HAART has been found to be associated with changes towards unsafe sex in some industrialized countries [1–6]. This study aimed to see whether HAART was related to such a behaviour change in Côte d'Ivoire, sub-Saharan Africa.
From February to September 2005, we enrolled two groups of HIV-1-infected patients newly attending the largest Ivorian HIV/AIDS day hospital (Unité de Soins Ambulatoires et de Conseils). Group I included consecutive patients (number ≥ 300) who received HAART after the initial consultation, whereas group II included a similar number of consecutive patients who did not receive HAART (remained untreated). The patients were followed for 6 months. A questionnaire was administered, at inclusion and 6 months thereafter. Patients were asked about their sexual practices during the 6 months before visit 1 (‘period 1’) and visit 2 (‘period 2’): the number of regular/casual sexual partners and condom use (any sexual act). Condom use was assessed on a four-level scale: never; less than half of the time; half of the time or more; always. Unsafe sex was defined as at least one unprotected sex (first three levels of the scale) with any sexual partner. Information was also collected on the potential predictors of unsafe sex. Untreated patients received the guarantee that they would receive HAART if their condition (clinical/biological) worsened during follow-up.
After univariate analyses, variables with P values of 0.10 or less were included in a multivariate model containing three principal independent variables: the ‘period’; the ‘group’; and their interaction term. Interaction terms between the independent predictors of unsafe sex and both the ‘group’ and the ‘period’ were examined. Variables with P values less than 5% (independent predictors) and less than 15% (interaction terms) were kept in the final model. The model was adjusted for sex, the presence of a regular sexual partner and sexual abstinence at baseline. Generalized estimating equations with repeated measures were used.
Overall, 615 patients were recruited (303 in group I and 312 in group II). The median age was 35 years. A total of 139 patients (22.6%) reported that their last sexual partner was HIV negative. For 202 patients (32.8%), that status was unknown. In each group, approximately one-third of the patients have disclosed their HIV status to a close person, and a similar proportion reported sexual abstinence during period 1. The median number of sexual partners was one regardless of the group and the period (data not shown).
Figure 1 presents the proportion of unsafe sex by group and by period. During period 1, unprotected sex was significantly higher in group II (P = 0.014). During period 2, patients from both groups reported a similar risk (P = 0.484). The difference between groups II and I decreased from +6.6% during period 1 to −1.3% during period 2 (P = 0.005). This was related to a significant increase in unprotected sex among treated patients (P < 0.0001) and stability among untreated patients (P = 0.301). Three factors were independently associated with unprotected sex in the presence of the three principal variables: in comparison with Centers for Disease Control and Prevention category C, it was more risky to belong to category A [relative risk (RR) 1.94; 95% confidence interval (CI) 1.40–2.67] or B (RR 1.84; 95% CI 1.34–2.54); younger age (< 40 years, RR 1.40; 95% CI 1.17–1.67) and alcohol consumption (RR 1.16; 95% CI 1.02–1.31) were also associated with unsafe sex.
The increase in risk taking among treated patients is consistent with the clinical improvements and other positive outcomes found to be associated with HAART [7–10]. In addition, the significant decrease in the intergroup gap over time highlighted an increasing adverse effect of HAART on sexual behaviour. These results are strengthened by the fact that, in our study, patients with less advanced infection (Centers for Disease Control and Prevention clinical stages A/B) reported unsafe sex more often than those with severe symptoms (stage C). Observed changes in unprotected sex among treated patients were unlikely to be attributable to those who became sexually active because we adjusted for sexual abstinence at baseline. The increase in risk taking among the treated patients was, partly, initially limited to steady sexual partners: the median number of partners did not increase during follow-up. This increase was observed after a short period of follow-up (6 months). One may hypothesize that if the positive outcomes become more evident and stable with time, treated patients could start seeking for unprotected sex with casual or serodiscordant partners. This concern is supported by the fact that more than half of our treated patients reported that their last sexual partner was HIV negative or of unknown status. Our results are consistent with previous findings showing an increase in unprotected sex after the introduction of HAART in developed countries [1,2]. Unprotected heterosexual contacts have also been found to be frequent  and specifically related to new HIV seroconversions  in Europe. Our results are not consistent with those of a meta-analysis that found that the prevalence of unprotected sex was not higher among HIV-infected individuals receiving HAART . The difference with our study (heterosexual context) may be caused by cultural specificities, but to our knowledge, only one prospective quantitative study on this subject has been conducted in sub-Saharan Africa . The latter was conducted in parallel with preventive interventions (contrary to our study) and did not find an increase in risk-taking after treatment initiation. This underscores the importance of coupling HAART along with counselling programmes aimed at encouraging patients to adopt and maintain safer sexual practices . As previously demonstrated, younger age  and alcohol consumption  were also associated with unsafe sex in our study.
Social desirability could have induced an underestimation of risk taking, but there is no reason for a differential report between groups. The patients were enrolled from a single clinic, which may induce a selection bias, but this clinic is the largest HIV/AIDS day hospital in Côte d'Ivoire and it receives patients from all over the country.
Our study supports a causal relationship between the use of HAART and an increase in sexual risk taking among HIV-1-infected patients in Côte d'Ivoire. Given the scale-up of antiretroviral therapy in sub-Saharan Africa, more research is needed to examine this issue in more depth.
The authors would like to thank all the patients for their participation and all the members of the Unité de Soins Ambulatories et de Conseils in Abidjan, Côte d'Ivoire. They also thank Fassery Dembele, Edouard Djo-Bi Djo, Adou Aman, Isabelle Adou Tchimou, Justine Kouamé, Fatoumata Kone Koffi, Alex Ani, Jonas Seri Boga, and Habane Guéhi Calixte for their assistance in the data collection.
The study was approved by the research ethics committees of Université Laval, Québec, Canada and of the Ministry of Health of Côte d'Ivoire. Informed written consent was obtained from all participants.
Sponsorship: M.A. is a national researcher of the Fonds de la Recherche en Santé du Québec, Canada (grant no. 8722).
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