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  IAS 2013: 7th IAS Conference on HIV
Pathogenesis Treatment and Prevention
June 30 - July 3 2013
Kuala Lumpur, Malaysia
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ART Linked to Lower Sexual (But Not Drug-Injecting) Risk Behavior in Meta-Analysis
  7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, June 30-July 3, 2013, Kuala Lumpur
Mark Mascolini
People taking antiretroviral therapy (ART) had lower odds of unprotected sex and new sexually transmitted infections (STIs) than did people not taking ART, according to results of a large meta-analysis [1]. This study found no link between taking ART and better or worse drug-injecting behavior.
Numerous studies have reached diverse conclusions about whether starting ART encourages people to take sexual or drug-injecting risks, discourages them from risky behavior, or does neither. The population studied, the endpoints, and study methods can all sway results. To get a bigger picture of ART-linked sexual or drug-injecting disinhibition--or lack thereof--researchers at Melbourne's Burnet Institute and collaborators at other sites conducted this systematic review and meta-analysis.
The investigators reviewed studies comparing the impact of ART or no ART on one of three outcomes in HIV-positive adults: (1) a new sexually transmitted infection (STI) diagnosis, (2) unprotected sex, defined as inconsistent condom use, and (3) unsafe injecting, defined as lending, borrowing, or reusing injecting equipment. Studies could not focus on antiretrovirals for prophylaxis and had to be published by December 2011. The researchers used a random-effects meta-analytical approach to synthesize data from individual studies.
Eleven studies including 16,138 participants (median 439) focused on how ART affects STI diagnoses through a median 6 months of follow-up. The pooled odds ratio (OR) indicated that ART lowered chances of a new STI about 40%, but the association stopped short of statistical significance (OR 0.58, 95% confidence interval [CI] 0.33 to 1.01, P = 0.053). One of the 11 studies found a significantly higher STI risk in people taking ART (OR 3.66, 95% CI 2.57 to 5.22) [2]. When the investigators eliminated this outlier study, ART significantly lowered odds of a new STI 52% (OR 0.48, 95% CI 0.38 to 0.61, P < 0.001). But the outlier study was by far the largest, with 11,516 participants, compared with 898 in the next-largest study.
Fifty-five studies with 6-month follow-up and including 30,017 people (median 287) examined the impact of ART on unprotected sex. Taking ART was associated with more than 25% lower odds of unprotected sex (OR 0.72, 95% CI 0.63 to 0.81, P < 0.001). Only 1 of these 55 studies found a significant association between ART and higher odds of unprotected sex (OR 1.55, 95% CI 1.04 to 2.32) [3]. This study involved 181 sexually active women in New Orleans, one quarter of whom were binge drinkers. A subgroup meta-analysis focused on having unprotected sex with an HIV-negative partner or a partner of unknown HIV status calculated even lower odds of unprotected sex with ART than did the main meta-analysis (OR 0.57, 95% CI 0.45 to 0.71, P < 0.001).
Four 6-month studies involving 1600 people (median 284) found no link between ART and safer or riskier drug-injecting habits (OR 0.90, 95% CI 0.60 to 1.35, P = 0.6).
The researchers cautioned that all studies in this meta-analysis were observational and that effects could change with longer follow-up. With those caveats in mind, they concluded that "providing ART does not increase sexual or injecting risk-taking behaviour." Indeed, the analysis linked ART to lower sexual risk taking and fewer new STI diagnoses. But an analysis like this, they added, does not establish causality. The investigators surmised that the beneficial association between ART and sexual risk taking or STIs could reflect "mutually reinforcing effects of HIV treatment and prevention messages among people receiving" antiretroviral therapy.
1. Doyle JS, Degenhardt L, Pedrana A, et al. Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behaviour: a meta-analytical review. 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, June 30-July 3, 2013, Kuala Lumpur. Abstract WEPDB0105.
2. Scheer S, Chu PL, Klausner JD, Katz MH, Schwarcz SK. Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS. Lancet. 2001;357:432-435. http://www.ncbi.nlm.nih.gov/pubmed/11273063
3. Theall KP, Clark RA, Powell A, Smith H, Kissinger P. Alcohol consumption, ART usage and high-risk sex among women infected with HIV. AIDS Behav. 2007;11:205-215. http://www.ncbi.nlm.nih.gov/pubmed/16897350