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.
1. San Francisco Department of Public Health, HIV/AIDS Statistics and Epidemiology Section. HIV/AIDS Epidemiology Annual Report 2001
. San Francisco: Department of Public Health; 2001:28–29.
2. Katz MH, Schwarcz SK, Kellogg TA, et al. Impact of highly active antiretroviral treatment of HIV seroincidence among men who have sex with men: San Francisco. Am J Public Health
3. Chen SY, Gibson S, Katz MH, et al. Continuing increases in sexual risk behavior and sexually transmitted diseases among men who have sex with men: San Francisco, Calif, 1999–2001. Am J Public Health
4. Chen SY, Weide D, McFarland W. Are recent increases in sexual risk behavior among older or younger men who have sex with men? Answer: both. AIDS
5. Elford J. Bolding G. Sherr L. High-risk sexual behaviour increases among London gay men between 1998 and 2001: what is the role of HIV optimism?AIDS
6. Van de Ven P, Prestage G, Crawford J, et al. Sexual risk behaviour increases and is associated with HIV optimism among HIV-negative and HIV-positive gay men in Sydney over the four-year period to February 2000. AIDS
7. Dodds JP, Nardone A, Mercey DE, et al. Increase in high risk sexual behaviour among homosexual men, London 1996-8: cross sectional, questionnaire study. BMJ
8. Dukers NHTM, Goudsmit J, de Wit JBF, et al. Sexual risk behaviour relates to the virological and immunological improvements during highly active antiretroviral therapy in HIV-1 infection. AIDS
9. Van de Ven P, Prestage G, French J, et al. Increase in unprotected anal intercourse with casual partners among Sydney gay men in 1996–98. Aust N Z J Public Health
10. Ekstrand ML, Stall RD, Bein E, et al. HIV treatment optimism is associated with sexual risk taking among gay men in San Francisco. Paper presented at: 4th
International Conference on Biopsychological Aspects of HIV infection; July 15–18, 1999; Ottawa, Canada.
11. The Henry J. Kaiser Family Foundation. World ‘Fails to Grasp’ Full Devastation’ of HIV/AIDS, Feacham Says
. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2002.
12. Van de Ven P, Kippax S, Knox S, et al. HIV treatments, optimism and sexual behavior among gay men in Sydney and Melbourne. AIDS
13. Bouhnik AD, Moatti JP, Vlahov D, et al. Highly active antiretroviral treatment does not increase sexual risk behaviour among French HIV infected injecting drug users. J Epidemiol Community Health
14. UNAIDS. Report on the Global HIV/AIDS Epidemic
. Geneva: UNAIDS; 2002:41.
15. Brown D. High HIV rates seen in young studies also note ‘prevention fatigue’ in older infected people. Washington Post
. February 7, 2001, A06.
16. Ostrow DE, Fox KJ, Chmiel JS, et al. Attitudes towards highly active antiretroviral therapy are associated with sexual risk taking among HIV-infected and uninfected homosexual men. AIDS
17. Centers for Disease Control and Prevention. Revised CDC protocol #1582-HIV Testing Survey
. Atlanta, GA: Centers for Disease Control and Prevention; 2001.
18. Kellerman SE, Lehman JS, Lansky A, et al. HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing. J Acquir Immune Defic Syndr
19. Hecht FM, Chesney MA, Lehman JS, et al. Does HIV reporting by name deter testing?AIDS