Sexual risk behaviors among heterosexual HIV serodiscordant couples in the era of post-exposure prevention and viral suppressive therapy

OBJECTIVES: To describe awareness and use of antiretroviral treatments, viral load monitoring, and post-exposure prevention; to assess changing concerns about HIV transmission; and to examine the effect of these advances on sexual behavior in HIV-serodiscordant heterosexual couples. METHODS: Cross-sectional analysis of a baseline sample of 104 couples (n = 208 individuals) from the California Partners Study II, an intervention trial for HIV-serodiscordant couples in California. Questions on sexual practices, viral load testing, HIV treatment, post-exposure prevention, and their effect on sexual behaviors, risk taking and transmission concerns were measured at intake. RESULTS: Over two-thirds of couple members surveyed reported unprotected sex with their partner in the past 6 months. Among seropositive respondents, 37% were taking protease inhibitor therapy, 92% had undergone viral load testing, and of those, 40% said it had ben undetectable at their most recent test. Most respondents, regardless of serostatus, said that viral load testing and awareness of post-exposure prevention had no effect on their condom use. In addition, perceiving that their partner had an undetectable viral load was associated with having protected sex among seronegative subjects (P < 0.05). Seropositive respondent taking protease inhibitors were 2.4 times less likely to report unprotected sex compared with those not taking protease inhibitors (P = 0.05). However, up to 33% of seropositive and 40% of seronegative respondents acknowledged decreased transmission concerns in the light of the new HIV treatments. In comparison with their seropositive partners, seronegative individuals were more likely to acknowledge increased risk taking and decreased HIV transmission concerns (P < 0.05). CONCLUSIONS: New medical advances were not associated with unprotected sex in HIV-serodiscordant couples. However, new treatment options may decrease concerns about HIV transmission, particularly among seronegative partners. Providers should discuss the effect of antiretroviral treatments on sexual transmission risk with their patients. The inclusion of seronegative partners in counseling interventions may decrease risk taking in serodiscordant couples.     

Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion

OBJECTIVES: To determine the potential for secondary HIV transmission among newly HIV-infected men who have sex with men (MSM) during their HIV antibody seroconversion period, and for the 12 months after seroconversion. DESIGN: A cohort study. METHODS: Risk assessment questionnaires administered before receipt of the first positive HIV antibody result, plasma and seminal viral load measurements, and risk assessments one month and quarterly after receipt of the first HIV-positive test, and generalized estimating equation modelling techniques to analyse behavioral trends. RESULTS: Of 66 seroconverters, more than half reported unprotected anal intercourse (UAI) with HIV-negative or unknown-serostatus partners during seroconversion, with 27% reporting insertive UAI with an HIV-negative partner. The initial median plasma viral load was 4.6 log/ml, the median seminal viral load was 2.7 log/ml, suggesting a high level of infectiousness. Compared with risk behavior during seroconversion, UAI with HIV-negative or unknown-serostatus partners was reduced after the receipt of positive antibody results; however, a substantial proportion of participants reported high-risk behaviors for transmission for 12 months of follow-up. After learning of their HIV infection, recent seroconverters did not reduce the risk of secondary transmission by engaging in proportionally more high-risk practices with HIV-infected partners (compared with HIV-negative or unknown-serostatus partners), or engaging in proportionally more receptive compared with insertive UAI. CONCLUSION: Substantial potential exists for secondary HIV transmission during and for one year after HIV seroconversion. Receipt of an HIV-positive test is associated with a significant reduction in risk behavior, reinforcing the need to identify and counsel recently HIV-infected MSM.     

Causes of death and risk factors among HIV-infected persons in the HAART era: analysis of a large urban cohort

Objective  

We aimed to examine the clinical outcome in HIV-1-infected patients after more than 10 years of highly active antiretroviral therapy (HAART).     

HIV in couples in South India; implications for prevention

We studied HIV prevalence in couples in Chennai, India. In 56% both partners were infected. Among discordant couples, 35 men and seven women were infected. Heterosexual intercourse is the primary risk factor. Concordance was related to sex with commercial sex workers for men and to genital ulcer disease for women. Median CD4 count was 97 cells/mm(3) among concordant men, 222 cells/mm(3) among discordant men. Condom use increased, and frequency of sexual intercourse decreased, among all couples after HIV diagnosis.     

