Survival sex and misconceptions about HAART associated with continued unsafe sex

Over 40% of individuals had unprotected sex after learning that they were HIV-positive in a study conducted in New York and published in the January 1^st 2004 edition of Clinical Infectious Diseases. Investigators also established that trading sex for drugs or money, and the use of HAART were the two factors most associated with unprotected sex after an HIV diagnosis.

A total of 246 HIV-positive individuals receiving their care at the Bronx-Lebanon Hospital Center were recruited to this study between September 1997 and February 1998. The investigators wished to assess the ongoing risk behaviours of the study population and the factors associated with ongoing risk behaviour.

Individuals participated in a single confidential interview designed to ascertain HIV risk behaviours. Patients were asked if they had had unprotected anal or vaginal sex since their HIV diagnosis, if they had had a sexually transmitted infection, and if they had shared injecting equipment for drug use. Questions were also asked about their total number of lifetime sexual partners, and if they had sex with men or women. Information was also collected on the use of anti-HIV medication.

All the patients admitted to having unprotected anal or vaginal sex before their HIV diagnosis. Heterosexual intercourse was the only HIV risk activity for 41% of patients, 34% were identified as having sex with another man as their HIV risk category, and 40% had injecting drug use as a possible HIV risk.

A total of 41% of patients reported unprotected sex after their HIV diagnosis, including 50% of women, 29% of heterosexual men, and 42% of men reporting sex with other men. Individuals who had known that they were HIV-positive for longer were more likely to report unprotected sex (p=0.001), and having a larger number of total lifetime sex partners was also predictive of having unprotected sex post-diagnosis with HIV (unprotected sex, median 40 partners, versus no unprotected sex median twelve partners, p=0.002).

A sexually transmitted infection (STI) was diagnosed in 25% of individuals after their HIV was detected, including 30% of women, 15% of heterosexual men, and 27% of men having sex with other men. A total of 45% of people with an STI reported trading sex for money or drugs. Having HIV for longer was also significantly associated with having an STI (p=0.003).

Investigators also gathered data on injecting drug use behaviour. A total of 15% of individuals said that they had shared injecting equipment after their HIV diagnosis, 67% of whom were women, and 40% reported trading sex for money or drugs.

After multivariate analysis, the investigators found that trading sex for money or drugs (adjusted odds ratio 4.0) and taking HAART (adjusted odds ratio 1.8) were both significantly associated with unprotected anal or vaginal sex after diagnosis with HIV.

Commenting on their findings the investigators observe that "trading sex for money or drugs is difficult to change, despite a person’s knowledge of HIV infection. Substance use… is highly prevalent…and along with poverty and economic need ('survival sex'), it may be driving HIV risk behaviour, particularly among women, through the exchange of sex or money for drugs."

The investigators suggest that the use of HAART might encourage some individuals to believe that the risk of HIV transmission has been eliminated. They also suggest that people benefiting from HAART may simply be having more sex, both protected and unprotected, due to their improved health.

The investigators conclude that "trade of sex for money or drugs is an important factor associated with transmission risk behaviour in HIV-seropositive persons, particularly women. Period risk assessment and screening for STIs should be a routine part of HIV primary care", they add, and "patients should be cautioned that the use of antiretroviral therapy does not guarantee against HIV transmission."

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