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Study warns HIV-positive gay men are engaging in unsafe sex

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New research suggests that safer-sex messages need to be reinforced among gay men living with an HIV-positive diagnosis. Nerys Hairon finds out more

Hairon, N. (2008) Study warns HIV-positive gay men are engaging in unsafe sex. Nursing Times; 104: 26, 21-22.

 

Gay men who know they are HIV-positive are more likely to engage in risky sexual behaviour than those who have undiagnosed HIV infection or are HIV-negative, new research has shown (Williamson et al, 2008). The study also found that a high proportion (41%) of HIV-positive gay men had undiagnosed infection.

As a result, the authors of the study call for sexual health clinics to proactively offer testing in an attempt to reduce undiagnosed HIV. They should also target repeat testing at high-risk men who have previously tested negative.

In addition, in order to reduce levels of sexual risk, clinic staff should initiate evidence-based behavioural interventions among both men diagnosed HIV-positive and those testing negative.

The study indicates that reinforcing and reiterating safer-sex messages among sexually active gay men is of paramount importance, and nurses are vital in promoting such messages.

Research suggests that attitudes towards and beliefs about highly active antiretroviral therapy (HAART) may have influenced levels of risky sexual behaviour.

Context

The Health Protection Agency (HPA) warned last year that there was a continuing epidemic of HIV and sexually transmitted infections (STI) among gay men in the UK (HPA, 2007; Hairon, 2007).

The agency disclosed that it was still seeing high levels of HIV transmission in this group, and anticipated just over 2,700 new diagnoses of HIV in gay men in 2006. It reported that, in recent years, the prevalence of all STIs, including HIV, had been increasing in this group. Since 2003, the number of HIV diagnoses reported annually in the UK has consistently increased and exceeded the annual number of diagnoses throughout the 1980s and 1990s.

While the HPA acknowledged that increased testing for HIV infection will have contributed in part to these recent high numbers of diagnoses, it also stated there was no suggestion that the overall level of underlying HIV transmission in gay men had fallen over this period.

The HPA also revealed that in 2006, estimated HIV prevalence increased to 73,000 in the UK, with about one-third of these people (21,600) being undiagnosed and therefore unaware of their HIV-positive status (HPA, 2007; Hairon, 2007).

Key findings

Williamson et al’s (2008) study involved cross-sectional surveys of men in commercial gay venues (bars, clubs and saunas) in London, Brighton, Manchester, Glasgow and Edinburgh in 2003–2005.

Anonymous, self-completion questionnaires and oral fluid samples (tested for HIV antibodies) were obtained. The Medical Research Council carried out the surveys in the two Scottish cities, and the UCL Centre for Sexual Health and HIV Research did so in the three English cities.

Out of 3,501 men with a confirmed oral fluid result, 318 (9%) were HIV-positive. Of these, 131 (41%) were undiagnosed (that is, they reported previously testing HIV-negative or had never tested and were not aware of their HIV-positive status).

Of the 131 men with undiagnosed HIV, 4% thought they might be HIV-positive, almost two-thirds (62%) thought they were HIV-negative and 34% reported they did not know their HIV status.

A significant finding in this study is the association between reported sexual risk behaviours and knowledge of HIV status. In general, both undiagnosed and diagnosed HIV-positive men reported significantly more sexual partners, sexual risk behaviour and STIs in the previous year than HIV-negative men. Men aware of their HIV-positive status reported the highest levels of sexual risk.

Compared with HIV-negative men, both undiagnosed and diagnosed men were significantly more likely to have had 10 or more sexual partners, 10 or more anal intercourse partners, two or more unprotected anal intercourse partners and an STI in the previous year. This was the case after adjusting for city of recruitment to the study, age, education, employment status and HIV testing history.

Recommendations

The authors point out that this is the first study to examine differences between gay men with diagnosed and undiagnosed HIV infection in the UK. They found 41% of men who tested positive were unaware of their status, higher than the HPA estimate of 32%.

