Assumed infectiousness, treatment adherence and sexual behaviours: applying the Swiss Statement on infectiousness to HIV-positive alcohol drinkers.

OBJECTIVES: The success of antiretroviral therapy (ART) for treating HIV infection is now being turned towards HIV prevention. The Swiss Federal Commission for HIV/AIDS has declared that HIV-positive persons who are treated with ART, have an undetectable viral load, and are free of co-occurring sexually transmitted infections (STIs) should be considered noninfectious for sexual transmission of HIV. This study examined the implications of these assumptions in a sample of HIV-positive individuals who drink alcohol. METHODS: People living with HIV/AIDS (n = 228) were recruited through community sampling. They completed confidential computerized interviews and underwent monthly unannounced pill counts for ART adherence. HIV viral loads were obtained from medical records. RESULTS: One hundred and eighty-five HIV-positive drinkers were currently receiving ART and 43 were untreated. Among those receiving ART, one in three were not virally suppressed and one in five had recently been diagnosed with an STI. Adherence was generally suboptimal, including among those assumed to be less infectious. As many as one in four participants reported engaging in unprotected intercourse with an HIV-uninfected partner in the past 4 months. There were few associations between assumed infectiousness and sexual practices. CONCLUSIONS: Less than half of people who drank alcohol and took ART met the Swiss criteria for noninfectiousness. Poor adherence and prevalent STI threaten the long-term potential of using ART for prevention. In the absence of behavioral interventions, the realities of substance use and other barriers call into question the use of ART as prevention among alcohol drinkers.

Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention.

OBJECTIVES: Sexually transmitted infections (STIs) significantly impact the health of people living with HIV/AIDS, increasing HIV infectiousness and therefore transmissibility. The current study examined STIs in a community sample of 490 HIV-positive men and women. METHODS: Assessments were performed using confidential computerized interviews in a community research setting. RESULTS: Fourteen per cent of the people living with HIV/AIDS in this study had been diagnosed with a new STI in a 6-month period. Individuals with a new STI had significantly more sexual partners in that time period, including non-HIV-positive partners. Participants who had contracted an STI were significantly more likely to have detectable viral loads and were less likely to know their viral load than participants who did not contract an STI. Multivariate analysis showed that believing an undetectable viral load leads to lower infectiousness was associated with contracting a new STI. CONCLUSIONS: Individuals who believed that having an undetectable viral load reduces HIV transmission risks were more likely to be infectious because of STI coinfection. Programmes that aim to use HIV treatment for HIV prevention must address infectiousness beliefs and aggressively control STIs among people living with HIV/AIDS.

Heterosexual anal intercourse among community and clinical settings in Cape Town, South Africa.

BACKGROUND: Anal intercourse is an efficient mode of HIV transmission and may play a role in the heterosexual HIV epidemics of southern Africa. However, little information is available on the anal sex practices of heterosexual individuals in South Africa. PURPOSE: To examine the occurrence of anal intercourse in samples drawn from community and clinic settings. METHODS: Anonymous surveys collected from convenience samples of 2593 men and 1818 women in two townships and one large city sexually transmitted infection (STI) clinic in Cape Town. Measures included demographics, HIV risk history, substance use and 3-month retrospective sexual behaviour. RESULTS: A total of 14% (n = 360) men and 10% (n = 172) women reported engaging in anal intercourse in the past 3 months. Men used condoms during 67% and women 50% of anal intercourse occasions. Anal intercourse was associated with younger age, being unmarried, having a history of STI, exchanging sex, using substances, having been tested for HIV and testing HIV positive. CONCLUSIONS: Anal intercourse is reported relatively less frequently than unprotected vaginal intercourse among heterosexual individuals. The low prevalence of anal intercourse among heterosexual individuals may be offset by its greater efficiency for transmitting HIV. Anal sex should be discussed in heterosexual HIV prevention programming.

Stigma and discrimination experiences of HIV-positive men who have sex with men in Cape Town, South Africa.

