Our findings align with previous work in this field. Analyses using data collected in earlier treatment eras (before 2004) within the Women's Interagency HIV Study revealed a positive association between awareness of HIV prevention benefits of ART and condomless sex.31,32 This association has similarly been reported by empirical analyses in the modern TasP era.29,30 Notably, the Swiss Cohort Study evaluated sexual behaviors before and after the release of the Swiss Consensus Statement in 200811 and found that participants interviewed after the release of the statement were more likely to report condomless sex; an association that was stronger among those with VL suppression.27 Furthermore, an accelerated increase in the prevalence of condomless sex was observed among Swiss Cohort Study participants in stable partnerships in the years after the release of the Swiss Consensus Statement (between 2008 and 2013).28 Although our study is cross-sectional, it adds to the evidence base that viral suppression with ART is increasingly being accurately viewed as an HIV prevention and safer sex strategy for WWH, particularly as evidence in support of TasP become more widely acknowledged.
In our analysis, partnered relationship status at interview was independently associated with condomless sex, consistent with previous work in local and international settings,27,28,36,51,52 likely reflecting a mutual decision between partners in a disclosed relationship to engage in condomless sex. Women educated beyond high school and reporting white ethnicity had greater odds of reporting condomless sex. This finding may be attributed to greater treatment optimism among women with higher socioeconomic backgrounds. Previous work supports this hypothesis, observing that people with HIV who are from marginalized socioeconomic groups or who are isolated from HIV services are less likely to be aware of HIV prevention benefits of ART.30,53,54 Residence in BC compared with Ontario or Quebec was also an independent correlate of condomless sex among women in this cohort, likely reflecting the localized, province-wide expansion of TasP in BC.55
It is important to acknowledge the high prevalence of sexual inactivity in this cohort. We excluded 773 women self-reporting no recent consensual sex from this analysis. Although the perspectives of sexually inactive WWH were not captured within this analysis, previous work has shown that many complex reasons drive sexual inactivity among WWH.66 Among CHIWOS participants, fear of transmitting HIV to sexual partners has been identified as a key factor driving intentional sexual abstinence.66 Although previous work has shown that awareness of HIV prevention benefits of ART is not a significant correlate of sexual inactivity in the CHIWOS cohort, women who have engaged in discussions around the prevention benefits of ART with their health care provider have been shown to demonstrate lower odds of sexual inactivity.42 Our analysis adds to this body of work revealing how the awareness of the HIV prevention benefits of ART expands HIV prevention options and may influence sexual decision making of sexually active WWH with serodiscordant male partners in the TasP era.
Within a sample of Canadian WWH with an undetectable VL on ART and reporting regular HIV-serodiscordant sexual partners, most were aware of the HIV prevention benefits of ART. We also observed an association between awareness of HIV prevention benefits of ART and condomless sex. Our findings support that an undetectable VL on ART may be accurately viewed as a safer sex option to minimize HIV transmission risk to HIV-serodiscordant regular male partners among WWH. However, awareness of the HIV prevention benefits of ART is not universal, and decisions related to safer sex strategies remain complex. This work highlights the critical need to advance safer sex discussions beyond condom use to better support WWH to make informed sexual decisions, and fully realize options for healthy, safe, pleasurable, and satisfying sexuality in the TasP era.23
The CHIWOS Research Team
Rahma Abdul-Noor (Women's College Research Institute), Aranka Anema (University of British Columbia), Jonathan Angel (Ottawa Hospital Research Institute), QC—Jean-Guy Baril (Université de Montréal), Fatimatou Barry (Women's College Research Institute), Greta Bauer (University of Western Ontario), Kerrigan Beaver (Women's College Research Institute), Denise Becker (Positive Living Society of British Columbia), Anita Benoit (Women's College Research Institute), Jason Brophy (Children's Hospital of Eastern Ontario), Lori Brotto (University of British Columbia), Ann Burchell (Ontario HIV Treatment Network), Claudette Cardinal (Simon Fraser University), Allison Carter (British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University), Angela Cescon (British Columbia