Author Affiliations: Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention (Drs Crepaz, Hart, and Marks) and Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine (Dr Hart), Atlanta, Ga. Dr Hart is now with the Department of Psychology, York University at Toronto, Toronto, Ontario.
Context Evidence suggests that since highly active antiretroviral therapy (HAART)
became available, the prevalence of unprotected sex and the incidence of sexually
transmitted infections (STIs) have increased.
Objective To conduct 3 meta-analyses to determine whether (1) being treated with
HAART, (2) having an undetectable viral load, or (3) holding specific beliefs
about HAART and viral load are associated with increased likelihood of engaging
in unprotected sex.
Data Sources A comprehensive search included electronic bibliographic databases,
including AIDSLINE, MEDLINE, PubMed, CINHAL, PsycInfo, ERIC, EMBASE, and Sociofile,
from January 1996 to August 2003, conference proceedings, hand searches of
journals, reference lists of articles, and contacts with researchers.
Study Selection Twenty-five English-language studies (some contributing >1 finding)
met the selection criteria and examined the association of unprotected sexual
intercourse or STIs with receiving HAART (21 findings), having an undetectable
viral load (13 findings), or beliefs about HAART and viral load (18 findings).
Data Extraction Reports were screened and information from eligible studies was abstracted
independently by pairs of reviewers using a standardized spreadsheet.
Data Synthesis Random-effects models were used to aggregate data. The prevalence of
unprotected sex was not higher among persons with the human immunodeficiency
virus (HIV) receiving HAART (prevalence range, 9%-56%; median, 33%) vs those
not receiving HAART (range, 11%-77%; median, 44%; odds ratio [OR], 0.92; 95%
confidence interval [CI], 0.65-1.31) or among HIV-positive persons with an
undetectable viral load (range, 10%-68%; median, 39%) vs those with a detectable
viral load (range, 14%-70%; median, 42%; OR, 0.99; 95% CI, 0.82-1.21). The
prevalence of unprotected sex was elevated (OR, 1.82; 95% CI, 1.52-2.17) in
HIV-positive, HIV-negative, and unknown serostatus persons who believed that
receiving HAART or having an undetectable viral load protects against transmitting
HIV or who had reduced concerns about engaging in unsafe sex given the availability
of HAART (range, 17%-81% [median, 49%] vs 9%-68% [median, 38%] for counterparts).
Conclusions In the studies reviewed, HIV-positive patients receiving HAART did not
exhibit increased sexual risk behavior, even when therapy achieved an undetectable
viral load. However, people's beliefs about HAART and viral load may promote
unprotected sex and may be amenable to change through prevention messages.
Nicole Crepaz, Trevor A. Hart, Gary Marks. Highly Active Antiretroviral Therapy and Sexual Risk BehaviorA Meta-analytic Review. JAMA. 2004;292(2):224–236. doi:10.1001/jama.292.2.224