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Over Half of US HIV+ People in Care Are Sexually Active, But Most Take Precautions
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19th Conference on Retroviruses and Opportunistic Infections, March 5-8, 2012, Seattle
Mark Mascolini
In the United States most HIV-positive people in care remain sexually active, according to results of a nationally representative sample studied by the CDC [1]. Although many people have sex without a condom, few have unprotected sex with an HIV-negative partner when they have a detectable viral load.
Many studies examine sexual behavior in HIV-positive people, but no research provides a nationally representative estimate of risk behavior and viral suppression in HIV-positive US adults in care. To address those issues, CDC investigators explored clinical and behavioral data from the Medical Monitoring Project, which was designed to produce nationally representative estimates of traits of interest in HIV-positive people. Researchers collected data via in-person interviews and linked those data with medical records for each person.
The CDC team defined unprotected discordant sex as any anal or vaginal sex without a condom with a partner of negative or unknown HIV status in the year before the interview. They defined durable viral suppression as a viral load undetectable or below 400 copies on all tests in the year before the interview.
Survey response rates were 76% for facilities approached and 53% for patients approached in those facilities. The researchers cautioned that these low rates may result in nonresponse bias, but they adjusted weighted data to minimize this bias.
The analysis involved 3767 people diagnosed with HIV for more than 12 months, including 1823 men who have sex with men (MSM), 918 men who have sex with women (MSW), and 1026 women who have sex with men (WSM). Blacks accounted for 22% of MSM, 55% of MSW, and 62% of WSM; respective proportions of whites were 54%, 17%, and 18%.
At the time of the interview, 40% of study participants were in their 40s and 36% were 50 or older. More than three quarters of survey respondents (78%) had HIV for more than 5 years, and two thirds had an AIDS diagnosis. While 89% of study participants were taking combination antiretroviral therapy, 65% had durable viral suppression.
More than half of respondents in each group were sexually active--58% of MSM, 56% of MSW, and 55% of WSM. While 25% of WSM were sexually active and not virally suppressed, 20% of MSM and 20% of MSW were sexually active and not virally suppressed. Overall, 12% of respondents had unprotected sex with a discordant partner, including 16% of WSM, 13% of MSM, and 9% of MSW. But only 7% of WSM, 6% of MSM, and 4% of MSW had condom-free sex with a discordant partner while not virally suppressed.
Higher proportions of MSM than MSW or WSM drank alcohol before or during sex in the past 12 months (46% versus 33% versus 29%), a higher proportion of MSM used noninjection drugs in the past year (34% versus 25% versus 18%).
Similar proportions of MSM and WSM had a sexually transmitted infection in the past year (16% and 13% versus 7% in MSW). But most people had not been tested for a sexually transmitted infection--including 52% of MSM, 66% of MSW, and 52% of WSM. On average, MSM had almost 5 times more sex partners than MSW and WSM (5.2 versus 1.5 versus 1.2), and a lower proportion of MSM discussed their HIV status before sex (67% versus 76% in MSW and 80% in WSM).
These last two findings and the substance-related differences above go a long way toward explaining why MSM continue to account for the largest portion of new HIV infections in the United States.
In all three study groups, people who achieved durable viral suppression on antiretroviral therapy were not more or less likely to have sex with an HIV-negative or status-unknown partner. But because 12% of HIV-positive adults engage in unprotected discordant sex, the CDC said, "additional prevention efforts should emphasize the importance of ongoing risk reduction."
Reference
1. Freedman M, Mattson C, Johnson C, et al. Medical monitoring project, 2009 to 2010-nationally representative estimates of sexual risk behaviors among HIV+ adults receiving medical care: US. 19th Conference on Retroviruses and Opportunistic Infections. March 5-8, 2012. Seattle. Abstract 1090.
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