BROWN (US) — When HIV-positive partners are not involved in counseling, they are more likely to engage in unsafe sex, even if they know their partner is HIV-negative or are not aware of their status.
When couples are receiving intensive counseling or are on antiretroviral therapy, on the other hand, they tend to refrain from engaging in risky sexual behavior.
The findings point to the need for more couple-based HIV counseling, especially in South Africa, where about 18 percent of adults carry the virus.
“The concept of Positive Prevention—the idea that one focus of prevention should be among people already infected with HIV since they are the only ones who could infect others—was first floated by the CDC in 2003 but hasn’t really taken hold in sub-Saharan Africa,” says Mark Lurie, professor of community health at Brown University.
“This paper clearly points to the urgent need to intervene among people already infected with HIV and especially those in ‘discordant’ relationships—relationships in which their partner is not infected.”
Details of the study are published in the journal AIDS and Behavior.
The study surveyed 1,163 sexually active HIV-positive men and women in a primary care program at Chris Hani Baragwanath Hospital in Soweto, near Johannesburg and asked whether they knew their closest sexual partner’s HIV status, how often they have sex, how often it is unprotected, and how often they have sex outside that relationship.
Although in some places around the world, specific high-risk groups of HIV-positive people have restricted their riskier sexual activities to people also already infected (a practice called sero-sorting), heterosexual couples in South Africa do not follow that example for the most part.
Of HIV-positive people who say their closest partner’s status was either HIV-negative or unknown, 18 percent still had unprotected sex with them in the last six months, compared to only 14 percent who knew their partner was already infected.
Risks such as having frequent sex (two sex acts in the last two weeks) and going to a partner outside the primary relationship were somewhat lower with HIV-negative or unknown partners than with HIV-positive partners, but not much more so.
“The difference for partners who were negative or status unknown versus those who were positive was not markedly different,” says PhD candidate Kartik Venkatesh.
In all, about 40 percent of the people surveyed knew their partner was also HIV positive. The same proportion didn’t know their partner’s status and 20 percent knew their partners to be HIV-negative. There was no correlation between how long the couples were together (a median of 3.4 years) and whether a partner’s status was known.
The factor that did seem to be associated with decreased sexual risk-taking behavior was receiving antiretroviral (ART) medication. Rather than people becoming emboldened by medication and improved health to take more risks—a practice called behavioral disinhibition—people in several African countries have tended to become more careful with treatment.
“Why we’re seeing this might be due to the fact that treatment is also accompanied by condoms and other prevention messages, so that when individuals are coming to get their treatment they are also getting sexual risk behavior prevention counseling,” Venkatesh says.
The prevalence of risk in South African couples and the likely role that counseling plays in curbing risk could add up to a significant potential benefit to increasing counseling couples about HIV.
Bringing men and women into counseling together may help overcome power imbalances between men and women that exacerbate the lack of communication about HIV status in some relationships, Venkatesh says.
“HIV prevention and treatment programs need to be more couples-friendly or family-focused.”
Researchers at Johns Hopkins University and the University of Stellenbosch and University of Witwatersrand, both in South Africa, contributed to the study, that was funded by the National Institutes of Health.
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