Heterosexual HIV transmission has become increasingly important in France as well as in other western countries. Whereas 29% of individuals living with HIV in France diagnosed before 1996 were infected through heterosexual contact, this percentage rose to 51% for the period from 1996 to 2003 . Since the availability of HAART, it seems more possible for people living with HIV to envisage living within a couple . Unlike other populations, such as gay men, little is known about the factors associated with unsafe sex among serodiscordant heterosexual couples [3,4]. The VESPA Study (‘VIH: Enquête Sur les Personnes Atteintes’), conducted among a national representative sample of people living with HIV attending outpatient services in France, gave us the opportunity to analyse the factors associated with unsafe sex among heterosexual individuals with HIV who reported having a steady partner either having HIV or of unknown HIV status. The aim of this analysis was to understand the determinants of unsafe sex within serodiscordant heterosexual couples in order to help develop programmes aimed at reducing unprotected sex and reducing HIV transmission from people with HIV to their steady partners.
We used data from the VESPA Study, a national cross-sectional survey conducted in 2003 among a random stratified sample of people living with HIV/AIDS (PLWHA). A detailed description of the study design is provided elsewhere in this issue , as well as the description of the weighting procedure used to ensure the representativeness of our sample.
Individuals who agreed to participate answered a face-to-face questionnaire (398 closed-ended questions) administered by a trained interviewer using the Computer Assisted Personal Interview system. This questionnaire dealt with a range of aspects of daily life and with socioeconomic conditions. In parallel, the consulting physician completed a short medical questionnaire.
This analysis was restricted to heterosexual adults who reported having a regular partnership for at least 12 months with a partner who is HIV-negative or of unknown HIV status.
In order to take into account the heterogeneity of our population, individuals were classified into six groups according to their sex, their origin and their mode of HIV acquisition. Men were divided into active or former injecting drug users (IDU), those infected through heterosexual contact born in France, and those infected through heterosexual contact born abroad referred to as ‘male IDU’, ‘native men’ and ‘immigrant men’, respectively. In the same way, women were divided into ‘IDU women’, ‘native women’ and ‘immigrant women’.
Sexual behaviour-related characteristics
The following characteristics were collected: the reported number of sexual partners during their lifetime and during the previous 12 months, the reported number of regular partnerships during their lifetime, and the existence of a regular partnership at the time of the survey. Participants who reported having a current regular partnership were asked about the length of that relationship and whether they had disclosed their HIV-positive status to their steady partner. Similarly, participants were asked whether they were aware of their partner's HIV status. In addition, specific questions about the use of condoms with their steady partner were also asked.
In order to minimize desirability bias and the underestimation of sexual risk-taking, the frequency of condom use was assessed using a fifth-level variable. For participants reporting having a steady partner during the previous 12 months, they were asked how often they used condoms for penetrative sex with him/her: never, hardly ever, sometimes, almost always, or always, the latter proposition indicating consistent condom use. Unsafe sex was defined as reporting inconsistent condom use during the previous 12 months with a steady partner who was either HIV-negative or of unknown HIV status. Participants who reported no penetrative sex during the previous 12 months were classified as practising safe sex.
Participants were asked about their alcohol consumption. As alcohol is commonly consumed by adults in France, only binge drinking (defined as taking at least six alcoholic drinks on a single occasion) was taken into consideration.
Socioeconomic characteristics included employment status and an appreciation of the household financial situation (satisfactory, difficult, very difficult).
The medical questionnaire included information about each person's viral load, CD4 cell count, clinical stage, time of diagnosis and HIV treatment.
Separate analyses were performed for men and women. Among the subsample of participants who indicated having a regular partnership during the previous 12 months with a steady partner who was either HIV-negative or of unknown HIV status, chi-squared tests were used to compare those practising unsafe sex with those who did not. To identify the factors independently associated with unsafe sex, logistic models were used. A stepwise procedure was used to select statistically significant factors in a multivariate model (entry threshold P < 0.20). Only factors that remained associated with a P value of 0.05 or less were finally kept in the multivariate model. Statistical analyses were performed using the SPSS version 12.0.1 software program (SPSS, Inc., Chicago, Illinois, USA).
