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Many South African patients whose HIV has been diagnosed have unprotected sex with a serodiscordant partner before starting ART
Michael Carter, 2016-06-02 08:10:00
Among a sample of South Africans living with diagnosed HIV infection in South Africa and waiting to start antiretroviral therapy (ART), one quarter reported recent condomless
sex with an HIV-negative/untested partner, according to research published in
the online edition of the Journal of
Acquired Immune Deficiency Syndromes.
investigation is the first to quantify HIV exposure associated with sexual
behaviour among tested-but-not-treated South African PLWH [people living with
HIV], and it provides much needed insight into the underpinnings of serodiscordant
condomless sex occurring among this population,” comment the researchers.
with a serodiscordant partner was associated with poor supportive norms about
condom use, low self-perceived ability to negotiate the use of condoms and
hazardous alcohol consumption.
Many people living with HIV now have a normal life expectancy thanks to ART and there is
compelling evidence that ART-treated individuals whose viral load is
undetectable are not infectious to their sexual partners.
Over 2 million HIV-positive
South Africans are now taking ART. However, a proportion of South Africans
whose HIV infection has been diagnosed do not promptly start antiretrovirals, either because they have not reached the CD4 cell threshold for starting treatment, for facility-related reasons or by personal choice.
These patients are therefore unable to benefit from this medication.
designed a study to assess the prevalence of serodiscordant condomless sex
among South African patients diagnosed with HIV who had not yet started ART.
The research also aimed to determine the number of sexual partners who were
potentially exposed to HIV and the factors associated with risky sex.
The study sample
comprised 266 sexually active adult patients receiving care in KwaZulu-Natal. They
completed a questionnaire enquiring about their sexual behaviour in the
previous four weeks, demographics, use of alcohol, mental health, HIV-related
stigma, knowledge of HIV prevention, attitudes towards condoms and power to
Most of the
patients (195) were female, the mean age was 31 years, the majority were
unemployed and lived in rural areas and 34% lived with a sex partner. The mean
period since diagnosis with HIV was 98 days and the mean CD4 cell count was 517
cells/mm3. None of the patients had started ART and only 10% had
started a clinic-based HIV literacy programme, a requirement before ART
initiation in South Africa. Hazardous alcohol use was reported by 14% of individuals
and 22% reported depression.
The majority of
the participants were sexually active, with 182 individuals reporting 766
sexual acts with 201 partners in the previous four weeks. Approximately 40% of
patients reported unprotected sex in this period and a total of 371 condomless
sex acts with 107 partners.
condomless sex was reported by one in four sexually active patients, who
engaged in 207 condomless sex acts with 66 serodiscordant partners in the four
weeks before the study.
for potential confounders, factors associated with serodiscordant condomless
sex included poorer supportive norms for condom use (p = 0.039), lower
perceived power to negotiate condom use (p = 0.003) and hazardous alcohol use
(p = 0.007).
findings…suggest the imperative to deliver behavioral prevention efforts at the
time of HIV diagnosis if an immediate test-and-treat approach is unfeasible,”
comment the investigators. “For example, as hazardous alcohol consumption was
associated with a greater than three-fold increase in the likelihood of
serodiscordant condomless sex, the implementation of alcohol screening and
brief interventions could help reduce both alcohol use and engagement in
high-risk sex. Similarly, evidence-based behavioural interterventions that
establish normative support for condoms and provide skills that empower safer
sex negotiation could further help curtail HIV transmission.”
However, the authors emphasise that their findings "provide a compelling justification for an immediate test-and-treat approach to be implented in South African clinical care settings." A recently-presented South African study has shown that offering treatment at the first clinic visit speeded up treatment initiation and improved viral suppression, with some evidence suggesting that the intervention especially improved treatment initiation among younger people (under 35) and among people diagnosed at a primary health clinic. South Africa will begin to offer HIV treatment for everyone diagnosed with HIV later this year, removing restrictions based on CD4 cell count.