Sexual and reproductive health risk behaviours among South African university students: results from a representative campus-wide survey

Among South African university students, HIV prevalence is lower than in age-peers, but at 3.8% it is not negligible. We examined prevalence of factors potentially associated with HIV risk, focusing on partnership characteristics and consistent condom use. We hypothesised that contraceptive-related factors, for example, desire to prevent pregnancy and not using hormonal contraceptives, would be positively associated with consistent condom use. Data were drawn from a representative interviewer-administered survey of 2nd to 4th year students conducted during registration at a university campus in KwaZulu-Natal. Of 576 students, 218 (83 women, 135 men) reported vaginal intercourse in the past 2 months. Of these, 7% of women and 43% of men reported past-year concurrent partnerships, and 24% knew/ suspected partner non-monogamy. Although reported condom use at last intercourse was 90%, 2-month consistent use was 53% (women) and 73% (men). Reported hormonal contraception use was low (women: 36.8%; men: 16.7%), and 68% used condoms for dual protection. In gender-stratified multivariable analyses, consistent condom use was higher for men who reported their partner did not use (vs. used) hormonal contraception (aOR = 5.84; 95%CI = 2.71, 12.57; p < 0.001) and who reported using condoms for dual protection (vs. single protection) (aOR = 2.46; 95%CI = 1.43, 4.25; p = 0.001). No contraception-related factors were associated with consistent condom use among women. Sexual partnership characteristics potentially place sexually active university students at high HIV risk and should be investigated further. Among men, but not women, contraceptive concerns were associated with consistent condom use. Promoting condoms for dual protection may resonate with students and should be continued.     

Tuberculosis among HIV-infected patients receiving HAART: long term incidence and risk factors in a South African cohort

OBJECTIVES: To determine the long-term incidence of tuberculosis (TB) and associated risk factors among individuals receiving HAART in South Africa. DESIGN: Prospective cohort study. METHODS: Microbiologically or histologically confirmed incident TB was identified in a hospital-based cohort of 346 patients receiving HAART between 1996 and 2005 in Cape Town. RESULTS: The TB incidence density rate was 3.5/100 person-years in the first year and significantly decreased during follow-up, reaching 1.01/100 person-years in the fifth year (P = 0.002 for trend). TB incidence during the study was highest among patients with baseline CD4 cell counts < 100 cells/microl and those with World Health Organization (WHO) clinical stage 3 or 4 disease (5.71 and 3.88/100 person-years, respectively). Risk of TB was independently associated with CD4 cell count < 100 cells/microl (adjusted risk ratio [ARR], 2.38; 95% confidence interval (CI), 1.01-5.60; P = 0.04), WHO stage 3 or 4 disease (ARR, 3.60; 95% CI, 1.32-9.80; P = 0.01) and age < 33 years (ARR, 2.86; 95% CI, 1.29-6.34; P = 0.01). Risk of TB was not independently associated with plasma viral load, previous history of TB, low socioeconomic status or sex. Despite similar virological responses to HAART, blood CD4 cell count increases were much smaller among patients who developed TB than among those who remained free of TB. CONCLUSIONS: Incidence of TB continues to decrease during the first 5 years of HAART and so HAART may contribute more to TB control in low-income countries than was previously estimated from short-term follow-up. Patients with advanced pretreatment immunodeficiency had persistently increased risk of TB during HAART; this may reflect limited capacity for immune restoration among such patients.     

Sexual risk behavior among HIV-infected women in South Africa at 12-months postpartum

The postnatal period is a time of increased susceptibility to HIV infection and superinfection for postpartum women, sexual partners, and infants. This study examined the effect of a prevention to mother-to-child transmission of HIV intervention compared to standard care, and factors associated with unprotected last sex and inconsistent condom use at 12-months postpartum. Participants were N?=?1399 HIV-infected women 6–30 weeks pregnant (M?=?18 weeks (SD?=?5.75)) assessed during pregnancy and 12-months postpartum. Women were aged an average of 28 (SD?=?5.82); 48% reported 10–11 years of education. Older age (adjusted odds ratio [AOR]?=?1.00) and being employed (AOR?=?1.51) were associated with greater odds of unprotected sex at 12-month postpartum. Disclosure of HIV status (AOR?=?0.64) and greater male involvement during pregnancy (AOR?=?0.92) were associated with lower odds of unprotected sex at 12-month postpartum. HIV negative or unknown partner status (AOR?=?0.45) and greater depressive symptoms (AOR?=?0.97) were associated with lower odds of inconsistent condom use at 12-months postpartum. The intervention was not associated with reduced sexual risk behavior. Future studies should address male involvement and consider measurement of culturally tailored male involvement constructs for men South Africa. Perinatal women may require support for sexual communication and gender equity to reduce sexual risk.     

The incidence of and risk factors for MRSA bacteraemia in an HIV-infected cohort in the HAART era

Objectives

To define the incidence and risk factors for methicillin resistant Staphylococcus aureus (MRSA) bacteraemia in an HIV‐infected population.

Methods

From January 1, 2000 to December 31, 2004, we conducted a retrospective cohort study. We identified all cases of Staphylococcus aureus bacteraemia (SAB), including MRSA, among patients enrolled in the Johns Hopkins Hospital out‐patient HIV clinic. A conditional logistic regression model was used to identify risk factors for MRSA bacteraemia compared with methicillin‐sensitive SAB and no bacteraemia in unmatched (1:1) and matched (1:4) nested case‐control analyses, respectively.

