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October 4

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HIV Prevention in the Era of New Treatments Craig Demmer, EdD, CHES

Advances in the treatment of HIV disease in recent years have prompted concern that individuals may regard HIV/AIDS as a less serious threat and consequently will be less committed to safer sex practices. This article reviews studies that have been conducted so far to assess the impact of new treatments for HIV on risk perceptions and behaviors among various population groups. Health practitioners need to be alerted to changing attitudes and preventive behaviors in their community stemming from the new treatments. Suggestions are offered to providers of HIV prevention services on how to address the issue of new treatments and the possibility of increasing complacency about safer sex practices. Keywords: HIV treatment; HIV prevention; safer sex practices; risk perceptions

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t has been more than 7 years since the introduction of new treatments for HIV disease. These treatments, commonly known as protease inhibitor combination therapies, have resulted in dramatic improvements in health for many people living with HIV (Altice & Friedland, 1998; Holzemer et al., 1999; Williams, 1999). Numerous studies have shown a strong association between use of combination therapies and a decline in opportunistic infections, hospitalization rates, and deaths in people with HIV infection (Casseb, Orrico, Feijo, Guaracy, & Medeiros, 2000; Corales, Taege, Rehm, & Schmitt, 2000; Roson, 2000; Schwarcz, Hsu, Vittinghoff, & Katz, 2000; Vittinghoff et al., 1999). Despite steady advances in treatment, HIV continues to be a major health problem in the United States. The rate of new HIV infections is no longer declining and has stabilized at approximately 40,000 new HIV infections a year in the United States (Fleming, Wortley, Karon, DeCock, & Janssen, 2000). A significant preventive implication of treatment advances for HIV/AIDS is Health Promotion Practice October 2003 Vol. 4, No. 4, 449-456 DOI: 10.1177/1524839903255415 ©2003 Society for Public Health Education

reduced concern about HIV and transmission risk (Kalichman, Ramachandran, & Ostrow, 1998). Individuals may perceive that HIV is less fatal and not as easily transmissible as a result of these new treatments. There may be an increased denial of risk and a weaker commitment to safe sex (Kalichman, Nachimson, Cherry, & Williams, 1998). The following factors may influence perceptions about the new treatments: (a) false reports in the media that there is a cure for AIDS or that a cure is close, (b) reports in the media that appear to emphasize that HIV/ AIDS is a chronic illness while paying less attention to its life-threatening aspects, (c) studies showing that certain anti-HIV treatments can reduce transmission of HIV from mother to infant, and (d) widespread evidence that combination therapies often result in reductions in viral load in the body (Kalichman, Nachimson et al., 1998; Kalichman, Ramachandran et al., 1998; Vanable, Ostrow, McKirnan, Taywaditep, & Hope, 2000). The reality is that these latest therapies for HIV do not work for everyone, and estimates of treatment failures range from 15% to 60% in various studies (Fatkenheuer et al., 1997; Gulick et al., 1997; Jaeger et al., 1998). Reasons for treatment failure include length of HIV infection, poor adherence to treatment, drug resistant strains of HIV, or stopping treatment due to intolerable side effects (Hecht et al., 1998; Holzemer et al., 1999; Jacobson et al., 2000; Malow et al., 1998). Each year, approximately 20,000 people die from AIDS in the United States (Raveis et al., 2000), and the decline in AIDS deaths seen since 1996 has slowed (Fleming et al., 2000). It is crucial that health practitioners continue to reinforce the importance of safer practices regardless of the relative effectiveness of treatments. Many important issues surround protease inhibitor treatments, including their long-term efficacy (Kravcik et al., 1998; Vanable et al., 2000). The purpose of this article is to analyze the findings of several studies that have assessed the impact of new HIV treatments on risk perception and sexual risk behavior. Specific suggestions are offered for addressing the issue of relapse in safer sex practices stemming from treatment advances. It is hoped that by highlighting this issue, health practitioners will be motivated to reevaluate current HIV prevention efforts and address

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changing attitudes and risk behavior that may stem from treatment advances.