Centre for Excellence in HIV/AIDS), Lynne Cioppa (Women's College Research Institute), Jeffrey Cohen (Windsor Regional Hospital), Guillaume Colley (British Columbia Centre for Excellence in HIV/AIDS), Tracey Conway (Women's College Research Institute), Curtis Cooper (Ottawa Hospital Research Institute), Jasmine Cotnam (Women's College Research Institute), Janette Cousineau (Women's College Research Institute), Janice Dayle (McGill University Health Centre), Marisol Desbiens (Women's College Research Institute), Hania Dubinsky (McGill University Health Centre), Danièle Dubuc (McGill University Health Centre), Janice Duddy (Pacific AIDS Network), Brenda Gagnier (Women's College Research Institute), Jacqueline Gahagan (Dalhousie University), Claudine Gasingirwa (Women's College Research Institute), Nada Gataric (British Columbia Centre for Excellence in HIV/AIDS), Saara Greene (McMaster University), Trevor Hart (Ryerson University), Catherine Hankins (UNAIDS), Bob Hogg (British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University), Terry Howard (Positive Living Society of British Columbia), Shazia Islam (Women's College Research Institute), Evin Jones (Pacific AIDS Network), Charu Kaushic (McMaster University), Alexandria Keating (ViVA and Southern Gulf Islands AIDS Society), Logan Kennedy (Women's College Research Institute), Mary Kestler (Oak Tree Clinic, BC Women's Hospital and Health Centre), Maxime Kiboyogo (McGill University Health Centre), Marina Klein (McGill University Health Centre), Gladys Kwaramba (Women's College Research Institute), Andrea Langlois (Pacific AIDS Network), Rebecca Lee (CIHR Canadian HIV Trials Network), Lynne Leonard (University of Ottawa), Johanna Lewis (Women's College Research Institute), Viviane Lima (British Columbia Centre for Excellence in HIV/AIDS), Elisa Lloyd-Smith (Providence Health Care), Carmen Logie (University of Toronto), Shari Margolese (Women's College Research Institute), Carrie Martin (Native Women's Shelter of Montreal), Renee Masching (Canadian Aboriginal AIDS Network), Lyne Massie (Université de Québec à Montréal), Melissa Medjuck (Positive Women's Network), Brigitte Ménard (McGill University Health Centre), Cari Miller (Simon Fraser University), Deborah Money (Women's Health Research Institute), Marvelous Muchenje (Women's Health in Women's Hands), Mary Mwalwanda (Women's College Research Institute), Mary (Muthoni) Ndung'u (Women's College Research Institute), Valerie Nicholson (Simon Fraser University), Illuminée Nzikwikiza (McGill University Health Centre), Kelly O'Brien (University of Toronto), Nadia O'Brien (McGill University Health Centre and Université de Montréal), Gina Ogilvie (British Columbia Centre for Disease Control), Susanna Ogunnaike-Cooke (Public Health Agency of Canada), Joanne Otis (Université du Québec à Montréal), Ali Palmer (Simon Fraser University), Sophie Patterson (Simon Fraser University), Doris Peltier (Canadian Aboriginal AIDS Network), Yasmeen (Ashria) Persad (Women's College Research Institute), Neora Pick (Oak Tree Clinic, BC Women's Hospital and Health Centre), Alie Pierre (McGill University Health Centre), Jeff Powis (Toronto East General Hospital), Karène Proulx-Boucher (McGill University Health Centre), Corinna Quan (Windsor Regional Hospital), Janet Raboud (Ontario HIV Treatment Network), Anita Rachlis (Sunnybrook Health Science Centre), Edward Ralph (St. Joseph's Health Care), Stephanie Rawson (Simon Fraser University, BC), Eric Roth (University of Victoria), Danielle Rouleau (Centre Hospitalier de l'Université de Montréal), Sean Rourke (Ontario HIV Treatment Network), Sergio Rueda (Ontario HIV Treatment Network), Mercy Saavedra (Women's College Research Institute), Kate Salters (Simon Fraser University), Margarite Sanchez (ViVA and Southern Gulf Islands AIDS Society), Roger Sandre (Haven Clinic), Jacquie Sas (CIHR Canadian HIV Trials Network), Paul Sereda (British Columbia Centre for Excellence in HIV/AIDS), Fiona Smaill (McMaster University), Stephanie Smith (Women's College Research Institute), Marcie Summers (Positive Women's Network), Tsitsi Tigere (Women's College Research Institute), Wangari Tharao (Women's Health in Women's Hands), Jamie Thomas-Pavanel (Women's College Research Institute), Christina Tom (Simon Fraser University, BC), Cécile Tremblay (Centre Hospitalier de l'Université de Montréal), Benoit Trottier (Clinique l'Actuel), Sylvie Trottier (Centre Hospitalier Universitaire de Québec), Christos Tsoukas (McGill University Health Centre), Sharon Walmsley (Toronto General Research Institute), Kath Webster (Simon Fraser University), Wendy Wobeser (Kingston University), Jessica Yee (Native Youth Sexual Health Network), Mark Yudin (St-Michael's Hospital), and Wendy Zhang (British Columbia Centre for Excellence in HIV/AIDS). All other CHIWOS Research Team Members wish to remain anonymous.