Results

Of 4607 patients followed for a total of 11 020 person‐years (PY) of follow‐up, 216 episodes of SAB occurred (incidence: 19.6 cases per 1000 PY), including 94 cases (43.5%) which were methicillin‐resistant. The incidence of MRSA bacteraemia increased from 5.3 per 1000 PY in 2000–2001 to 11.9 per 1000 PY in 2003–2004 (P=0.001). Multivariate analysis demonstrated that independent predictors of MRSA bacteraemia (vs. no bacteraemia) were injection drug use (IDU), end‐stage renal disease (ESRD) and CD4 count <200 cells/μL.

Conclusions

MRSA bacteraemia was an increasingly common diagnosis in our HIV‐infected cohort, especially in patients with history of IDU, low CD4 cell count and ESRD.     

Sexual risk behaviour and HAART: a comparative study of HIV-infected persons on HAART and on preventive therapy in Kenya

Unprotected sex (UPS) among persons receiving highly active antiretroviral therapy (HAART) remains a concern because of the risk of HIV-transmission. A cross-sectional study comparing the sexual risk behaviour of 179 people living with HIV/AIDS (PLHA) receiving HAART with that of 143 PLHA receiving preventive therapy (PT) with cotrimoxazole/isoniazid was conducted in Mombasa, Kenya. Forty-five percent of all participants were sexually active in the last six months. Participants receiving PT were more likely to report > or =2 partners (13% vs.1%; P = 0.006). Participants receiving PT reported more UPS with regular partners (odds ratio [OR]: 3.9; 95% confidence interval [CI]: 1.8-8.4) and also more sexually transmitted infections (STI) symptoms (OR: 1.7; 95% CI: 1.0-2.8; P = 0.059). More than 40% of all participants did not know the HIV-status of regular partners. Therefore, HAART was not associated with increased sexual risk behaviours though considerable risk of HIV-transmission remains. HIV-care services need to emphasize partner testing and consistent condom use with all partners.     

Symptom interpretation: implications for delay in HIV testing and care among HIV-infected late middle-aged and older adults

Physical symptoms and the attributions assigned to them are fundamental aspects of individuals' illness representations and influence health behaviours. The effects of the presence or absence of symptoms and the interpretation of these symptoms on the initiation of HIV testing and medical care are explored using data from a psychosocial study of HIV illness in late middle-aged and older men and women. The absence of symptoms negatively influenced willingness both to seek testing and to seek medical care. While the presence of symptoms would be expected to lead to testing and the initiation of medical care, the effect of symptoms was dependent on causal interpretations of the symptoms. Symptoms attributed (or misattributed) to other illnesses or to normal aging did not lead to initiation of testing or care. These results appear to be due to people's lay belief that illness must include symptoms and due to a resistance against accepting an illness identity. This research suggests that HIV education and counselling should emphasize the need for individuals at risk for HIV to seek testing and medical care even if symptoms of the disease are absent.     

Constructions of sexuality and HIV risk among young people in Venda,South Africa: implications for HIV prevention

The study explored constructions of sexuality among young people of Venda in Limpopo, South Africa, and cultural practices that can be used to develop context-specific HIV prevention programmes. HIV prevention can be promoted by including some cultural practices in prevention programmes and changing some aspects of culture that may contribute negatively to health. Six focus group discussions were held with school-going young people (Grades 10 to 12) in urban and rural areas to explore their constructions of sexuality and HIV risk. Four focus group discussions were held with community leaders in the same areas to explore their constructions of young people’s sexuality and cultural practices relevant to HIV prevention. Through discourse analysis, the following dominant discourses that influence young people’s sexual risk behaviour were identified: rite of passage, the male sexual drive discourse (sex is natural and unavoidable); discourse of hegemonic masculinity (sex to prove masculinity); sex as a commodity; non-adherence to cultural practices; and HIV is normalised (AIDS is like flu). Some alternative constructions and shifts in gender norms were noticed, especially among female participants. The constructions of young people were not culture-specific but similar to those identified in other South African cultures. Community leaders identified a few cultural practices that could be considered in HIV prevention, for example, reinstating the rite of passage to provide age-appropriate sex and HIV education (behavioural intervention), and promoting traditional male circumcision (biological intervention). Cultural practices that contribute negatively to health should be challenged such as current constructions of gender roles (masculinity and femininity) and the practice that parents do not talk to young people about sex (both structural interventions).     

