FOCUS A Guide to
AIDS
Research and Counseling
Volume 14 Number 5 April 1999
Beyond Complacency: The Effects of Treatment on HIV Transmission Perry N. Halkitis, PhD and Leo Wilton, MA The interaction between the success of HIV antiviral therapy and prevention efforts is complex, and it is becoming clear that an optimistic view of the HIV epidemic may actually lead to an increase in the number of HIV infections.1 Data from several sources—for example, a survey of gay men in Sydney, a study of young men who have sex with men in New York, and preliminary data on both gay men and injection drug users in New York and San Francisco— demonstrate significant increases in the rate of unsafe sexual behavior among both HIV-infected and uninfected people. These patterns of unsafe practice are further demonstrated by the increasing prevalence of other sexually transmitted diseases around the country as illustrated by data from New York and San Francisco. Several studies suggest that the new optimistic culture arising from successful antiviral treatment has become the catalyst for behavior change that has resulted in these increases in unsafe sex. This article briefly reviews these studies and then evaluates the beliefs regarding the relationship between infectivity and treatment, which may fuel these increases in unsafe sex.
Optimism and Behavior Recent studies have indicated that increases in unsafe sex may be related to beliefs about the lack of severity of HIV disease. For example, in a New York study of 14 serodiscordant male couples, 24 percent of respondents engaged in unprotected anal intercourse two months prior to assessment, and half of the sample agreed that a reduction in the seropositive partner’s viral
load decreased the risk of transmission. Similarly, a New York study of men who have sex with men—the Seropositive Urban Men’s Study (SUMS)—found that men who engaged in unprotected anal intercourse with partners who were seronegative or of unknown status believed that they were less infectious because they were on antiviral therapy and had negligible viral loads. A study of 298 men attending a 1997 gay pride event in Atlanta found that those who had engaged in unprotected anal receptive intercourse indicated that they were less worried about unsafe sex because of treatment advances.2 Of 54 men surveyed in a 1997 San Francisco study, 26 percent were less concerned about becoming seropositive now that protease inhibitors were available: 15 percent were more willing to engage in unsafe sexual behaviors and risk HIV infection and 15 percent reported already taking such a risk.3 In addition, unsafe sex between HIVpositive partners, which may lead to reinfection, has also increased in light of the new treatments. The Seropositive Urban Men’s Study found that HIV-infected gay and bisexual men in primary relationships reported higher rates of unprotected insertive anal intercourse with other infected partners than with uninfected partners. Anecdotal reports indicate that some gay men in metropolitan areas attend “poz bareback parties,” where seropositive gay and bisexual men gather to have unprotected sex with multiple partners. Complicating the effects of optimism about new antiviral treatments is a misunderstanding about the meaning of an “undetectable” viral load reading. For example, a Canadian study found that a significant proportion of participants perceived unprotected vaginal and anal intercourse to be less risky and safer sexual practices to be less important if viral load was “undetectable.”4
Editorial: Transmitting Myths Robert Marks, Editor There is a type of scientific data that slips into human consciousness, integrated silently, like viral RNA, I guess, affecting our decisions without requiring much reflection. The success of combination therapy has injected several assumptions into the collective consciousness of those communities most affected by HIV disease. Among these ideas are that getting infected is no big deal because drugs can treat you, that people using the new treatments are somehow less likely to infect seronegative partners, and even that having an “undetectable” viral load is tantamount to being seronegative. There has been a great deal of speculation and a rush of studies over the past 18 months seeking to determine exactly how much these attitudes, if they exist, affect behavior. For example, do people believe that low viral load diminishes infectivity, do these people increase unprotected behaviors as a result, and how many people believe this and act on this belief?
