Sexual Risk Behaviour and Viral Suppression Among HIV-Infected Adults Receiving Medical Care in the United States

Christine L. Mattson; Mark Freedman; Jennifer L. Fagan; Emma L. Frazier; Linda Beer; Ping Huang; Eduardo E. Valverde; Christopher Johnson; Catherine Sanders; A.D. McNaghten; Patrick Sullivan; Amy Lansky; Jonathan Mermin; James Heffelfinger; Jacek Skarbinski

Disclosures

AIDS. 2014;28(8):1203-1211.

Abstract and Introduction

Abstract

Objective: To describe the prevalence and association of sexual risk behaviours and viral suppression among HIV-infected adults in the United States.

Design: Cross-sectional analysis of weighted data from a probability sample of HIV-infected adults receiving outpatient medical care. The facility and patient response rates were 76 and 51%, respectively.

Methods: We analysed 2009 interview and medical record data. Sexual behaviours were self-reported in the past 12 months. Viral suppression was defined as all viral load measurements in the medical record during the past 12 months less than 200 copies/ml.

Results: An estimated 98 022 (24%) HIV-infected adults engaged in unprotected vaginal or anal sex; 50 953 (12%) engaged in unprotected vaginal or anal sex with at least one partner of negative or unknown HIV status; 23 933 (6%) did so while not virally suppressed. Persons who were virally suppressed were less likely than persons who were not suppressed to engage in vaginal or anal sex [prevalence ratio, 0.88; 95% confidence interval (CI), 0.82–0.93]; unprotected vaginal or anal sex (prevalence ratio, 0.85; 95% CI, 0.73–0.98); and unprotected vaginal or anal sex with a partner of negative or unknown HIV status (prevalence ratio, 0.79; 95% CI, 0.64–0.99).

Conclusion: The majority of HIV-infected adults receiving medical care in the U.S. did not engage in sexual risk behaviours that have the potential to transmit HIV, and of the 12% who did, approximately half were not virally suppressed. Persons who were virally suppressed were less likely than persons who were not suppressed to engage in sexual risk behaviours.

Introduction

The number of persons aged 13 years and older newly infected with HIV in 2010 in the United States was estimated to be 47 500, and 88% of all new HIV infections were attributed to sexual transmission.^[1] Recent estimates suggest that approximately four transmissions occur per 100 HIV-infected persons annually;^[2] however, nationally representative data on sexual risk behaviours have not been available since the late 1990s.^[3] Thus, national data on the sexual risk behaviour of HIV-infected persons are needed to inform prevention efforts to reduce sexual transmission of HIV and the acquisition of other sexually transmitted infections (STIs).

Providing antiretroviral therapy (ART) improves individual health outcomes and observational evidence and a randomized clinical trial have demonstrated that taking ART substantially reduces the risk of heterosexual HIV transmission.^[4,5] Although this finding has profound implications for HIV prevention, access to ART does not eliminate all the barriers that may interfere with the elimination of HIV transmission, including delayed diagnosis, lack of continuous care, suboptimal adherence, drug resistance and subsequent increases in risky sexual behaviour (i.e. risk compensation).^[6–10] Findings from prior investigations of the association between ART provision and increased sexual risk behaviour are mixed.^[11–14] Soon after effective therapy became widely available in developed countries, evidence suggested a resurgence of HIV and other STIs, especially syphilis, among MSM.^[13,15] Some data, including meta-analyses, have indicated no increases in sexual risk behaviour among persons who received ART or were virally suppressed, but the prevalence of unprotected sex was higher among HIV-infected adults who believed that ART or viral suppression protects against transmission.^[12,14]

In this report, we present data (overall and stratified by viral suppression) to describe sexual risk behaviours in a national sample of HIV-infected adults receiving medical care in the United States. Given the increased probability of HIV transmission when individuals are not virally suppressed, we also assess the association between sexual risk behaviour and viral suppression.