Since the primary mode of HIV transmission in sub-Saharan Africa is heterosexual, research focusing on the sexual behaviour of men who have sex with men (MSM) is scant. Currently it is unknown how many people living with HIV in South Africa are MSM and there is even less known about the stigmatisation and discrimination of HIV-positive MSM. The current study examined the stigma and discrimination experiences of MSM living with HIV/AIDS in South Africa. Anonymous venue-based surveys were collected from 92 HIV-positive MSM and 330 HIV-positive men who only reported sex with women (MSW). Internalised stigma was high among all HIV-positive men who took part in the survey, with 56% of men reporting that they concealed their HIV status from others. HIV-positive MSM reported experiencing greater social isolation and discrimination resulting from being HIV-positive, including loss of housing or employment due to their HIV status, however these differences were not significant. Mental health interventions, as well as structural changes for protection against discrimination, are needed for HIV-positive South African MSM.

Potential markers of female condom use among inner city African-American women.

Despite the availability of the female condoms and theoretically based interventions to promote its use, studies have indicated a low level of acceptability of their use among women in most populations. We aimed to determine female condom use prevalence and the potential markers among African-American women. In an intervention trial to test the efficacy of the Information-Motivation-Behavioral Skills model in increasing condom use, we utilized the baseline data of 280 subjects and examined the potential predictors of female condom use. Chi square statistic and unconditional logistic regression were used to test for group independence among users and non-users of the female condom and to assess the potential markers of female condom use respectively. After adjustment for relevant covariates associated independently with female condom use, the significant potential markers for female condom use were age, multiple sexual relationships, knowledge of female condom, and educational status. Women having multiple sexual relationships compared with a monogamous relationship were five times more likely to use the female condom, while women with high school education were three times more likely to use the female condom; prevalence odds ratio, POR=5.32, 95% CI=1.79-15.83 and POR=3.01, 95% CI=1.01-8.93. Women who were not knowledgeable of the female condom, compared to those who were, were 81% less likely to use the female condom, POR=0.19, 95% CI=0.08-0.45. Among African-American women in this sample, knowledge of female condom use, age, educational status, and multiple sexual relationships were significant markers of female condom use. This study is therefore suggestive of the need to educate African-American women on female condom use, given the obstacles in male condom negotiation, especially among the socio-economically challenged.

High risk sexual behavior and alcohol consumption among bar-going gay men.

OBJECTIVES: To determine whether alcohol use prior to sexual behavior influenced the occurrence of unprotected anal intercourse among bar-going gay men. METHODS: Anonymous AIDS behavioral risk surveys were administered to men entering gay bars in 16 cities on three nights in February 1993 in six states in the United States. RESULTS: Of the 1519 men who completed the survey, 85% were current alcohol drinkers. Men who had unprotected anal intercourse after consuming alcohol drank more and reported more incidents of unprotected anal intercourse than men who had unprotected anal intercourse but not after drinking. Overall, unprotected anal intercourse occurred less frequently after alcohol consumption than without prior consumption. CONCLUSIONS: This study found that heavy alcohol use and frequent high-risk sexual behavior occurred among the same individuals. However, we found no evidence for a causal link between alcohol use and unprotected sexual behavior in this sample of bar-going gay men.

Factors associated with risk for HIV infection among chronic mentally ill adults.

OBJECTIVE: Chronic mentally ill adults have been found to be at risk for HIV infection. The authors investigated the prevalence of HIV risk behaviors among psychiatric outpatients. Correlates of HIV risk factors and characteristics of patient relationships in which risk occurred were investigated. METHOD: Structured interviews were conducted with 95 chronic mentally ill adults from urban community support service programs. The interviews focused on sexual and substance use behavior, history of HIV risk behaviors, and relationship characteristics related to risk. RESULTS: The study showed that 27% of all patients had had two or more sex partners in the previous year and 18% had received money or drugs for sex. High rates of illicit drug use were also found, with frequent use of drugs or alcohol in association with sexual activity. Multiple regression analyses showed that use of illicit drugs, meeting sex partners in psychiatric clinics, and meeting partners in bars accounted for a substantial proportion of the variance in HIV risk behavior. CONCLUSIONS: These results suggest an urgent need for HIV prevention programs targeted at urban chronic mentally ill adults. Risk-producing characteristics of patient relationships and social networks should be addressed in the development of prevention interventions.

Outcome of cognitive-behavioral and support group brief therapies for depressed, HIV-infected persons.