References 1. Halkitis PN. Advances in treatment of HIV disease: Complexities of adherence and complications for prevention. The Health Psychologist. 1998; 20(1): 6-7,14. 2. Kalichman SC, Nachimson D, Cherry C, et al. AIDS treatment advances and behavioral prevention setbacks: Preliminary assessment of reduced perceived threat of HIV-AIDS. Health Psychology. 1998; 17(6): 546-550. 3. Dilley JW, Woods WJ, McFarland W. Are advances in treatment changing views about high-risk sex? New England Journal of Medicine. 1997; 337(7): 501-502. 2 FOCUS
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The data are inconclusive, but many studies have found that for small but significant minorities, such beliefs play an important role in precipitating unprotected sex. It remains unclear, as at least one researcher has suggested, whether this significant minority would be having unprotected sex anyway, that these individuals would have found some other justification for unsafe behavior. In any case, it is crucial for providers to understand the science behind assumptions about infectivity and transmission in the context of the new treatment landscape. This issue of FOCUS clarifies three concepts regarding the science: the possibility of transmitting drugresistant virus to seronegative partners, the possibility of reinfecting a seropositive person with drug-resistant virus, and the possibility of transmitting HIV when the seropositive partner’s viral load is below the level of detection. Perry Halkitis and Leo Wilton seek to answer these
Ultimately, however, the beliefs some people have about the effects of treatment success and the meaning of viral load are not supported by the scientific literature. First and foremost, the long-term efficacy of antiviral treatment remains unclear, suggesting that the success of the new treatments may lead to a false sense of security. Second, research indicates that problems in treatment, medication adherence, and the natural evolution of the virus may result in viral mutations and increased drug resistance. Finally, while antiviral treatment has been proven to reduce viral load in the blood, HIV may lie dormant, potentially in a mutated state, in the lymph and other systems. Recent data also suggest that some people have been infected with mutated and drug-resistant strains of the HIV virus, diminishing or eliminating options for treatment. While not proven, it appears that this may occur not only with seronegative people but also with seropositive individuals, who may
questions by reviewing the relevant literature. Their conclusions offer no concrete answers about probability but do confirm the possibility of transmission in all three of these cases. June Crawford, Susan Kippax, and Paul Van de Ven look at the implications of this science in the context of the explicit sexual agreements between partners in many couples. They focus on negotiated safety agreements, in which, by definition, both partners are seronegative, because this is the area where there is the most research. There’s a faint aroma of complacency in the air these days and a sense that not only have the consequences of HIV infection changed, but also the science of transmission. In order for clients to make appropriate decisions about risk, they must understand the certainty and limits of scientific knowledge. Mental health providers cannot expect themselves to interpret complex studies of basic HIV science, but they can become aware of the current scientific consensus in key areas and inform discussions of risk that arise within the counseling room.
become reinfected with a drug-resistant or more virulent strain of HIV, events that may complicate treatment. The rest of this article reviews the most recent research on viral mutation and drug resistance, the potential for reinfection, and the meaning of viral load and implications for infectivity.
Viral Mutation and Resistance Like all bacteria and viruses that cause disease, HIV has the potential to alter its genetic composition, yielding a variety of strains and subtypes. The introduction of combination therapy, in particular, the widespread use of protease inhibitors as well as continued use of nucleoside analogues such as zidovudine (ZDV; AZT), has significantly increased the prevalence of mutated viruses that can “outsmart” antiviral treatments. According to the Stanford HIV RT and Protease Sequence Database, drug resistance arises from mutations in the HIV genome specifically in the regions that encode the molecular targets of therapy: the
protease and reverse transcriptase enzymes.5 For individuals who initially succeed on combination therapy, the development of drug resistance is often associated with increases in viral load as medications fail to control infection. Evidence suggests that even when viral load is detected at levels less than 500, replication and mutation of the virus can still occur.6 Treatment failures due to drug resistance can lead to disease progression and limited treatment alternatives. Equally important, drug-resistant strains of HIV may be transmitted to others, similarly limiting their treatment options.1 Concern regarding drug resistance has emerged largely as a result of the introduction of protease inhibitors, although there has been ample evidence of virus resistant to medications, including the nucleoside reverse transcriptase inhibitors zidovudine (ZDV), didanosine (ddI), and zalcitabine (ddC), and lamivudine (3TC), and the nonnucleoside reverse transcriptase inhibitors. Research also indicates that a virus can contain several mutations and therefore be resistant to drugs in many classes. As significantly, viral mutation in response to one medication in a class of drugs, for example, the protease inhibitors, may result in resistance to all medications in that class. For example, the Stanford project cited above found that of the 18 mutations induced to evade indinavir, 17 evaded ritonavir, and 16 evaded saquinavir.5 Another example is that a similar mutation at one spot can cause resistance to all three licensed non-nucleoside reverse transcriptase medications. Resistance is closely connected to proper dosage and adherence to medications. For example, in one study of 88 people, treatment failure was directly related to adherence rates. The study found that treatment failure, as measured by viral load level, increased from 20 percent to 94 percent when adherence rates fell from 95 percent to 70 percent.7 Data from numerous sources, including the Seropositive Urban Men’s Study and the Seropositive Urban Drug Injectors’ Study, indicate adherence levels are approximately 50 percent across all classes of antiviral drugs.
