Many South African people whose HIV has been diagnosed have unprotected sex with a serodiscordant partner before starting ART

Among a sample of South Africans living with diagnosed HIV infection in South Africa and waiting to start antiretroviral therapy (ART), one quarter reported recent condomless sex with an HIV-negative/untested partner, according to research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

“The present investigation is the first to quantify HIV exposure associated with sexual behaviour among tested-but-not-treated South African PLWH [people living with HIV], and it provides much needed insight into the underpinnings of serodiscordant condomless sex occurring among this population,” comment the researchers.

Unprotected sex with a serodiscordant partner was associated with poor supportive norms about condom use, low self-perceived ability to negotiate the use of condoms and hazardous alcohol consumption.

Many people living with HIV now have a normal life expectancy thanks to ART and there is compelling evidence that ART-treated individuals whose viral load is undetectable are not infectious to their sexual partners.

Over 2 million HIV-positive South Africans are now taking ART. However, a proportion of South Africans whose HIV infection has been diagnosed do not promptly start antiretrovirals, either because they have not reached the CD4 cell threshold for starting treatment, for facility-related reasons or by personal choice. These patients are therefore unable to benefit from this medication.

Investigators designed a study to assess the prevalence of serodiscordant condomless sex among South African people diagnosed with HIV who had not yet started ART. The research also aimed to determine the number of sexual partners who were potentially exposed to HIV and the factors associated with risky sex.

The study sample comprised 266 sexually active adults receiving care in KwaZulu-Natal. They completed a questionnaire enquiring about their sexual behaviour in the previous four weeks, demographics, use of alcohol, mental health, HIV-related stigma, knowledge of HIV prevention, attitudes towards condoms and power to use/negotiate condoms.

Most of the study sample (195) were female, the mean age was 31 years, the majority were unemployed and lived in rural areas and 34% lived with a sex partner. The mean period since diagnosis with HIV was 98 days and the mean CD4 cell count was 517 cells/mm³. None of the participants had started ART and only 10% had started a clinic-based HIV literacy programme, a requirement before ART initiation in South Africa. Hazardous alcohol use was reported by 14% of individuals and 22% reported depression.

The majority of the participants were sexually active, with 182 individuals reporting 766 sexual acts with 201 partners in the previous four weeks. Approximately 40% reported unprotected sex in this period and a total of 371 condomless sex acts with 107 partners.

Serodiscordant condomless sex was reported by one in four sexually active individuals, who engaged in 207 condomless sex acts with 66 serodiscordant partners in the four weeks before the study.

After controlling for potential confounders, factors associated with serodiscordant condomless sex included poorer supportive norms for condom use (p = 0.039), lower perceived power to negotiate condom use (p = 0.003) and hazardous alcohol use (p = 0.007).

“The findings…suggest the imperative to deliver behavioral prevention efforts at the time of HIV diagnosis if an immediate test-and-treat approach is unfeasible,” comment the investigators. “For example, as hazardous alcohol consumption was associated with a greater than three-fold increase in the likelihood of serodiscordant condomless sex, the implementation of alcohol screening and brief interventions could help reduce both alcohol use and engagement in high-risk sex. Similarly, evidence-based behavioural interterventions that establish normative support for condoms and provide skills that empower safer sex negotiation could further help curtail HIV transmission.”

However, the authors emphasise that their findings "provide a compelling justification for an immediate test-and-treat approach to be implemented in South African clinical care settings." A recently-presented South African study has shown that offering treatment at the first clinic visit speeded up treatment initiation and improved viral suppression, with some evidence suggesting that the intervention especially improved treatment initiation among younger people (under 35) and among people diagnosed at a primary health clinic. South Africa will begin to offer HIV treatment for everyone diagnosed with HIV later this year, removing restrictions based on CD4 cell count.