Belief that HAART makes HIV less serious linked with shift to unsafe sex in Dutch gay men

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Gay men are realistic about the benefits of HAART, but those who believe that HIV is less of a threat since the introduction of HAART are more likely to start having unprotected anal sex, according to a Dutch study published in the January 23rd edition of AIDS. The investigators from the Amsterdam Cohort Study believe that their findings have important implications for HIV prevention strategies, but are unconvinced that trying to change beliefs about the reduced seriousness of HIV will be an effective prevention tool.

A total of 217 HIV-negative gay men in Amsterdam aged under 31 were recruited to the study and interviewed at six-monthly intervals between the autumn of 1999 and spring 2002. The average age of the men was 29.8 years, over 93% were Dutch and two-thirds were defined as highly educated.

The aim of this longitudinal study was to determine the relationship between beliefs about HAART and risky sexual behaviour. Three sets of HAART-related beliefs were identified by the investigators: a perception that HIV was less of a threat due to HAART; a perception that there was less of a need for safer sex because of HAART; and a perception that HAART was an effective cure for HIV.



Receptive anal intercourse refers to the act of being penetrated during anal intercourse. The receptive partner is the ‘bottom’.


Insertive anal intercourse refers to the act of penetration during anal intercourse. The insertive partner is the ‘top’. 

safer sex

Sex in which the risk of HIV and STI transmission is reduced or is minimal. Describing this as ‘safer’ rather than ‘safe’ sex reflects the fact that some safer sex practices do not completely eliminate transmission risks. In the past, ‘safer sex’ primarily referred to the use of condoms during penetrative sex, as well as being sexual in non-penetrative ways. Modern definitions should also include the use of PrEP and the HIV-positive partner having an undetectable viral load. However, some people do continue to use the term as a synonym for condom use.

longitudinal study

A study in which information is collected on people over several weeks, months or years. People may be followed forward in time (a prospective study), or information may be collected on past events (a retrospective study).

odds ratio (OR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

The young gay men in the study were asked to say how strongly they agreed or disagreed with 17 questions designed to assess these perceptions on a scale of one to seven (seven indicating strong agreement). They were then asked about changes in their sexual risk behaviour in the previous six months, particularly if they had moved from having protected receptive or insertive anal sex with a casual partner to having unprotected receptive or insertive anal sex with one or more casual partners.

Investigators studied the association between the different HAART-related beliefs and changes in sexual behaviour to see if they could find a relationship between treatment beliefs and an adoption of risky sexual practices.

Median scores were low for all three set of HAART-related beliefs, with gay men disagreeing that HAART made HIV less of a threat (median score two), that HAART made safer sex less necessary (median score one), and that HAART cured HIV (median score 1.5).

A total of 28 men changed from having protected receptive anal sex to unprotected receptive anal sex once, and two men twice. In addition, 49 men changed from having protected insertive anal sex to insertive anal sex without a condom, with one man reporting doing this twice. In total, twelve men changed to having both receptive and insertive anal sex without a condom.

Investigators found that there was a significant relationship between a tendency to perceive HIV as less of a threat since HAART and a move to having unprotected receptive anal sex (adjusted odds ratio 1.60; 95% CI, 1.16 – 2.22, p<0.01). In addition, men adopting unprotected receptive sex were statistically more likely to adopt insertive anal sex without a condom (adjusted odds ratio 8.83, 95% CI, 2.65 – 29.18, p<0.01).

The investigators comment that “to our knowledge, this is the first study to use longitudinal data in investigating the association between HAART-related beliefs and a change to unprotected anal intercourse in homosexual men.” They emphasise that despite the fact that most men were realistic about the benefits of HAART, “men who inclined towards agreement with perceiving less HIV threat since HAART are more likely to change from protected to unprotected receptive anal intercourse.” The investigators add that “the findings of this study are supportive of the hypothesis that perceiving less HIV threat since HAART is a cause of the change to high-risk sexual behaviour.”

The findings of this study differ to a cross-sectional UK study published last year (see link below), which found that gay men were realistic, not optimistic about HAART. The Dutch investigators suggest that the different findings could be explained by the different methodology used in the two investigations.

Several implications arising from this study for HIV prevention are outlined by the investigators. They suggest that as HIV treatments continue to improve and progress is made towards a vaccine, gay men are likely to become less likely to perceive HIV as a threat. This will probably result in an increase in risky sexual behaviour, and an increase in the number of infections with gonorrhoea, syphilis and, probably, HIV. Efforts to prevent the transmission of HIV amongst gay men, stressing the value of condoms to risk reduction, should therefore continue, particularly given the long-term side-effects of HAART, the transmission of drug-resistant HIV and the large number of gay men with undiagnosed HIV infection.

However, the investigators caution that “it remains to be determined whether addressing the reduced HIV threat is an effective prevention strategy.” They note that HIV treatments are improving and that HAART does reduce infectiousness, “giving men who perceive less HIV threat strong arguments to do so, making this belief resistant to change.”

Further information on this website

Gay men realistic, not optimistic about HAART says study - news story

The dark side of HAART optimism? More unsafe sex and poor adherence - news story

Safer sex fatigue and HAART optimism explain rise in US bareback sex - news story

Amsterdam's young gay men getting HIV from steady partners - news story

HIV incidence increasing most rapidly among older gay men in Amsterdam - news story


Stolte IG et al. Homosexual men change to risky sex when perceiving less threat of HIV/AIDS since availability of highly active antiretroviral therapy: a longitudinal study. AIDS 18: 303 – 309, 2004.