1. Patterson S, Cescon A, Samji H, et al. Life expectancy of HIV
-positive individuals on combination antiretroviral therapy
. BMC Infect Dis. 2015;15:274.
2. Kumar S, Gruskin S, Khosla R, et al. Human rights and the sexual and reproductive health of women
living with HIV
—a literature review. J Int AIDS Soc. 2015;18(suppl 5):20290.
3. Amin A. Addressing gender inequalities to improve the sexual and reproductive health and wellbeing of women
living with HIV
. J Int AIDS Soc. 2015;18(suppl 5):20302.
4. Persson A. “The world has changed”: pharmaceutical citizenship and the reimagining of serodiscordant sexuality among couples with mixed HIV
status in Australia. Sociol Health Illn. 2016;38:380–395.
5. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV
transmission. Cochrane database Syst Rev. 2002:Cd003255.
6. Stevens P, Galvao L. “He won't use condoms”: HIV
's struggles in primary relationships with serodiscordant partners. Am J Public Health. 2007;97:1015–1022.
7. Pulerwitz J, Amaro H, De Jong W, et al. Relationship power, condom use and HIV
risk among women
in the USA. AIDS care. 2002;14:789–800.
8. Ngure K, Mugo N, Celumcde C, et al. A qualitative study of barriers to consistent condom use among HIV
-1 serodiscordant couples in Kenya. AIDS care. 2012;24:509–516.
9. McDonald K. “The old-fashioned way”: conception and sex in serodiscordant relationships after ART. Cult Health Sex. 2011;13:1119–1133.
10. Spongberg M, Kippax S, Crawford J, et al. “If it's not on…”: heterosexuality for HIV
. Venereology. 1996;9:15–23.
11. Vernazza P, Hirschel B, Bernasconi E, et al. Les personnes séropositives ne souffrant d'aucune autre MST et suivant un traitement antirétroviral efficace ne transmettent pas le VIH par voie sexuelle. Bull des Médecins Suisses. 2008;89:165–169.
12. Vernazza P. The debate continues: does “undetectable” mean “uninfectious”? HIV
13. Vernazza P, Bernard E. HIV
is not transmitted under fully suppressive therapy: the Swiss Statement—eight years later. Swiss Med Wkly. 2016;146:w14246.
14. Cohen M, Chen Y, McCauley M, et al. Final results of the HPTN 052 randomized controlled trial: antiretroviral therapy
transmission [Oral presentation, 8th IAS Conference on HIV
Pathogenesis, Treatment and Prevention]. J Int AIDS Soc. 2015;18(suppl 4):15.
15. Rodger A, Cambiano V, Bruun T, et al. HIV
Transmission Risk through Condomless Sex
+ Partner on Suppressive ART: PARTNER Study. Boston, MA: CROI; 2014.
16. Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV
transmission in serodifferent couples when the HIV
-positive partner is using suppressive antiretroviral therapy
. JAMA. 2016;316:171–181.
17. Grulich A, Bavinton B, Jin F, et al. HIV
Transmission in Male Serodiscordant Couples in Australia, Thailand and Brazil [Oral Presentation: 1019LB]. Seattle, WA: CROI; 2015.
18. Attia S, Egger M, Muller M, et al. Sexual transmission of HIV
according to viral load and antiretroviral therapy
: systematic review and meta-analysis. AIDS. 2009;23:1397–1404.
19. Loutfy MR, Wu W, Letchumanan M, et al. Systematic review of HIV
transmission between heterosexual serodiscordant couples where the HIV
-positive partner is fully suppressed on antiretroviral therapy
. PLoS One. 2013;8:e55747.
20. WHO. Antiretroviral Treatment as Prevention of HIV
and TB. 2012. Available at: http://http://www.who.int
21. Montaner JS. Treatment as prevention–a double hat-trick. Lancet. 2011;378:208–209.
22. Haire B, Kaldor J. HIV
transmission law in the age of treatment-as-prevention. J Med Ethics. 2015;41:982–986.
23. Lasry A, Sansom S, Wolitski R, et al. HIV
sexual transmission risk among serodiscordant couples: assessing the effects of combining prevention strategies. AIDS. 2014;28:1521–1529.
