Key points are not available for this paper at this time.
Introduction HIV continues to spread through sexual transmission in the United States and elsewhere 1. One source of transmission is unsafe sex among people who know they are infected with HIV. Of the estimated 800 000–900 000 people living with HIV in the United States 2, about two-thirds are aware of their seropositive status 3 and over 70% are sexually active after they learn they are infected 4–8. Many engage in safer-sex practices; however, a considerable percentage of seropositive persons (range 10% to 60% depending on the specific sex acts) 9,10 continue to engage in unprotected sexual behaviors that place others at risk for infection and place themselves at risk for contracting secondary infections (e.g., syphilis, gonorrhea, herpesvirus-6) that may accelerate HIV disease 11,12. As more and more people with HIV live longer and healthier lives because of antiretroviral therapy 13, an increasing number of sexual transmissions of HIV may stem from those who know they are infected and engage in unprotected sex 9,10,14. It is, therefore, exceedingly important to understand the factors promoting risky sex in this population so that behavioral interventions can be designed optimally for HIV-positive persons. Indeed, these interventions may be a highly cost-effective approach to reducing sexual transmission of the disease. Numerous studies have examined correlates of risky sex in HIV-seropositive persons. The diversity of results makes it difficult to attain an integrated understanding of the findings without a comprehensive review of the literature. Two papers 9,14 provide qualitative reviews of factors associated with unsafe sex in persons living with HIV/AIDS. Those papers are valuable, but they did not cover the full range of psychosocial or medical constructs that have been investigated, did not include all of the studies that examined a specific construct, and did not provide data on strength of association with risky sex. Additionally, the previous reviews did not examine whether there are common and unique risk-promoting factors for HIV-positive men and women. In the present paper, we comprehensively review studies that have examined psychological, social, interpersonal, and medical variables as correlates of sexual risk behavior in persons who know they are HIV positive. We review constructs central to many of the prevailing behavior models e.g., health belief model (HBM) [15, social-cognitive theory (SCT) 16, theory of reasoned action (TRA) 17, theory of planned behavior (TPB) 18, AIDS risk reduction model (ARRM) 19, and information–motivation–behavioral skills model (IMB) 20,21. These general constructs include HIV knowledge (HBM, IMB, ARRM), perceived barriers to behavior (HBM), perceived risk (HBM, ARRM), perceived efficacy of a preventive behavior (HBM, ARRM), social support (ARRM), communication (ARRM), commitment (ARRM), health beliefs (TRA, TPB), attitudes (TRA, TPB), intentions (TRA, TPB, IMB), perceived social norms (TRA, TPB), perceived behavioral control (TPB), self-efficacy (SCT, IMB, ARRM), and outcome expectancies (SCT). Our intent was not to place these models into competition with each other, because few studies explicitly tested those models or systematically compared variables from the different theories. Rather, we attempted to determine whether individual variables that represented the general constructs received support in the literature. Additional constructs were also examined, such as emotional states, personality variables, coping, attributions about one's HIV infection, interpersonal and partner variables, medical status and treatment, and beliefs about antiretroviral therapy. HIV counseling/testing was not included as a variable in the review because its association with sexual behavior was reviewed in a recent paper 22. Effect sizes were calculated that indicated the magnitude of association between individual variables and unprotected sexual behaviors of people living with HIV, and the studies were stratified by gender of participants in an attempt to identify risk-promoting factors for HIV-positive men and women. Methods Literature available in AIDSLINE, MedLINE, and PsychINFO from 1980 to June, 2001 was searched using the following keywords: HIV, AIDS, HIV-positive, HIV-infected, sexual behavior, risk behavior, sexual risk-taking, unprotected sex, unsafe sex, and condom use. Additional studies were identified through the bibliographies of the articles located. English language articles published in peer-reviewed journals that contained any of the key words were screened for inclusion. Studies were included if they met all of the following criteria. Contained a measure of a social, psychological, interpersonal, or medical variable as well as a measure of sexual risk behavior in HIV-positive men or women. Measured any of the following sexual behavior variables: any unprotected insertive or receptive anal intercourse, unprotected vaginal intercourse, or unprotected oral sex consistency of condom use number of unprotected sex partners other sexual risk measures that combined two or more components from the previous categories the presence of sexual transmitted infections after having been diagnosed HIV-seropositive. Instances of unprotected sexual behaviors had to have occurred after study participants became aware of their seropositive status. Twelve studies 6,7,23–32 included unprotected oral sex as a risk behavior; in each case it was part of an overall risk index that included unprotected vaginal, anal, or oral sex. Studies that used an index that combined sexual risk behavior with other risky behaviors such as drug use 33, needle sharing, exchanging sex for money or drugs, or pregnancy 34 were excluded in order to focus unambiguously on unprotected sex as the primary outcome variable. The term ‘unprotected’ rather than ‘unsafe’ was used because some studies did not specify the HIV serostatus of the sex partners, thus clouding the meaning and potential consequences of the behavior. Reported that some type of statistical test (e.g., chi square, t-test, analysis of variance, regression