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FOCUS Apr-99 HIV Treatment and HIV Transmission F AGuide toOAIDSCResearch andU Counseling Volume 14 Number 5 April 1999S load decreased the risk of transmission. Beyond Complacency: The Effects Similarly, a New York study of men who have sex with men—the Seropositive Urban of Treatment on HIV Transmission Men’s Study (SUMS)—found that men who Perry N. Halkitis, PhD and Leo Wilton, MA engaged in unprotected anal intercourse with partners who were seronegative or of unknown status believed that they were less The interaction between the success of infectious because they were on antiviral HIV antiviral therapy and prevention efforts therapy and had negligible viral loads. A is complex, and it is becoming clear that an study of 298 men attending a 1997 gay optimistic view of the HIV epidemic may pride event in Atlanta found that those who actually lead to an increase in the number 1 had engaged in unprotected anal receptive of HIV infections. Data from several intercourse indicated that they were less sources—for example, a survey of gay men worried about unsafe sex because of treat- in Sydney, a study of young men who have ment advances.2 Of 54 men surveyed in a sex with men in New York, and preliminary 1997 San Francisco study, 26 percent were data on both gay men and injection drug less concerned about becoming seropositive users in New York and San Francisco— now that protease inhibitors were available: demonstrate significant increases in the 15 percent were more willing to engage in rate of unsafe sexual behavior among both unsafe sexual behaviors and risk HIV infec- HIV-infected and uninfected people. tion and 15 percent reported already taking These patterns of unsafe practice are such a risk.3 further demonstrated by the increasing In addition, unsafe sex between HIV- prevalence of other sexually transmitted positive partners, which may lead to rein- diseases around the country as illustrated fection, has also increased in light of the by data from New York and San Francisco. new treatments. The Seropositive Urban Several studies suggest that the new opti- Men’s Study found that HIV-infected gay mistic culture arising from successful and bisexual men in primary relationships antiviral treatment has become the catalyst reported higher rates of unprotected for behavior change that has resulted in insertive anal intercourse with other infect- these increases in unsafe sex. This article ed partners than with uninfected partners. briefly reviews these studies and then eval- Anecdotal reports indicate that some gay uates the beliefs regarding the relationship men in metropolitan areas attend “poz between infectivity and treatment, which bareback parties,” where seropositive gay may fuel these increases in unsafe sex. and bisexual men gather to have unprotect- ed sex with multiple partners. Optimism and Behavior Complicating the effects of optimism Recent studies have indicated that about new antiviral treatments is a misun- increases in unsafe sex may be related to derstanding about the meaning of an beliefs about the lack of severity of HIV “undetectable” viral load reading. For disease. For example, in a New York study of example, a Canadian study found that 14 serodiscordant male couples, 24 percent a significant proportion of participants of respondents engaged in unprotected anal perceived unprotected vaginal and anal intercourse two months prior to assess- intercourse to be less risky and safer ment, and half of the sample agreed that a sexual practices to be less important reduction in the seropositive partner’s viral if viral load was “undetectable.”4 questions by reviewing the rele- Editorial: Transmitting Myths vant literature. Their conclu- Robert Marks, Editor sions offer no concrete answers about probability but do confirm the possibility of transmission There is a type of scientific The data are inconclusive, but data that slips into human con- many studies have found that for in all three of these cases. sciousness, integrated silently, small but significant minorities, June Crawford, Susan Kippax, like viral RNA, I guess, affecting such beliefs play an important and Paul Van de Ven look at the our decisions without requiring role in precipitating unprotected implications of this science in much reflection. The success of sex. It remains unclear, as at the context of the explicit sexual combination therapy has inject- least one researcher has suggest- agreements between partners in ed several assumptions into the ed, whether this significant many couples. They focus on collective consciousness of minority would be having unpro- negotiated safety agreements, those communities most affect- tected sex anyway, that these in which, by definition, both ed by HIV disease. individuals would have found partners are seronegative, Among these ideas are that some other justification for because this is the area where getting infected is no big deal unsafe behavior. there is the most research. because drugs can treat you, that In any case, it is crucial for There’s a faint aroma of com- people using the new treatments providers to understand