Counselling during routine HIV care reduces rates of risky sex among people on ART in South Africa

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HIV prevention counselling delivered during routine care reduces sexual risk behaviour in people receiving antiretroviral therapy (ART) in South Africa, according to research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Approximately 2000 people were randomised to receive risk-reduction counselling or standard of care. Over 18 months of follow-up, people in the intervention arm were less likely to report any recent unprotected sex and also recent unprotected sex with a partner who was HIV negative or of unknown HIV status.

“Results demonstrated a substantial decline in HIV risk behavior and persistence of reduced risk behavior supported by the continued presence of the intervention,” comment the authors. “The intervention was delivered during routine clinical care visits, on an ongoing basis, by trained lay counselors…this approach provides effective and continuing intervention exposure linking HIV treatment with prevention while deploying resources effectively.”

However, the counselling did not have any effect on rates of sexually transmitted infections (STIs).


risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

detectable viral load

When viral load is detectable, this indicates that HIV is replicating in the body. If the person is taking HIV treatment but their viral load is detectable, the treatment is not working properly. There may still be a risk of HIV transmission to sexual partners.

standard of care

Treatment that experts agree is appropriate, accepted, and widely used for a given disease or condition. In a clinical trial, one group may receive the experimental intervention and another group may receive the standard of care.

A significant proportion of people taking ART in South Africa do not achieve an undetectable viral load. In addition to the potential impact on their own health, these patients remain potentially infectious and could pass on HIV during unprotected sex.

An international team of investigators wanted to see if HIV prevention counselling delivered during routine care reduced rates of unprotected sex among people receiving ART.

They therefore designed a study involving 1891 people who received care at 16 sites in South Africa between 2008 and 2010. Half the sites were randomised to provide prevention counselling during clinical visits; the others standard of care. Prevention counselling was provided by trained lay counsellors. The counselling was based on an intervention called Options that had previously been shown to reduce sexual risk taking among people living with HIV in the United States.

The aim of the study was to see if counselling reduced the number of sexual events without a condom in the past four weeks with a partner of any HIV status. Data were also gathered to determine if the intervention had an impact on rates of unprotected sex with partners who were believed to be HIV-negative or were of unknown HIV status. Assessments were conducted at baseline, month 6, month 12 and month 18. Participants in the study were also screened at baseline and at regular intervals during follow-up for penile/vaginal bacterial STIs.

At baseline, the participants had a mean age of 37 years. Approximately two-thirds had been taking HIV therapy for less than two years, 30% had a CD4 count below 200 cells/mm3 and a quarter had a detectable viral load.

During follow-up, the reported number of unprotected sex acts with partners of any HIV status during the previous four weeks declined significantly in both arms of the study. However, the magnitude of the reduction was greater in the intervention arm (p < 0.002). Results favoured the intervention arm at all follow-up points.

People in the intervention arm were also significantly less likely to report recent unprotected sex with an HIV-negative partner or partner of unknown status (p < 0.0001).

“The findings support the efficacy of our intervention for reduction of HIV risk among HIV-infected South Africans on ART,” write the authors.

Despite these apparent differences in sexual risk behaviour, approximately 7% of people in both study arms were diagnosed with an STI during follow-up.

“Our intervention provides effective, efficient, continuing support for HIV risk reduction among HIV-infected South Africans on ART,” the researchers conclude.


Fisher JD et al. HIV prevention counseling intervention delivered during routine clinical care reduces HIV risk behavior in HIV-infected South Africans receiving antiretroviral therapy: the Izindlela Zokuphila/Options for Health Ranomized Trial. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0000000000000348 (2014).