24. Kaida A, Patterson S, Carter A, et al. Contraceptive choice and use of dual protection among women
living with HIV
: priorities for integrated care. Perspect Sex Reprod Health. 2017 [In Press].
25. Welbourn A. Desires denied. In: Jolly S, Cornwall A, Hawkins K, eds. Women
, Sexuality and the Political Power of Pleasure. London, NY: Zed Books; 2013.
26. Crepaz N, Hart T, Marks G. Highly active antiretroviral therapy
and sexual risk behavior: a meta-analytic review. JAMA. 2004;292:224–236.
27. Hasse B, Ledergerber B, Hirschel B, et al. Frequency and determinants of unprotected sex among HIV
-infected persons: the Swiss HIV
cohort study. Clin Infect Dis. 2010;51:1314–1322.
28. Kouyos RD, Hasse B, Calmy A, et al. Increases in condomless sex
in the Swiss HIV
cohort study. Open Forum Infect Dis. 2015;2:ofv077.
29. Chen Y. Treatment-related optimistic beliefs and risk of HIV
transmission: a review of recent findings (2009–2012) in an era of treatment as prevention. Curr HIV
/AIDS Rep. 2013;10:79–88.
30. Hanif H, Bastos F, Malta M, et al. Where does treatment optimism fit in? Examining factors associated with consistent condom use among people receiving antiretroviral treatment in Rio de Janeiro, Brazil. AIDS Behav. 2014;18:1945–1954.
31. Wilson T, Minkoff H. Brief report: condom use consistency associated with beliefs regarding HIV
disease transmission among women
receiving HIV antiretroviral therapy
. JAIDS. 2001;27:289–291.
32. Wilson T, Feldman J, Vega M, et al. Acquisition of new sexual partners among women
infection: patterns of disclosure and sexual behavior within new partnerships. AIDS Educ Prev. 2007;19:151–159.
33. Bunnell R, Ekwaru J, Solberg P, et al. Changes in sexual behavior and risk of HIV
transmission after antiretroviral therapy
and prevention interventions in rural Uganda. AIDS. 2006;20:85–92.
34. Kennedy C, O'Reilly K, Medley A, et al. The impact of HIV
treatment on risk behaviour in developing countries: a systematic review. AIDS Care. 2007;19:707–720.
35. Venkatesh K, Flanigan T, Mayer K. Is expanded HIV
treatment preventing new infections? Impact of antiretroviral therapy
on sexual risk behaviors in the developing world. AIDS. 2011;25:1939–1949.
36. Cicconi P, Monforte A, Castagna A, et al. Inconsistent condom use among HIV
in the “Treatment as Prevention Era”: data from the Italian DIDI study. J Int AIDS Soc. 2013;16:18591.
37. Suzan-Monti M, Lorente N, Demoulin B, et al. Sexual risk behaviour among people living with HIV
according to the biomedical risk of transmission: results from the ANRS-VESPA2 survey. J Int AIDS Soc. 2016;19:20095.
38. Zakher B, Blazina I, Chou R. Association between knowledge of HIV
-positive status or use of antiretroviral therapy
and high-risk transmission behaviors: systematic review. AIDS care. 2014;26:514–521.
39. POZ Magazine. 5 Reasons “HIV
Undetectable” must Mean “Untransmittable” 2016. Available at: https://http://www.poz.com
40. CATIE. Three Reasons Why CATIE Supports U=U for Sexual Transmission 2017. Available at: http://http://www.catie.ca
41. Lourenco L, Lima VD, Heath K, et al. Process monitoring of an HIV
treatment as prevention program in British Columbia, Canada
. JAIDS. 2014;67:e94–e109.
42. Kaida A, Carter A, De Pokomandy A, et al. Sexual inactivity and sexual satisfaction among women
living with HIV
in the context of growing social, legal, and public health surveillance. J Int AIDS Soc. 2015;18(suppl 5):20284.
43. Loutfy M, Greene S, Kennedy VL, et al. Establishing the Canadian HIV Women
's sexual and reproductive health cohort study (CHIWOS
): operationalizing community-based research in a large national quantitative study. BMC Med Res Methodol. 2016;16:101.
44. Public Health Agency of Canada
. Population Specific HIV
/AIDS Status Report: Women
2012. Available at: http://librarypdf.catie.ca/pdf/ATI-20000s/26407.pdf.
45. Rhode D. Feminist critical theories. Stanford L Rev. 1990;42:617–638.
46. Webster K, Carter A, Proulx-Boucher K, et al. Strategies for recruiting women
living with HIV
in community-based research: lessons from Canada
. Prog Community Health Partnersh. [In press].