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Lippincott Williams & Wilkins

Abstract and Introduction
Materials and Methods
Results
Discussion
References

Table 1. Sociodemographic and clinical characteristics of adults with HIV diagnosis for at least 12 months and receiving medical care in the United States, Medical Monitoring Project, 2009.
Characteristic	Total^a (n = 4094) Weighted % (95% CI)	MSM (n = 1897) Weighted % (95% CI)	MSW (n = 1016) Weighted % (95% CI)	WSM (n = 1093) Weighted % (95% CI)	P for modified Rao-Scott chi-square test
Age at the time of interview (years)
18–29	7 (6–8)	8 (6–9)	4 (2–5)	9 (7–11)	<0.001
30–39	17 (15–18)	16 (14–18)	12 (10–15)	21 (18–24)
40–49	40 (38–42)	41 (39–44)	39 (36–42)	39 (35–43)
≥50	36 (35–38)	35 (33–38)	45 (42–49)	31 (28–34)
Race/ethnicity
Black, non-Hispanic	41 (33–49)	22 (16–28)	56 (46–67)	62 (54–70)	<0.001
White, non-Hispanic	35 (28–41)	54 (48–61)	17 (11–23)	18 (14–22)
Hispanic	19 (14–24)	19 (16–22)	22 (13–32)	17 (10–24)
Multiracial/other	5 (4–6)	5 (4–6)	5 (3–7)	3 (2–5)
Education
<High school	23 (20–25)	9 (7–11)	36 (33–40)	34 (31–38)	<0.001
High school	27 (24–30)	22 (19–24)	34 (31–37)	30 (26–34)
>High school	50 (46–55)	69 (65–74)	30 (25–34)	36 (32–40)
At or below the poverty level^b	44 (40–48)	26 (23–29)	58 (54–62)	62 (57–67)	<0.001
Experienced homelessness^b	9 (8–10)	6 (5–8)	14 (11–16)	8 (7–10)	<0.001
In jail >24 h^b	6 (5–7)	3 (3–4)	11 (8–14)	5 (4–7)	<0.001
Continuous health insurance or coverage^b	72 (67–76)	72 (66–78)	71 (65–76)	74 (69–79)	0.238
HIV diagnosis ≥5 years earlier	78 (76–80)	78 (75–80)	77 (74–81)	80 (77–83)	0.444
Prescribed antiretroviral therapy	89 (88–91)	90 (89–92)	91 (89–93)	86 (83–89)	0.006
≥3 viral load measurements^b	62 (60–65)	61 (59–64)	66 (62–71)	60 (56–64)	0.236
All viral load measures in the past year <200 copies/ml	59 (56–62)	63 (60–66)	58 (54–62)	53 (49–57)	<0.001
Clinical status
AIDS or CD4⁺ cell count 0–199 cells/μl (nadir)	68 (66–70)	65 (63–68)	76 (73–80)	65 (62–68)	<0.001
No AIDS and CD4⁺ cell count 200–499 cells/μl (nadir)	25 (23–27)	28 (25–31)	18 (15–21)	27 (24–29)
No AIDS and CD4⁺ cell count ≥500 cells/μl (nadir)	7 (6–8)	7(5–9)	5 (4–7)	8 (6–10)

CI, confidence interval; MSM, men have sex with men; MSW, men who have sex with women; WSM, women who have sex with men.
^aExcludes persons who reported no sexual behaviour and did not report their sexual orientation as heterosexual, homosexual or bisexual. Includes transgender participants (n = 64) and women who have sex with women (n = 26) because sample sizes were too small to provide valid estimates for separate analysis.
^bRefers to the 12 months before interview (June 2008–May 2009).

Table 2. Sexual and drug-use behaviours of men who have sex with men, men who have sex with women and women who have sex with men with HIV diagnosis for at least 12 months receiving medical care in the United States, Medical Monitoring Project, 2009.
Characteristics^a	Total^b (n = 4094) Weighted % (95% CI)	MSM (n = 1897) Weighted % (95% CI)	MSW (n = 1016) Weighted % (95% CI)	WSM (n = 1093) Weighted % (95% CI)	P for modified Rao-Scott chisquare test
Number of sex partners
None	38 (35–40)	31 (28–34)	43 (38–47)	46 (43–48)	<0.001
1	38 (36–41)	31 (28–33)	44 (41–48)	47 (44–50)
≥ 2	24 (21–27)	39 (34–42)	13 (11–15)	8 (5–10)
Self-reported sexually transmitted infection
Yes	13 (11–15)	16 (13–19)	6 (5–8)	12 (8–16)	<0.001
No	31 (29–33)	32 (29–34)	26 (23–30)	35 (31–39)
Not tested	56 (54–58)	52 (49–56)	68 (64–72)	53 (49–57)
Used noninjection drugs	27 (26–29)	35 (32–37)	24 (21–27)	17 (15–19)	<0.001
Drank alcohol before/during sex	24 (22–26)	32 (29–35)	19 (16–32)	15 (13–18)	<0.001
Drug use before or during sex
Any drug	11 (10–13)	16 (14–18)	7 (5–9)	7 (5–8)	<0.001
Stimulants	5 (4–6)	7 (6–9)	2 (1–3)	3 (2–4)	<0.001
Poppers	3 (2–4)	6 (4–7)	–—	–—
Methamphetamines	2 (2–3)	5 (3–6)	–—	–—
Exchanged sex for money/goods	4 (3–4)	3 (2–4)	5 (3–7)	2 (1–3)	0.009

