December 2005

Prevention for Positives
Study in Kenya underscores need to include people living with HIV/AIDS in prevention efforts

Nurses at the Mkomani BOMU clinic, a study site which offers HIV treatment, speak with two patients. Photo credit: Avina Sarna

A comprehensive approach to prevention requires that HIV-positive persons do not fall outside the scope of prevention efforts. Instead, these individuals need to take protective and preventive measures since they run the risk of both infecting their sexual partners and reinfecting themselves with different strains of the virus.

As access to treatment expands, many HIV-positive people on antiretroviral therapy (ART) are living longer, healthier, and more sexually active lives. Those results, while encouraging, raise new concerns within the public health community. Do HIV-positive persons receiving ART engage in more risky sexual behaviors after feeling better in response to the therapy? Even if unsafe behaviors do not increase after treatment, do patients on ART continue to have unprotected sex with their partners?

To examine the impact of ART on sexual risk behavior in a developing country setting, researchers from the Horizons Program, the International Center for Reproductive Health, and implementation partners from Kenya Ministry of Health facilities conducted a study in Mombasa. In addition to documenting the changes in sexual behavior among people on ART over a 12-month period, the study compares the sexual risk behaviors of HIV-infected individuals receiving ART to those of HIV-infected individuals on preventive therapy. This comparison is revealing since both groups are in regular contact with health workers and thus exposed to similar HIV/AIDS messages.

Researchers interviewed 179 HIV-infected persons who had been receiving ART for six months and 143 HIV-infected persons who had been receiving opportunistic infection prophylaxis, or preventive therapy, for at least five months. The patients were recruited as they came in for routine follow-up services at four HIV care clinics in Mombasa: Coast Province General Hospital, Mkomani BOMU clinic, Magongo clinic, and Port Reitz District Hospital. Both groups received free treatment from these facilities.

After providing written informed consent, the patients answered questions on their sexual behavior over the past six months in their choice of English or Kiswahili. The questions asked about their type of partners, knowledge of their partners’ HIV status, disclosure of their own HIV status to partners, condom use at last sex, and consistent condom use.

All patients were in regular contact with health workers at the facilities where they received routine medical care on a monthly basis. The clients on ART also received additional intensive counseling on treatment adherence. Although this counseling included some mention of sexual behavior, it was not emphasized or discussed in detail.

More than half (60 percent) of the study participants were female and almost half (47 percent) were married. The average age was 37 years. The sample was fairly well educated; 40 percent had up to 12 years of schooling and another 43 percent had attended up to seven years of school. Patients receiving preventive therapy were significantly more likely to be employed and have a higher economic status than patients on ART.

Sexual Activity

The study found that there was no difference between the groups as to whether respondents were sexually active in the last six months. But ART patients were less likely than patients on preventive therapy to report having casual or multiple partners.

Less than half of all patients on ART and those receiving preventive therapy reported having sex during the past six months. There was little difference between men and women, although married respondents were more likely to report having sex than single, widowed, or separated respondents.

Among respondents who were sexually active, more than nine out of ten (92 percent) reported having sex with a regular partner. The patients receiving ART were more likely to report having sex with a regular partner compared to those receiving preventive therapy (97 vs. 88 percent). ART recipients were less likely to report having sex with a casual partner (3 vs. 23 percent) and with multiple partners (1 vs. 13 percent) than those receiving preventive therapy.

Condom Use

Condom use is an effective means of lowering the risk of HIV transmission for people living with HIV/AIDS who are sexually active. Patients on ART were more likely to report condom use at last sex (93 vs. 77 percent) and consistent condom use with their regular partners (53 vs. 22 percent) during the past six months compared to those on preventive therapy.

Since most survey participants reported having sex with a regular partner, researchers explored the factors influencing condom use with these partners. For this investigation, unprotected sexual intercourse was defined as no condom use at last sex or inconsistent condom use with regular partners during the last six months.

The multivariate analysis found that males, married respondents, and those on preventive therapy were significantly more likely to report having unprotected sex with a regular partner. More specifically, patients receiving preventive therapy were four times more likely to report having unprotected sex with a regular partner compared to patients receiving ART. Married or cohabiting patients were three times more likely to report having unprotected sex compared to single (never married, widowed, or separated) respondents.

