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Sexual and drug risk-related behaviours after initiating highly active antiretroviral therapy among injection drug users
This study of IVDUs and others in men who have sex with men suggest there are different patterns of HIV transmission between the two groups.
David Vlahova,b; Mahboobeh Safaiena; Shenghan Laia; Steffanie A. Strathdeea; Lisette Johnsona; Timothy Sterlingc; David D. Celentanoa
From the aDepartment of Epidemiology, Johns Hopkins School of Hygiene and Public Health, Baltimore, the bCenter for Urban Epidemiologic Studies, New York Academy of Medicine, New York and the cDivision of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore,
Maryland, USA. AIDS 2001;15:2311-2316
Objective: To assess whether initiation of highly active antiretroviral therapy (HAART) is associated with a subsequent resumption of sexual and drug use risk behaviors.
Methods: Within an ongoing prospective study of HIV-seropositive injection drug users (IDUs), a subsample with at least one CD4 cell count < 500 ? 106 cells/l after 1996 (when HAART became available) and three consecutive visits were selected for analysis. Patients underwent semi-annual interviews for risk behaviors and reports of medication use. Data from visits immediately prior to and following initiation of HAART for the treated group, and from consecutive visits for the eligible but untreated group were compared using linear growth curve analysis.
Results: Of 316 eligible HIV-seropositive IDUs, 133 reported HAART use during the study period; 95% were African American, 76% were male, and median age at enrollment was 34 years. The proportion who reported any sexual activity increased over time from 55 to 61% for the HAART-treated group, but decreased from 67 to 63% in the untreated group (P = 0.03); the respective values for unprotected sex were 18 versus 20% and 36 versus 28% (P = 0.06). In both treated and untreated groups, the proportion injecting drugs declined (P = 0.04), whereas the proportion reporting needle sharing decreased marginally (P = 0.11). However, trends in use of shooting galleries between the groups differed (P = 0.04) increasing slightly from 2.3 to 3% in the treated group while decreasing from 12 to 5% in the untreated group.
Conclusion: In persons treated with HAART, self-report of high-risk behaviors remained stable or showed some increase. Persons initiating HAART should be counselled to refrain from high-risk behaviors.
The major finding of this study is that a subgroup of HIV-infected IDUs receiving HAART reported an increase in some high-risk behaviours following initiation of these medications. Although the magnitude of change in absolute terms was small, the increases in sexual activity, including unprotected sexual activity after initiation of HAART, indicate that earlier concerns about relapse following initiation of HAART are not entirely unfounded and merit further attention.
Earlier studies of high-risk behavior and HAART were based mainly on surveys of beliefs and attitudes among gay men about how they might respond to starting HAART [5,15-17]. More recent studies have reported that HAART is strongly associated with unprotected sex among HIV-infected men who have sex with men [18,19] Longitudinal data and data on injection drug users have been sparse. However, a recent analysis from a cohort study on injection drug users with HIV infection from France reported no increase in sexual risk activity among IDUs subsequent to initiation of HAART [10]. Combined, the studies of IDUs argue against large-scale resumption of high-risk sexual activ- ities following initiation of HAART in this population.
In terms of drug use behavior, our data show that HAART was not associated with a resumption of injection drug use. In fact, declines in drug use were noted over time, and in the proportion among active injectors reporting needle sharing. This is not unexpected, given the advancing maturity of our cohort.
Although HAART can reduce viral load levels and therefore diminish the risk of HIV transmission, this may be offset by an increase in unprotected sexual activity. More detailed studies of transmission risk for different levels of risk behavior following treatment will undoubtedly emerge. In the meantime, patients should be advised to maintain safe sex practices and reduced drug risks after initiation of HAART.
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