OBJECTIVE: Although many studies have documented patterns of emotional distress in persons with HIV disease, there have been few controlled evaluations of therapy outcomes with these individuals. This research evaluated the effects of brief cognitive-behavioral or social support group therapy with this population. METHOD: Sixty-eight depressed men with HIV infection were randomly assigned to one of three conditions: eight-session cognitive-behavioral groups, eight-session social support groups, or a comparison condition. Before and after intervention and at 3-month follow-up, all participants were individually assessed by using measures of symptoms of distress as well as substance use and sexual practices. RESULTS: Relative to the comparison group, both the cognitive-behavioral and social support group therapies produced reductions in depression, hostility, and somatization. The social support intervention also produced reductions in overall psychiatric symptoms and tended to reduce maladaptive interpersonal sensitivity, anxiety, and frequency of unprotected receptive anal intercourse, while the cognitive-behavioral intervention resulted in less frequent illicit drug use during the follow-up period. Tests for clinical significance of change particularly underscored benefits of the social support group intervention both at postintervention and at long-term follow-up. CONCLUSIONS: Brief group therapy for depressed persons with HIV infection produced reductions in symptoms of distress. The two forms of therapy resulted in shared and unique improvements in functioning, although social support groups focused on emotional coping presented greater evidence of clinically significant change. As more persons contract HIV infection and live longer with HIV disease, further research is needed to evaluate outcomes of mental health services with these individuals.

Human immunodeficiency virus in semen and plasma: investigation of sexual transmission risk behavioral correlates.

Risks for sexually transmitted HIV may be related to concentrations of virus detected in semen and previous research shows a small to moderate association between viral load in blood and semen. This study examined the association between viral load in semen and plasma in a community sample of HIV-infected men and is the first study to examine semen viral load in relation to sexual transmission risk behaviors. A sample of 44 HIV-positive men recruited from community service agencies provided semen, blood, and urine samples and completed clinical interviews assessing health and behavior. We failed to find an association between viral load in semen and plasma, Spearman rho = 0.07, p > 0.1. When restricted to participants with detectable virus in semen and plasma, the correlation remained nonsignificant, rho = -0.16, p > 0.1. Men who had higher semen viral loads relative to their plasma viral load were distinguished by having engaged in significantly higher rates of unprotected intercourse as the insertive sex partner in the previous 3 months. Semen viral load was not, however, related to recent or current sexually transmitted infections (STIs). This study is among the first to examine sexual transmission risk behaviors as marker for HIV infectiousness. Results caution against inferring sexual transmission infectiousness based on plasma viral load and suggest that HIV-positive men who practice higher rates of insertive intercourse may be more infectious even in the absence of other STIs.

Post-exposure prophylaxis for HIV infection in gay and bisexual men. Implications for the future of HIV prevention.

OBJECTIVE: To assess the psychological and behavioral characteristics of gay and bisexual men who intend to use antiretroviral post-exposure prophylaxis (PEP) to prevent HIV infection. METHODS: Gay and bisexual men who had not tested HIV seropositive and were not in long-term exclusive sexual relationships (n = 327) completed anonymous surveys consisting of demographic characteristics, gay community acculturation, experience with and attitudes toward PEP, substance use, and sexual behavior in the past 6 months. SETTING: A large annual Gay Pride festival in Atlanta, Georgia. RESULTS: There were 8 (3%) men who had already used PEP and 85 (26%) who planned to use PEP to prevent themselves from becoming HIV infected. Compared to the 242 (74%) men who did not indicate plans to use PEP, those planning to use PEP were younger, less well educated, more likely to have used illicit substances in the past 6 months, and were more likely to have a history of injection drug use. Men intending to use PEP were also more likely to have practiced unprotected anal and oral intercourse as the receptive partner and were more likely to have multiple anal intercourse partners with whom they were receptive. CONCLUSIONS: Gay and bisexual men are generally supportive of the immediate use of PEP and a significant number of men are planning to use PEP, particularly less educated men who use multiple substances and practice the highest-risk sexual behaviors. Concurrent behavioral interventions must, therefore, be considered critical in the advancement of PEP.

Health literacy and health-related knowledge among persons living with HIV/AIDS.