In-depth interviews with respondents provided insight into the barriers to condom use for married or cohabiting respondents. As one 34-year-old male patient on ART with an HIV-negative spouse explained in response to a question on using condoms, “To tell you the truth it is not easy to use a condom especially using it on your wife, how do I go to shops to buy a condom and use it on my wife, I would rather not have sex…. There was a day that I used a condom after a long time without having sex and it broke…since that day my wife told me she will never use a condom…. She said if it is a matter of infecting her then it would have long ago happened…she said we would rather both of us die....” He added, “…besides she kept on asking me how we would get a child if we keep on using the condom.”

Disclosure of HIV Status

Ensuring the prevention of HIV transmission requires a range of protective measures, including knowledge of partners’ HIV status and disclosure of one’s serostatus to sexual partners. However, in both the ART group and the preventive therapy group, around 40 percent of the sample did not know their regular partners’ HIV status. Additionally, about 20 percent did not disclose their own serostatus to their regular partners.

Jerry Okal (left), the study’s key research assistant, with a community health worker who counsels ART patients on adherence. Photo credit: Paul Munyao

The findings about disclosure to casual partners and sex workers were also of concern. Among the individuals who reported having sex with a casual partner, the majority did not know the HIV status of these partners (11/17), and did not disclose their own HIV status to these partners (12/17). Almost a third (5/17) reported not using a condom at last sex with a casual partner. One respondent from each group (one male and one female) reported having sex with a sex worker during the last six months; neither disclosed his or her own status to these partners or used a condom.

Implications

This study found lower levels of sexual risk behavior (such as multiple partners, sex with casual partners, and inconsistent condom use) among people living with HIV/AIDS who were receiving ART compared to those receiving preventive therapy. Thus, the study provided no evidence to suggest that sexual risk behavior is higher among patients on ART.

Although levels of self-reported risk behavior were lower among patients receiving ART, a considerable risk of HIV transmission still exists for both groups. This may be especially true when considering that the study relied on self-reported sexual behavior, which may have been underestimated. Lack of knowledge of partners’ HIV status and low levels of disclosure of one’s own status, coupled with inconsistent condom use, sets the stage for HIV transmission, especially within regular partner relationships. Transmission of resistant viral strains and reinfection with new strains are potential public health risks. Further, unprotected sex carries the added risks of unwanted pregnancy and HIV transmission to the child.

“Traditionally, the focus of prevention programs has been on groups with multiple partners…this study highlights the need for a greater focus on regular partner relationships of HIV-positive persons,” explained Dr. Avina Sarna of Horizons/Population Council, one of the study’s principal investigators.

Most counseling in HIV care services is directed toward treatment adherence. The patients on ART in this study received at least three preparatory counseling sessions on adherence, followed by ongoing support. Additionally, patients receiving ART have advanced HIV disease and may perceive the seriousness of their illness differently than those on preventive therapy, possibly resulting in less risky sexual behavior.

Nevertheless, HIV care services need to include prevention messages that emphasize disclosure of HIV status, partner testing, and consistent condom use with all partners, irrespective of partner status, with a special focus on regular partner relationships. “Health workers in ART treatment programs tend to spend a lot of time on issues related to medications and side effects and very little time on prevention. Clearly, preventive behavior needs a larger share of counseling time,” stressed Dr. Sarna.

Horizons and its partners are currently following a cohort of HIV-infected patients receiving ART to examine changes in their sexual risk behavior over a 12-month period. Results of this research will be available in early 2006. In addition, based on findings from the study in Mombasa, plans are underway for additional research that will test different strategies, such as couple counseling and development of a personal risk reduction plan for positive prevention.

This article was written by Hena Khan, in conjunction with members of the research team, which includes Avina Sarna and Susan Kaai of Horizons/Population Council and Stanley Luchters of the International Centre for Reproductive Health.

For more information about this study, contact Avina Sarna (asarna@popcouncil.org) or go to the Horizons treatment, care, and support publications for updates on this research.

© 2005 The Population Council, Inc.

See Also

• FRONTIERS – Prevention

• Population Council – Microbicides

• Population Council – Prevention

• Population Council – Treatment, Care, and Support

• Population Council – Journals and Newsletters

---

Print this page

@ E-mail this page

This page updated 27 January 2006

---