47. Carter A, de Pokomandy A, Loutfy M, et al. Validating a self-report measure of HIV
viral suppression: an analysis of linked questionnaire and clinical data from the Canadian HIV Women
's Sexual and Reproductive Health Cohort Study. BMC Res Notes. 2017;10:138.
48. Loutfy M, Tyndall M, Baril JG, et al. Canadian consensus statement on HIV
and its transmission in the context of criminal law. Can J Infect Dis Med Microbiol. 2014;25:135–140.
49. Berger B, Ferrans C, Lashley F. Measuring stigma in people with HIV
: psychometric assessment of the HIV
stigma scale. Res Nurs Health. 2001;24:518–529.
50. Wright K, Naar-King S, Lam P, et al. Stigma scale revised: reliability and validity of a brief measure of stigma for HIV
+ youth. J Adolesc Health. 2007;40:96–98.
51. Marshall BD, Milloy MJ, Kerr T, et al. No evidence of increased sexual risk behaviour after initiating antiretroviral therapy
among people who inject drugs. AIDS. 2010;24:2271–2278.
52. Ayiga N. Rates and predictors of consistent condom-use by people living with HIV
/AIDS on antiretroviral treatment in Uganda. J Health Popul Nutr. 2012;30:270–280.
53. Rojas Castro D, Fugon L, Bourgeois-Fisson E, et al. The “Swiss Statement”: who knows about it? How do they know? What are its effects on people living with HIV
/AIDS? AIDS care. 2012;24:1013–1019.
54. Brennan D, Welles S, Miner M, et al. HIV
treatment optimism and unsafe anal intercourse among HIV
-positive men who have sex with men: findings from the positive connections study. AIDS Educ Prev. 2010;22:126–137.
55. Montaner JS, Lima VD, Barrios R, et al. Association of highly active antiretroviral therapy
coverage, population viral load, and yearly new HIV
diagnoses in British Columbia, Canada
: a population-based study. Lancet. 2010;376:532–539.
56. Persson A. Reflections on the Swiss Consensus Statement in the context of qualitative interviews with heterosexuals living with HIV
. AIDS Care. 2010;22:1487–1492.
57. Ezeanochie M, Olagbuji B, Ande A, et al. Fertility preferences, condom use, and concerns among HIV
in serodiscordant relationships in the era of antiretroviral therapy
. Int J Gynaecol Obstet. 2009;107:97–98.
58. Supreme Court of Canada
. R. v. D.C. 2 S.C.R. 626. 2012. Available at: http://scc-csc.lexum.com/scc-csc/scc-csc/en/item/10010/index.do.
59. Supreme Court of Canada
. R. v. Mabior. 2 S.C.R. 584. 2012. Available at: https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/10008/index.do.
60. Baeten JM, Kahle E, Lingappa JR, et al. Genital HIV
-1 RNA predicts risk of heterosexual HIV
-1 transmission. Sci Transl Med. 2011;3:77ra29.
61. Kovacs A, Wasserman SS, Burns D, et al. Determinants of HIV
-1 shedding in the genital tract of women
. Lancet. 2001;358:1593–1601.
62. Cu-Uvin S, DeLong AK, Venkatesh KK, et al. Genital tract HIV
-1 RNA shedding among women
with below detectable plasma viral load. AIDS. 2010;24:2489–2497.
63. Kalichman S, Pellowski J, Turner C. Prevalence of sexually transmitted co-infections in people living with HIV
/AIDS: systematic review with implications for using HIV
treatments for prevention. Sex Transm Infect. 2011;87:183–190.
64. Kelley CF, Haaland RE, Patel P, et al. HIV
-1 RNA rectal shedding is reduced in men with low plasma HIV
-1 RNA viral loads and is not enhanced by sexually transmitted bacterial infections of the rectum. J Infect Dis. 2011;204:761–767.
65. Loutfy M, Margolese S, Money D, et al. Canadian HIV
pregnancy planning guidelines. J Obstetrics Gynecol Can. 2012;34:575–590.
66. Kaida A, Patterson S, Nicholson V, et al. The influence of the criminalization of HIV
non-disclosure on intentional sexual inactivity among women
living with HIV
(Abstract SS3.04, Oral). Paper presented at: 26th Canadian Association of HIV
Research (CAHR) Conference; April 6–9, 2017; Montreal, Quebec.