognosis of children who were infected with HIV at birth. Many are now entering adolescence and young adulthood.

Research involving adolescents and young adults infected with HIV through sex showed that many reported unprotected sex after their diagnosis with HIV.

Investigators from the Adolescent Master Protocol (AMP) of the Pediatric HIV/AIDS Cohort Study (PHACS) wanted to establish the prevalence and timing of sexual intercourse and the factors associated with sexual initiation and risky behaviour in adolescents who had been infected with HIV since birth.

A total of 330 individuals aged between ten and 18 years were recruited to the study. They completed computer-assisted questionnaires about their sexual behaviour at baseline. Repeat questionnaires were completed at six monthly follow-up appointments.

The mean age on entry to the study was 13.5 years. Approximately half were female and 71% were black. Just over a third (37%) were living with their biological mother. Substance abuse was reported by 17%. The majority had well-controlled HIV infection: 31% had a viral load above 5000 copies/ml and 75% had a CD4 cell count above 500 cells/mm³.

Overall, 28% reported anal or vaginal sex at baseline or during follow-up. The proportion of those who were sexually experienced increased with age. Sexual intercourse was reported by 53% of 16 year-olds and by 87% of 18 year-olds.

Median age at first sexual intercourse was 13 years for boys and 14 years for girls. Boys also reported oral sex at an earlier age than girls (13 vs 15 years).

A same-sex partner was reported by 13% of males and 21% of females.

Initiating sexual activity during follow-up was associated with non-adherence to antiretroviral therapy (HR = 2.87; 95% CI,1.32-6.25, p = 0.008); older age at baseline (HR = 1.55; 95% CI, 1.20-2.01, p = 0.001) and experience of genital touching at baseline (HR = 2.72; 95% CI, 1.01-7.31, p = 0.05).

Overall, 62% of those reporting sexual intercourse (at baseline or initiation during follow-up) reported unprotected sex. Unprotected sex was reported by two-thirds of those reporting anal sex. Four male participants reported anal sex with a male partner; in three instances, this was unprotected.

Factors associated with reporting unprotected sex were living in a household with an annual household income below $20,000 (p = 0.03) and living with a biological relative other than the biological mother (p = 0.04).

A significant proportion (n = 38; 42%) of sexually active participants had a viral load above 5000 copies/ml. Drug-resistance data were available for 37 of these individuals: 30 (87%) were identified as harbouring virus that was resistant to at least one antiretroviral (ARV) and 22% had resistance to drugs from the main three classes of anti-HIV drugs.

“This resistance is permanent, limiting the treatment options both for the PHIV+ youth and their partners,” comment the authors.

The majority (82%) of participants reported knowing they were HIV positive when they first had sex. A third of these individuals disclosed their HIV status to their first sexual partner. Regardless of disclosure, the majority of individuals (83% disclosed; 84% non-disclosed) reported discussing the use of condoms with their partner.

However, rates of condom use were significantly higher among those who disclosed compared to those who did not disclose their HIV status (67 vs 22%, p = 0.04).  

“HIV disclosure as well as condom use and adherence should be emphasized, so that sexual partners were empowered to make safe choices”, write the authors.

They conclude, “interventions that enhance ARV medication adherence, consistent condom use, and HIV disclosure to sexual partners are essential as…youth prepare for independent living and transition to adulthood”.

Tassiopoulos K et al. Sexual risk behavior among youth with perinatal HIV infection in the United States: predictors and implications for intervention development. Clin Infect Dis, online edition, DOI: 10.1093/cid/cis816, 2012.