Epidemiology & Social: Concise Communications
Attitudes towards highly active antiretroviral therapy are associated with sexual risk taking among HIV-infected and uninfected homosexual men
Ostrow, David E.; Fox, Kelly J.a; Chmiel, Joan S.b; Silvestre, Anthonyc; Visscher, Barbara R.d; Vanable, Peter A.e; Jacobson, Lisa P.a; Strathdee, Steffanie A.a
From Loyola University School of Medicine, Maywood, Illinois, the aDepartment of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, the bDepartment of Preventive Medicine, Northwestern University Medical School, Chicago, Illinois, the cUniversity of Pittsburgh, Pittsburgh, Pennsylvania, the dUniversity of California at Los Angeles, Los Angeles, California, and the eDepartment of Psychology, Syracuse University, New York, USA.
Requests for reprints to: S. A. Strathdee, Department of Epidemiology, Johns Hopkins School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
Received: 21 September 2001;
revised: 30 November 2001; accepted: 6 December 2001.
Objective: To determine whether attitudes towards highly active antiretroviral therapy (HAART) are associated with unprotected anal sex among sexually active homosexual men.
Design: Cross-sectional study nested within an ongoing prospective cohort study.
Setting: Multicenter AIDS Cohort Study, from April through September 1999.
Participants: Five-hundred and forty-seven homosexual men reporting anal sex (218 HIV-negative and 329 HIV-positive) during study interviews in 1999, including a 20-item validated scale on attitudes toward HAART and HIV risk behaviors (e.g., ‘Because of HAART, I am less concerned about becoming HIV-infected or infecting someone'), and safer sex fatigue (e.g., ‘I am tired of always having safer sex').
Main outcome measures: Self-reported unprotected receptive anal sex (RAS) and insertive anal sex (IAS) in the prior 6 months.
Results: More than 50% of HIV-negative and HIV-positive men who reported having anal sex also reported recent unprotected RAS and/or IAS. HIV-negative men who most agreed that HAART reduced concern about becoming infected were more likely to report unprotected RAS compared to other HIV-negative men [adjusted odds ratio (AOR), 3.31; 95% confidence interval (CI), 1.27–8.62]. Moreover, HIV-positive men with greatest reduced concern due to HAART or safer sex fatigue were more likely to report unprotected IAS (AOR, 6.05; 95% CI, 2.24–16.63 and AOR, 4.57; 95% CI, 1.70–12.24, respectively) compared to other HIV-positive men.
Conclusions: Among sexually active homosexual men, lessened concern about HIV transmission due to HAART was strongly associated with sexual risk taking, as was safer sex fatigue among HIV-positive men. Prevention programs should take into account underlying attitudes for unprotected sex in the era of HAART among both HIV-infected and uninfected men.
In the first decade of the HIV epidemic, significant declines in high risk sexual behaviors and HIV incidence were documented among homosexual men in the USA and elsewhere [1–4]. In the Multicenter AIDS Cohort Study (MACS), one of the largest studies of homosexual men, HIV incidence decreased dramatically from 4–8 per 100 person years (py) during 1984–1985, and fluctuated between 0.5 and 2.5 per 100 person years in the late 1980s to mid 1990s [2,5].
Beginning in 1996, the advent of highly active antiretroviral therapy (HAART) led to impressive declines in HIV-associated morbidity and mortality [6,7]. More recently, concerns have surrounded the potential for these therapies to contribute to complacency towards HIV/AIDS among the homosexual community, with an unintended consequence being relapse towards unprotected anal sex [8–10].
Some cities in North America have reported increased rates of HIV infection and sexually transmitted diseases (STD) among homosexual/bisexual men [11,12]. Some studies suggested that virologic and clinical improvements due to HAART may influence sexual behaviors among homosexual men [10,13] but few studies have systematically studied this phenomenon. In particular, HIV-infected and uninfected persons may respond differently in the era of HAART.
We investigated attitudinal and health factors associated with unprotected anal sex among HIV-infected and uninfected homosexual men since the introduction of HAART. Our study population, comprised of homosexual men in four large metropolitan areas, provide new findings particularly relevant for developing timely behavioral interventions.
