A study examining unsafe sexual behaviors among HIV-positive adults in Honduras found that unprotected sex is common, especially among women, individuals with a recent HIV diagnosis, those who have difficulty obtaining condoms and those who have experienced discrimination because of their infection (odds ratios, 1.8–2.6).1 Fifty-seven percent of sexually active HIV-positive women reported inconsistent condom use with their regular, casual or commercial partners in the past 12 months, compared with 38% of their male counterparts. Levels of other risk behaviors also varied by sex. Regardless of their sexual activity, women were more likely than men to report having difficulty obtaining condoms (24% vs. 15%) and to have experienced HIV-related discrimination in the past year (65% vs. 55%).
To examine risk behaviors and STI prevalence among HIV-positive adults in Honduras, researchers conducted a cross-sectional study in 2006 in Tegucigalpa and San Pedro Sula, the two cities where most Hondurans who receive HIV care live. HIV-positive men and women aged 18 or older were recruited from public-sector HIV service providers and nongovernmental organizations; they were eligible if they were living in or receiving care in either study city, had a documented HIV test result and were able to provide written informed consent. In all, 810 individuals enrolled.
Study assessments included an audio computer-assisted interview, a physical exam by a doctor or nurse, and STI testing of blood, urine and vaginal swabs. The biologic samples were screened for chlamydia, gonorrhea, Mycoplasma genitalium, trichomoniasis, syphilis and herpes simplex virus type 2. The study questionnaire asked about demographic characteristics, current and recent sexual behavior, HIV knowledge, health-seeking behaviors, past-year and lifetime use of drugs and alcohol, and experiences of HIV-related discrimination. The main outcome of interest was having had unprotected sex with any partner in the past year. Chi-square and t tests were used to test for gender differences; logistic regression analyses that controlled for potential confounders, as well as study site and gender, were used to identify predictors of unsafe sex in the past year among sexually active participants.
The mean age of participants was 37, and more than half (55%) were women. Only 29% of the sample had at least a high school education; 11% were illiterate. Forty-five percent were married or in a union, and 43% were unemployed. Most respondents were receiving antiretroviral treatment (84%), and 22% had received their HIV diagnosis in the year before the survey. One-quarter had used drugs in the past 12 months, and 17% had used alcohol in the previous four weeks. Overall, 60% of participants reported experiencing discrimination; women were more likely to do so than men (65% vs. 55%).
Most respondents reported having had sex during the previous 12 months; the proportion was higher among men than women (70% vs. 58%). Among these sexually active respondents, men were more likely than women to report having paid for sex (18% vs. 4%) and having had a same-sex partner (20% vs. 5%), while a higher proportion of women than men reported having experienced forced sex (17% vs. 10%). Just 38% of women and 62% of men reported having used a condom at last sex; similar proportions (38% and 59%, respectively) reported consistent condom use with their regular partner during the past year. Overall, 57% of women and 38% of men had had unprotected sex in the past year with at least one of their partners. The main reasons for nonuse were having a regular partner and being drunk; only 20% of women and 9% of men attributed their nonuse to their partner’s already being infected. Twenty percent of all respondents—including 24% of women and 15% of men—reported having difficulty obtaining condoms. Overall, 78% of the sample tested positive for herpes, while 12% had Mycoplasma genitalium, 5% had trichomoniasis, 1% each had syphilis and chlamydia, and 0.2% had gonorrhea. Women were more likely than men to test positive for all but the last two.
In the bivariate analyses, participants were more likely to have had unprotected sex in the past 12 months if they were female or unemployed, had received an HIV diagnosis within the past year, had only a regular partner, had difficulty obtaining condoms or had experienced HIV-related discrimination. In multivariate analyses, the odds of having had unprotected sex were elevated among women (odds ratio, 1.9), those with a recent HIV diagnosis (2.0), those reporting difficulty in obtaining condoms (2.6) and those who had experienced discrimination (1.8).
The researchers acknowledge several limitations. The findings may not represent HIV- positive adults who receive private care or live in other regions of Honduras; in addition, selection into the study may have been affected by staff bias, and misclassification of participants’ sexual activity may have occurred. Despite these limitations, the researchers note that the study—the first to assess risk behaviors and STI prevalence among HIV-positive people in Central America—found “high rates of unprotected sex among sexually active HIV-positive men and women,” as well as a link between having experienced discrimination and not using condoms. They conclude that in addition to highlighting “a pressing need to strengthen prevention” efforts to reduce high-risk behaviors, the findings indicate that “it is imperative to address vulnerability and risk related to discrimination against HIV-positive individuals.”
1. Paz-Bailey G et al., Unsafe sexual behaviors among HIV-positive men and women in Honduras: the role of discrimination, condom access, and gender, Sexually Transmitted Diseases, 2012, 39(1):35–41.