analysis, correlation, discriminant analysis) was used to examine the association between unprotected sex and a psychological, social, interpersonal, or medical variable. Studies conducted with HIV-positive and HIV-negative samples had to provide separate analyses of the seropositives or statistically test an interaction with HIV serostatus. If more than one article examined similar risk factors and reported findings from the same dataset, only one of the articles was included. For example, Robins et al. 35 was included instead of Robins et al. 36 because the former focused explicitly on unprotected sex acts. Heckman et al. 37 was included instead of Heckman et al. 38 because they reported findings based on a larger sample. Calculation of effect sizes (r) Effect sizes indicating the magnitude of association between unprotected sex and correlates are presented as correlation coefficients calculated according to procedures described by Rosenthal 39. A positive effect size indicates that a specific variable (as described in Table 1) was associated with an increased likelihood of unprotected sex, whereas a negative effect size indicates that a variable was associated with a decreased likelihood of unprotected sex. When a single study examined more than one correlate of sexual risk behavior, an effect size was calculated for each finding.Table 1: Summary of findings on the correlates of unprotected sex among HIV-seropositive study participants. Ninety-three percent of the reviewed articles reported univariate/bivariate findings, and only 39% of all of the studies reported some multivariate analyses. In many cases, it was difficult to interpret the multivariate results across studies because each multivariate model included a different set of predictor variables in the equation. Conversely, the univariate/bivariate analyses provided an opportunity to detect an association unclouded by other variables. Therefore, effect sizes were based on the univariate/bivariate results. In the few cases in which only multivariate results were reported 4,23,40–42, effect sizes were based on those findings. Effect sizes were calculated with the DSTAT program 43. Study results given in frequencies and chi-square were translated into a phi coefficient. Means and standard deviations, Student's t, and F values were translated into point-biserial coefficients. For a few studies 4,37,40–42,44–47, effect sizes were estimated based on the sample sizes of the subgroup comparisons and the reported significance levels (e.g., P < 0.05, P < 0.01; see 39). Nine papers 32, 48–55 reported that a finding was significant but did not provide sufficient information to estimate an effect size. In those cases, a significance level of P < 0.05 was simply reported. Finally, some papers described a finding as ‘not significant’ and did not provide information necessary for estimating an effect size. Those results are denoted as NS. Construct dimensions The findings are organized into 19 construct dimensions (see Table 1). Each dimension includes one or more specific variables examined in relation to sexual risk behavior. The construct label captures the general essence of the variables within a dimension; however, those variables may differ in specific meaning or definition. Consequently, there was no attempt to aggregate effect sizes within a dimension. Effect sizes or other information about significance are provided for each variable in the category. The findings are presented separately for studies that examined HIV-seropositive men, HIV-seropositive women, and HIV-seropositive men and women combined. Results and discussion The review included 61 English language published articles contributing tests of association for 126 psychological, social, interpersonal, and medical variables. The majority of the studies were conducted in the United States; 11 were conducted elsewhere (Thailand 56, Canada 57,58, Europe 24,40,49,53,59–61, Australia 62). Thirty-seven investigations reported sexual risk behavior among men primarily men who have sex with men (MSM); 13 studies provided analyses on women mainly heterosexuals or injection drug users (IDU), and 17 studies pooled men and women in the analyses. These pooled analyses included considerably more men (mostly MSM) than women (mostly heterosexual or IDU). In general, participants were recruited from HIV outpatient clinics, sexually transmitted disease (STD) clinics, local or state health departments, or other community locations. Most of the IDU samples were recruited from drug treatment outreach programs. Only two studies used probability-sampling methods 45,63. Some constructs (HIV/AIDS knowledge, self-efficacy) were not examined in samples of women. Further, there were several instances in which specific variables were examined in only one study. In those cases, caution must be used in drawing conclusions about an association or lack of association. The findings are summarized in Table 1. Information is provided on the study reference number, the effect size or other statistical information about the finding(s), sample size, and type of sample. Significant results (P < 0.05) are indicated in bold. Variables central to prevailing behavior models The findings support several constructs of the prevailing behavior models. Specifically, unprotected sex was associated with having less knowledge about HIV/AIDS, its transmission, and health risks (TRA, IMB, ARRM, HBM), believing that safer sex decreases sexual pleasure (HBM, TRA), having less intention to engage in safer sex (TRA, TPB), having little commitment to self or others to practice safer sex (ARRM), lack of confidence in one's ability to enact safer sex practices (SCT, IMB, ARRM), perceiving that one has little behavioral control over condom use (TPB), having problems communicating to partners about safer sex (ARRM), and perceiving barriers to condom use (HBM). Other variables that may be viewed within the confines of these models received little or no support in the literature. There was only limited evidence that unprotected sex was associated with not perceiving a social norm for safer sex (TRA, TPB) or lack of social