In 1984–1985 and 1987–1991, 5622 homosexual men were enrolled in the MACS at four locations: Baltimore, Maryland; Chicago, Illinois; Los Angeles, California; and Pittsburgh, Pennsylvania. Details on MACS recruitment and data collection have been published elsewhere . Our study sample was restricted to participants who attended the MACS semiannual visit during April–September 1999 and reported engaging in insertive anal sex (IAS) or receptive anal sex (RAS) in the past 6 months.
Participants completed a 20-item survey including personal attitudes towards HAART and risk behaviors, sensation seeking, and safer sex fatigue. Respondents were asked to express disagreement or agreement with each statement on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Responses were categorized as belonging to one of five subscales based on previous validation studies [15–17]. Reduced HIV concern (e.g., ‘Because of combination drug treatments for HIV, I am less concerned about becoming HIV positive or infecting someone'; Cronbach's α, 0.85); substance use sexual expectancies (e.g., ‘When I am high or drunk I find it more difficult to stay within my sexual limits'; Cronbach's α, 0.81); safer sex fatigue (e.g., ‘I feel tired of always having to monitor my sexual behavior'; Cronbach's α, 0.73); viral load/transmission beliefs (e.g., ‘It would be more difficult for an HIV-positive person to infect a partner through unsafe sex if the HIV-positive person was taking combination drug treatments’ Cronbach's α, 0.83); and sexual sensation seeking (e.g., ‘I like wild ‘‘uninhibited’’ sexual encounters'; Cronbach's α, 0.81).
Categorical scores on the attitudinal subscales were compared among men who reported engaging or not engaging in unprotected RAS and IAS, stratified by HIV-serostatus. Logistic regression models were developed to identify correlates of unprotected RAS and unprotected IAS. Multivariate models adjusted for age; among HIV-positive men, we also adjusted for most recent CD4 cell count, HIV-1 viral load, and use of HAART [18,19]. Statistical significance was defined as P < 0.05.
We also determined whether men who experienced a sudden decrease in HIV-1 RNA levels below the standard limit of detection (400 copies/ml) were more likely to engage in unprotected anal sex. This analysis was restricted to 184 men who initiated HAART prior to September 1998, who could have known if they had a subsequent change in HIV RNA detectability.
Of 1156 men attending visit 31, 611 (52.9%) reported having either RAS or IAS in the prior 6 months and were thus eligible for this analysis. Of these, 547 men (89.5%) completed the attitudinal survey (218 HIV-negative and 329 HIV-positive). Compared to the 64 sexually active men who did not complete the attitudinal survey, the 547 men did not differ significantly by HIV serostatus, race, income or reports of RAS and IAS. However, men in the study sample were slightly older (mean, 45.1 versus 43.1 years;P = 0.02) and reported a greater number of male partners in the prior 6 months (median, 4.0 versus 2.5;P = 0.03), respectively. We also compared demographic and behavioral data for the study sample to that of the 938 men (353 HIV negative and 585 HIV positive) completing the attitudinal survey (data not shown). The study sample did not differ significantly from the total who completed the survey by age, race, income, or number of male partners in the prior 6 months. Of the 547 men included in our analyses, 82% were white.
Comparing subgroups of men within the study sample, there were some slight differences by HIV serostatus. HIV-negative men were older than HIV-positive men (mean, 46.6 versus 44.1 years;P < 0.01) and reported more male partners in the past 6 months (median, five versus four partners;P = 0.02). However, there were no significant differences in the proportions that reported unprotected IAS and RAS by HIV serostatus.
Duration of study participation was also similar (mean, 14 years). Clinical characteristics of HIV-positive men engaging in anal sex did not deviate appreciably from all HIV-positive men completing the attitude survey.
Among HIV-positive men, reduced HIV concern, substance use-related sexual expectancies, safer sex fatigue, viral load/transmission beliefs and sensation seeking were all significantly associated with unprotected IAS, as was having a known HIV-positive sexual partner. Among HIV-negative men, reduced HIV concern and having a primary partner was significantly associated with unprotected RAS; having a casual partner was inversely associated with RAS (Table 1).