OF NEW HIV TREATMENTS > IMPACT ON RISK PERCEPTION AND BEHAVIOR Studies of the impact of treatment advances have focused on gay men, HIV-positive individuals, young individuals, and women. Gay Men Since 1996, studies have been conducted to assess the impact of improved HIV treatments on preventive attitudes and behavior. Most of these studies have focused on gay men (Kalichman, Nachimson et al., 1998; Kelly, Otto-Salaj, Sikkema, Pinkerton, & Bloom, 1998; Vanable et al., 2000). This is not surprising because the AIDS epidemic has affected gay men more than other groups in society (in the Western world). Studies on treatment attitudes and sexual risk behavior have been conducted in the United States as well as abroad. Lert (2000) reported a high degree of awareness of new HIV treatments among gay men in European countries: 70% in 1997 in Switzerland and 93% in 1997 in France. In a study by Adam et al. (1998), between 4% and 6% of gay men in Switzerland and France believed that infected individuals receiving the new treatments no longer transmitted the virus. Furthermore, 5% of the Swiss men and 8% of the French men reported that they were less likely to protect themselves because of the new treatments (Adam et al., 1998). In a study of British men, 36% reported being less worried about HIV since the introduction of new treatments (Elford et al., 1998). In his analysis of studies in Europe investigating the impact of new treatments, Lert (2000) concluded that a significant proportion of gay men feel reduced concern about HIV infection and indicate weakened preventive behavior. Lert cautioned, however, that most of these studies have methodological weaknesses and fail to establish a causal link between attitudes about new treatments and relapse to unsafe sexual practices. Nevertheless, Lert suggested that decreasing perceived risk and small changes in behavior could lead to major epidemiological effects. In the United States, similar findings have been reported among samples of gay men (see Table 1). Awareness of the new treatments appears high: more than 80% (Kelly, Otto-Salaj, Sikkema, Pinkerton, &

The Author Craig Demmer, EdD, CHES, is an associate professor of health education and promotion in the Department of Health Services at Lehman College of the City University of New York.

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Bloom, 1998; Vanable et al., 2000). Rather than merely reporting descriptive statistics as Kelly, Hoffmann, Rompa, and Gray (1998) did, both Vanable et al. (2000) and Kalichman, Ramachandran, and Ostrow (1998) conducted bivariate and multivariate analyses that indicated men who engage in unprotected anal sex appear to be more likely to believe that the new HIV treatments lessen the risk of HIV transmission. In the study by Kalichman, Ramachandran, and Ostrow (1998), 23% of men who engaged in unprotected anal sex (receptive) believed that the new treatments reduce the threat of HIV transmission compared with 5% of men who did not engage in unprotected anal sex (receptive) (p < .01). Furthermore, men who engaged in receptive unprotected anal sex were more likely to practice more unsafe sex now than they used to and were less worried about unsafe sex because of the new treatments (p < .01). Similarly, in the study by Vanable et al. (2000), men who had recently engaged in unprotected anal sex with an HIVpositive partner perceived this activity to be less risky than did those who had not engaged in this activity (p < .02). Those who reported recent unsafe sex were also more likely to believe that the risk of HIV transmission was reduced if an HIV-positive partner was receiving combination therapies and had an undetectable viral load (p < .01). Both studies provide alarming data on the prevalence of high-risk sex among gay men in this era of treatment advances. In the study by Kalichman, Nachimson, Cherry, and Williams (1998), 20% had engaged in highrisk sex (unprotected anal sex as the receptive partner) within the past 6 months. In the study by Vanable et al. (2000), the proportion was 46%, and of these, 12% had engaged in unprotected anal sex with a partner who was HIV positive. HIV-Positive Individuals Few studies have focused exclusively on the impact of treatment advances on attitudes and sexual risk behavior of HIV-infected individuals. In the Kelly, Hoffmann, Rompa, & Gray (1998) study of both HIVpositive and HIV-negative gay men, 18% of HIV-positive gay men on combination therapy reported that they practiced safer sex less often since the new HIV treatments became available. Similar findings were reported by Kravcik et al. (1998), who surveyed only HIVinfected individuals (most of whom were gay) attending a university-based clinic. A total of 20% of respondents believed that the risk of HIV transmission was reduced and safer sex was less important for those receiving combination therapies versus those not on combination therapies (p < 01). Similar findings were reported in overseas studies of HIV-infected individuals. In a sample of 1,800 men attending a gay pride festival, 19% of infected gay men reported that they were more likely to take a risk with unprotected anal intercourse because of HIV treatment advances (Hickson, Reid, Henderson, Weatherburn, &

