Reducing sexual transmission of HIV from those who know they are infected: the need for personal and collective responsibility

Introduction Fifteen years after the identification of HIV, approximately two-thirds of those in the United States who are infected with the virus are aware of their seropositive status 1. People who are aware of their infection can decrease the risk of developing AIDS by taking antiretroviral therapy. It is less clear, however, whether awareness has decreased the risk of transmitting the virus through unsafe sex. As more people are tested for HIV, a larger proportion of all transmission will be from people who know they are infected. Reducing this transmission is an immensely important public health concern, compounded by the long period in which many seropositive people remain asymptomatic and by new medical advances that enable infected people to live longer, healthier lives 2-5. However, there are few programs for helping these people reduce sexual risk in the ensuing years. HIV counseling and testing remain the primary means for delivering behavioral intervention to seropositive persons tested at publicly funded testing sites 6,7. Although counseling and testing are valuable for establishing awareness of serostatus and for providing medical referrals, they are limited in their capacity to help infected people change their sexual risk behaviors and maintain those changes. Post-test counseling is usually delivered in a single brief session shortly after test results are conveyed. This is a time when many people who have tested positive may be unprepared psychologically or limited in their motivation or ability to assimilate prevention messages. For the most part, people who test positive for HIV must draw on their own internal resources (e.g., felt responsibility to protect others) in their attempts to change their behaviors. Seropositive people are asked to behave in ways that minimize the likelihood of transmitting the virus and to be accountable for their actions. Prevention efforts must also provide the social conditions that encourage and reinforce safe behavior. In this review, we examine sexual risk-taking of seropositive persons and discuss the roles of personal and collective responsibility for reducing transmission of HIV. First, we describe findings of studies that have examined sexual risk behaviors of seropositive adults. Second, we consider some of the psychological factors associated with risky sex in this group and whether and how interventions aimed at increasing a sense of personal responsibility to avoid transmitting HIV may enhance prevention efforts. Although some commentators have suggested that the normalization of HIV infection has substantially reduced the social barriers to responsibility-based messages 8, others have more cautiously pointed to the need for more research and reflection 9. Third, we discuss the role of collective responsibility in HIV prevention efforts. Policymakers, researchers, and citizens alike have an obligation to help combat the HIV/AIDS epidemic. Social attitudes, norms, and practices, both within risk populations and in the broader society, influence behavior that spreads disease. Insufficient attention to the ecology of HIV prevention limits the effectiveness of individual-level interventions and hinders the development of interventions to address directly the social forces that provide too many incentives for risk and too few rewards for safety. Prevalence of unsafe sex Most adults are sexually active. If anything, people who have contracted HIV have been more sexually active than people who remain uninfected. Many of those with HIV infection do change their sexual practices after testing positive 10. Nevertheless, studies indicate that more than 70% of seropositive men and women engage in oral, vaginal, or anal sex after they become aware they have HIV 11-15 and that the probability of sexual activity increases with the length of time since they tested seropositive (unpublished data). Some infected people do not reveal their serostatus to their sex partners. Of HIV-positive adults (mostly men), 30% had not informed any past partners, and 29% had not informed any current partners even after an average of 6h of counseling over 2 years 13. Another study found that 52% of sexually active HIV-positive men kept their infection status secret from one or more sex partners 16. The prevalence of disclosure is somewhat higher among seropositive women than men 17, stemming in part from the fact that women have fewer sex partners 18,19. As the number of partners increases, the likelihood of informing any of them decreases 16,20. Most seropositive men and women disclose their status to primary sex partners 21-26, but disclosure to other partners is less likely 19,26. The HIV serostatus of the partner also influences disclosure: seropositive men who have sex with men (MSM) who engaged in anal intercourse informed 86% of HIV-positive partners, 46% of HIV-negative partners, and 18% of partners whose serostatus they did not know 19. Disclosure is associated with an increased likelihood of protected sex with uninfected partners 20. Table 1 presents findings of studies that have examined the prevalence of unprotected anal or vaginal intercourse amongst HIV-positive adults. Although the varying recall periods for the self-reports make comparisons difficult, a sizable percentage of seropositive men and women engage in unprotected sexual intercourse after they learn they are infected. The studies would overestimate transmission risk if unprotected sex occurred primarily with other infected persons. HIV-positive MSM have been found to be three times more likely to have engaged in unprotected insertive anal intercourse with HIV-positive partners than with other partners 19. The results of other studies are similar 11,13,14,32,33,37-39. In these partner-specific analyses, only 35-45% of the partners were seropositive; thus, many of the other partners may have been placed at risk.Table 1: Prevalence of sexual risk behaviors among seropositive persons aware of their serostatus.Individual-level processes Personal responsibility Undoubtedly, most seropositive people feel a unique sense of responsibility to protect sex partners 36. They know that it is wrong to endanger others by exposing them to HIV without their knowledge. This is most evident when there is emotional involvement with a partner and commitment to an ongoing relationship. Indeed, disclosure of seropositive status and protected sexual activity are most likely to occur when there is commitment to partners at risk for infection, and least likely to occur with casual partners of unknown serostatus 20. The desire for intimacy and sexual pleasure may, at times, overcome motivation of serodiscordant couples to use condoms during sexual intercourse 40. Nevertheless, just as committed relationships and reduction in the number of sex partners protect against contracting HIV, they protect against transmitting the virus. Sexual partnerships of two seropositive persons also protect against infecting others. In sexual encounters with casual partners, good intentions may not always be translated into protective behavior. Some infected persons may want to disclose and feel that it is the right thing to do but may reason that their physical appearance, preferred sex activities, or nonverbal cues (e.g., leaving medication or printed materials in plain sight) constitute disclosure. Direct disclosure is often difficult; it may stigmatize a person and precipitate other negative outcomes (e.g., refusal to have any type of sex). Some infected persons who withhold disclosure may attempt to protect partners by using a condom or by restricting the range of sexual activities. Nevertheless, keeping one‚s seropositive status secret keeps the partner from making an informed decision about risk and deters honest communication and negotiated behavior. Psychological factors The responsibility to protect others can become psychologically and behaviorally challenging. Some infected people may question why they are the ones who must shoulder the responsibility for protecting others and may cognitively shift the responsibility to the partner. This cognitive shift may be initiated and reinforced by general prevention messages such as, ‚everyone who is sexually active should use a condom.