In multivariate logistic regression models, HIV-positive men who had the highest scores (i.e., upper quartile) for reduced HIV concern were six times more likely to engage in unprotected IAS, compared to those in the lower quartile (Table 2). Safer sex fatigue was also independently associated with unprotected IAS. Not surprisingly, HIV-positive men were much more likely to report unprotected IAS if they had a known HIV-infected sexual partner. Independent predictors of unprotected RAS among these HIV-infected men were similar (data not shown). Current or lagged (visit 30) measures for HIV-1 viral load or CD4 cell count were not significantly associated with unprotected IAS or RAS.
Among HIV-negative men, those with moderate or high scores indicating reduced HIV concern were significantly more likely to report engaging in unprotected RAS (Table 1). HIV-negative men were significantly less likely to report unprotected RAS if they reported having more than one casual male sexual partner in the past 6 months. Findings for unprotected IAS were similar (data not shown).
We tested the hypothesis that a favorable change in HIV-1 viral load (i.e., decrease from detectable to undetectable levels) would be associated with unprotected anal sex. Of 184 men, 107 (58.2%) had detectable viral loads prior to HAART which subsequently decreased to undetectable levels. Contrary to expectation, in multivariate models controlling for the variables described in Table 2, men who experienced a decrease in HIV RNA to below the level of detection were somewhat less likely to engage in unprotected IAS or RAS, but not significantly so [adjusted odds ratio (AOR), 0.55; 95% confidence interval (CI), 0.22–1.37; and AOR, 0.84; 95% CI, 0.38–1.85, respectively).
Despite reductions in HIV risk behaviors observed earlier in the epidemic, approximately half of the HIV-negative and HIV-positive homosexual men in the MACS who reported recently having anal sex did not consistently use condoms. Recent increases in the incidence of HIV and STD have also been documented among homosexual men in other settings, suggesting that this may be a widespread phenomenon [10,12,20].
Among HIV-positive men, decreased concern about infecting someone due to availability of HAART was associated with a three- to sixfold higher odds of unprotected IAS. Similarly, decreased concern about becoming HIV infected due to availability of HAART was independently associated with unprotected RAS among HIV-seronegative men. Our findings suggest that the effect of safer sex fatigue or burnout is more pronounced among HIV-seropositive men relative to HIV-seronegative men, among whom it was a key factor associated with sexual risk taking. These data raise considerable public health concerns regarding the potential for increased HIV transmission among homosexual men in countries where HAART is widely used. Although optimal adherence to HAART can significantly reduce plasma HIV-1 levels, a substantial proportion of patients may be infectious or harbor HIV-1 drug-resistant strains .
As an alternative to promoting consistent condom use, some authors have proposed a role for practicing ‘negotiated safety’ (i.e., unprotected sex within the context of a relationship where both partners’ HIV status is concordant) . We found that HIV-positive men were more likely to engage in unprotected IAS if their partner was also HIV-infected, perhaps under the assumption that re-infection is not a health risk. While the health risks due to re-infection with another HIV subtype are speculative, STD transmission risks persist.
One potential form of negotiated safety could take into account the insertive partner's viral load when deciding whether or not to use a condom during anal intercourse. We tested this hypothesized determinant of unprotected sex and were unable to confirm that men who experienced a dramatic decrease in viral load to below detectable levels were more likely to engage in unprotected anal sex. This is consistent with results from a community-based sample of HIV-positive men in Chicago,  but is contrary to a recent report on homosexual men in Amsterdam .
Our results may underestimate the extent to which attitudes about HAART have influenced rates of unprotected anal sex and changing community norms regarding safer sex. Earlier in the epidemic, HIV-positive and HIV-negative men in the MACS had significantly reduced their levels of unprotected anal sex . The finding that at least some of these men are now increasingly engaging in unprotected anal sex raises concerns about trends among the general population of homosexual/bisexual men. However, as we restricted our study sample to men who currently engaged in anal sex, our findings may not extend to men who engage in other sexual activities.
