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HIV Prevention Fatigue Among High-Risk Populations in San Francisco

Stockman, Jamila K. MPH*; Schwarcz, Sandra K. MD, MPH*; Butler, Lisa M. PhD, MPH†; de Jong, Bouke MD‡; Chen, Sanny Y. MPH*; Delgado, Viva MPH*; McFarland, Willi MD, PhD*

JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 April 2004 - Volume 35 - Issue 4 - pp 432-434
Letters To The Editor

From *San Francisco Department of Public Health AIDS Office, †Center for AIDS Prevention Studies University of California San Francisco, San Francisco ‡Stanford University Stanford, CA

Supported by a grant from the Centers for Disease Control and Prevention (U62/CCU906255-10). The contents of this manuscript are solely the responsibility of the authors and do not necessarily reflect the official views of the Centers for Disease Control and Prevention.

To the Editor:

Since the late 1990s, HIV-related risk behavior among men who have sex with men (MSM) has increased in San Francisco and other cities worldwide. 1–9 This increase in risk behavior is corroborated by rises in sexually transmitted diseases and, in some places, HIV incidence. 1,4 For example, in San Francisco, unprotected anal intercourse increased from 30%in 1994 to 46%in 1999; male rectal gonorrhea increased from 72 cases in 1994 to 237 in 2001; and annual HIV incidence increased from 1.3%in 1997 to 4.7%in 1999 among MSM seeking anonymous HIV testing. 2,10 Researchers have explored the hypothesis that the resurgence of high-risk behavior is partly a result of optimistic beliefs about the effectiveness of highly active antiretroviral therapy (HAART), known as “HAART optimism.” 2–4,10,11 Specifically, as a result of the availability of HAART, HIV-negative persons are less concerned about contracting HIV and HIV-positive persons are less concerned about transmitting HIV; thus both groups may be more likely to engage in unsafe sex. 2,12 However, some studies have not found a sufficiently high proportion of subjects who report diminished fear of acquiring or transmitting HIV infection as a result of HAART. 2,13,14 Another potential factor that may contribute to increases in risk behavior is HIV prevention fatigue 4,15; i.e., an attitude that HIV prevention messages, programs, outreach, or counseling services have become tiresome. In one recent study, Ostrow et al. 16 found that safer sex fatigue (fatigue in maintaining safe sex practices) was associated with unprotected anal intercourse among HIV-positive gay men but not among HIV-negative gay men. 16 We examined HIV prevention fatigue in community-based samples of 3 high-risk populations collected during a survey of HIV testing practices.

We analyzed data from the 2001 cross-sectional, anonymous, HIV Testing Survey (HITS) in San Francisco. HITS followed a standard protocol developed by the Centers for Disease Control and Prevention assessing HIV testing behaviors, reasons for avoiding testing, attitudes and beliefs about HIV testing, and sexual and drug risk behaviors. The HITS methods and eligibility criteria are described in detail elsewhere. 17–19 The San Francisco HITS final sample for this study included 303 HIV-negative or untested participants who had been intercepted and interviewed at different recruiting venues. We recruited 105 MSM from gay bars, 99 heterosexuals from the municipal sexually transmitted disease clinic, and 99 injection drug users (IDUs) from street locations in heavy drug use neighborhoods.

Participants were asked a series of questions about their level of agreement with statements pertaining to attitudes and beliefs about HIV on a 4-point scale. Six of the questions reflected a similar concept, which we called HIV prevention fatigue (Table 1). The Cronbach α (0.73) indicated that the HIV prevention fatigue scale was internally consistent. An HIV prevention fatigue score, the average of the 6 items, was assigned to each participant. The score ranged from 3.67 (highest level of fatigue) to 1.00 (lowest level of fatigue). Because the fatigue score was not normally distributed, we used the Kruskal-Wallis or Wilcoxon rank sum tests to compare scores by demographic characteristics, risk behaviors, and level of HAART optimism. To show differences more clearly, we present mean fatigue scores in Table 1.

Among all participants, the mean HIV prevention fatigue score was 2.02. Overall, there was no significant difference in fatigue by age, gender, race, or monthly income. However, those with a high school education or less expressed a higher level of HIV prevention fatigue than those who had more than a high school education (P = 0.022).

The level of HIV prevention fatigue varied by risk population (P = 0.001). In pairwise comparisons, IDU participants had a higher level of fatigue toward HIV prevention messages than heterosexuals (P < 0.001). Within each high-risk population, there were no significant differences in fatigue by gender, race, or monthly income. A significant difference in fatigue by age was observed only among IDU participants; IDUs less than 25 years of age had a higher level of HIV prevention fatigue than those older than 25 years (P = 0.012). The finding of increased fatigue among younger IDUs is contrary to expectation; we would expect that those who had experienced the HIV epidemic and prevention messages longer would have more fatigue. The finding may challenge the face validity of the scale as measure fatigue, or the scale may tap into rebelliousness or contrariness to conventional prevention messages among younger IDUs. HIV prevention fatigue was not associated with unprotected anal intercourse among MSM or unprotected vaginal intercourse among heterosexuals, at last sex. However, a significant association between prevention fatigue and high-risk injection behavior was observed among IDU participants. IDU participants who reported sharing cookers, cotton, rinse water, or other equipment, but not needles or syringes, while shooting up in the past 12 months expressed a higher level of HIV prevention fatigue than those who reported never sharing equipment with others (P = 0.020).

We also hypothesized that HIV prevention fatigue was associated with HAART optimism. We used agreement with a single item, “You are less careful about being safe with sex or drugs than you were 5 years ago because there are better treatments for HIV now,” as a marker of HAART optimism. Those who had a high level of HAART optimism had a significantly higher level of prevention fatigue than those who had a low level of HAART optimism, overall and within each high-risk population (all P values <0.001).

Like Ostrow et al., we did not find a direct association between HIV prevention fatigue and high-risk sexual behavior among HIV-negative gay men. 16 We did, however, find a positive association between prevention fatigue and risky injection practices and younger age among IDUs. We also found that prevention fatigue was associated with HAART optimism. Together with the limited research available, our data suggest that prevention fatigue may be a concern for certain populations at risk for acquiring HIV (e.g., young IDUs) or transmitting HIV to others (e.g., HIV-positive MSM 16 or MSM with optimistic attitudes toward HAART). Considering that HIV is likely to be with us for decades to come, some amount of prevention fatigue may be inevitable for other populations. Our scale may aid future researchers to develop precise measures to monitor HIV prevention fatigue in diverse populations at risk.

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