To what extent do gay men modify their sexual risk behaviour after testing HIV positive? Two Australian surveys conducted over the last few years have found that in the immediate aftermath of diagnosis, gay men considerably reduce the number of partners they have sex with – many stopping sexual activity altogether – and also reduce the amount of condomless sex they have with partners of unknown HIV status. There was also an increase in HIV status disclosure.
None of these changes might be regarded as particularly surprising and this piece of research cannot determine whether these changes are sustained. What was more interesting was that the only factor that was associated with a higher likelihood of such reductions in HIV risk behaviour was peer support from other men with HIV (and not from anyone else).
Finding out whether HIV-positive people reduce or increase their HIV risk behaviour after they are diagnosed is of obvious relevance to HIV prevention, especially if they do not go on antiretroviral therapy (ART) or otherwise fail to achieve an undetectable viral load.
It has never been a settled question, however, because different surveys have discovered very different things. This is compounded by the fact that a lot of surveys have only measured condomless sex or the number of sexual partners without ascertaining the HIV status of condomless-sex partners or whether the HIV-positive person is virally undetectable
Nonetheless, survey results have varied hugely, ranging from a study from San Francisco that estimated that gay men with HIV had reduced their chances of passing on HIV by 97% by two years after diagnosis, to a UK study that found higher rates of risky sex in diagnosed HIV-positive people than undiagnosed.
There have also been fewer studies conducted in recent years when a higher rate of people diagnosed may go on to treatment straight away and/or be virally suppressed.
The two surveys
Between 2008 and 2015, Australian researchers conducted two questionnaire surveys of gay men with HIV who had been diagnosed less than two years previously: one in the years before treatment upon diagnosis was generally recommended (2008-2010), and one in the years after (2011-2015). In total 712 men, or about 10% of all gay men diagnosed with HIV during this period, answered one of the surveys, though only 564 completed the questions about their sexual behaviour, 263 in the first time period and 301 in the second. Although the two questionnaires asked different questions they were conceived as a single piece of research and men could only answer once.
In the first questionnaire, men were asked to compare the number of casual partners they had sex with in the four weeks before and the four weeks after diagnosis, and also to compare how many partners who they knew to have HIV and they had condomless sex with, especially as the ‘top’ partner. They were also asked to rate on a one to ten scale the amount of post-diagnosis support they received from gay friends, a regular partner, parents, their doctor and other people with HIV.
In the later time period, these questions were replaced with simpler direct questions such as “Have you done any of the following since you were diagnosed with HIV? Reduced your number of partners; avoided sex with HIV-negative partners; told people your HIV status before sex.” The support question was replaced by “Since diagnosis have you sought support from other positive men through HIV organisations, support groups or online forums?”
Taking both surveys together, most men were aged 30-50 and most were graduates. Nearly two-thirds (63%) of respondents had been diagnosed less than a year, and one-third less than three months, before they answered the survey. Three-quarters estimated they had caught HIV less than a year before diagnosis, and half less than three months before.
A quarter were not native Australians and a third had a regular partner when they were diagnosed. More than one in five had significant, and one in seven severe, depression, and 70% said they were more depressed after than before being diagnosed.
Respondents to the 2008-2010 questionnaire reported less condomless sex with casual partners after diagnosis than before – 27% (14% as insertive partner) versus 16% (6.2% as insertive partner). Before diagnosis nearly all of this was with HIV-negative or status-unknown partners, but after diagnosis less than 10% reported this, indicating that the proportion having condomless sex with known HIV-positive partners had switched from 0.9% to 6.2%.
However the reduction in condomless sex with casual partners was largely due to respondents stopping sex altogether after diagnosis. In the four weeks before diagnosis, 46% reported any sex with casual partners; in the four weeks afterwards, 30.5%, and 22% stopped condomless sex with HIV negative or status-unknown partners.
The only factor statistically associated with a reduction in the number of casual partners was greater personal support from other people with HIV. People reporting greater than average personal support from HIV-positive peers were nearly 40% more likely to reduce their number of casual sex partners or stop casual sex altogether.
In the second survey 56% of respondents said they had reduced the number of men they had sex with since their diagnosis and 47% said they had stopped having sex altogether, at least for a while. Thirty-eight per cent said they had stopped having sex with partners of HIV-negative or unknown status and a third said they were now more likely to disclose their HIV status before sex. Less than one in seven had made no adjustment to their HIV risk behaviour.
Those who reduced their number of casual partners or stopped sex altogether were nearly twice as likely to report having received support from HIV-positive peers and so did men who said they were more likely to disclose their HIV status. The minority of men who had made no change in their risk behaviour were 70% less likely to report support from other people with HIV. Reducing the amount of casual sex or stopping it altogether was also associated with a higher score for depression, which is not surprising as significant depression is associated with less sexual activity.
Discussion and conclusions
This is one of the first behavioural surveys to try and capture HIV-positive men’s changes in behaviour post-diagnosis since universal treatment started to be recommended, and it finds a significant role in support from HIV-positive peers (and only them – not regular friends, partners, family or doctor).
It is important to emphasise that the surveys only capture behaviour in the immediate post-diagnosis period – in the first survey, only in the four months afterwards, and even in the second, two-thirds had been diagnosed less than a year.
As the researchers themselves comment, “Following an HIV diagnosis, some individuals may withdraw into themselves or spend time considering what the future holds. One aspect of this may be a period of celibacy or reduced sexual interest.”
Another important consideration is that neither survey asked the participants whether they were on treatment or had an undetectable viral load. This is important as a person’s perception of their own infectiousness may make a considerable difference to whether they serosort, use condoms or indeed have sex at all.
How does one reconcile this with surveys that show that HIV-positive people in general tend to have more casual and condomless sex and very high levels of sexually transmitted infections? One reason may be that after the post-diagnosis period, HIV-positive men simply revert to, or even exceed, previous levels of sexual activity. However while this may be the case, ‘serosorting’ behaviour appears to continue and while HIV-positive men may have more condomless sex, a lot of it is with men with HIV, as surveys from both San Francisco and London suggest.
This may have positive effects in the gay community in general as it reduces the amount of sex that risks HIV transmission, but negative effects on the HIV-positive men themselves, as it restricts them to a smaller pool of partners with much higher rates of circulating STIs.
What this Australian survey shows, however, is that peer support from other men with HIV can also have a positive effect.
Prestage G et al. Impact of peer support on behavior change among newly diagnosed Australian gay men. JAIDS, early online publication, DOI:10.1097/QAI.0000000000001017. Abstract here. 2016.