Our findings support the importance of attitudes as determinants of sexual behavior and behavioral change [3,24]. Attitudinal factors that arose in part due to reductions in morbidity and mortality in the era of HAART were significantly associated with sexual risk taking among both HIV-positive and HIV-negative men. It is therefore important to measure such attitudes directly when designing and evaluating behavioral interventions.
The advent of HAART has had a significant impact on the attitudes and behaviors of both HIV-positive and HIV-negative sexually active men participating in the MACS. Our findings are consistent with recent studies from San Francisco that indicate that the beneficial effect of HAART on reducing HIV incidence has been counterbalanced by an increase in high risk behavior [12,20,25,26]. These findings emphasize the need to tailor prevention programs towards men's HIV serostatus, partnerships, and risk-taking propensities.
1. Doll LS, Ostrow, DG. Homosexual and bisexual behavior. In Sexually Transmitted Diseases; 3rdedn. Edited by Holmes KK, Sparling PF, Mardh P-A, et al. New York: McGraw-Hill; 1999: 151–162.
2. Ostrow DG, DiFranceisco WJ, Chmiel JS, Wagstaff DA, Wesch J. A case-control study of human immunodeficiency virus type 1 seroconversion and risk-related behaviors in the Chicago MACS/CCS Cohort, 1984–1992. Am J Epidemiol 1995, 142: 875–883.
3. Ekstrand ML, Coates TJ. Maintenance of safer sexual behaviors and predictors of risky sex: the San Francisco Men's Health Study. Am J Public Health 1990, 80: 973–977.
4. Schechter MT, Craib KJ, Willoughby B. et al. Patterns of sexual behavior and condom use in a cohort of homosexual men. Am J Public Health 1988, 78: 1535–1538.
5. Kingsley LA, Zhou SYJ, Bacellar H. et al. and the Multicenter AIDS Cohort Study Group. Temporal trends in human immunodeficiency virus type 1 seroconversion 1984–1989. A report from the Multicenter AIDS Cohort Study (MACS). Am J Epidemiol 1991, 134: 331–336.
6. Detels R, Munoz A, McFarlane G. et al. Effectiveness of potent antiretroviral therapy on time to AIDS and death in men with known HIV infection duration. JAMA 1998, 280: 1497–1503.
7. Hammer SM, Squires KE, Hughes MD. et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. AIDS Clinical Trials Group 320 Study Team. N Engl J Med 1997, 337: 725–733.
8. Dilley JW, Woods WJ, McFarland W. Are advances in treatment changing views about high risk sex? New Engl J Med 1997, 277: 145–153.
9. Kelly J, Hoffman R, Rompa DJ, Gray ML. Protease inhibitor combination therapies and perceptions of gay men regarding AIDS severity and the need to maintain safer sex. AIDS 1998, 12: F91–F95.
10. Dukers NHTM, Goudsmit J, de Wit J, Prins M, Weverling J, Coutinho RA. Sexual risk behavior relates to the virological and immunological improvements during highly active antiretroviral therapy in HIV-1 infection. AIDS 2001, 15: 1–10.
11. Strathdee SA, Martindale SL, Cornelisse PGA. et al. Trends in HIV infection and associated high risk behaviours among young gay and bisexual men. Can Med Assoc J 2000, 162: 21–25.
12. Page-Shafer KA, McFarland W, Kohn R. et al. Increases in unsafe sex and rectal gonorrhoea among men who have sex with men: San Francisco, California, 1994–1997. MMWR 1999, 48: 45–48.
13. Kravcik S, Victor G, Houston S. et al. Effect of antiretroviral therapy and viral load on the perceived risk of HIV transmission and the need for safer sexual practices. J Acquir Immune Defic Syndr Hum Retrovirol 1998, 19: 124–129.
14. Kaslow RA, Ostrow DG, Detel R. et al. The Multicenter AIDS Cohort Study: rationale, organization, and selected characteristics of the participants. Am J Epidemiol 1987, 126: 310–318.
