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As Perceived AIDS Threat Diminishes, MSM Engage in Riskier Sex

A survey spanning almost two decades shows a consistent increase in condom-less anal sex and number of sexual partners in MSM as many see antiretroviral therapy as a "protective back-up" measure to avoid HIV infection.

In the fight against HIV, a virus that has infected a staggering 3.6 million individuals worldwide, one of the greatest successes in healthcare lies in the different treatment options that have been developed and refined over the years, namely antiretroviral therapy (ART). As a result of this life-saving therapy, a diagnosis of HIV is no longer seen as a death sentence.

However, as more individuals begin to take ART as a means of prevention, community-held beliefs pertaining to risk are changing. According to a study conducted by University of Connecticut researchers, as more uninfected men who have sex with men (MSM) use ART as a kind of “protective back-up,” they are becoming more likely to engage in riskier sexual acts, such as engaging in condom-less anal sex with their partners.

“ART is now being used as a means of primary HIV prevention,” the study authors write. One example the authors cite is the fact that the co-formulated antiretroviral medication “tenofovir disoproxil fumarate and emtricitabine (TDF/FTC, Truvada)” has received approval to be used as a means of PrEP, or pre-exposure prophylaxis in those who are not infected with the virus; it is being “integrated into HIV prevention services.” In addition, ART has also been found to reduce “HIV infectiousness” of those who are infected, which means that it is also being used to prevent transmission to sexual partners. Indeed, according to the press release, “This [has] shifted [the] focus of HIV prevention campaigns away from condom use as a form of protection towards detecting and treating those already infected.”

Interestingly, despite these efforts, the number of new HIV infections in major cities have not seen “significant reductions.” In fact, the number of these infections seem to have remained stable or have been steadily rising among the MSM population in countries who have notably “scaled-up HIV testing programs and access to ART.”

One example that supports these observations can be found in a large community-level trial that had been conducted in South Africa that administered early ART as a means of prevention. Researchers found that ART “demonstrated high-levels of uptake and viral suppression, but failed to show significant impacts on new HIV infections.” The study authors mentioned a few different potential reasons that ART may have a more limited impact on new infections, such as: large numbers of infected individuals that have remained undetected, “poor retention in care,” and lack of ART adherence.

In another study, researchers utilized a survey spanning 19 years to examine community-held beliefs on HIV treatment as prevention and sexual behaviors among MSM who attended a gay pride festival in Atlanta. The researchers looked at “four waves of behavioral surveillance data” from 1997, 2005, 2006, and 2015. The surveys included questions pertaining to sexual behavior, HIV treatment beliefs, substance use, and perceived sexual risks regarding the treatment status of potential sexual partners; 1,931 MSM completed these surveys.

The researchers found that in those who were unaware of their HIV status and those who were uninfected, the act of engaging in condom-less sex increased from the 43% percent noted in 1997 to 61% in 2015. The number of those who reported having multiple sex partners also increased from 9% in 1997 to 33% in 2015. The number of HIV-positive men engaging in condom-less sex also increased; the number went from 25% in 1997 to 67% in 2015. Only 9% of HIV-positive men reported having unprotected sex with two or more partners in the six months before the survey was conducted in 1997; in 2015, this number rose to 52%.

According to the press release, “In 1997, condoms were used about eight out of ten times (82%) when HIV-positive men had intercourse, but it dropped by 2015 to less than one in two (47%) instances.” The more that individuals engage in sexual acts without condoms, the greater their risk becomes for being infected with other sexually transmitted diseases, such has chlamydia, syphilis, or gonorrhea, “which in turn can increase risks for HIV transmission.”

The study authors also reported an increase in the belief that “ART prevents HIV and therefore make[s] condom-less anal sex safe” among both infected and uninfected individuals. When it came to how they perceived HIV risk, they believed it to be much lower if their sexual partner “had an undetectable blood plasma viral load."

“Treatment-related behavioral beliefs in this study paralleled a resurgence in condom-less anal sex among men who have sex with men measured over nearly two decades. The current study adds to the mounting evidence that substantial changes have occurred in community-held beliefs that condom-less anal sex is safer in the era of HIV treatment as prevention,” according to study leader, Seth Kalichman, PhD from the University of Connecticut.

In addition, the study authors stressed that in order to maximize the level of prevention that ART offers against HIV, there needs to be increased efforts to “control co-occurring STIs,” including STI screening in sexual health services provided to MSM. The authors state that supportive ancillary services are also needed to “sustain increases in HIV treatment.” In order to sustain viral suppression, infected individuals who are receiving ART should also have access to adherence counseling.

The study authors concluded, “In the absence of prevention counseling, which should include interventions for continued condom use and access to PrEP, repeated HIV testing represents an idle response for those who test HIV negative until the point they become infected. Reaping the public health benefits of ART for prevention will therefore require increased attention to resolving behavioral beliefs, reducing sexual risk behaviors and investment in prevention services.”