CI, confidence interval; MSM, men who have sex with men; MSW, men who have sex with women; WSM, women who have sex with men; dash, coefficient of variation was >0.30 (sample size too small to produce valid estimates).
^aRefers to the 12 months before interview (June 2008–May 2009)
^bExcludes persons who reported no sexual behaviour and did not report their sexual orientation as heterosexual, homosexual or bisexual. Includes transgender participants (n = 64) and women who have sex with women (n = 26) because sample sizes were too small to provide valid estimates for separate analysis.

Table 3. Weighted percentage of sexual risk behaviours and associations with viral suppression ^a among adults with HIV diagnosis for at least 12 months and receiving medical care in the United States, Medical Monitoring Project, 2009.
	Total^b			MSM			MSW			WSM
	%	PR (95% CI)	test	%	PR (95% CI)	P for modified Rao-Scott chi-square test	%	PR (95% CI)	P for modified Rao-Scott chi-square test	%	PR (95% CI)	P for modified Rao-Scott chi-square test
Vaginal/anal sex
Suppressed	53	0.88 (0.82–0.93)	<0.01	55	0.87 (0.80–0.96)	<0.01	54	0.93 (0.84–1.04)	0.21	48	0.81 (0.71–0.93)	<0.01
Not suppressed	60	Ref		63	Ref		58	Ref		59	Ref
Unprotected vaginal or anal sex
Suppressed	22	0.85 (0.73–0.98)	0.03	28	0.78 (0.66–0.93)	<0.01	14	1.00 (0.66–1.51)	0.99	21	0.85 (0.67–1.07)	0.16
Not suppressed	26	Ref		35	Ref		14	Ref		24	Ref
Unprotected vaginal or anal sex with a partner of negative or unknown HIV status
Suppressed	11	0.79 (0.64–0.99)	0.04	12	0.76 (0.60–0.97)	0.03	8	0.82 (0.44–1.53)	0.52	14	0.87 (0.63–1.20)	0.41
Not suppressed	14	Ref		15	Ref		10	Ref		16	Ref

CI, confidence interval; MSM, men who have sex with men; MSW, men who have sex with women; PR, prevalence ratio; WSM, women who have sex with men.
^aNote: viral suppression is defined as all viral load measurements in the 12 months before interview undetectable or <200 copies/ml.
^bExcludes persons who reported no sexual behaviour and did not report their sexual orientation as heterosexual, homosexual or bisexual. Includes transgender participants (n = 64) and women who have sex with women (n = 26) because sample sizes were too small to provide valid estimates for separate analysis.

Table 4. Weighted percentage of sexual risk behaviours and associations with viral suppression ^a and antiretroviral therapy use among adults with HIV diagnosis for at least 12 months and receiving medical care in the United States, Medical Monitoring Project, 2009.
	Total^b
	% (95% CI)	PR (95% CI)	P for modified Rao-Scott chi-square test
Vaginal/anal sex
Suppressed	52 (49–55)	0.78 (0.70–0.86)	<0.01
Prescribed ART, not suppressed	58 (55–61)	0.87 (0.79–0.95)	<0.01
Not prescribed ART, not suppressed	67 (62–72)	Ref
Unprotected vaginal or anal sex
Suppressed	22 (19–25)	0.67 (0.52–0.85)	<0.01
Prescribed ART, not suppressed	25 (21–29)	0.75 (0.62–0.91)	<0.01
Not prescribed ART, not suppressed	33 (26–40)	Ref
Unprotected vaginal or anal sex with a partner of negative or unknown HIV status
Suppressed	11 (9–13)	0.60 (0.42–0.85)	0.01
Prescribed ART, not suppressed	13 (11–16)	0.74 (0.56–0.98)	0.04
Not prescribed ART, not suppressed	18 (14–23)	Ref

ART, antiretroviral therapy; CI, confidence interval; PR, prevalence ratio.
^aNote: viral suppression is defined as all viral load measurements in the 12 months before interview undetectable or <200 copies/ml.
^bExcludes persons who reported no sexual behavior and did not report their sexual orientation as heterosexual, homosexual or bisexual. Includes transgender participants (n = 64) and women who have sex with women (n = 26) because sample sizes were too small to provide valid estimates for separate analysis.