Study: HIV diagnosis won’t stop unprotected sex

Study shows prevention efforts are hindered

Research in an inner-city population has showed that many of the people, particularly women, diagnosed with HIV infection continued to engage in unprotected sex after their diagnosis and prevention education.

"What we found was that more than 40% of all patients had some HIV risk behavior after they knew they were positive," says Joseph P. McGowan, MD, medical director of the Center for AIDS Research and Treatment at North Shore University Hospital in Manhasset, NY.

The study was conducted among patients at the Bronx-Lebanon Hospital Center in New York City, where McGowan previously worked.

Also, the study found that 25% of those infected with HIV had a new sexually transmitted disease (STD) diagnosis, and 15% used injection drugs. 1

In further examination of the data from 256 HIV-infected patients, researchers found unprotected sex was reported by heterosexual women more than by heterosexual men. Men who have sex with men (MSM) had similar rates as the women of failing to use protective measures during sex.

Sex traders at risk

Those who reported that they traded sex for money or drugs reported the highest rates of having unprotected sex of all other HIV-positive groups after receiving an HIV diagnosis, adds McGowan.

"We focused on the women, and what we found was that if there was a history of trading sex for money or drugs then that was highly associated with having unprotected sex after HIV infection," he says.

Patients who had been diagnosed with HIV infection more than five years ago had the highest rates of unprotected sex, with 54% reporting having had unprotected sex.

By contrast, 27% of patients who had been diagnosed less than a year earlier reported having unprotected sex, and 36% of patients who had been diagnosed between one and four years said they had unprotected sex, McGowan adds.

Investigators also found that study participants who were on highly active antiretroviral therapy (HAART) also were more likely to have unprotected sex, he points out.

"If someone was on HAART and traded sex for money or drugs, they were 11 times more likely to have unprotected sex than those who didn’t trade sex or have HAART," McGowan notes.

The association between unprotected sex and HAART might be due to the fact that people feel safer when on antiretroviral drugs, and perhaps, do not feel they are at risk for transmitting the virus, he speculates.

However, there was no indication that the patients who were on HAART were basing their behavior on their viral loads, which — if low — can reduce the risk of transmitting HIV, says McGowan.

Another possibility for this finding is that some of the people who trade sex and are on HAART may be selling their medicine to buy drugs, he says.

Researchers theorize that the women who trade sex have low self-esteem and may be less empowered to enforce condom use on their clients and sexual partners, McGowan adds.

"And if they insist on condom use, it might also reveal their status, and that would affect their ability to proceed with the sexual interaction," he says.

Prevention counseling had been given to all of the people involved in the study, first after they received word that they were HIV-positive and then on an annual basis, McGowan says.

"These behaviors are very hard to change," he continues. "Many studies show that drug use and trading sex, especially if it’s survival sex, is very difficult to change after an individual finds out he or she is positive."

A more optimistic way to view the findings is to note that there was a 60% drop in unsafe sexual behavior among the HIV-positive patients, because 100% of them had engaged in unsafe sexual practices prior to their HIV diagnosis, says McGowan.

What these findings mean for HIV clinicians is that they need to enhance their safe sex messages and counseling for HIV-positive patients, he points out.

"The safe sex message should be given in a nonjudgmental way in an ongoing fashion," McGowan says. "We stress that how you give the message is very important; we want to give it in a way that motivates them to change."

Simply telling people to use condoms is not effective, he says.

For some patients, the problem may be their drug use, especially crack cocaine and alcohol use, so that has to be addressed in a nonjudgmental way, McGowan adds.

"We need to set achievable goals for people, and instead of saying Stop using drugs,’ say Let’s try to cut back on drugs,’" he suggests.

"Yes, they may be engaged in unsafe sex, and, yes, they are HIV-positive; but we don’t want to approach them in a judgmental or condescending way because we understand their motivations are not that they want to get people infected," explains McGowan.

Reference

1. McGowan JP, Shah SS, Ganea CE, et al. Risk behavior for transmission of human immunodeficiency virus (HIV) among HIV-seropositive individuals in an urban setting. Clin Infect Dis 2004; 38:122-127.