Even at viral load levels of less than 500, HIV replication and mutation still occur. 4. Kravcik S, Victor G, Houston S, et al. Effect of antiretroviral therapy and viral load on the perceived risk of HIV transmission and the need for safer sexual practices. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998; 19(2): 124-129. 5. Shafer RW, Winters MA, Palmer S, et al. Multiple concurrent reverse transcriptase and protease mutations and multidrug resistance of HIV-1 isolates from heavily treated patients. Annals of Internal Medicine. 1998; 128(11): 906-911. 6. Crandall KA, Kelsey CH, Imamichi H, et al. Parallel evolution of drug resistance in HIV: Failure of nonsynonymous/synonymous substitution rate ratio to detect selection. Molecular Biology and Evolution. 1999; 16(3): 372-382. 7. Paterson D, Swindells S, Mohr J, et al. How much is enough? A perspective study of adherence to protease inhibitor therapy using MEMSCap. Presentation from the 6th Conference on Retroviruses and Opportunistic Infections, Chicago, February 1999. 8. Kalish M, Stoeckli T, Steffen I, et al. Molecular epidemiology of HIV-1 in Switzerland. Presentation from the 12th World AIDS Conference, Geneva, Switzerland, June-July 1998.
The Potential for Reinfection The transmissibility of drug-resistant HIV has implications not only for seronegative but also for seropositive individuals. While the concept of “reinfection” is controversial,
recent evidence suggests the existence of more than one strain of the virus in a person. The effect of such coinfection on antiviral treatment remains unclear. Researchers have long identified several risks to unprotected sex between seropositive partners. Among these risks have been infection with other sexually transmitted diseases that would flourish in the presence of a compromised immune system, and reinfection with HIV, an event that might activate the immune system leading, ironically, to further HIV replication in immune system cells. More recently, such practices have also been associated with hepatitis C transmission. Some researchers hypothesize that reinfection may have even more serious consequences when a seropositive person becomes exposed to a drug-resistant or more virulent strain of HIV. Some researchers contend that reinfection may also result in increased HIV levels in the blood. Swiss researchers have identified 159 subtype strains of HIV-1 in humans, and similar subtypes have been identified across other studies in Argentina, Brazil, Thailand, and Ukraine.8 The most prevalent in North America, Western Europe, and Australia is subtype B, while subtype C predominates in Africa and most of Asia. The subtypes A, D, E, and F have been found in smaller numbers. While evidence for dual infections exists, it is unclear if those infections result from simultaneous or consecutive infection. Researchers at the University of Alabama have accumulated evidence suggesting that the possibility of humans infected with two or more strains of HIV is probably greater than originally assumed.9 In their work with chimpanzees, the researchers were able to infect previously infected animals with a second strain of the virus and to detect the second strain up to six weeks later. Data from a Rio de Janeiro cohort supports the possibilities of dual infection, a recombinant strain, or a mosaic composition. Of the 791 blood donors studied over the course of a year, 3.8 percent had a dual HIV infection of two subtypes of the virus, and 7.6 percent had a recombinant infection.10 Neither of these studies was able to determine the biochemical effects of dual infection and its impact on antiviral treatment. Among the possibilities are that the second strain of the virus will predominate or that a recombinant and potentially more pathogenic version will develop.
The Meaning of Viral Load and Infectivity Combination treatment has been accompanied by improved monitoring of viral activity and disease progression. 3 FOCUS
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9. Fultz PN, Yue L, Wei Q, et al. Human immunodeficiency virus type 1 intersubtype (B/E) recombination in a superinfected chimpanzee. Journal of Virology. 1997; 71(10): 7990-7995. 10. Ramos A, Tanuri A, Schechter M, et al. Dual and recombinant infections: An integral part of the HIV-1 epidemic in Brazil. Emerging Infectious Diseases. 1999; 5(1): 65-74.