BACKGROUND: Functional health literacy is associated with illness-related knowledge, understanding, and treatment perceptions for several chronic illnesses. This study examined health literacy in relation to knowledge and understanding of HIV/AIDS. METHODS: Persons living with HIV/AIDS recruited from AIDS service organizations and HIV clinics completed the Test of Functional Health Literacy for Adults (TOFHLA) reading comprehension scale and measures of health status, knowledge and understanding of health status, perceptions of primary care givers, and perceptions of anti-HIV treatments. RESULTS: Eighteen percent of the sample scored below the cutoff for marginal functional health literacy on the TOFHLA. Controlling for years of education, persons of lower health literacy were significantly less likely to have an undetectable HIV viral load, somewhat less likely to know their CD4 cell count and viral load, and lower health-literacy persons who knew their CD4 count and viral load were less likely to understand their meaning. Lower health literacy was also related to misperceptions that anti-HIV treatments reduce risks for sexually transmitting HIV and beliefs that anti-HIV treatments can relax safer-sex practices. CONCLUSIONS: Poor health literacy creates barriers to fully understanding one's health, illness, and treatments. Misperceptions of treatment in the case of HIV infection creates danger for potentially transmitting treatment-resistant strains of HIV. These results have implications for patient education and treatment programming for people who have poor health-literacy skills and are living with HIV/AIDS.

Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people.

BACKGROUND: As many as one in three HIV-positive people continue unprotected sexual practices after learning that they are HIV infected. This article reports the outcomes of a theory-based intervention to reduce risk of HIV transmission for people living with HIV infection. METHODS: Men (n=233) and women (n=99) living with HIV-AIDS were randomly assigned to receive either (1) a five-session group intervention focused on strategies for practicing safer sexual behavior, or (2) a five-session, contact-matched, health-maintenance support group (standard-of-care comparison). Participants were followed for 6 months post-intervention. RESULTS: The intervention to reduce risk of HIV transmission resulted in significantly less unprotected intercourse and greater condom use at follow-up. Transmission-risk behaviors with non-HIV-positive sexual partners and estimated HIV transmission rates over a 1-year horizon were also significantly lower for the behavioral risk-reduction intervention group. CONCLUSIONS: This study is among the first to demonstrate successful HIV-transmission risk reduction resulting from a behavioral intervention tailored for HIV-positive men and women.

Context framing to enhance HIV-antibody-testing messages targeted to African American women.

African American women (N = 100) recruited from an urban clinic were randomly assigned to view 1 of 3 experimental videotapes promoting HIV testing: (a) an ethnicity-matched information control videotape; (b) the same ethnicity-matched videotape presented by an African American woman (gender-ethnicity-matched control condition); or (c) an experimental videotape with a culturally relevant context that embedded HIV-testing information within a frame of reference emphasizing personal loss. Consistent with D. Kahneman and A. Tversky's (1979) prospect theory, women who viewed the context-framing videotape were most likely to have been tested during a 2-week follow-up interval. Among women who expressed intentions to get tested after viewing the videotapes, 63% of those in the message-framing condition were tested for HIV during a 2-week period compared with 23% in the gender-ethnicity-matched condition, and none in the ethnicity-matched condition.

Self-efficacy and disclosure of HIV-positive serostatus to sex partners.

HIV-positive persons face significant challenges to disclosing their HIV serostatus, and failure to disclose can place their sex partners at risk. The current study examined HIV serostatus disclosure in 266 sexually active HIV-positive persons recruited from the community. Results showed that 41% had not disclosed their HIV serostatus to sex partners. Men who had not disclosed to partners indicated lower rates of condom use during anal intercourse and scored significantly lower on a measure of self-efficacy for condom use compared to individuals who had disclosed. Emotional distress was also greatest among persons who had not recently disclosed. Having not disclosed to sex partners was closely associated with lower self-efficacy for disclosing, with women who had not disclosed reporting the lowest disclosure self-efficacy. As people living with HIV-AIDS are encouraged to disclose their HIV status, interventions are needed to facilitate disclosure decision making.

Reinforcement value of unsafe sex as a predictor of condom use and continued HIV/AIDS risk behavior among gay and bisexual men.

