Unprotected sex in France linked to anxiety, depression, lipodystrophy, not HIV treatment success

French people recently infected with HIV are increasingly likely to have unprotected sex with casual partners as the time from diagnosis increases, according to a study published in the journal AIDS this month. The trend appears to be linked to anxiety, depression and lipodystrophy rather than assumptions about infectivity made by people with undetectable viral load, as previous cross-sectional studies had suggested.

Researchers recruited 233 people with primary HIV infection from the ongoing PRIMO cohort between November 1996 and February 2002 at 66 French hospitals. The study sample was followed up with blood tests and physical examinations after one month, three months, six months and then at six monthly intervals. All patients included in this report had at least three months follow-up (median 2 years, IQR 12 - 42 months) At every visit from month three a questionnaire was administered by the clinic doctor, which asked patients to state the number of partners they had had anal or vaginal sex with since their last visit. They were also asked to specify their partners’ sex, HIV status, if the relationship was casual or regular and if a condom was used.

Sexual behaviour carrying a risk of HIV transmission was defined by the investigators as anal or vaginal sex without a condom with a partner who was HIV negative or whose HIV status was unknown.

Of the 233 people enrolled to the study, 79% were men and 61% gay men. All 47 women in the study said they were heterosexual and the average age of the population was 31. The average duration of follow-up was a little over two years and over the period of the study three quarters started HAART. Most people on the study were sexually active with 87% having at least one sexual partner, and unprotected sex was reported by 32% of the study participants.

In total, 61 separate incidents of unprotected sex with HIV negative partners or partners of unknown status were reported by 43 people in the study, with the incidence increasing from a little over 5% in 1998 to 21.1% in 2001-02.

Viral load and CD4 counts were similar in patients having unsafe sex carrying a risk of transmission and in those reporting either protected sex or unprotected sex only with other HIV-positive people, prompting the investigators to comment that “the patient’s knowledge of his/her response to HAART (good or bad) was not a major determinant of subsequent at-risk sexual behaviour.” However people with lipodystrophy or anxiety and depression were statistically more likely to have anal or vaginal intercourse without a condom with casual partners and the researchers suggest that “future studies should certainly be carried out to further explore these issues.”

As the study included both gay men and heterosexual men and women it was possible to determine if gay men were more likely to have more unsafe sex. The investigators noted that “heterosexual men and women tended to report more frequent [sexual behaviour risk] than homosexual men, after adjustment for casual partners.”

The authors conclude that levels of unprotected sex with casual partners who are HIV-negative or of unknown status is increasing and that as many of the HIV-positive people have detectable viral loads there is a concern “about the potential for re-emerging HIV epidemics.”