Authors Perry N. Halkitis, PhD is Clinical Assistant Professor of Applied Psychology at New York University and the Associate Director of the Center for HIV/AIDS Educational Studies and Training. He is CoPrincipal Investigator of the Seropositive Urban Men’s Study and Intervention Trial, and the former Director of Research at the Gay Men’s Health Crisis. Leo Wilton, MA is a doctoral candidate in counseling psychology at New York University, a research associate at the Center for HIV/AIDS Educational Studies and Training, and a therapist at the Trustees of Columbia University Community Support Systems Program.
Measures of serum HIV levels, referred to as viral load assays, have been used as markers of HIV disease progression and overall health, determinants of when to initiate antiviral therapy, indicators of the success of antiviral therapy, and, indirectly, measures of treatment adherence. Such assays are currently able to detect HIV at levels as low as 20 copies per milliliter of blood; however, not all laboratories use tests with sensitivities this low. Recently, researchers have suggested that viral load may have different implications for disease progression in women versus men. Although combination therapy can reduce the concentration of HIV to levels at which virus cannot be detected by viral load assays, this does not signify the complete eradication of virus from the body. But, as noted earlier, many people have interpreted an “undetectable” viral load to mean that a seropositive person is uninfectious. These extremely low viral load levels are now referred to as “below the level of detection” to indicate that HIV may still be present and to more clearly communicate that detection is affected by technology as much as by the presence of the virus. Research suggests that while blood level assays may demonstrate no significant detectable viral activity, HIV may lie dormant in the immune system, perhaps mutating naturally or in response to antiviral treatment. This phenomenon becomes apparent when people with viral loads below the level of detection discontinue antiviral treatment or when their strain of HIV becomes resistant to a drug or drugs they are taking—changes that are often accompanied by increases in viral load. In addition, a viral load below the level of detection does not signify that other body fluids, specifically genital fluids, are free of the virus. In one study, subjects on combi-
nation therapy who had suppressed levels of HIV in their blood did not have virus-free semen samples. In another cohort, subjects with detectable viral load levels in their blood presented with equal or higher levels of HIV in their seminal fluids.
Conclusion Risky behaviors seem to be increasing, and this increase may be associated with an optimism regarding the manageability and reduced threat of HIV disease. This optimism may be based not only on misleading media attention, but also on confusion about the effects of treatment on HIV transmissibility In response, clinicians and educators must raise awareness among both seronegative and seropositive individuals about the possibilities of viral mutation and resistance to antiviral therapies; they must also seek to contradict assumptions about infectivity in light of treatment advances and the concept of “undetectable” viral load. Because reinfection remains a risk, providers must raise issues of safer sex for people with HIV, even when partners themselves are seropositive, As we approach the third decade of AIDS, these messages must be stronger than ever because complacency has had an impact on behavior. Unfortunately, many AIDS service organizations have failed to respond adequately to the challenges of education regarding new treatments and adherence, the meaning of viral activity, and the dangers of drugresistant viral transmission. The AIDS epidemic is now in its adolescence, and our increased knowledge has transformed it into a much more complex disease. Providers must respond with more sophisticated and relevant strategies that take into account the depth and range of information that we have and the depth and range of the misunderstandings this information can induce.
Clearinghouse: Treatment/Prevention References
AIDS. 1998; 9(10): 579-586.
Egger M, Hirschel B, Francioli P, et al. Impact of new antiretroviral combination therapies in HIV infected patients in Switzerland: Prospective multicentre study. British Medical Journal. 1997; 315(7117): 1194-1199.
Kalichman SC. Post-exposure prophylaxis for HIV infection in gay and bisexual men: Implications for the future of HIV prevention. American Journal of Preventative Medicine. 1998; 15(2): 120-127.
Ezzy DM, Bartos MR, de Visser RO, et al. Antiretroviral uptake in Australia: Medical, attitudinal and cultural correlates. International Journal of STDs and
Kalichman SC, Kelly JA, Morgan M, et al. Fatalism, future outlook, current life satisfaction, and risk for human immunodeficiency virus (HIV) infection
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among gay and bisexual men. Journal of Consulting and Clinical Psychology. 1997; 65(4): 542-546. Kelly JA, Hoffmann RG, Rompa D, et al. Protease inhibitor combination therapies and perceptions of gay men regarding AIDS severity and the need to maintain safer sex. AIDS. 1998; 12(10): F91-F95. Kelly JA, Otto-Salaj LL, Sikkema KJ, et al. Implications of HIV treatment advances for behavioral research on AIDS: Protease inhibitors and new challenges in HIV secondary prevention. Health Psychology. 1998; 17(4): 310-319.