One worrying issue emerging in this study is that around two-thirds of the men with undiagnosed HIV still perceived their status to be negative. Just under half reported testing negative in the 12 months leading up to the surveys. This suggests that relying on a past HIV-negative test result, even within the last year, may be an ineffective prevention strategy, without the added interventions of condom use and reduced partner numbers.

Williamson et al (2008) argue that sexual health services are ideally placed to recall men for regular re-testing who have tested negative for HIV but who report high-risk behaviours. Services throughout the UK should ‘assiduously offer HIV testing’ to gay men presenting with STIs, they recommend.

However, the authors stress that men who were aware of their HIV-positive status reported the highest levels of sexual risk. The higher likelihood of unprotected anal intercourse with two or more partners among men diagnosed over a year ago suggests that maintaining safer-sex behaviour may be problematic for men living with HIV.

Consequently, the authors recommend that behaviour change, including the promotion of lower-risk sexual practices, condom use and reducing the number of partners, should continue to be a major part of HIV prevention in the UK.

Williamson et al (2008) conclude there is a need for a reinvigorated and tailored approach to HIV prevention among gay men. The higher level of sexual risk revealed among men already diagnosed HIV-positive suggests reducing levels of undiagnosed infection would not in itself be enough to reduce new infections. Evidence-based behavioural interventions to reduce sexual risk among men living with diagnosed HIV and among those at high risk of seroconversion are required. Implementing and evaluating such strategies should be a priority, the authors say.

The impact of new treatments

One possible explanation for higher levels of sexual risk behaviour among gay men diagnosed HIV-positive may be the availability of HAART, and attitudes surrounding these treatments. Researchers have investigated this association, as evidence suggests that since HAART became available, the prevalence of unprotected sex and the incidence of STIs have increased.

A meta-analytic review by Crepaz et al (2004) found that the prevalence of unprotected sex was not higher among people with HIV receiving HAART compared with those not receiving it. However, the prevalence of unprotected sex was higher in HIV-positive, HIV-negative and those with unknown HIV status who believed that receiving such treatment or having an undetectable viral load protected against HIV transmission. This was also the case for people who had reduced concerns about unsafe sex given the availability of HAART.

The authors concluded that HIV-positive patients receiving HAART did not demonstrate increased sexual risk behaviour, even when such treatment achieved an undetectable viral load. However, they found that people’s beliefs about the therapy and viral load may promote unprotected sex and may be amenable to change through prevention messages.

Conclusion

The study by Williamson et al (2008) emphasises the importance of reinforcing safer-sex messages to HIV-positive people and those who are either at risk of contracting the infection or who may have contracted it recently. Nurses working in both the community and specialised sexual health services are vital in promoting HIV prevention messages to at-risk groups.

Key messages for practice

  • Nearly half the men (41%) with an HIV-positive result were undiagnosed – this means they were not receiving the benefits of clinical care.

  • Sexual risk and STIs were highest among men who were aware of their HIV-positive status.

  • Clinics should proactively offer testing to increase diagnosis and target repeat testing at high-risk men with a previous negative result.

  • Practitioners should implement evidence-based behavioural interventions to reduce risk among men living with an HIV-positive diagnosis and those testing negative.

Source: Williamson et al (2008)

References

Crepaz, N. et al (2004) Highly active antiretroviral therapy and sexual risk behavior. Journal of the American Medical Association; 292: 2, 224–236.

Hairon, N. (2007) More action needed to prevent HIV and improve diagnosis. Nursing Times; 103: 51, 21–22.

Health Protection Agency (2007) HPA Warns of Continuing HIV and STI Epidemic in Gay Men. Press release, 23 November 2007. London: HPA.

Williamson, L.M. et al (2008) Sexual risk behaviour and knowledge of HIV status among community samples of gay men in the UK. AIDS; 22: 9, 1063–1070.

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