A year after learning their HIV status, women in Uganda and Zimbabwe who have tested positive for the virus have unprotected sex less often than they had before they learned they were infected, according to findings from a longitudinal study.1 A comparison of women's self-reported sexual behavior three months before the positive HIV test and 12–16 months after the test revealed that the proportion of sexually active respondents who reported having unprotected vaginal sex in a typical month declined from 74% to 56%, and the mean number of unprotected acts fell from 11 to seven. Encouragingly, no increase in the frequency of unprotected sex occurred among women who had received negative HIV test results.
Relatively little is known about whether African women increase their use of condoms or engage in sex less frequently after learning that they have HIV—or whether those who find out that they do not have the virus subsequently become less vigilant about protecting themselves. To examine these issues, researchers pooled results from a study examining the impact of hormonal contraception on HIV risk and from an ancillary study designed to examine behavioral changes among respondents who received positive HIV test results. Women in Zimbabwe and Uganda were eligible for the initial study, launched in 1999, if they were aged 18–35, HIV-negative and sexually active; all participants in Zimbabwe and most of those in Uganda were recruited from family planning and maternal-child health clinics, although about 10% of women in the sample were recruited from STI clinics and other sites serving women at high risk for HIV.
Roughly every three months, participants were interviewed about their reproductive, sexual and contraceptive behavior, tested for HIV, offered free condoms and, unless they were pregnant, given contraceptive counseling (which included information on condom negotiation and the opportunity to practice putting condoms on a wooden model). During the interviews, participants were asked how many times they had sex in a typical month (out of the past three months) and the number of times their partner used a male condom during a typical month. They also provided information about their social, demographic and behavioral characteristics.
The women were followed for two years or until they tested positive for HIV; those with positive tests were informed of the outcome and underwent a second test to confirm the results. Starting in 2001, women who tested positive became eligible for the ancillary study, which involved follow-up and counseling sessions similar to those of the main study; in addition, between June 2003 and the study's conclusion in 2004, HIV-positive women who met certain criteria were offered highly active antiretroviral therapy.
The analytic sample consisted of the 151 women who became infected with HIV and for whom follow-up data were available, and 650 randomly selected women (out of 4,226) who remained uninfected. Analyses focused on data from interviews conducted 2–6 months before the positive test—or, for women who had not tested positive, from interviews conducted 2–6 months before a randomly selected negative test—and interviews conducted 12–16 months after the test. In addition to compiling descriptive statistics, the researchers estimated the odds that a woman reported at the "after" visit that she had unprotected vaginal sex at least once in a typical month, compared with the odds that she had made a similar report at the "before" visit. They also examined changes in the proportion of women's vaginal sex acts that were protected.
In both the infected and uninfected groups, women's mean age at the "before" visit was 25. About half were employed, and nearly three-quarters were using hormonal contraceptives. Age at first sex was similar in the two HIV groups (18), but women who tested positive were more likely than those who remained uninfected to have reported at the "before" visit that they had had multiple partners in the previous three months (7% vs. 3%).
At both time points, the vast majority of women (>90%) reported that they had vaginal sex at least once in a typical month. Among these sexually active women, the proportion of HIV-positive respondents who said they had unprotected vaginal sex at least once in a typical month decreased from 74% to 56%. Moreover, among those who had had unprotected sex, the mean number of unprotected sex acts declined from 11 to seven, and the number of total sex acts fell from 20 to 10. In contrast, the proportion of HIV-negative women who said they had unprotected sex at least once in a typical month increased slightly (from 75% to 79%), and among these inconsistent condom users there was little change in the number of total sex acts (from 15 to 14) or unprotected sex acts (12 at both time points). Among women who were inconsistent condom users, the proportion of sex acts that were unprotected was similar at the two time points (25–30%), regardless of whether the women had tested positive.
Multivariate analyses revealed that HIV-positive women were twice as likely to report consistent condom use at the "after" visit as at the "before" visit (odds ratio, 2.0). In addition, the number of unprotected sex acts in this group declined by 38%, after the researchers adjusted for respondent characteristics. No changes in these outcomes were apparent in the HIV-negative group.
The study's limitations include the possibility of social desirability bias and the lack of information about the HIV status of women's partners. In addition, women who tested positive may have been engaging in riskier-than-normal behavior in the months before their positive test; thus, the decline in their number of unprotected sex acts may have reflected in part "a return to more typical behavior" rather than a response to learning their HIV status, the researchers note. Nonetheless, the findings suggest that women in Uganda and Zimbabwe who receive HIV counseling and condom supplies engage in unprotected sex (and sex in general) less frequently after testing positive for the virus, and that the changes in sexual behavior continue for at least a year after diagnosis, thus reducing "the risk of HIV transmission to susceptible partners." Equally important, the investigators add, women do not have unprotected sex more frequently after learning that they do not have HIV, an observation that may allay concerns "that a negative HIV result may be perceived as an endorsement of risky behavior."—P. Doskoch
1. Turner AN et al., Unprotected sex following HIV testing among women in Uganda and Zimbabwe: short- and long-term comparisons with pre-test behaviour, International Journal of Epidemiology, 2009, 38(4):997– 1007.