The number of HIV-positive gay men reporting unprotected anal sex with casual partners increased significantly in Amsterdam between 2000 and 2003, according to a study published in the September 24th edition of AIDS. The study also revealed that although HIV-positive men have a generally neutral view about the impact of HAART on their infectiousness, men who perceived themselves to have a low viral load were more likely to have unprotected sex with regular partners who were HIV-negative or of unknown status. In reality, almost a third of these men had detectable viral loads and were potentially infectious.
Investigators from the Amsterdam Cohort Study wished to see if HIV-positive gay men were engaging in more unprotected anal sex since the advent of HAART. They also wished to determine if beliefs about the impact of HAART on the seriousness of HIV infection and infectiousness, and perceived and actual CD4 cell counts and viral load were connected with sexual risk behaviour.
Between 2000 and 2003 three separate questionnaires were mailed to gay men enrolled in the cohort. The questionnaires enquired about personal sexual behaviour, HAART-related beliefs, and perceptions about individuals CD4 cell count and viral load. Data on individuals' actual CD4 cell counts and viral load were obtained from clinic records.
As the investigators wished to look at trends in sexual behaviour over time, they restricted their analyses to the 57 men who returned all three questionnaires. These men had a median age of 43 years, and had been HIV-positive for a median of 4.7 years. The overwhelming majority (80%) of men were Dutch, and 78.9% were taking HAART.
Between 2000 and 2003 the percentage of men reporting unprotected anal sex with a casual partner increased from 10.5% to 27.8%, a statistically significant increase (p < 0.01). The percentage of men reporting unprotected anal sex with a regular HIV-negative partner (or a partner whose HIV status they did not know), also increased from 5.3% in 2000 to 10.7% in 2003, however this increase was not statistically significant (p = 0.37).
Answers to questions designed to assess optimism about HAART indicated that individuals had a neutral view about the impact of HAART on infectiousness, and most men did not perceive that there was any less a need for safer sex because of HAART.
Overall, men had a very favourable view of their own viral loads, with median optimism scores being at the top of the investigators scale, ‘7, very favourable.’ Analysis of clinic records revealed that by 2003, 79% of men enrolled in the study had an undetectable viral load.
No significant association was found between any of the items designed to assess HAART optimism and unprotected anal sex with casual partners.
However, the investigators did find that unprotected sex with regular partners who were either HIV-negative or of unknown HIV status was associated with a favourable perception of personal viral load (p < 0.01). In further analysis, the investigators found that men with a favourable perception of their viral load were more likely to have unprotected sex with regular partners who were of a different or unknown HIV status than men who did not have a favourable perception of their personal viral load.
When the investigators looked at the actual viral loads of the men with favourable perceptions who reported unprotected sex with regular HIV-negative partners (or partners of unknown HIV status), they found that 30% actually had a detectable viral load, and that these individuals’ viral loads ranged from 400 copies/ml to 16,000 copies/ml.
No association was found between perceived or actual CD4 cell count and sexual risk taking.
The investigators write, “our findings indicate that men’s perceptions of their viral load levels, and not their actual HIV-1-RNA levels, are related to unprotected anal intercourse with steady partners of negative or unknown HIV status.”
“It is alarming that some men with a favourable perception of their viral load while actually having a detectable viral load engage in unsafe sex with steady partners who may be HIV-negative, posing a high risk of HIV transmission. In addition to discussing the actual HIV-1-RNA levels and CD4 cell counts, care-givers should enquire into patients’ perceptions of their viral load in relation to sexual behaviour, and actively prevent 'false' perceptions,” conclude the investigators.
Stolte IG et al. Perceived viral load, but not actual HIV-1-RNA load, is associated with sexual risk behaviour among HIV-infected homosexual men. AIDS 18: 1943-1949, 2004.