Among the 2932 participants in the VESPA Study, 1888 individuals reported being heterosexual. A total of 680 of this group reported having a regular partnership of more than 12 months with a partner who was either HIV-negative or of unknown HIV status. We excluded from the analysis 12 participants diagnosed as HIV infected for less than 12 months (because among them risky sexual behaviour during the previous 12 months may have occurred before diagnosis) as well as five women whose steady partner was a woman. Our study population therefore comprised 663 individuals.
In our selected population, the mean age was 42 years. Male IDU accounted for 20% of the sample, 31% were native men and 8% were immigrants. Among the 41% of women, 6% were IDU, 19% were native women and 16% were immigrants.
Only 22% of individuals had graduated from high school, 63% had children, and 56% were employed. Seventy-two per cent reported having a satisfactory household financial situation, whereas 19 and 9% reported having a difficult and very difficult situation, respectively. Regarding alcohol consumption, 10% indicated that they indulged in binge drinking at least once a month.
Thirty-one per cent of the study population was diagnosed as having contracted HIV after 1995. Eighty per cent were being treated with HAART, 22% were in the C stage, 69% had an undetectable viral load (< 400 copies/ml) and 91% had a CD4 cell count greater than 200 cells/ml.
Participants reported a median of eight sexual partners in their lifetime. Seven per cent reported having casual partners in the previous 12 months. With respect to partnership characteristics, the average length of the relationship was 11 years (SD 8.4). Five per cent of the sample had not disclosed their HIV-positive status to their partner. In addition, 8% of participants were not aware of the HIV status of his/her partner.
Seventeen per cent of individuals reported that condom use had been a source of tension or discord with their partner during the previous 12 months, and 23% had not experienced another steady relationship during his/her lifetime.
Unsafe sex with a steady partner (HIV-negative or of unknown HIV status) was reported by 26% of men and 34% women (P = 0.024).
Unsafe sex with a steady partner without HIV among men
Among men, the sociodemographic factors associated with unsafe sex were being under 40 years of age and reporting a difficult or very difficult household financial situation (Table 1). The number of sexual partners during one's lifetime was not associated with unsafe sex, but individuals reporting no other stable relationship during their lifetime tended to be associated with unsafe sex. Regarding partnership characteristics, those individuals in longer relationships engaged more often in unsafe sex. Lack of awareness of the partner's HIV status and HIV-positive status disclosure to the partner (P = 0.236) were not associated with unsafe sex. Participants reporting that condom use was a source of tension or discord with the partner did not report more risky behaviour, neither did those who reported having casual partners during the previous 12 months. With respect to the consumption of alcohol, a report of binge drinking at least once a month was associated with unsafe sex. Current injection drug use, which involved a small proportion of participants, was also associated with more risky behaviours.
None of the medical characteristics, such as time since diagnosis, being on HAART, having an undetectable viral load, or having a CD4 cell count less than 200 cells/ml, were associated with unsafe sex.
In the multivariate model (Table 1), men in longer relationships, those reporting household financial difficulties, and binge drinking at least once a month remained independently associated with unsafe sex with the steady partner during the previous 12 months.
Unsafe sex with a steady partner without HIV among women
For women also, unsafe sex was associated with difficulties regarding the household financial situation, but unlike men, younger age was not (Table 1). Women with a history of drug use tended to report risky behaviours more often.
Regarding partnership characteristics, a lack of awareness of the partner's HIV status was significantly associated with unsafe sex, but HIV-positive status disclosure to the partner was not. Women reporting that condom use was a source of tension or discord with the partner also reported more risky behaviour. Other sex-related characteristics (length of the relationship, number of partners, report of casual partners), the consumption of products and medical characteristics were not found to be associated with unsafe sex.
In multivariate analysis (Table 1), being a woman with a history of drug use, not being aware of the partner's HIV status, and reporting household financial difficulties all remained independently associated with unsafe sex with the steady partner. In addition, being an immigrant woman was independently associated with safer sex.
Among heterosexual individuals in a steady serodiscordant relationship, 26% of men and 33% of women reported having unsafe sex. Women living with HIV engaged more often in sexual risk-taking, as previously shown [6–8], and the pattern of predictors of unsafe sex was different to some degree between the sexes.
