International AIDS Conference Sexual risk behavior is still a concern among HIV infected persons receiving HAART: Insights from Mombasa, Kenya A. Sarna, S. Luchters, S. Geibel, P. Munyao, S. Kaai, K. Shikely, K. Mandaliya, J. van Dam, and M. Temmerman International AIDS Conference Toronto 15 August 2006 asarna@popcouncil.org

Introduction With the introduction of HAART, PLHA are living longer, healthier, and potentially more sexually active lives. Widespread concern of an increase in risk behavior with HAART Unprotected sex by PLHA is an area of concern: Risk of HIV transmission Risk of re-infection with new, drug-resistant virus DOTS- Directly Observed Treatment Short-course

Objective To document change in sexual risk behavior of HIV-infected persons receiving HAART

Methodology (1) Cohort study Study sites 3 public sector and 1 NGO clinics in Mombasa Population of HIV-infected persons 234 treatment naïve patients recruited (Sept 2004 and Nov 2005) Context of an adherence intervention study Followed for 12 months 183 remained in follow up at 12 months; Data from 183 patients being presented 24 PLHA died, 5 transferred out of Mombasa, 4 refused, 3 went up country for extended period, 2 incapacitated, 1 imprisoned, 1 withdrawn by hospital committee

Methodology (2) Ethical approvals obtained: Data collection KNH-ERC Population Council (IRB) Written informed consent from all participants Data collection Semi-structured questionnaire In-depth interviews with 20 patients Reporting reference period 12 months

Counseling Safe sex counseling was provided at time of VCT for all subjects. Intensive counseling for treatment adherence. Importance of avoiding risky sexual behavior was stressed during initiation of HAART and follow up.

Definitions Regular partner: spouse/live-in sexual partner/ regular boyfriend or girlfriend; never paid for sex Casual partner: sexual partner the respondent is not living with; had sex rarely or only once Sex worker: sexual partner to whom respondent paid money in exchange for sex Unprotected sex: no condoms used at last sex or inconsistent condom use in past 12 months

Demographics Mean age 37.5 (23-58 years) Females 64% Education No education 6% Primary Ed 50% Secondary Ed 37% Diploma/Univ 7% Marital status Married/cohabiting 50% Single 12% Widowed/divorced 38% Median CD4 (baseline) 105 cells/mm3 (SD 53)

Self reported Sexual Activity (n = 183) NS difference between baseline and 12 months

Self reported Sexual Activity (n = 183) Married respondents were more likely to report sex compared to single/widowed 81% vs. 35%; p < .001 Baseline CD4 counts (disease stage) and change in CD4 counts not associated with reporting sex

Type of partners Of those who were sexually active Baseline (n = 92) % 12 months (n = 105) Regular partners 94 91 Casual partners 12 8 Sex Worker 2 NS differences between baseline and 12 months

Regular partner relationships Baseline (n = 92) % 12-mon (n = 105) Partner’s HIV status Positive Negative Unknown* 39.5 11.6 48.8 49.5 16.8 33.7 Disclosure Yes* 72.1 84.2 *p < .05

Self-reported Condom Use with Regular Partners DAART: Month 1 (n=104), Month 2 (n=99), Month 3 (n=93), Month 4 (n=90), Month 5 (n=93), Month 6 (n=88) Non-DAART: Month 1 (n=93), Month 2 (n=82), Month 3 (n=80), Month 4 (n=80), Month 5 (n=88), Month 6 (n=93) *p < .001

Unprotected sex with regular partners (preliminary analysis) Of those reporting sex with a regular partner (n = 95) Unprotected Sex % Marital status: Married / cohabiting (n=68) Single/divorced/widowed (n=27) 72 59 Partners status: Positive (n=47) Negative (n=16) Unknown (n=32) 75 63 Disclosure of own status*: Yes (n=80) No (n=15) 74 40 Change in CD4 counts: <100 cell (n=19) 101- 250 cell (n=39) 251 cell (n=31) Depression Minimal (n=64) Mild to Moderate (n=14) Moderate to severe (n=7) 58 62 81 50 57 *Significant

Casual partners Baseline 12 months Reported sex with CP 12% (11/92) 8% (8/105) Knows partner’s status Positive Negative Unknown 1/11 2/11 8/11 4/8 Disclosed: Yes Condom use at last sex 4/11 6/8

Other partners Sex workers Male partners 2 respondents reported sex at 12 months Both males Did not disclose, partner’s status unknown Did not use condoms Male partners 1 respondent reported at baseline Used condoms

Conclusions There is no evidence to suggest an increase in risk behavior after HAART (multiple partners, sex workers) But, considerable risk of HIV transmission remains especially in regular partner relationships A better understanding of the dynamics of disclosure and condom use with regular partners is needed when designing programs for prevention with positives

Acknowledgements Researchers S Luchters, S Geibel, S Kaai, P Munyao, K Mandaliya, K Shikely, M Hawken, J van Dam, M Temmerman, A Sarna Partners International Centre for Reproductive Health Government of Kenya (GOK) CPGH, PRDH, Bomu Clinic in Mombasa Family Health International (FHI) Management Sciences for Health, Rational Pharmaceutical (MSH RPM Plus) Horizons Program/Population Council Supported by President’s Emergency Plan for AIDS Relief through USAID

Thank you