15. Vanable PA, Ostrow DG, McKiran DJ, Taywaditep, Hope BA. Impact of combination therapies on HIV risk perceptions and sexual risk among HIV-positive and HIV-negative gay and bisexual men. Health Psychol 2000, 19: 134–145.
16. Dermen KH, Cooper ML. Sex-related alcohol expectancies among adolescents: I. Scale development. Psychol Addictive Behaviors 1994, 8: 152–160.
17. DiFranceisco W, Ostrow DG, Chmiel JS. Sexual adventurism, high-risk behavior, and human immunodeficiency virus-1 seroconversion among the Chicago MACS-CCS cohort, 1984 to 1992. A case-control study. Sex Transm Dis 1996, 23: 453–460.
18. Carpenter CC, Cooper DA, Fischl MA. et al. Antiretroviral therapy in adults: updated recommendations of the International AIDS Society-USA Panel. JAMA 2000, 283: 391–390.
19. Department of Health and Human Services and Kaiser Family Foundation Panel on Clinical Practices for the Treatment of HIV Infection. Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents.
January 2000. http://hivatis.org.
20. 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 (9254): 432–435.
21. Barroso PF, Schechter M, Gupta P, et al. Effect of antiretroviral therapy on HIV shedding in semen. Ann Intern Med 2000, Aug 15, 133:280–284.
22. Kippax S, Noble J, Prestage G. Sexual negotiation in the AIDS era: negotiated safety revisited. AIDS 1997, 11: 191–197.
23. Vanable PA, Ostrow DG, McKirnan DJ. A preliminary study of the effect of viral load on sexual risk taking among HIV-positive gay men. Presented at the Annual Meeting of the Society of Behavioral Medicine. Nashville, Tennessee, March 2000.
24. Ostrow DG, McKirnan D, Klein C, DiFranceisco W. Patterns and correlates of risky behavior among HIV-positive gay men: Are they really different from HIV-negative men? AIDS and Behavior 1999, 3: 99–110.
25. Blower SM, Gershengorn HB, Grant RM. A tale of two futures: HIV and antiretroviral therapy in San Francisco. Science 2000, 287: 650–654.
26. Catania JA, Osmond D, Stall RD. et al. The continuing HIV epidemic among men who have sex with men. Am J Public Health 2001, 91: 907–914.
This article has been cited 105 time(s).
Bmc MedicineWhen to start antiretroviral therapy: the need for an evidence base during early HIV infectionBmc Medicine
Janac-Journal of the Association of Nurses in AIDS CarePre-Exposure Prophylaxis: An Ethical DiscussionJanac-Journal of the Association of Nurses in AIDS Care
Access to antiretroviral treatment and sexual behaviours of HIV-infected patients aware of their serostatus in Cote d'Ivoire
Behavior ModificationChanging HIV and AIDS-related behavior - Promising approaches at the individual, group, and community levelsBehavior Modification
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivIt's not just what you say: Relationships of HIV dislosure and risk reduction among MSM in the post-HAART eraAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
Sexually Transmitted InfectionsLow HIV-testing rates among younger high-risk homosexual men in AmsterdamSexually Transmitted Infections
AIDS and BehaviorMedication adherence and sexual risk behavior among HIV-Infected adults: Implications for transmission of resistant virusAIDS and Behavior
Journal of Urban Health-Bulletin of the New York Academy of MedicineSexual Risk Behavior and Drug Use in Two Chicago Samples of Men Who Have Sex with Men: 1997 vs. 2002Journal of Urban Health-Bulletin of the New York Academy of Medicine
Jama-Journal of the American Medical Association
Highly active antiretroviral therapy and sexual risk behavior - A meta-analytic review
Jama-Journal of the American Medical Association, 292(2):
Janac-Journal of the Association of Nurses in AIDS CareProtective Factors for HIV Infection Among Mexican American Men Who Have Sex With MenJanac-Journal of the Association of Nurses in AIDS Care
Age and gender in the management of HIV-relevant sexual risks: theoretical background and first results of a population survey in the German speaking part of Switzerland
Sozial-Und Praventivmedizin, 47(6):
Journal of Urban Health-Bulletin of the New York Academy of MedicineThe urban environment and sexual risk behavior among men who have sex with menJournal of Urban Health-Bulletin of the New York Academy of Medicine
