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November 17, 2004

HAART and Sexual Risk Behavior

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2004;292(19):2335-2336. doi:10.1001/jama.292.19.2335-b

To the Editor: The meta-analytic review by Dr Crepaz and colleagues1 provides reassurance that neither HAART use nor viral load were associated with increased sexual risk behavior. This is welcome news for those engaged in accelerating access to HIV treatment, since a key premise of scale-up efforts is that treatment and prevention are mutually reinforcing.2 However, we are concerned that these conclusions are not based on data from resource-poor settings, where the prevalence of HIV/AIDS is highest. Sixteen of the 25 studies sampled populations from the United States; the other 9 were from industrialized countries. Furthermore, gay men were overrepresented in the analysis, accounting for the totality of 12 samples and the majority of 3 others; intravenous drug users accounted for the totality of 2 additional studies. The authors note that heterosexual respondents receiving HAART were significantly less likely to engage in unprotected sex than untreated respondents, but this was not found among men who have sex with men only. It may be that among general populations, treatment does in fact support prevention. In Côte d’Ivoire, Moatti et al found that the prevalence of risky sexual behavior was significantly lower among treated than among untreated individuals.3 Such findings underscore the need for evidence that is more directly relevant to treatment scale-up in the developing world.

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