TABLE 1 Studies Assessing the Impact of New HIV Treatments on Attitudes and Behavior Study

Research Design

Sample

Key Findings

Recommendations

Cross-sectional, 379 gay/bisexual 83% were aware of new treatments; 13% Include behavior counseling Kelly, in HIV treatment programs; felt that AIDS was less serious than in men recruited Hoffmann, self-adminisfrom a gay festi- the past; 7% felt that being HIV positive messages should emphatered anonyRompa, & size the seriousness of val, AIDS orga- was no longer a big deal due to new mous quesGray AIDS and the difficulties treatments; 8% said they practice safer nization, and tionnaire (1998) of treatment regimens sex less often since new treatments gay newspaper came along in a large Midwestern city Cross-sectional, 554 gay men Vanable, self-adminisrecruited at a Ostrow, gay street fair McKirnan, tered anonyin Chicago Taywaditep, mous questionnaire and Hope (2000)

84% had heard about the new HIV treat- Risk reduction interventions and media messages must ments; 67% believed that new treatbe accurate and include ments made others more tempted to information about the have unsafe sex; those who reported uncertainty of long-term reduced HIV concern were more likely effectiveness of new treatto have unprotected anal sex, unproments, the fact that they do tected anal sex with an HIV-positive not always work now with partner, and more sexual partners; men who had recent unsafe sex with an HIV- patients, and the fact that an undetectable viral load positive partner were more likely than does not mean that a perother men to diminish the risk of transson should forgo safer sex mission in those with an undetectable practices viral load

Kalichman, Cross-sectional, 298 gay or bisex- Men who practiced unprotected anal sex HIV prevention interventions must monitor the ual men attend- (receptive) were more likely than other Nachimson, self-adminiseffects of treatment men to believe that new treatments ing a gay festitered, anonyCherry, advances on behavior reduce the threat of HIV transmission val in Atlanta, mous quesand and that it was safe to have anal sex with Georgia tionnaire Williams a partner with an undetectable viral load; (1998) men who practiced unprotected anal sex (receptive) were also more likely than other men to report they were engaging in more unsafe sex now than they used to and were less worried about unsafe sex due to the new treatments Kravcik et al. (1998)

Cross-sectional, 147 HIV-positive 20% believed that the risk of HIV trans- HIV prevention messages must continue to stress the mission was reduced if a partner was men and woself-adminisconsistent use of safer sex receiving new treatments; 19% felt that men (majority tered, anonypractices; health profesthe new treatments reduced the need were gay men) mous quessionals must reinforce the for safer sex attending an tionnaire importance of safer pracHIV clinic in tices regardless of new Canada treatments

Demmer and Caroleo (2001)

Cross-sectional, 258 college stuself-adminisdents in New tered, anonyYork mous questionnaire

80 HIV-positive Cross-sectional, Catz, anonymous women Meredith, questionnaire and Mundy attending an (interview HIV clinic in (2001) format) Missouri

Further research needs to 60% had heard of the new treatments; 17% felt that AIDS was less serious than identify factors that influin the past; 8% felt that being HIV posi- ence perceptions of the tive was no longer a big deal due to new new treatments; college AIDS prevention programs treatments; 21% stated they practice safer sex less often since new treatments need to incorporate information about new treatarrived ments and emphasize the continued need for safer sex practices 40% felt that AIDS was less serious than HIV prevention intervenin the past; 41% felt that being HIV posi- tions must monitor the tive was no longer a big deal due to new effects of treatment treatments; 15% stated they practice safer advances on behavior sex less often due to new treatments; 31% had unprotected sex in the past 6 months Demmer / HIV PREVENTION ERA OF NEW TREATMENTS