Social aspects of antiretroviral therapy scale-up: introduction and overview
Gender, sexuality, and antiretroviral therapy: using social science to enhance outcomes and inform secondary prevention strategies
Health PsychologyEffects of Disengagement Coping With HIV Risk on Unprotected Sex Among HIV-Negative Gay Men in New York CityHealth Psychology
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivBeliefs about transmission risk and vulnerability, treatment adherence, and sexual risk behavior among a sample of HIV-positive men who have sex with menAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
AIDS and Behavior
Why HIV infections have increased among men who have sex with men and what to do about it: Findings from California focus groups
AIDS and Behavior, 7(4):
Plos OneElevated Risk for HIV-1 Infection in Adolescents and Young Adults in Sao Paulo, BrazilPlos One
Janac-Journal of the Association of Nurses in AIDS CareSafe Sex Fatigue, Treatment Optimism, and Serosorting: New Challenges to HIV Prevention Among Men Who Have Sex With MenJanac-Journal of the Association of Nurses in AIDS Care
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivDevelopment of a treatment optimism scale for HIV-positive gay and bisexual menAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
AIDS Education and Prevention
Hiv Treatment Optimism and Unsafe Anal Intercourse Among Hiv-Positive Men Who Have Sex With Men: Findings From the Positive Connections Study
AIDS Education and Prevention, 22(2):
Social Science & MedicineThe search for social validation and the sexual behavior of people living with HIV in Rio de Janeiro, Brazil: Understanding the role of treatment optimism in contextSocial Science & Medicine
AIDS Education and Prevention
Factors associated with unprotected sexual intercourse with steady male, casual male, and female partners among men who have sex with men in Barcelona, Spain
AIDS Education and Prevention, 18(3):
Canadian Medical Association JournalContraception in Canada: a review of method choices, characteristics, adherence and approaches to counsellingCanadian Medical Association Journal
AIDS Education and Prevention
Residual injection risk behavior, HIV infection, and the evaluation of syringe exchange programs
AIDS Education and Prevention, 19(2):
AIDS Education and Prevention
Acquisition of new sexual partners among women with HIV infection: Patterns of disclosure and sexual behavior within new partnerships
AIDS Education and Prevention, 19(2):
Journal of Adolescent HealthThe HPV vaccine and behavioral disinhibition - ResponseJournal of Adolescent Health
Sexually Transmitted DiseasesOutbreak of syphilis among men who have sex with men in Houston, TexasSexually Transmitted Diseases
Journal of Urban Health-Bulletin of the New York Academy of Medicine
Sexual risk reduction among HIV-positive drug-using men who have sex with men
Journal of Urban Health-Bulletin of the New York Academy of Medicine, 80(4):
Journal of Infectious DiseasesIncrease in HCV incidence among men who have sex with men in Amsterdam most likely caused by sexual transmissionJournal of Infectious Diseases
AIDS and BehaviorThe WHOMEN's Scale (Women's HAART Optimism Monitoring and EvaluatioN Scale v.1) and the Association with Fertility Intentions and Sexual Behaviours Among HIV-Positive Women in UgandaAIDS and Behavior
Perceived viral load, but not actual HIV-1-RNA load, is associated with sexual risk behaviour among HIV infected homosexual men
Sexually Transmitted InfectionsRecent trends in diagnoses of HIV and other sexually transmitted infections in England and Wales among men who have sex with menSexually Transmitted Infections
Health PsychologyChanges in HIV treatment beliefs and sexual risk behaviors among gay and bisexual men, 1997-2005Health Psychology
Archives of Sexual Behavior
Barebacking among gay and bisexual men in New York City: Explanations for the emergence of intentional unsafe behavior
Archives of Sexual Behavior, 32(4):
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivSexual risk behaviour, viral load, and perceptions of HIV transmission among homosexually active Latino men: an exploratory studyAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