Before discussing our results, a limitation must be acknowledged. Our study shares with many others some of the general methodological problems related to sexual risk behaviour assessment based on reported behaviours, which may be affected by social desirability bias. In order to minimize this bias, the frequency of condom use was assessed using a five-level variable, and the highest threshold was used to classify individuals who reported having safe intercourse. Several studies have shown that such methods are quite reliable and they have been widely used in several countries .
Concerning factors associated with unsafe sex, it appears that a difficult household financial situation was the only factor commonly associated with unsafe sex with the steady partner in both men and women. It may reflect a general impact on behaviour of economic vulnerability and the inability to negotiate condom use. In both sexes, none of the characteristics of disease progression or response to treatment were found to be associated with unsafe sex. This is not a consensual result because discrepant findings have been published in previous literature [7,10,11].
No difference was found between native and immigrant individuals regarding sexual risk-taking among men; but among women, immigrant individuals reported safer practices. The majority of immigrants originated from sub-Saharan Africa , where sexual coercion and sex inequalities are not infrequent [12,13], and are known to be associated with risky sexual behaviour . These immigrants with HIV living in France, both men and women, also often face multiple social difficulties (such as unemployment, financial precariousness or housing problems). Despite all these elements, sexual risk-taking was not reported by them more frequently. It is an important result given the growing percentage of immigrant individuals within the French population living with HIV .
Among women, and as previously shown among heterosexual and homosexual serodiscordant couples [3,14,15], being unaware of the regular partner's HIV status is associated with higher rates of unsafe sex. Women living with HIV care about protecting their partners more frequently than protecting themselves from sexually transmitted infections , suggesting the need to promote HIV screening for their partners. This association was not found among men, that is when the partner at risk of HIV infection is a woman. Women are often not empowered to negotiate condom use, as it is a male-controlled method of contraception. This result advocates sex-specific interventions to prevent HIV infections for women, as described elsewhere [13,16,17].
In addition, the length of the relationship was found to be associated with unsafe sex among men. This result is consistent with another study conducted among gay couples , and it probably expresses lassitude in using condoms. However, this was not found among women, that is, when the partner at risk of HIV infection is a man.
Our results confirm the finding that women who acquire HIV infection through drug use may encounter particular challenges in practising safer sex consistently with regular partners [19,20]. Alcohol consumption, which has previously been identified as a factor linked to high-risk sexual behaviours , was found in our study to be associated with unsafe sex only among men. Given the nature of the study design and the questions asked, issues of intimacy and trust between partners, factors shown to be important in influencing safer sex in other research  could not be investigated in this study.
In conclusion, inconsistent condom use among HIV-serodiscordant heterosexual couples is quite frequent. Couple-level interventions are therefore essential in order to prevent HIV transmission and to encourage successful communication and negotiation. Interventions must especially be targeted toward protecting women, who are not on an equal footing with men regarding condom use in the context of a regular couple relationship.
Sponsorship: This study was supported by the French National Agency for AIDS Research (ANRS, France, n ANRS-EN12-VESPA). M.P. is supported by Sidaction.
1. Lert F, Obadia Y, Group V. First result ANRS/VESPA study among representative sample of HIV-infected people. Rev d'Epidemiol Santé Publique 2005; 53:79–98.
2. Castilla J, Del Romero J, Hernando V, Marincovich B, Garcia S, Rodriguez C. Effectiveness of highly active antiretroviral therapy in reducing heterosexual transmission of HIV. J Acquir Immune Defic Syndr 2005; 40:96–101.
3. Buchacz K, van der Straten A, Saul J, Shiboski SC, Gomez CA, Padian N. Sociodemographic, behavioral, and clinical correlates of inconsistent condom use in HIV-serodiscordant heterosexual couples. J Acquir Immune Defic Syndr 2001; 28:289–297.
4. Kalichman SC, Williams EA, Cherry C, Belcher L, Nachimson D. Sexual coercion, domestic violence, and negotiating condom use among low-income African American women. J Womens Health 1998; 7:371–378.
5. Dray-Spira R, Spire B, Heard I, Lert F, and the VESPA Study Group. Heterogeneous response to HAART across a diverse population of people living with HIV: results from the ANRS-EN12-VESPA Study. AIDS 2006; 20(Suppl. 1):S5–S12.
