HAART use and good adherence means less risky sex says Californian study

Use of, and adherence to, HAART is associated with less sexual risk taking, according to a study conducted in California and published in the June 1^st edition of the Journal of Acquired Immune Deficiency Syndromes.

"Previous research suggested that the availability of HAART was associated with increased risky sexual behaviour", note the investigators with several studies conducted amongst gay men in San Francisco indicating that "unprotected sex increased…with the dissemination of HAART."

However, such studies did not examine the relationship between the use of HAART and unprotected sex cross-sectionally in the same patients. Therefore, investigators sought to correlate sexual behaviour with the use of, and adherence to HAART, in a diverse population of HIV-positive individuals.

Recruitment took place between 1998 and 1999 at six public HIV clinics in California. To be eligible individuals had to be 18 years of age or over, have been diagnosed with HIV for at least three months and to have had sex in the last three months.

Interviewers administered a standardised questionnaire enquiring about sexual behaviour, HAART use and adherence.

A total of 886 individuals participated in the study. The median age was 37 years, 88% were men, 39% white, 37% Latino and 16% black, and 62% were infected with HIV due to sex between men.

The median duration of HIV infection was six years and median CD4 cell count was 346 cells/mm³.

Of the 689 patients taking HAART, 215 (31%) reported unprotected anal or vaginal sex compared to 86 (46%) individuals not taking antiretroviral therapy (odds ratio 0.5, p

Adherence data were available for 683 patients taking HAART. A total of 142 (28%) individuals reporting that they took 95% or more of their doses of antiretroviral medication, said that they had unprotected anal or vaginal sex, compared to 72 (41%) of the 175 less adherent patients (odds ratio 0.6, p

In multivariate analysis, the investigators found that individuals taking HAART were still less likely to engage in high risk sex after controlling for race, marijuana use, alcohol use, depression, and clinic attendance (p

However, having three or more sexual partners and use of amphetamines increased the odds of unprotected sex to the point where the relationship between the use of antiretrovirals and less unprotected anal or vaginal sex ceased to be significant (odds ratio, 0.8, p

"In a large Californian clinic's population with diverse HIV risk factors, about one-third of patients reported anal or vaginal sex without a condom over the past three months and approximately one quarter reported antiretroviral adherence of less than 95%", write the investigators. However, "antiretroviral therapy users reported lower prevalence of unprotected anal or vaginal sex. Good antiretroviral adherence was also associated with a lower likelihood of unprotected sex in most stratified analyses".

Studies amongst gay men in London and discordant heterosexual couples in California have previously shown that HAART use is associated with less sexual risk taking, note the investigators.

In the light of these studies and their own findings, they question if it is possible to generalise the findings of studies, which were conducted amongst gay men in San Francisco in the HAART era, whcih found an increase in sexual risk taking. They write, "our results suggest that increases in risk behaviour associated with antiretroviral therapy may not reflect the behaviour of a more diverse sample of patients in California". In addition they question the notion of "safer sex fatigue" commenting that longer duration of clinic attendance was associated with less unprotected sex.

Limitations of the study are noted. These include the self-reporting of sexual risk taking and adherence.

Nevertheless, the investigators conclude, "antiretroviral use is associated with less sexual risk taking. A mechanism for associations of both antiretroviral use and adherence with less unprotected sex could be connected to personality traits such as compliance with authority, aversion to risk, or self-protection. Patients who are responsible and health conscious enough to achieve optimal adherence might also be aware of the health risks of unsafe sex and thus be more likely to use condoms."