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July 14, 2004

Highly Active Antiretroviral Therapy and Sexual Risk BehaviorA Meta-analytic Review

Author Affiliations

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.

JAMA. 2004;292(2):224-236. doi:10.1001/jama.292.2.224

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.