Evolution of cervical cytologic changes among HIV-infected women with normal cytology in the HAART era

The influence of HAART on the evolution to cervical squamous intraepithelial lesions (SIL) among HIV(+) women with a normal cytological test in the HAART era was studied. A retrospective cohort study (1997-2005) of HIV-infected women treated with HAART was conducted. Those with a normal cervical cytology (Papanicolaou test) and at least one subsequent test were included. Survival (time until diagnosis of SIL), univariate, and multivariate analyses were performed. A total of 133 HIV-infected patients treated with HAART were included. The incidence of SIL was 35% (47 patients). SIL was diagnosed in 36 of 110 (33%) patients with a baseline and final immunological status of >200 CD4 cells/microl and in 6 of 9 (67%) patients with a baseline and final immunological status of < or =200 CD4 (OR: 0.24, 95% CI: 0.06-1.03, p = 0.041). SIL was diagnosed in 10 of 60 (17%) patients with an undetectable baseline and final HIV viral load and in 36 of 70 (51%) patients with a detectable HIV viral load (OR: 0.19, 95% CI: 0.07-0.46, p < 0.001). A high incidence of SIL (cancer precursor lesions) was observed among HIV(+) women without a background of cervical pathology. The effect of HAART on the control of HIV replication and of immunological status (>200 CD4) through the follow-up was associated with a reduction of SIL.     

New challenges in HIV care: prevention among HIV-infected patients

The HIV-infected population has been understudied and underserved with respect to risk reduction and prevention interventions. Increases in high-risk sex practices and sexually transmitted diseases (STDs) have prompted considerable concern and have led to initiatives to implement routine STD screening and risk reduction counseling among the HIV-infected population. Available evidence indicates that risk reduction counseling can be effective. Improved attention to risk reduction counseling in the HIV medical care setting in needed, and efforts to improve access and maintain linkage to care must be increased. This article summarizes a presentation given by Carlos del Rio, MD, at the March 2003 International AIDS Society-USA course in Atlanta.     

Homosexual activity among rural Indian men: implications for HIV interventions

A cross-sectional survey of 2910 rural Indian men aged 18-40 years from five rural districts in five different states revealed that nearly 10% of single and 3% of married men had had unprotected anal sex with a man in the past year. Homosexually active men are not a separate sexual category,and report extensive mixing with female partners.They have more female partners than other men and they practised anal intercourse in 11% of their heterosexual contacts.     

HIV risk exposure among South African children in public health facilities

The study investigates the risk exposure to HIV infection among South African children aged 2-9 years served by public health services. Together with their biological mothers, 3471 children and were recruited from inpatient and outpatient children in the Free State Province. Blood samples were taken by professional nurses and a history taken of exposure factors associated with HIV transmission. DNA testing was used to confirm biological maternity where the child was HIV-positive and the mother HIV-negative. Mother-child pairs were stratified by mother's HIV status. Exposure factors related to the child's HIV status were examined in each stratum using a chi-square test. Independent factors were then included in a multiple logistic regression model. Having an HIV-positive mother was strongly related to HIV infection in children (OR: 310; 95%CI: 148-781). However, seven HIV-positive children had HIV-negative mothers. Transmission in this group was significantly associated with breastfeeding by a non-biological mother (OR: 437; 95%CI: 53-5020), being fed with expressed breast milk from a milk room (OR: 37.6; 95%CI: 6.2-259.0), dental injection history (OR: 31.5; 95%CI: 4.5-189.4) and visits to a dentist (OR: 26.9; 95%CI: 4.4-283.5). Although mother-to-child-transmission is shown to be the primary mode of HIV transmission in South African children, the few HIV-positive children infected by other modes of transmission suggest a potential risk of non-vertical HIV infections. These infections can be prevented through education and improved infection-control procedures.     

Sexual risk behaviors and HIV/AIDS awareness among males in a rural community in Goa

To study the heterosexual risk behaviors and to study the level of HIV/ AIDS awareness among males in a rural community in Goa. Survey was cross-sectional and community based. A sample of 300 males aged 15-49 years selected by stratified random sampling. An "UNAIDS protocol for measurement of HIV/STD prevention indicators" was used. SPSS software package was used for statistical analysis. One hundred and ninety eight (66%) males reported ever having sexual intercourse, of these 17% were single. Fifty three (17.7%) males reported intercourse with a non-regular partner in the past 12 months, of these 90.6% had intercourse with strangers, 92.5% had paid for sex and only 43.4% had used a condom for the last sexual encounter with a non-regular partner. Less educated males (<10th class), single and those employed have higher sexual indulgence with non-regular sexual partners. The level of knowledge about HIV/ AIDS was very high in all areas of causation and prevention. Although the awareness about sexual risk behavior was high, condom use was very low resulting in high risk behavior related to HIV/ AIDS and STDs among males. The study highlights the need for more effective behaviour change communication (BCC) strategies in the community as well as innovative methods like village level peer education.