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Keogh, 1998). In a recent study of HIV-infected individuals in Australia, 9% agreed with the statement “I feel more confident about unprotected sex because of the new treatments” (McDonald, Bartos, Grierson, & de Visser, 2000). Young Individuals There has been little data on the impact of new HIV treatments on the attitudes and risk behavior of young people, despite the fact that this group often engages in high levels of unsafe sexual behavior. In a study by Prince and Bernard (1998), only 10% of students reported that they used condoms consistently. Other studies have documented that young people in general are not worried about getting HIV and do not feel vulnerable to contracting the disease (Thompson, Anderson, Freeman, & Swan, 1996; Ajuluulchukwu, Crumey, & Faulk, 1999). Clearly, this is a group that requires further research on the impact of treatment advances on their attitudes and behavior. In one of the few studies that examine young people, Demmer and Caroleo (2001) found that 60% of students attending a college in New York City were aware of the new HIV treatments. This is a decreased percentage compared with gay men (Kelly, Hoffman, Rompa, & Gray, 1998; Vanable et al., 2000). However, it is not surprising considering that college-aged individuals have been less affected by HIV/AIDS than have gay men. In the general population in European countries, awareness of new treatments is even lower: less than 30% (Lert, 2000). Unfortunately, no data regarding awareness of new treatments among the general public in the United States exist. In Demmer and Caroleo’s (2001) study, 60% of students believed that the new medications were a real breakthrough in the treatment of HIV and AIDS. A significant minority of students (17.5%) felt that AIDS was a less serious threat than in the past, and 8% believed that being HIV positive was not a big deal due to treatment advances. A small group of students (4%) indicated that new medical treatments for HIV and AIDS made safer sex less important than it was, and if someone was HIV positive but taking new medications that reduce viral load, safer sex was not important (5%). Although one half of all students in the sample indicated they and their friends practiced safer sex since the new treatments arrived, 21% of students indicated they no longer did. Analysis of variance revealed no statistically significant differences between perceptions of the new treatments and attitudes and behavior. Women A recent study by Catz, Meredith, and Mundy (2001) demonstrated that HIV-positive women were far more likely to believe that AIDS is a less serious threat than in the past and that being HIV positive is not that big a deal

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now that treatments are better. Although their study shares the same methodological weaknesses of other studies examining the impact of new treatments, it provides interesting findings on a sample of HIV-positive women. Furthermore, they were also more likely to have engaged in unsafe sex (31%) within the past 6 months. The only statistically significant finding in the study was that women who had a lower viral load and a higher CD4 count were more likely to have engaged in recent high-risk behavior (p < .05). There was no association between whether a woman was currently receiving antiretroviral therapy and recently engaging in highrisk sex. In addition, 40% of women felt it was safe for HIV-positive women to get pregnant if they were on the new medications, 36% felt having children when you are HIV positive is not that big a deal now that treatments are better, 31% believed that men who were not infected found HIV-positive women to be sexually desirable, and 13% had not disclosed their serostatus to at least one sexual partner. Based on these findings, it is evident that more research and interventions are needed relating to secondary transmission of HIV among infected women in this era of new treatments.

> IMPLICATIONS FOR PRACTICE

There are methodological limitations associated with many of the studies in the United States that have examined the impact of new HIV treatments on attitudes and behavior. These studies typically use correlation analyses that preclude a causal explanation between treatment attitudes and risk behavior. An additional limitation is a reliance on convenience samples, which limits the generalizability of findings to the broader population. Nevertheless, preliminary evidence suggests that a small but significant proportion of HIV-positive and HIV-negative individuals believe that unprotected sex may have less serious consequences because of new HIV treatments (Kelly, Hoffman, Rompa, & Gray, 1998; Kravcik et al., 1998; Vanable et al., 2000). Further research on this issue is needed using larger random samples and detailed statistical analyses. It is critical to explore the impact of new treatments on other groups susceptible to HIV/AIDS, such as women, injection drug users, and heterosexual men (Kelly, Otto-Salaj, Sikkema, Pinkerton, & Bloom, 1998). Based on the data available to date, it is essential to begin to address the impact of treatment advances in HIV prevention messages and programs. It should be noted that even modest levels of reduced concern about HIV risk can result in significant increases in HIV transmission (Vanable et al., 2000). Health educators should be alert to the possibility that increasing numbers of individuals, particularly teenagers and young adults, may abandon safer sex practices based on their perceptions of the latest HIV treatments (Fleming et al., 2000). The following are a few suggestions for practitioners involved in HIV prevention.