Sexual Agreements Between Men in Relationships
recent study on this type of agreement and its relation to risk behavior.
June Crawford, PhD, Susan Kippax, PhD, and Paul Van de Ven, PhD
In the early 1990s, U.S. and Dutch researchers identified what they called “relapse” among men who had been using condoms consistently but were no longer doing so. Australian and British researchers questioned this interpretation, noting that the relapse data did not draw a distinction between unprotected anal intercourse within regular relationships and unprotected anal intercourse with casual partners. Following a debate within the research community, Susan Kippax and coresearchers in Australia coined the term “negotiated safety” to describe a pattern of behavior they had observed: the partners within a regular relationship entered into an agreement that as long as each engaged in no unprotected anal intercourse outside of the relationship, then both could engage in unprotected anal intercourse within the relationship.1,2 It was appropriate in this context to use the term “safety” if both partners had been tested for HIV antibodies and found reliably to be seronegative, and provided of course that the agreement was kept. Since that time, there has been some confusion surrounding the discourse of negotiated safety. Some have suggested that what the researchers put forward as a description of a pattern of practice devised by men as a possible safe sex
Since the beginning of the epidemic, sexual partners have negotiated agreements about sexual activity both within and outside a relationship. Some of the issues covered in these agreements have included types of activity, the use of protection, and sexual activity outside the relationship. Over the past several years, the concept of “negotiated safety,” has gained some currency, referring particularly to agreements regarding unprotected anal intercourse within gay male relationships in which both partners are seronegative. Other types of agreements are less precisely conceptualized, but do commonly occur, for example, the agreement between partners in seropositive couples—both gay and heterosexual —to have unprotected sex since both partners are already HIV-infected. This article looks at the range of agreements among gay men regarding anal intercourse. It focuses in particular on negotiated safety and the results of a
Negotiated Safety
Some researchers criticized “negotiated safety” as a strategy, calling it “negotiated danger,” because there was room for slippage in the practice.
Malow RM, McPherson S, Klimas N, et al. Adherence to complex combination antiretroviral therapies by HIV-positive drug abusers. Psychiatric Services. 1998; 49(8): 1021-1022. Rabkin JG, Ferrando S. A “second life” agenda. Psychiatric research issues raised by protease inhibitor treatments for people with the human immunodeficiency virus or the acquired immunodeficiency syndrome. Archives of General Psychiatry. 1997; 54(11): 1049-1053. Remien RH, Wagner G, CarballoDieguez A, et al. Who may be engaging in high-risk sex due to medical treat-
ment advances? AIDS. 1998: 12(12): 1560-1561.
011-61-2-9385-6409, june.crawford@ unsw.edu.au (e-mail).
Rosser BRS. The impact of new advances in treatment on HIV prevention: Implications of the XI International AIDS Conference on future prevention directions. In Wright MT, Rosser BRS, de Zwart O, eds. New International Directions in HIV Prevention for Gay and Bisexual Men. New York: Haworth Press, 1998: 143-149.
Perry N. Halkitis, PhD, New York University, Department of Applied Psychology, 293 Greene Street, East 537G, New York, NY 10003, 212-9985373, pnh1@is6.nyu.edu (e-mail).
Contacts
Brenda Lein, Information and Advocacy Department, Project Inform, 205 13th Street, Suite 2001, San Francisco, CA 94103, 415-558-8669, blein@projinf.org (e-mail).
June Crawford, PhD, National Centre in HIV Social Research, University of New South Wales, Sydney 2052 Australia,
See also references cited in articles in this issue.
