Unsafe sex increases after starting anti-HIV treatment in Cote d'Ivoire

Starting antiretroviral therapy is associated with increased sexual risk taking, according to a study conducted in Cote d’Ivoire and published in the January 2008 edition of AIDS. Younger age and alcohol consumption were also associated with unprotected sex.

Several studies in industrialised countries have noted increased levels of unprotected sex since effective antiretroviral therapy became available. The exact reasons for this are unclear and a meta-analysis found that levels of unprotected sex were not increased amongst HIV-positive individuals taking anti-HIV treatment.

There are few data describing sexual risk-taking amongst antiretroviral-treated patients in Africa. Therefore investigators at the largest HIV treatment centre in Cote d’Ivoire designed a study to see if taking antiretroviral therapy was associated with changes in sexual behaviour.

The study was conducted between February and September 2005. It involved 303 HIV-positive patients who were about to start antiretroviral therapy and 312 HIV-positive individuals who were not taking anti-HIV drugs.

On entry to the study, and then six months later, individuals completed a questionnaire enquiring about their sexual behaviour. The patients were asked to say if they used condoms always, half or more of the time, less than half the time, or never. Sexual behaviour between the two time periods and the two groups were then compared.

Overall, 23% of patients said their last sexual partner was HIV-negative and 33% said they did not know the HIV status of their partner. In each group, a third of patients disclosed their HIV status to their partner, and a third of individuals reported no sexual partners at all. The median number of sexual partners for treated and untreated patients was one. The patients had a median age of 35 years.

In the six month period prior to entry to the study, the patients who were not about to start anti-HIV treatment reported significantly more unprotected sex than the individuals initiating antiretroviral therapy (p = 0.014).

However, answers to the second questionnaire showed that there was no difference in the prevalence of sexual risk-taking between the two groups of patients in the second six-month period. This was because there was a significant 7% increase in the amount of unprotected sex reported by the patients taking anti-HIV treatment (p

Three factors were independently associated with unprotected sex. These were: being in good health (no symptoms of HIV, relative risk [RR], 1.94; 95% CI: 1.40 – 2.67; mild symptoms of HIV infection, RR, 1.84; 95% CI: 1.34 – 2.54); younger age (under 40 years, RR, 1.40; 95% CI: 1.17 – 1.67); and, alcohol consumption (RR, 1.16; 95% CI: 1.02 – 1.31).

“The increase in risk taking among treated patients is consistent with the clinical improvements and other positive outcomes associated with highly active antiretroviral therapy [HAART]”, write the investigators.

Only one prospective African study was included in the recent meta-analysis that found no relationship between the use of antiretroviral therapy and increased sexual risk taking. The investigators note that patients in this study received “preventative interventions” in parallel to their anti-HIV treatment. They therefore conclude, “this underscores the importance of coupling HAART along with counselling programmes aimed at encouraging patients to adopt and maintain safer sex practices.” They add, “given the scale-up of antiretroviral therapy in sub-Saharan Africa, more research is needed to examine this issue in more depth.”