The pleasure or reinforcement value of high-risk sex may be an important influence on success in risk reduction efforts. Seronegative gay and bisexual men (N = 297) completed measures assessing their unprotected and safer sex practices, as well as measures of cognitive and skill factors and a measure assessing the subjective reinforcement value of unprotected anal intercourse. Regression analyses showed that the reinforcement value of unprotected anal intercourse accounted for variance in predicting levels of condom use above that that could be accounted for by factors such as knowledge, behavior change intentions, perceived vulnerability, condom attitudes, and sexual communication skills. Only reinforcement value of unprotected sex and substance use significantly predicted how frequently participants engaged in high-risk sex. Increased attention to the valence of sexual reinforcers will improve HIV risk reduction models and enhance AIDS prevention efforts.

Negative affect and sexual risk behavior: comment on Crepaz and Marks (2001).

In this commentary, the authors highlight the findings of the meta-analysis by N. Crepaz and G. Marks (2001). The role of affect in sexual risk behavior, although intuitively obvious, is not well understood and has been largely ignored by HIV prevention researchers in favor of social-cognitive models of behavior. Crepaz and Marks synthesized the results from studies that have examined the relation of negative affect (e.g., depression, anxiety, anger) to sexual risk behavior and concluded that in the literature to date, these variables appear unrelated. The authors suggest that the Crepaz and Marks findings are not surprising given the methods used in the reviewed studies and suggest methodological approaches that will allow more sensitive analyses of the association between affect and sexual risk behavior.

Continued high-risk sex among HIV seropositive gay and bisexual men seeking HIV prevention services.

The authors examined HIV risk-related sexual behaviors in an ethnically diverse sample of HIV seropositive gay and bisexual men (N = 86). Measures of sexual behavior, substance use, condom attitudes, behavior change intentions, and engagement in risk-reducing practices were completed. Thirty-nine percent of the men reported engaging in unprotected anal intercourse in the past 3 months. Unprotected anal intercourse was associated with using nitrite inhalants, sex partners who used substances before sex, and low intentions to change risk behavior. These results highlight the difficulties that people living with HIV infection face in maintaining a lifetime of safer sex and the necessity of integrating clinical and prevention interventions for these persons.

AIDS treatment advances and behavioral prevention setbacks: preliminary assessment of reduced perceived threat of HIV-AIDS.

Recent advances in AIDS treatment have brought renewed optimism for prolonging the lives of those infected with HIV. This article examined beliefs about how new treatments may reduce HIV transmission risk among 298 HIV-negative gay and bisexual men attending a gay pride festival. Results from an anonymous survey showed that men who practiced unprotected anal intercourse as the receptive partner (UAR intercourse) were younger, less well educated, and more likely to believe that it is safe to have UAR intercourse with an HIV-positive man who has an undetectable viral load and that new treatments for HIV relieve their worries about unsafe sex. As HIV treatments continue to advance, new challenges for HIV prevention will likely emerge.

Risk for HIV infection among bisexual men seeking HIV-prevention services and risks posed to their female partners.

The present study interviewed gay (n = 473) and bisexual men (n = 146) as part of an HIV prevention program and investigated social cognitive factors associated with HIV risk. Results indicated that HIV risk in homosexual men was associated with sexual openness and connections to gay communities, factors not associated with risk for bisexual men. Compared with men at lower risk, those who practiced high-risk sex scored lower on measures of perceived safer sex norms, safer sex self-efficacy, and social skills. Bisexual men with primary female partners often had not disclosed their bisexuality to female partners (75%), and 64% had not modified their behavior to protect female partners. Bisexual men who engage in high-risk behaviors therefore pose a risk to female partners who may be unaware of their involvement with men.

Factors associated with severity of depression and high-risk sexual behavior among persons diagnosed with human immunodeficiency virus (HIV) infection.

Whereas some people appear to cope after learning that they have human immunodeficiency virus (HIV) infection, others experience depression and suicidal ideation. In this study, 142 persons with HIV infection were administered the Center for Epidemiological Studies Depression Scale (CES-D). High levels of depression were predicted by lower perceived social support, attributions that health was influenced more by chance, high-risk sexual behavior practices, and greater number of HIV illness symptoms and greater duration of time knowing of one's own positive serostatus. Ongoing high-risk sexual behavior practices were predicted by higher levels of recreational drug use and of depression. These findings highlight the need for improved mental health services for persons with HIV conditions.