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,
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 .
Combined, the studies of IDUs argue against large-scale resumption of
high-risk sexual activ- ities following initiation of HAART in this
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
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.