Patients who do not take their anti-HIV drugs properly are more likely to have unprotected sex, according to a US study published in the May 2003 edition of the journal Sexually Transmitted Diseases.
The impact of HAART on the risk-taking behaviour of HIV-positive patients is the subject of intensive research, with several studies finding that patients who are doing well on HAART are more likely to have unprotected sex. There is also concern that increasing numbers of new infections are with HIV which is resistant to anti-HIV drugs (see links below). Investigators in Denver, Colorado, wished to see if there was a link between unprotected sex or sharing needles and levels of adherence to HAART in their patients.
The study involved 95 randomly selected patients and involved the completion of a questionnaire which asked about sexual and drug taking behaviour in the past three months. Patients were also asked to recall their level of adherence to HAART over the past three days and their answers were checked with reference to pharmacy records.
On the basis of their answers, patients were placed into one of three HIV transmission risk categories. High risk patients were those reporting unprotected anal or vaginal sex or needle sharing. Low risk patients reported anal or vaginal sex with a condom and/or protected or unprotected oral sex. Patients assessed as having no HIV transmission behaviour reported no sex or needle sharing.
The average age of patients in the study was 40 years, 82 (86%) were men, 54 (57%) were white and 73 (77%) were gay. Sixty-nine patients (73%) were taking HAART.
The majority of the study population were sexually active, with 60% reporting at least one episode of anal, oral or vaginal sex in the previous three months. Although 17% reported only having oral sex, 21% said that they had had anal or vaginal sex without a condom. Only one patient reported needle sharing, and he had also had unprotected anal sex with multiple partners.
The likelihood of using condoms was not affected by the patients being the insertive partner or the perceived HIV-status of the partner. There was a trend for condoms to be used more often with casual partners rather than a regular partner (43% versus 31%). Patients who told their casual partners their HIV status were just as likely to have unprotected sex as patients who never disclosed that they were HIV-positive.
Patients reporting unprotected anal or vaginal sex were younger, better educated, and more likely to have a problem with drugs or alcohol. There was also a non-significant association with being in employment and never having had an AIDS-defining illness.
When the investigators looked at adherence to HAART, they found that: 'high-risk behaviour was associated with lower rates of adherence to antiretroviral therapy and higher plasma HIV' [viral loads].
The investigators note that patients with 'the highest self-reported risk' of HIV transmission behaviour 'had the lowest adherence' They add that those who reported higher levels of risk behaviour had higher plasma and presumably genital HIV viral loads and were more likely to transmit HIV, which given their poor adherence was likely to be drug resistant.
Patients in the study had a high level of knowledge of safer sex, and the investigators suggest that HIV prevention efforts targeted at HIV-positive patients should focus on behaviour change, which 92% of patients in the study said they would welcome.
Further information on this website
US study finds poor adherence, depression, drug use and unprotected sex linked - news story February 2003
HIV-positive gay men on HAART no more likely to have unprotected sex than untreated men - news story February 2003
Unprotected sex in France linked to anxiety, depression, lipodystrophy, not treatment success - news story November 2002
Flaks RC et al. HIV transmission risk behaviour and its relation to antiretroviral treatment adherence. Sexually Transmitted Diseases, 30: 399 – 404, 2003.