the placency in the air these days are somehow less likely to infect science behind assumptions and a sense that not only have seronegative partners, and even about infectivity and transmis- the consequences of HIV infec- that having an “undetectable” sion in the context of the new tion changed, but also the sci- viral load is tantamount to being treatment landscape. This issue ence of transmission. In order for seronegative. There has been a of FOCUS clarifies three con- clients to make appropriate deci- great deal of speculation and a cepts regarding the science: the sions about risk, they must rush of studies over the past 18 possibility of transmitting drug- understand the certainty and months seeking to determine resistant virus to seronegative limits of scientific knowledge. exactly how much these attitudes, partners, the possibility of rein- Mental health providers cannot if they exist, affect behavior. For fecting a seropositive person expect themselves to interpret example, do people believe that with drug-resistant virus, and complex studies of basic HIV low viral load diminishes infectiv- the possibility of transmitting science, but they can become ity, do these people increase HIV when the seropositive part- aware of the current scientific unprotected behaviors as a result, ner’s viral load is below the level consensus in key areas and and how many people believe this of detection. Perry Halkitis and inform discussions of risk that and act on this belief? Leo Wilton seek to answer these arise within the counseling room. References Ultimately, however, the beliefs some become reinfected with a drug-resistant or 1. Halkitis PN. Ad- people have about the effects of treatment more virulent strain of HIV, events that vances in treatment of HIV disease: Complex- success and the meaning of viral load are may complicate treatment. The rest of this ities of adherence and not supported by the scientific literature. article reviews the most recent research on complications for pre- First and foremost, the long-term efficacy viral mutation and drug resistance, the po- vention. The Health of antiviral treatment remains unclear, tential for reinfection, and the meaning of Psychologist. 1998; 20(1): 6-7,14. suggesting that the success of the new viral load and implications for infectivity. treatments may lead to a false sense of 2. Kalichman SC, security. Second, research indicates that Viral Mutation and Resistance Nachimson D, Cherry problems in treatment, medication adher- Like all bacteria and viruses that cause C, et al. AIDS treatment advances and behav- ence, and the natural evolution of the disease, HIV has the potential to alter its ioral prevention set- virus may result in viral mutations and genetic composition, yielding a variety of backs: Preliminary increased drug resistance. Finally, while strains and subtypes. The introduction of assessment of reduced antiviral treatment has been proven to combination therapy, in particular, the perceived threat of HIV-AIDS. Health reduce viral load in the blood, HIV may lie widespread use of protease inhibitors as Psychology. 1998; dormant, potentially in a mutated state, in well as continued use of nucleoside ana- 17(6): 546-550. the lymph and other systems. Recent data logues such as zidovudine (ZDV; AZT), has 3. Dilley JW, Woods also suggest that some people have been significantly increased the prevalence of WJ, McFarland W. Are infected with mutated and drug-resistant mutated viruses that can “outsmart” antivi- advances in treatment strains of the HIV virus, diminishing or ral treatments. According to the Stanford changing views about eliminating options for treatment. While HIV RT and Protease Sequence Database, high-risk sex? New not proven, it appears that this may occur drug resistance arises from mutations in the England Journal of Medicine. 1997; not only with seronegative people but also HIV genome specifically in the regions that 337(7): 501-502. with seropositive individuals, who may encode the molecular targets of therapy: the 2 FOCUS April 1999 protease and reverse transcrip- recent evidence suggests the existence of tase enzymes.5 more than one strain of the virus in a per- Even at viral For individuals who initially son. The effect of such coinfection on succeed on combination thera- antiviral treatment remains unclear. load levels of py, the development of drug Researchers have long identified several resistance is often associated risks to unprotected sex between seroposi- less than 500, with increases in viral load as tive partners. Among these risks have been HIV replication medications fail to control infection with other sexually transmitted infection. Evidence suggests diseases that would flourish in the presence and mutation that even when viral load is of a compromised immune system, and detected at levels less than 500, reinfection with HIV, an event that might still occur. replication and mutation of the activate the immune system leading, ironi- virus can still occur.6 Treatment cally, to further HIV replication in immune failures due to drug resistance system cells.
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