Who defines ‘Positive prevention’?

Structured, theory-based prevention programmes for people with HIV can be very effective, the XVII World AIDS Conference heard on Monday, with one programme reporting a 67% decline in risk in gay men given peer training. But it also heard that there is disagreement among HIV-positive activists as to whether people with HIV should be targets for interventions to reduce HIV transmission at all.

A session on `Positive Prevention` introduced two surveys of sexual behaviour among people with HIV from the global South and North, and also two radically different intervention models.

The first behavioural survey (Shuper) was one of HIV-positive men and women in the Umyungundlovu District of KwaZulu Natal Province in South Africa, a region with one of the highest local HIV prevalences anywhere in the world – 44.4% of the adult population. A survey coordinated by the University of Toronto conducted confidential, computer-assisted questionnaires of 202 people living with HIV and taking antiretrovirals.

The study found that one in three patients had had unprotected sex in the last four weeks and one in six with a possibly serodiscordant partner. The study’s most striking finding was the degree to which unprotected sex amongst positive women was related to social vulnerability. Although the women were less sexually active than the men (38% had had any sex in the last four weeks compared with 52% of the men), more of them had had unprotected sex (40% versus 27%), though this was no more likely to be potentially serodiscordant.

The vast majority of women were unemployed (85%) but all the women who reported unprotected sex were unemployed, compared with 70% of those who did not. Other correlates of unprotected sex in women were physical abuse within the relationship, feeling lonely and marginalised, and low perceived power to negotiate condom use.

In contrast one of the biggest predictors of unprotected sex in the men was alcohol use before sex: 83% drank before unprotected sex compared with 48% before protected sex.

Suspicion about the efficacy of condoms was related to unprotected sex in both men and women, with 40% agreeing that “condoms are not strong and break easily” and over one in five agreeing that “the free condoms supplied by the government contain HIV.”

A survey of HIV-positive men and women in Europe produced not dissimilar findings. Eurosupport 5 is a European network surveying sexual behaviour in people with HIV in 16 HIV clinics in 13 European countries. A cross-sectional questionnaire sent out to a randomly selected group of patients enquired about sexual behaviour and also about psychological factors.

Although the questionnaire was sent out to over 3000 people only 1212 replied, a response rate of 39%, which may compromise its representativeness.

Of those who replied 58% were gay men, 24% women and 18% heterosexual men. Of note, 13% of heterosexual men and 10% of women reported having anal sex.

Gay men were somewhat more likely to report having had unprotected sex with possibly serodiscordant partners (37%, versus 31% in women and 25% in straight men).

Unprotected sex in all patients was associated with having a positive partner. In women, older age, cannabis use and wanting a child were associated with unprotected sex, in gay men younger age, use of recreational and erectile-dysfunction drugs, were associated with unprotected sex, and worryingly, with having better-quality sex. Socioeconomic status was correlated positively with unprotected sex in gay men (employment) but negatively in straight men (poorer education).

There was an interesting correlation between taking antiretrovirals and having unprotected sex in gay men. Those on antiretrovirals were less likely to have unprotected sex generally, and men who knew their viral load – regardless of whether they were undetectable or not - were half as likely to have unprotected sex than those who did not know it.

The two studies of behavioural interventions in people with HIV were very different. One (Dawson Rose), conducted by UCSF, randomised 44 primary care physicians to train or not to train in the delivery of tailored risk reduction messages to patients. The training taught doctors how to better ask patients about sexual behaviour, assess risk behaviour, and deliver risk reduction advice. Data were then collected from 386 of their patients over the following six months to see if the training had any effect.

Patients of doctors who underwent the training had, at six months, 57% fewer partners in general (though they had more sex), and 56% fewer partners who were potentially serodiscordant than patients of doctors who had not received the training.

In contrast with this provider-delivered advice, the second intervention, from the Fenway HIV clinic in Boston (O’Cleirigh), devised a peer-taught modular series of training for HIV-positive gay men in which social workers and psychologists collaborated with patient focus groups, and then trained HIV-positive peer trainers to deliver it. The ENHANCE Project consisted of four hour-long modules. All 195 patients received the first one (“Having Sex”), and could then choose three other modules from a list of six. These other modules were “Getting the Relationships You Want”, “Disclosure”, “Cultures, Communities and You,” “Managing Stress”, “Triggers for Risky Sex”, and “Party Drugs” – in that order of popularity.

Thirty per cent of patients reported any sexual risk at baseline and were followed-up for 12 months, with a 12-month retention rate of 78%. The patient group was a largely white (79%), well-educated group with a mean age of 43 and ten years’ diagnosis with HIV. However psychological assessment also revealed a lot of vulnerability; 43% said they had been sexually abused as a child, 27% had major depression, and 10% had experienced panic attacks.

The striking thing about this training was that – in contrast with what has been seen in some other studies – patients with high levels of risk behaviour at baseline responded to it especially well, while those who did not have high levels of risk to start with did not change their behaviour. The estimated number of sexual risk episodes in the 30% of high-risk patients declined from 15 in the previous six months at baseline, to 5 six months after the start of training, and was still 6.4 at 12 months, representing a 57% reduction in risk behaviour. The overall reduction in risk over three measures (any risky sex, number of different risky behaviours, and the proportion of anal sex that was unprotected) was 33%.

Introducing the session, HIV activist Philippa Lawson, one of the founders of the International Community of Women Living with HIV, commented that ‘positive prevention’ only made sense as a separate concept for the minority of people with HIV worldwide who knew their status. She commented that the involvement of people living with HIV in prevention programme design was rare and reported that at the Living 2008 Summit, a pre-conference satellite meeting for people with HIV, delegates could only agree on a definition of ‘positive prevention’ as encompassing general healthy living and AIDS prevention, with a vocal group of delegates seeing any focus on HIV transmission as being tantamount to saying that people with HIV had sole or extra responsibility for preventing it. She ended her talk by asking delegates to consider how people with HIV could get more involved and develop more sense of ownership over HIV prevention.