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. 

In This Article

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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