Patient Education and CounselingSexual risk behavior among HIV-positive men who have sex with men: A literature reviewPatient Education and Counseling
AIDS and BehaviorPrevalence of treatment optimism-related risk behavior and associated factors among men who have sex with men in 11 states, 2000-2001AIDS and Behavior
Journal of Behavioral MedicineBeliefs about treatments for HIV/AIDS and sexual risk behaviors among men who have sex with men, 1997-2006Journal of Behavioral Medicine
Psychological BulletinMoral Agency and the Sexual Transmission of HIVPsychological Bulletin
Clinical Infectious DiseasesTreatment to Prevent Transmission of HIV-1Clinical Infectious Diseases
Clinical Infectious Diseases
Key issues for a potential human immunodeficiency virus vaccine
Clinical Infectious Diseases, 36(5):
Journal of Psychosomatic ResearchViral load and HIV treatment attitudes as correlates of sexual risk behavior among HIV-positive gay menJournal of Psychosomatic Research
Journal of Community PsychologyImpact of beliefs about HIV treatment and peer condom norms on risky sexual behavior among gay and bisexual menJournal of Community Psychology
Quality of Life ResearchImpacts of HIV infection and HAART use on quality of lifeQuality of Life Research
AIDS Research and Human Retroviruses
Failure to detect human immunodeficiency virus type 1 superinfection in 28 HIV-seroconcordant individuals with high risk of reexposure to the virus
AIDS Research and Human Retroviruses, 20(9):
AddictionHighly active antiretroviral therapy (HAART) among HIV-infected drug users: a prospective cohort study of sexual risk and injecting behaviourAddiction
Australian and New Zealand Journal of Public Health
Epidemic infectious syphilis in inner Sydney - strengthening enhanced surveillance
Australian and New Zealand Journal of Public Health, 30(6):
Long-term psychosocial challenges for people living with HIV: let's not forget the individual in our global response to the pandemic
AIDS Patient Care and StdsSafer sexual behaviors after 12 months of antiretroviral treatment in Mombasa, Kenya: A prospective cohortAIDS Patient Care and Stds
Jama-Journal of the American Medical Association
Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men - A meta-analysis
Jama-Journal of the American Medical Association, 300():
Journal of Travel Medicine
Effect of maximizing a travel medicine clinic's prevention strategies
Journal of Travel Medicine, 12(6):
AIDS and BehaviorBehavioral interventions for HIV-positive and HCV-positive drug usersAIDS and Behavior
AIDS and BehaviorAlcohol consumption, art usage and high-risk sex among women infected with HIVAIDS and Behavior
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivThe impact of HIV treatment on risk behaviour in developing countries: A systematic reviewAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
AIDS and BehaviorProspective study of attitudinal and relationship predictors of sexual risk in the multicenter AIDS cohort studyAIDS and Behavior
Bulletin of the World Health Organization
Second-generation HIV surveillance: better data for decision-making
Bulletin of the World Health Organization, 82(2):
AIDS and BehaviorBehavior surveillance: Prevalence and factors associated with high-risk sexual behavior among HIV-Infected men in brazil in the Post-HAART eraAIDS and Behavior
Substance Use & MisuseClub drugs as causal risk factors for HIV acquisition among men who have sex with men: A reviewSubstance Use & Misuse
Sexually Transmitted InfectionsPrevalence of seroadaptive behaviours of men who have sex with men, San Francisco, 2004Sexually Transmitted Infections
Journal of Behavioral MedicineHIV treatment beliefs and sexual transmission risk behaviors among HIV positive men and womenJournal of Behavioral Medicine
American Journal of Health Behavior
Risk behaviors of youth living with HIV: Pre- and post-HAART
American Journal of Health Behavior, 29(2):
Pharmacology & TherapeuticsImmunotherapy for the treatment of drug abusePharmacology & Therapeutics
Plos OneAssociation of Attitudes and Beliefs towards Antiretroviral Therapy with HIV-Seroprevalence in the General Population of Kisumu, KenyaPlos One