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References 1. Davies P. Project Sigma. On relapse: Recidivism or rational response? In Aggleton P, Davies P, Hart G, eds. AIDS, Rights, Risks and Reasons. London: Falmer Press, 1992. 2. Kippax S, Crawford J, Davis M, et al. Sustaining safe sex: A longitudinal study of a sample of homosexual men. AIDS. 1993; 7(2): 257-263. 3. Stall R, Ekstrand M. The quantitative/ qualitative debate over “relapse” behaviour: Comment. AIDS Care. 1994; 6(5): 619-624. 4. Kippax S, Noble J, Prestage G, et al. Sexual negotiation in the AIDS era: Negotiated safety revisited. AIDS. 1997; 11(2): 191-197. 5. Bosga MB, de Wit JBF, de Vroome EMM, et al. Differences in perception of risk for HIV infection with steady and non-steady partners among homosexual men. AIDS Education and Prevention. 1995; 7(2): 103-115. 6 FOCUS
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strategy was being recommended as such an approach. Critics of the strategy called it “negotiated danger,” pointing out that there was room for slippage in the practice: for example, the potential for agreements to be broken, the fact that reliable knowledge of one’s HIV status required two seronegative test results at an interval of approximately four months, and the need for mutual honesty between partners.3 It is clear that as a risk reduction strategy, negotiated safety is complicated. In continuing to research the kinds of agreements that men make and the behavior in which they engage, the Australian team has found that negotiated safety agreements, as well as agreements to engage in no unprotected anal intercourse at all, may in fact be helpful in the sustaining of safe sexual practice.4 While many studies have found that unprotected anal intercourse is far more common in regular relationships than in casual partnerships,2,5-7 only a small number of studies separately consider practices that may differ according to whether they are with regular or with casual partners. A recent large national telephone survey of men who have sex with men in Australia, known as Male Call 96, included questions about agreements in regular relationships. Out of 3,039 men who responded to the survey, 1,070 were in “regular” (sometimes referred to as “primary”) male-to-male relationships of more than six months duration. Researchers excluded from the analysis 30 men in relationships in which both partners were seropositive, leaving 1,040 men who contributed to the analysis discussed here. One of the findings from this survey was that over 80 percent of the men in such relationships had agreements with their partners regarding sexual practice within the relationship. The most common form
of agreement was to have no unprotected anal intercourse either within or outside the relationship. Negotiated safety agreements were almost as common. Again, a negotiated safety agreement is one in which: both partners have tested HIV antibody negative; the partners have talked with each other and come to an agreement; and the agreement includes a provision that there will be no unprotected anal intercourse outside the relationship. In general, the Male Call study found a close relationship between type of agreement and risk practice. Under the conditions of a negotiated safety agreement that is followed by both partners, unprotected anal intercourse within the relationship is not a risk practice because both partners are seronegative. Unprotected anal intercourse between men in serodiscordant relationships or in relationships where the HIV serostatus of one or both partners is unknown carries some risk, and all unprotected anal intercourse with casual partners is regarded as risky. (The Male Call study did not investigate oral sex practices at all.) The study found that few people with negotiated safety agreements reported engaging in risky practices. Nevertheless, negotiated safety is not a simple and straightforward strategy, depending as it
Few study participants with negotiated safety agreements engaged in risky practices. But, negotiated safety is not simple; it depends on reliable information regarding serostatus and requires open and honest communication in case a partner breaks the agreement.
Comments and Submissions We invite readers to send letters responding to articles published in FOCUS or dealing with current AIDS research and counseling issues. We also encourage readers to submit article proposals, including a summary of the idea and a detailed outline of the article. Send correspondence to: Editor, FOCUS UCSF AIDS Health Project, Box 0884 San Francisco, CA 94143-0884
does on reliable and up-to-date information regarding the serostatus of both partners. It also requires open and honest communication between partners in the event that one of them breaks the agreement. Such an event would necessitate a return to consistent condom use or the avoidance of anal intercourse until seronegative status could be re-established.
Other Types of Agreement
6. Dawson J, Fitzpatrick R, Reeves G, et al. Awareness of sexual partners' HIV status as an influence upon high-risk sexual behaviour among gay men. AIDS. 1994; 8(6): 837-841. 7. Detels R, English P, Visscher BR, et al. Seroconversion, sexual activity and condom use among 2915 HIV seronegative men followed for up to two years. Journal of Acquired Immune Deficiency Syndrome. 1989; 2(1): 77-83. 8. Van de Ven P, French J, Crawford J, et al. Sydney gay men's agreements about sex. In Aggleton P, Davies P, Hart G, eds. Families and Communities Respond to AIDS. London: University College of London Press. In press.
