Risky sex leads to treatment optimism, not the other way round, finds study

The relationship between unprotected sex and HIV treatment optimism amongst gay men may be more complex than previously thought, according to a US study published in the December 1^st edition of the Journal of Acquired Immune Deficiency Syndromes.

Although investigators found that treatment optimism was associated with sexual risk taking in the recent past, they also found that treatment optimism did not predict an increased risk of risky sex, but rather that risky sex predicted treatment optimism. They believe that this could be because gay men who consider themselves most at risk of HIV rationalise their behaviour with beliefs about the effectiveness of HIV treatment.

HAART and more sexual risk taking?

In recent years, several studies have indicated that gay men in the US, Europe and Australia are having more unprotected anal sex. This has been accompanied by an increase in rates of sexually transmitted infections. These changes appeared to coincide with the availability of effective anti-HIV therapy in the late 1990s, and concern has been expressed that the reductions in illness and death among gay men brought about by HAART was leading to “treatment optimism” - a belief that HIV infection is now a less serious condition - and that precautions to avoid infection are thus less important.

There are conflicting data about the extent to which treatment optimism can explain changes in gay men’s sexual behaviour. Most studies suggesting a link have relied on cross-sectional data, with longitudinal data lacking.

Study design

Investigators from the Young Men’s Survey, a longitudinal study involving over 1250 gay and bisexual men in Arizona, New Mexico and Texas wished to see if treatment optimism really did predict unprotected anal sex, or if it was an attempt to rationalise past risky sexual behaviour.

Two analyses were conducted. First, a cross-sectional study was conducted. Men were asked to say how susceptible they thought they were to HIV infection. They were then asked to say if they agreed or disagreed with statements regarding HAART making HIV less serious. The second longitudinal part of the study was designed to see if optimistic beliefs about HIV treatment really did predict an increased risk of unprotected anal sex.

Sexual risk taking was assessed by asking the young men how often in the preceding two months they had had anal sex with a condom, anal sex without a condom but without ejaculation, and anal sex without a condom with ejaculation with both primary and casual partners.

Data was collected in two waves, the first in 1998/99, the second in 2000/01. A total of 837 men provided data in 1998/99 and 561 in 2000/01.

Results

In their cross-sectional analysis, the investigators found that men reporting unprotected anal sex were significantly more optimistic about HIV treatment than men who did not report unprotected sex (p < 0.01). They also found that men who thought themselves susceptible to HIV infection were more likely to report unprotected anal sex and to agree with statements indicative of optimism about HIV treatment (p < 0.05).

In their second, longitudinal analysis the investigators found optimism about HIV treatment in 1998/99 did not predict risky sex in 2000/01. However, risky sex in 1998/99 did significantly predict treatment optimism in 2000/01 (p < 0.05).

“Our data suggest that sexual risk behaviour may precede and lead to subsequent treatment optimism” about HAART, write the investigators. They add that it was only among men who think themselves susceptible to HIV that they found any association between optimism and risk behaviour and suggest “one explanation for this finding is that higher levels of treatment optimism are, in part, a result of previous risk behaviour.”

The investigators note that their longitudinal data supports the hypothesis “that sexual risk behaviour precedes treatment optimism rather than the reverse.”

They conclude “our findings suggest that although risk and treatment optimism are related, the association may be more complex than previously thought.”