Sexually Transmitted Infections
Prevention interventions for HIV positive individuals
Sexually Transmitted Infections, 78(6):
Sexually Transmitted InfectionsRecent trends in HIV and other STIs in the United Kingdom: data to the end of 2002Sexually Transmitted Infections
Sexually Transmitted InfectionsHIV status of sexual partners is more important than antiretroviral treatment related perceptions for risk taking by HIV positive MSM in Montreal, CanadaSexually Transmitted Infections
AIDS and BehaviorRisk perception and sexual risk behaviors among HIV-positive men on antiretroviral therapyAIDS and Behavior
Life projects and therapeutic itineraries: marriage, fertility, and antiretroviral therapy in Nigeria
Journal of Urban Health-Bulletin of the New York Academy of MedicineIntegrating HIV prevention activities into the HIV medical care setting: A report from the NYCHIV Centers ConsortiumJournal of Urban Health-Bulletin of the New York Academy of Medicine
AIDS Education and Prevention
Sexual risk behavior has decreased among men who have sex with men in Los Angeles but remains greater among heterosexual men and women
AIDS Education and Prevention, 20(4):
Journal of Community HealthUnsafe Sex Among HIV Positive Individuals: Cross-Sectional and Prospective PredictorsJournal of Community Health
Optimistic perception of HIV/AIDS, unprotected sex and implications for prevention among men who have sex with men, Sao Paulo, Brazil
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivIs AIDS chronic or terminal? The perceptions of persons living with AIDS and their informal support partnersAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
Integrating HIV care and HIV prevention: legal, policy and programmatic recommendations
Bmj OpenDoes antiretroviral therapy initiation increase sexual risk taking in Kenyan female sex workers? A retrospective case-control studyBmj Open
What is the Place of Pre-Exposure Prophylaxis in HIV Prevention?
AIDS Reviews, 15(2):
Plos OneChanging Risk Behaviours and the HIV Epidemic: A Mathematical Analysis in the Context of Treatment as PreventionPlos One
Studies in Family PlanningThe Need to Reemphasize Behavior Change for HIV Prevention in Uganda: A Qualitative StudyStudies in Family Planning
Bmc Public HealthAlcohol use and HIV serostatus of partner predict high-risk sexual behavior among patients receiving antiretroviral therapy in South Western UgandaBmc Public Health
Plos OneDisinhibition in Risky Sexual Behavior in Men, but Not Women, during Four Years of Antiretroviral Therapy in Rural, Southwestern UgandaPlos One
AIDS and Behavior"It's Hard to Know What is a Risky or not a Risky Decision": Gay Men's Beliefs About Risk During SexAIDS and Behavior
JAIDS Journal of Acquired Immune Deficiency SyndromesSexual Behavior and Reproductive Health Among HIV-Infected Patients in Urban and Rural South AfricaJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesHIV Treatments Optimism Among Gay Men: An International PerspectiveJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesTrends in HIV Prevalence Among White and African-American Civilian Applicants for United States Military Service, 1985 to 2003JAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesHIV Sexual Risk Behavior Over 36 Months of Follow-Up in the World's First HIV Vaccine Efficacy TrialJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesHIV Transmission Risk Behavior Among Men and Women Living With HIV in 4 Cities in the United StatesJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesEffectiveness of Highly Active Antiretroviral Therapy in Reducing Heterosexual Transmission of HIVJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesHigh-Risk Sexual Behavior in Adults With Genotypically Proven Antiretroviral-Resistant HIV InfectionJAIDS Journal of Acquired Immune Deficiency Syndromes
Sexually Transmitted DiseasesHIV Superinfection in the Era of Increased Sexual Risk-TakingSexually Transmitted Diseases
HIV; highly active antiretrovial therapy; attitudes; homosexual men; sexual behavior
© 2002 Lippincott Williams & Wilkins, Inc.
Highlight selected keywords in the article text.