Authors June Crawford, PhD is a Research Consultant at the National Centre in HIV Social Research at the University of New South Wales in Sydney, Australia. Susan Kippax, PhD is Director of the National Centre in HIV Social Research. Paul Van de Ven, PhD is Deputy Director of the National Centre in HIV Social Research.
In the Male Call study, a small but important minority of men in relationships, around 11 percent, had “unsafe” agreements. Such agreements included those in which partners of different or unknown serostatus agreed to unprotected anal intercourse within the relationship, and all arrangements, including those between seroconcordant partners, that did not include a pact to have no unprotected anal intercourse outside the relationship. As might be predicted, men with unsafe agreements were likely to report behavior that risked HIV transmission. For these men, most risk practice was with regular partners, and the risk was due to absence of information regarding serostatus. Encouraging regular partners to be tested and to disclose their test results to one another may be one way to decrease the number of men who have unsafe agreements. In the Male Call survey, there were very few serodiscordant couples, but from this and other studies, it has been found that agreements are very common among such couples. In the case of serodiscordant couples, most agreements are to have no unprotected anal intercourse either within or outside the relationship, although again a small minority report agreements which permit behavior (particularly within the relationship) that risks HIV transmission. Studies other than the Male Call study have determined that agreements between partners in seroconcordant positive couples are also common, and that many such couples engage in unprotected anal intercourse.8 Although both partners are living with HIV disease, there are other issues such as infection with other sexually transmissible infections and different strains or mutations of HIV that may need to be taken into account when seropositive couples make decisions regarding anal intercourse within the relationship. It is clear that gay men in relationships can and do enter into agreements regarding the practice of anal intercourse both within and outside the relationship. Some of these agreements are complex and rely on accurate understandings of HIV testing
and transmission issues. In the light of new treatments that appear to be effective in maintaining health for many people living with HIV, it is possible that negotiation of agreements between men, whatever their own and their partner’s serostatus, may become even more complicated. The advent of new treatments and the availability of testing for viral load have the potential to increase the complexity of the information that may affect agreements. For example, a person’s viral load may appropriately or inappropriately enter into agreements of discordant couples. It is not only discordant couples who may find negotiation more complex. Even among men who are HIV-seronegative, new treatments may bring about change in cultural meanings attached to what is implied by being or becoming HIV-seropositive.
Conclusion It is important for researchers to continue to investigate what understandings gay men have regarding the new treatments, whether they incorporate these understandings (either accurate or inaccurate) into their agreements, and what happens to their sexual practice in this new context. This research is aimed at providing answers to questions that will help counselors and educators formulate programs aimed at preventing transmission of HIV.
Clarification In the February issue of FOCUS, the article “HIV Partner Counseling and Referral” omitted information that helps to understand the value of the detuned assay for partner counseling. The assay is a form of the antibody test that determines if seroconversion occurred either within the four months prior to antibody testing or at a time greater than four months prior to testing. Since it can take two months after exposure to seroconvert, partner counseling and referral guidelines identify the “critical interview period” for people who test “antibody positive/detuned negative” as being two months plus four months, for a total of six months. The critical interview period is the time frame during which identified sexual or needle-sharing partners may have been exposed and should be located for partner counseling and referral services. 7 FOCUS
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Recent Reports
FOCUS A Guide to
AIDS
Research and Counseling
Executive Editor; Director, AIDS Health Project James W. Dilley, MD Editor Robert Marks Assistant Editors Alex Chase John Tighe Founding Editor; Advisor Michael Helquist Medical Advisor Stephen Follansbee, MD Design Saul Rosenfield Production Tania Lihatsh Shauna O’Donnell Andrew Tavoni Circulation Carrel Crawford Shauna O’Donnell Interns Laura Meyers Rahim Rahemtulla FOCUS is a monthly publication of the AIDS Health Project, affiliated with the University of California San Francisco. Twelve issues of FOCUS are $36 for U.S. residents, $24 for those with limited incomes, $48 for individuals in other countries, $90 for U.S. institutions, and $110 for institutions in other countries. Make checks payable to “UC Regents.” Address subscription requests and correspondence to: FOCUS, UCSF AIDS Health Project, Box 0884, San Francisco, CA 941430884. Back issues are $3 each: for a list, write to the above address or call (415) 476-6430. To ensure uninterrupted delivery, send your new address four weeks before you move. Printed on recycled paper. ©1999 UC Regents: All rights reserved. ISSN 1047-0719
Effects of Treatment on Risk Perception Kravcik S, Victor G, Houston S, et al. Effect of antiretroviral therapy and viral load on the perceived risk of HIV transmission and the need for safer sexual practices. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998; 19(2): 124-129. (Ottawa General Hospital; and Health Canada, Ottawa.)
