HIV-positive gay men on HAART no more likely to have unprotected sex than untreated men

Otherwise healthy HIV-positive gay men on HAART are not “throwing caution to the winds” and having more unprotected anal sex according to a UK study published in the February 2003 edition of the journal Sexually Transmitted Infections.

However, the study did find that over a fifth of HIV-positive gay men had had unprotected anal sex with at least one partner in the past year and had high rates of other sexually transmitted infection.

Between July 1999 and August 2000, investigators involved in the SHARP (Sex, Health and Anti-Retrovirals Project) study recruited 405 HIV-positive gay men attending a large HIV outpatient clinic in central London to a study designed to see if there was a link between sexual risk taking and HAART.

Each patient was asked to complete a computer assisted self interview which asked questions about number and type of sexual partner (casual, regular, HIV status), HIV disclosure, and sexual behaviour. Patients were also asked to assess the state of their own health to say what their views and experiences of HAART were.

Results from the questionnaire were matched with sexual health records and other medical records to provide details of age, years since HIV diagnosis, CD4 count and viral load.

The overwhelming majority of men in the study, 90%, had had sex with another man in the previous six months. Of these, 14% had had sex with their primary partner only, 46% only with casual partners and 30% with a combination of both primary and casual partners.

Detailed information on almost 400 sexual contacts was obtained. HIV status was disclosed to a little under a third of these, and 13% of the men in the study reported having unprotected anal sex with a primary partner who was either HIV-negative or untested.

Seventy–three percent of men in the study rated their health as either very or fairly good. These men were more likely than those in poorer health to report unprotected anal sex with at least one partner in the past six months (21% versus 17%).

Nearly three quarters of the study sample were on HAART. Although they tended to be older than patients not on HAART and to have been diagnosed with AIDS, they were almost as likely as men not on HAART to assess their health as good (72% versus 75%).

Men on HAART tended to have fewer sexual partners (nine versus 20 in the past six months) and to have had less unprotected insertive anal sex in the past year (27% versus 36%) and to have had fewer sexually transmitted infections.

Adjustment for age, CD4 count and number of years since HIV diagnosis reduced the differences, but men on therapy remained significantly less likely to have had insertive unprotected anal sex with a new partner.

There appeared to be no evidence of “HAART optimism” leading to an increase in risky sexual behaviour, with, “87% of men on HAART report[ing] they were ‘just as likely to practice safer sex as they always were’, and only 4% agreed that being on new drugs that reduce viral load means that safer sex is not important.”

The investigators observe that their finding “clearly show that men on HAART do not take higher levels of sexual risk.”

However, the investigators go on to note that 22% of men in the study had had insertive unprotected anal sex with a new partner at least once in the past six months, and that most of these partners had been casual. They add that HIV status was only disclosed in a third of these instances.

HIV-positive men in the study also had high levels of sexually transmitted infections, with just under a quarter having had at least one in the past year. This compared to 10% of HIV-negative gay men in an earlier study conducted at a London sexual health clinic.

Concerning the link between HAART and treatment optimism the investigators state, “men on HAART are no more likely to have unprotected anal intercourse than those not on HAART. Together with data showing fewer other STI in the last year, lower viral load and fewer partners, a consistent picture emerges of lower risk of onward transmission of HIV among men taking HAART.”

The investigators speculate that age, or selection bias may account for this, but that their data “suggest that it is unlikely that taking HAART itself leads HIV-positive gay men to throw caution to the winds.”

However the high rate of unprotected sex amongst their patients leads the study authors to call for more effort to be directed “towards risk reduction interventions for known HIV positive gay men.”

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