6. Gollub EL, Rey D, Obadia Y, Moatti JP. Gender differences in risk behaviors among HIV+ persons with an IDU history The link between partner characteristics and women's higher drug-sex risks The Manif 2000 Study Group. Sex Transm Dis 1998; 25:483–488.
7. Wolf K, Young J, Rickenbach M, Vernazza P, Flepp M, Furrer H, et al
. Prevalence of unsafe sexual behavior among HIV-infected individuals: the Swiss HIV Cohort Study. J Acquir Immune Defic Syndr 2003; 33:494–499.
8. Peretti-Watel P, Spire B, Schiltz MA, Bouhnik AD, Heard I, Lert F, Obadia Y, and the VESPA Group. Vulnerability, unsafe sex and non-adherence to HAART: evidence from a large sample of French HIV/AIDS outpatients (VESPA/ANRS 2003). Social Science and Medicine 2006; 62:2420–2433.
9. Spira A, Bajos N, Giami A, Michaels S. Cross-national comparisons of sexual behavior surveys–methodological difficulties and lessons for prevention. Am J Public Health 1998; 88:730–731.
10. Bouhnik AD, Moatti JP, Vlahov D, Gallais H, Dellamonica P, Obadia Y. Highly active antiretroviral treatment does not increase sexual risk behaviour among French HIV infected injecting drug users. J Epidemiol Community Health 2002; 56:349–353.
11. Van de Ven P, Mao L, Fogarty A, Rawstorne P, Crawford J, Prestage G, et al
. Undetectable viral load is associated with sexual risk taking in HIV serodiscordant gay couples in Sydney. AIDS 2005; 19:179–184.
12. Erulkar AS. The experience of sexual coercion among young people in Kenya. Int Family Plan Perspect 2004; 30:182–189.
13. Ehrhardt AA, Exner TM, Hoffman S, Silberman I, Leu CS, Miller S, Levin B. A gender-specific HIV/STD risk reduction intervention for women in a health care setting: short- and long-term results of a randomized clinical trial. AIDS Care 2002; 14:147–161.
14. Denning PH, Campsmith ML. Unprotected anal intercourse among HIV-positive men who have a steady male sex partner with negative or unknown HIV serostatus. Am J Public Health 2005; 95:152–158.
15. Glass TR, Young J, Vernazza PL, Rickenbach M, Weber R, Cavassini M, et al
. Is unsafe sexual behaviour increasing among HIV-infected individuals? AIDS 2004; 18:1707–1714.
16. Miller S, Exner TM, Williams SP, Ehrhardt AA. A gender-specific intervention for at-risk women in the USA. AIDS Care 2000; 12:603–612.
17. Ehrhardt AA, Exner TM. Prevention of sexual risk behavior for HIV infection with women. AIDS 2000; 14(Suppl. 2):S53–S58.
18. Moreau-Gruet F, Jeannin A, Dubois-Arber F, Spencer B. Management of the risk of HIV infection in male homosexual couples. AIDS 2001; 15:1025–1035.
19. Eich-Hochli D, Niklowitz MW, Clement U, Luthy R, Opravil M. Predictors of unprotected sexual contacts in HIV-infected persons in Switzerland. Arch Sex Behav 1998; 27:77–90.
20. Skurnick JH, Abrams J, Kennedy CA, Valentine SN, Cordell JR. Maintenance of safe sex behavior by HIV-serodiscordant heterosexual couples. AIDS Educ Prev 1998; 10:493–505.
21. Delor F. Séropositifs. Trajectoires identitaires et rencontres du risque (in French, English title: Seropositif: Identity trajectories and encounters with the risk)
. Paris: l'Harmattan; 1997.
The VESPA study group includes: A.D. Bouhnik (INSERM U379/ORS PACA), R. Dray-Spira (INSERM U88), J. Fagnani (CNRS-UMR Matisse), I. Heard (INSERM U430), F. Lert (INSERM U88), Y. Obadia (ORS PACA/INSERM U379), P. Peretti-Watel (ORS PACA/INSERM U379), J. Pierret (CERMES-INSERM U504-UMR 8559), B. Riandey (INED), M.A. Schiltz (CERMES-INSERM U504-UMR 8559), R. Sitta (INSERM U88), and B. Spire (INSERM U379/ORS PACA).