According to a Canadian study, 22 percent of seropositive subjects believed that taking some form of antiviral therapy reduced their risk of transmitting HIV to others, and 20 percent believed that treatment diminished the importance of safer practices for sex and injection drug use. Researchers recruited 147 participants from a university-based HIV clinic, 88 percent of whom were men. Subjects reported sources of infection as follows: 77 percent through sexual intercourse (89 percent male-to-male), 8 percent through injection drug use, and 8 percent through blood transfusions. Ninety-five percent were on antiviral therapy, and 69 percent were taking at least one protease inhibitor. Subjects completed a questionnaire assessing their perceptions of the risk of HIV transmission from an infected man with a CD4+ cell count of about 200 to an uninfected partner under three hypothetical scenarios: in the “no therapy” case, the HIV-infected partner received no treatment; in the “RTI therapy” case, he was taking zidovudine (ZDV; AZT) with lamivudine (3TC); and in the “PI therapy” case, he was on ZDV, 3TC, and a protease inhibitor and had “undetectable” viral load. For each scenario, respondents ranked the relative risk of transmission for unprotected anal, vaginal, and oral sex, and for needle sharing. For at least one of these risk behaviors, 10 percent believed that RTI therapy reduced risk, and 20 percent believed that PI therapy reduced risk. Respondents also rated the importance of safer sexual and needle-sharing practices: 10 percent believed that RTI therapy decreased the importance of safer practices, and 19 percent believed that PI therapy decreased the importance of safer practices.
Risk Perceptions among Gay Men Kalichman SC, Nachimson D, Cherry C, et al. AIDS treatment advances and behavioral prevention setbacks: Preliminary assessment of reduced perceived threat of HIV-AIDS. Health Psychology. 1998; 17(6): 546-550. (Medical College of Wisconsin; and Georgia State University.)
A study of seronegative or untested gay 8 FOCUS
April 1999
and bisexual men not in long-term relationships found that 23 percent who had engaged in unprotected anal receptive intercourse during the previous six months believed that this was safe if an HIV-infected partner had an undetectable viral load. Of subjects who did not participate in unprotected anal receptive intercourse during this period, only 5 percent shared this belief. The sample consisted of 298 men—93 percent gay and 7 percent bisexual— recruited at an Atlanta gay pride festival. The mean age was 33; and 85 percent were White, 7 percent were African American, and 8 percent were of other ethnic backgrounds. Eighty-five percent had tested seronegative, and 15 percent had not tested. Twenty percent had engaged in unprotected anal receptive intercourse in the previous six months. These “highest risk” subjects were younger and had completed fewer years of education than “lower risk” subjects. Highest risk subjects were more likely than lower risk subjects to state that they practiced more unsafe sex than they used to and that they were less worried about becoming infected because of new treatment efficacy. Highest risk subjects considered the risks for unprotected anal receptive intercourse to be lower with HIV-infected partners taking protease inhibitors and lower still with partners with undetectable viral loads. Among lower risk subjects, however, perceived risk remained consistent regardless of a partner’s treatment status or viral load.
Next Month The AIDS epidemic has always posed some thorny ethical issues for mental health providers. In the May issue of FOCUS, Sally Jue, LCSW, a Los Angeles trainer and consultant, reviews a recent model for ethical decision making that she and her colleagues developed for the American Psychological Association. The model outlines a process for defining and responding to ethical dilemmas and identifies key ethical principles that are crucial to this endeavor. Also in the May issue of FOCUS, Steve Heilig, MPH, Director of Public Health and Education at the San Francisco Medical Society, discusses HIV-related “rational” suicide and issues related to societal and personal control.
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