support from family, friends, and partners (ARRM). Surprisingly, having a negative attitude toward using condoms (TRA, TPB) was not found to be associated with unprotected sex in five studies. This surprising finding suggests that other protective processes (e.g., sexual communication) may overcome these negative attitudes in HIV-seropositive persons. Further, there were no significant effects for outcome expectancies (beliefs about the consequences that follow from specific behaviors; SCT). This construct, however, was examined in only one study 64 and it was operationalized in a very specific manner (belief that condoms can be sexy and erotic, belief that negotiating safer sex will gain partner's trust, and belief that disclosing seropositive status to sex partners will increase sexual pleasure). Additional psychological, interpersonal, and social factors Our review included many other variables that were not tied directly to these theoretical models. Several partner variables were found to be associated with unprotected sex in HIV-seropositive persons. The evidence was quite clear in 9 out of 11 studies that seropositive men and women are significantly more likely to engage in unprotected sex with partners reported to be seropositive than with uninfected partners. This finding indicates that many seropositive persons attempt to prevent transmission of HIV. The finding also suggests, however, that seropositive persons who have unprotected sex with seroconcordant partners place themselves at risk for contracting secondary infections that may accelerate their HIV disease 11,12. Studies indicate that unprotected sex was not more likely to occur with primary than non-primary partners, which is inconsistent with the elevated rates of risky sex with primary partners observed in general MSM populations 65–73. It is plausible that HIV-positive persons have unprotected sex with seroconcordant partners regardless of whether partners are primary or non-primary 62,73. When the partners are seronegative or of unknown serostatus, unprotected sex might be more likely to occur with non-primary partners than with primary partners. This trend is seen in three of five studies, although the results failed to reach statistical significance 62–64. Other studies uncovered risk for HIV transmission with other types of partners. HIV-positive MSM were more likely to have unprotected sex with anonymous than known partners at risk for infection. an partner and having a partner who was to engage in risky sex also increased the likelihood of unprotected sex in MSM HIV-positive IDU were more likely to have unprotected sex with their IDU partners than with partners and seropositive women who with their significant others also to have unprotected sex with those partners Finally, living with a sex partner was a risk-promoting and a partner's for but not the for was associated with unprotected sex in HIV-positive women. to previous sexual having a number of sex partners was associated with unprotected sex in seropositive the association was less in seropositive women or in combined For those having more sexual was a risk-promoting not examined in Therefore, for men and women, having more sexual in of number of partners or number of is risk although several studies indicated that having problems communicating with partners was associated with unprotected sex, there was little evidence that of one's seropositive status from sex partners was associated with risky sexual behavior. Indeed, as in a recent study the of safer sex among was very similar to the of safer sex among may negative consequences from disclosing (e.g., to have sex, of but attempt to be with those partners. not that safer sex will because some partners may engage in risky sexual after of their risk There was little evidence that emotional such as or emotional in seropositive men or women were associated with sexual risk behavior, although there was some evidence that was a risk toward other may to a which may of one's behavior or focused on the of the partner similar findings were seen for attributions about one's HIV infection. MSM who their infection to that did to or for their infection to other persons were more likely than other men to have in unprotected anal with partners perceived to be HIV negative or of unknown HIV serostatus Further, MSM and heterosexual men who for more to sex partners than to themselves were at increased risk for in unprotected anal or vaginal In studies of two of investigations of MSM found that use of (e.g., from about one's was associated with unprotected sexual There was little evidence that men or women who used or were at significant risk for in unprotected sex. Of the many personality variables that were examined, only a few were found to be unprotected sex was associated with and sexually and among women it was to less less and more Only a of studies examined or variables. or that people with HIV were not found to be risk factors for unprotected sex in a combined sample of seropositive men and women study examined the association between and sexual risk behavior. HIV-positive men and women living in the United States who were to practices were more likely than their to have in unprotected sex factors recent studies examined whether highly active antiretroviral therapy was associated with sexual risk behavior. et al. found that HIV-positive persons were MSM) an increase in the risk of an infection, syphilis, compared with those who were not study found that HIV-seropositive MSM were three more likely to unprotected sexual practices with HIV-negative or unknown partners after they compared with their behavior that therapy this study did not an association for other partner or in other men and Two other studies also did not the effects of on sexual behavior in a sample of MSM or a sample of men and women combined Further, a study by et al. that heterosexual were less likely to engage in unprotected sex if the seropositive was as a these findings not provide evidence that is a risk for unprotected sex. Other studies examined and status in relation to sexual risk behavior. the findings are very One study found that