‚ It may serve to rationalize high-risk acts and alleviate feelings of guilt or anxiety. Some infected persons may reason that partners who are willing to forego condoms have accepted the risk that they may be exposed to the virus and so do not need to be notified or protected. Shifts in responsibility to protect may be influenced by the psychological states of infected persons. Anger, anxiety and tension may promote psychological overload that may trigger motivation to escape the aversive psychological state as well as the burden to protect partners 39,41. Motivation to escape may induce a person to make external attributions of responsibility for protection (i.e., more responsibility attributed to sex partners than to self) or to use drugs before sex. These escape mechanisms may increase the likelihood of unprotected sexual intercourse 39. Importantly, negative affect and motivation to escape are not conducive to processing, assimilating, or acting on prevention messages. Receptiveness to those messages may be increased by interventions that help seropositive people maintain positive affective states. When people feel good about themselves and feel respected, they may be more likely to accept responsibility for their actions, more likely to orient themselves to the future, and more likely to consider the consequences of their behaviors 42-44. The importance of responsible behavior has been a major feature of post-test counseling, and its underlying value of preventing further HIV transmission may be widely accepted by most seropositive people. But messages about personal responsibility to protect others can easily be perceived as victim blaming that only enhances the stigma of the disease and lessens the motivation to protect others. Such messages and the perceptions of social hostility they may engender can also have the broader effect of polarizing the political climate in which prevention messages are offered. We strongly believe that all infected people should receive a dual-theme message that emphasizes protecting their own health as well as that of their partners. This type of message has been featured in some brochures and literature for HIV-positive persons 45-47. The issue of self-protection has surfaced strongly in the context of combination antiretroviral therapies. It is important that infected people gain access to these therapies and adhere strictly to prescribed treatment regimens. Adherence can lower viral load, help prevent drug resistance, and significantly improve health and prolong life 2-5. Similarly, seropositive people who adhere to safer-sex guidelines protect themselves. Unsafe sex can lead to secondary infections (e.g., syphilis, gonorrhea, herpesvirus associated with Kaposi‚s sarcoma) that may accelerate disease progression 48-52 and heighten the infectiousness of HIV 53,54. This type of self-protective message may be quite powerful when communicated to HIV patients by their health-care providers. Individual-level approaches to prevention Messages about self-protection and social responsibility to protect others are needed now more than ever, because the success of medical treatments may have unintended behavioral consequences for HIV prevention. Lowering viral load and keeping it low may reduce the likelihood that a seropositive person may infect a partner during sexual contact 55-57. However, as treatment options enable people with HIV infection to live longer and feel healthier, those people may become more sexually active. Those who believe that low viral load renders them non-infectious may stop using condoms. Furthermore, as therapeutic successes are publicized, people‚s perceptions of HIV disease may change. What was once viewed as an acute and fatal disease may now be viewed as a chronic, manageable and survivable disease 58. These perceptions may increase sexual risk behaviors among infected and uninfected people. Recent studies suggest that optimism about the new HIV therapies is associated with sexual risk-taking in MSM 58-60. Moreover, people at risk for infection may increasingly turn to HIV therapy as a perceived prophylaxis after possible sexual exposures to the virus 61. Prevention messages for seropositive people and interventions for reducing sexual risk behaviors can be implemented in public clinic settings and managed care facilities. The HIV outpatient clinic is an ideal, yet underused, setting for delivering prevention messages and addressing individual behavior change. The setting provides an opportunity to reach a large number of seropositive people, to integrate behavioral intervention into routine medical care, to provide ongoing counseling and support, and to involve clinic staff (e.g., nurses, physicians, social workers) in prevention activities. Sexually transmitted disease (STD) and tuberculosis clinics afford the same opportunities. Recently published findings are encouraging. HIV-positive patients who reported that clinic staff had discussed the issue of disclosure with them were more likely than other HIV patients to have informed uninfected sex partners of their risk 20. These intervention opportunities hinge on seropositive people‚s access to care and on the capacity and ability of health-care workers to provide such messages. Clinics provide an environment for developing and reinforcing attitudinal and behavioral norms for safer sex. The use of peer leaders in gay bars has promoted shifts in sexual attitudes and behaviors 62-64. Safer sex norms can be promoted in clinics through visual cues (posters in waiting rooms and medical examining rooms), printed information, communication from providers, and a more open discussion with patients about disclosure and sexual risk. Complementary approaches can be instituted at community-based organizations (e.g., AIDS service organizations). Finally, client-centered approaches to counseling also show much promise. Brief client-centered counseling has reduced the risk for new infections in people attending STD clinics 65 and may be effective in HIV clinics as well. The counseling involves working with patients to establish achievable steps they can take to reduce their risk behavior. Social workers, nurses, and physicians can easily conduct this type of intervention after proper training. At the very least, health-care providers must be able to recognize the need for, and believe in the value of, behavioral intervention and appropriate referrals. Social aspects of individual choice So far we have focused on some of the ways in which seropositive persons may cope with their infection. This focus posits the HIV-seropositive diagnosis as a profound event in a person‚s life. Learning one‚s seropositive status no doubt has powerful psychological and behavioral consequences. 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