Determine Attitudes and Knowledge About Treatments A first priority for health practitioners is to explore individuals’ perceptions about new treatments for HIV and determine their level of knowledge about these treatments. A theoretical approach to HIV prevention has been useful in developing effective interventions in the past (Basen-Engquist, 1994), and the need for theory-based interventions in this new era of HIV/AIDS is more important than ever. The health belief model can serve as a useful framework for exploring high-risk sexual behaviors and intentions prompted by recent treatment advances (Kalichman, Ramachandran, & Ostrow, 1998). Developed in the 1950s and one of the most frequently used theories in health behavior applications, the health belief model hypothesizes that health-related action depends on the following: (a) the belief that one is susceptible to a health problem, (b) the belief that the health problem is a serious threat, (c) the belief that one can overcome the barriers to changing the health problem, (d) the belief that there are benefits to overcoming the health problem, and (e) the belief that one has the competence (self-efficacy) to overcome health problem (Rosenstock, Strecher, & Becker, 1994). Health practitioners can ask individuals the following questions:

• Have you heard of new treatments for HIV? What do

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you know about them? Do you worry about getting infected now that there are new treatments for HIV? (perceived susceptibility) Do you think HIV is less serious now? Why do you think HIV is less serious or just as serious as a result of these new treatments? Do these new treatments make HIV less infectious and easy to transmit (perceived threat)? Individuals may be more likely to engage in unsafe sexual behavior if they perceive HIV to be a less serious threat and not as easily transmissible because of the new treatments. If a partner is HIV positive and receiving combination therapies, an individual may abandon safer sex practices based on the belief that the partner is less infectious. The individual may believe that getting HIV is not such a big deal anymore with “potent” therapies available (Vanable et al., 2000). Do you practice safer sex less often as a result of the new treatments? If the answer is “yes,” ask what the reasons are. What would some of the barriers be to practicing safer sex nowadays (perceived barriers)? Why should people continue to practice safer sex? What would be the benefits of continuing to practice safer sex nowadays (perceived benefits)? How confident are you that you will consistently practice safer sex during this time of new treatments (perceived self-efficacy)?

Health practitioners need to remember that HIV knowledge in and of itself has not always been sufficient to motivate the adoption and maintenance of safer sex behaviors (Becker & Joseph, 1988; DiClemente,

1991). The same may be true for knowledge about new HIV treatments. This is an area that requires future research. Explore the Influence of the Social Network An individual’s behavior may be affected by the norms of the community. Prior research has demonstrated that individuals are more likely to engage in AIDS risk behaviors if they perceive that their peers are engaging in this type of behavior (Auerbach & Coates, 2000; Walter et al., 1992). The health practitioner can help individuals determine how peers in their social network feel about the new treatments as well as their level of risk behavior. Individuals need to realize the influence of peer pressure on decisions to engage in unsafe sex in this new era. Social support has been shown to predict safer sex behavior (Basen-Engquist, 1992). Practitioners can ask individuals how helpful their sexual partners, friends, parents, siblings, other relatives, and coworkers are in discussing sexual risk behavior and how supportive are they in encouraging safer sex practices in this era of new treatments. Use Counseling Strategies Counseling interventions have been effective in reducing HIV risk behaviors (Kamb, Bolan, & Zenilman, 1997; National Institute of Mental Health, 1998). Practitioners can provide counseling to individuals to help them deal with the psychological implications of the new treatments, which may make them more susceptible to engaging in high-risk behaviors (Kalichman, Ramachandran, & Ostrow, 1998; Demmer, 2000). One-on-one counseling and small-group discussions are a good environment for individuals to discuss new information about the latest HIV treatments and to share their experiences about the challenge of maintaining safer sex practices. In group settings, individuals can receive encouragement and support to remain HIV negative and to continue practicing safer sex. Update Educational Materials and Interventions Various types of educational materials ranging from printed materials to videos have been widely used in HIV prevention (Kalichman, Cherry, & BrowneSperling, 1999). However, current HIV prevention materials may need to be evaluated to determine whether they adequately address issues arising from the latest treatments. Materials may need to be revised or developed to include information about the latest HIV treatments and the implications for risk behavior and transmission. Practitioners should tailor this information to the skills, needs, and interests of diverse individuals and communities (Zimmerman, Janz, & Wren,