having an was associated with increased unprotected sex in MSM but two other studies did not the effect in MSM or in other samples studies found that a was associated with increase sexual risk behavior whereas other studies did not A inconsistent for number of HIV and of A few studies examined whether beliefs about therapy were associated with unprotected sexual behavior. et al. found that having about in unsafe sex because of the of therapy was significantly associated with risky sexual behavior in MSM study and a study of heterosexual did not support for such an association. Further, the belief that therapy makes people with HIV less was not associated with unprotected sex in a sample of MSM In the results of the medical studies that behavioral interventions for HIV-seropositive persons will to be and not focused only on those treatment with those who have those who are or have or those who a specific type of medical and unique risk-promoting factors for HIV-positive men and women few variables were examined in seropositive men and women, so there was only limited opportunity to identify common and unique risk-promoting the some of these variables were on an individual they are to their common effects in men and women. In unprotected sex was associated with having HIV-positive partners, believing that safer sex decreases sexual having less intention to use less perceived control over condom having had a number of previous sex partners or and It was more difficult to identify processes in the literature. one for unprotected vaginal was more likely among those who perceived that they had little control over their partner's use of a those who were less those partner to have and those who used methods other than These findings that gender in sexual may to unsafe sex in or seroconcordant heterosexual of reviewed studies and for A number of of the reviewed studies of the investigations did not specify the HIV serostatus of sex partners. Consequently, in many cases it was whether HIV-seropositive persons were having unprotected sex that there was a of HIV. investigations of the sexual behavior of HIV-positive persons to the between unprotected sex with a partner of unknown or which risk of HIV transmission, and unprotected sex with seroconcordant partners, which risk for secondary infections Most analyses were based on tests of therefore, the findings specify Indeed, the between some psychosocial factors and unprotected sexual behavior may be For example, less in one's ability to enact safer sex, perceiving that one has little behavioral control over condom having little commitment to self or others to practice safer sex, or may be as a as a of unprotected sex. studies are to to of the statistical models used to the The majority of the studies reported only univariate/bivariate analyses. These types of analysis provide an opportunity to detect an association unclouded by other however, in more among variables may the effects that a given variable may have on sexual behavior. For example, sexually may in having a number of sex partners. The association between sexual and unprotected sex may after statistically for number of partners. Further, variables may with each other, and their may have with risky sex than of the variables For example, having sexual communication skills and a sex partner of unknown serostatus may to very risk for unsafe sex. attain a more multivariate models tests of interaction effects are in studies. In to the the studies as a provide limited information on variables that may be associated with sexual risk behavior. is to examine interpersonal based on and as well as and from a HIV-seropositive status or sexual is also to the effects of and on risk behavior. Further, given the increasing of HIV infections in there is an to studies that examine these as well as and interpersonal variables in for interventions The findings of this review the types of that to be in behavioral interventions for HIV-seropositive men and women. The is to identify and for these A full range of is interventions that focus on behavioral and the of sexual and that focus on community and practices are also because interventions not occur in a One in which to interventions for HIV-seropositive men and women is the HIV outpatient This as well as clinics, the opportunity to behavioral with medical and behavior across or support can interventions to each they This approach may be for some types of risk factors (e.g., knowledge, behavioral Specifically, it is important that interventions HIV-seropositive persons about and its treatment and provide information that knowledge about transmission HIV that secondary infections can accelerate their HIV disease may also be Further, interventions are a for that attempt to increase and commitment of participants to partners and may be to HIV-positive by their primary interventions can also include (e.g., in HIV to to HIV-seropositive persons in a manner of the of safer sex. Of some HIV-positive people may more from to personality (e.g., sexual emotional and others for one's HIV sexual risk behavior. The of interventions will on whether and people at AIDS are to specific of HIV-seropositive persons and provide to In to these it is also important that interventions focus on the of As in this several interpersonal and partner variables are associated with risky sex in HIV-seropositive and unprotected sex may occur within interventions are to positive persons to increase their skills in negotiating safer-sex sexual and communicating with sex partners. This focus may be for women. designed to these types of skills can be at HIV and These can as well as be by or and behavior and Finally, processes must also be and practices that and people based on a medical or sexual and that in social status and social based on or of may an attempt to self and it is important to among and to identify these and other factors that may HIV and to for to attitudes and practices within this type of approach with and interventions for HIV-positive persons will provide a opportunity for reducing the of HIV The to for on the of this review
Crepaz et al. (Tue,) studied this question.