"Survival Sex" and Substance Abuse May Hinder HIV Prevention Efforts

ALEXANDRIA, Va. -- Even after receiving risk-reduction counseling, some individuals who know they are HIV-positive are engaging in high-risk behavior that could transmit their infection, according to a study in the Jan. 1, 2004 issue of Clinical Infectious Diseases, now available online.

Interviews with 256 individuals who attended a New York City HIV clinic revealed that 41 percent engaged in unprotected sex after learning they were HIV positive, the study reports.

Trading sex for drugs or money was an important factor associated with high-risk behavior, particularly for women. Lead author Dr. Joseph P. McGowan of the Bronx-Lebanon Hospital Center in New York says HIV-positive women may be more likely to have unprotected sex because of a "lack of empowerment or low self esteem. For example," he said, "does the woman have the ability to say no if the man doesn't use a condom?" Often, said McGowan, the women have a history of exchanging sex for money or drugs, which probably led them to become HIV-positive initially. Such "survival sex" is a difficult-to-change habit fueled by both economic need and addiction.

Highly active antiretroviral therapy (HAART) patients were more likely to have unprotected sex than those who did not receive the treatment, perhaps because HAART patients believed they would not transmit HIV to their partners. However, said Dr. McGowan, although HAART can help decrease the risk of HIV transmission, the risk is not eliminated. In fact, a patient receiving HAART may transmit a drug-resistant form of HIV.

Reducing transmission of HIV is an intricate problem, said McGowan. In the study, McGowan and his colleagues concluded that ongoing risk-reduction counseling and substance abuse treatment for HIV-infected persons must be part of the solution. "I think what we need to do is make a safe sex counseling message an ongoing part of clinical care," he said, "not counseling once a year. We need to do it much more often in a proactive way." McGowan also noted that monotonous warnings can lead to patient "fatigue," in which risky behavior increases as the message wears off. "We need to develop some motivational interviewing skills and techniques which include the patient in the process to set achievable goals," McGowan said. "Rather than telling a patient to stop using drugs, you would ask, `Do you think you can cut back on your drug use?'"

Finally, the counseling should not be separate from the cure. "Prevention and treatment have to go hand-in-hand," said McGowan.

To help medical caregivers better incorporate prevention into their treatment of HIV-infected persons, the Jan. 1, 2004 issue of Clinical Infectious Diseases will also include a summary of recommendations. The summary is authored by Dr. Kenneth H. Mayer of the HIV Medicine Association (HIVMA), part of the Infectious Diseases Society of America (IDSA). The recommendations were developed by HIVMA, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Prevention in Clinical Care Working Group. The full recommendations are available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm.

Source: IDSA