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1995). Because publications about HIV treatments can be complex and full of scientific jargon, it is essential that practitioners present this information in a clear and meaningful manner. Messages about the latest treatments and the continued need for safer sex should be repeated and varied to make individuals think about their behavior and not to bore them. Messages can be communicated in different ways (e.g., changing the content each time but having a common theme), in different contexts (discussion groups, health education fairs, and clinic visits), and by different people (health educators, physicians, celebrities, and peers) (Zimmerman et al., 1995). Messages about treatment advances and the continued need for safer sex must be communicated beyond the office, and outreach activities should be conducted in places where individuals live, work, and socialize. Outreach is particularly important for individuals on the fringes of society such as sex workers, drug users, and homeless individuals (Zimmerman et al., 1995). Monitor Media Reports for Accuracy It is crucial that public statements and media reports are “accurate and conservative” in describing the latest HIV treatments and that they do not mislead people into thinking that HIV is no longer a serious disease (Kelly, Hoffman et al., 1998; Kravcik et al., 1998; Vanable et al., 2000). Health practitioners must monitor and scrutinize media reports, evaluate their accuracy, and assess the potential impact of these reports on the perceptions of community members. Increase Collaborative Efforts Practitioners need to keep abreast of the latest developments in HIV treatments and prevention. This can be a challenge, especially if providers of AIDS prevention services do not have access to scientific journal articles (Kelly et al., 2000). Active collaboration between researchers and community providers of HIV prevention services is essential (Kelly et al., 2000). Researchers can identify local providers of HIV prevention services and offer to send them the latest articles on new HIV treatments and issues relating to prevention. It would be even more helpful if researchers could summarize and simplify this information for community providers in the form of regular newsletters or memoranda. This is obviously more work for researchers, but it would meet a definite need among community providers of HIV prevention services. Furthermore, any research-based HIV prevention interventions that are developed to address the impact of new treatments are more likely to be adopted by community providers if they are given implementation manuals, staff training workshops, and consultation by researchers (Kelly et al., 2000). In community settings, providers of HIV prevention services should consider working more closely with each other and sharing experiences and information 454

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relating to new HIV treatments. Exchange programs can be developed between community HIV prevention organizations whereby personnel with expertise in the new HIV treatments and prevention initiatives visit each other’s organizations and conduct discussion groups and training sessions for staff members and clients. Evaluate New Interventions During the past two decades, a variety of effective interventions have been developed to promote safer sex practices (Auerbach & Coates, 2000; Kelly, Somlai, et al., 2000). Future HIV prevention efforts that address the impact of new treatments must be evaluated to determine their effectiveness. Evaluating HIV prevention programs is not easy, requiring adequate technical assistance and resources and commitment and support from all parties involved (Nwokolo, Temprosa, Finkelstein, Lewis, & Jones, 1999).

> CONCLUSION

This is a crucial point in the history of the HIV/AIDS epidemic. Improved treatments have prompted concern that individuals will become more complacent and abandon safer sex practices. Preliminary evidence suggests that this is already happening, although further research is needed using more rigorous methodologies and statistical analyses. Health practitioners need to consider how to deal with this emerging problem. Close collaboration is needed between researchers, practitioners, policy makers, and community members (Auerbach & Coates, 2000). There may be less support for HIV prevention in the future based on the perception that new treatments have made AIDS a less serious disease. It is likely that practitioners will combat apathy from both individuals at risk and policy makers and funding sources. Against this backdrop, practitioners will need to modify and strengthen their HIV prevention efforts.

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