Using HIV Status and Viral Load Knowledge for Decision Making in Sexual Behavior: Outcome Analysis from the Medical Monitoring Project in Texas
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Sears, SC. MPH 1 ; Odem, SL. MPH 1 ; Poe, JD. MSSW 1 ; Wu, M. MPH 1 ; Mgbere,O. PhD, MS, MPH 2 ; Singh, M. PhD 2 ; McNeese, ML. PhD, MPH 2
1 TB/HIV/STD Epidemiology & Surveillance Branch, Texas Department of State Health Services, Austin, TX
2 Office of Surveillance and Public Health Preparedness, Houston Health Department, Houston TX Background
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Condom use has been the most widely recognized and promoted form of protected sexual behavior.
However, research shows there are other harm reduction strategies for sexual behavior that can be effectively used by HIV-positive persons.
Serosorting, selecting partners of concordant HIV serostatus, and having an undetectable viral load (VL) are two such harm reduction strategies. Objective
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This analysis assessed the association of HIV status and VL knowledge with sexual behavior decision making among people living with HIV (PLWH) receiving care in Texas. Methods
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The Medical Monitoring Project (MMP) is an ongoing surveillance system funded by the Centers of Disease Control and Prevention (CDC) that uses a three stage cluster sampling method to assess behaviors and clinical characteristics of PLWH who are receiving outpatient medical care.
From the Texas and Houston MMP facilities, 470 of 800 sampled persons participated in the 2012 cycle.
Data were collected using an in-person interview and a medical record abstraction.
In the interview, participants were asked to rate their level of agreement with four statements related to serosorting and viral load as well as about their sexual behaviors in the past 12 months.
The weighted interview dataset was analyzed to assess participant responses using SAS 9.3. Differences were assessed using Rao-Scott chi-square tests at significance level of p<0.05.
Data are weighted to adjust for non-response bias. 5
Results Demographics N=470 6
Characteristics N % Gender Male 328 70% Female 133 28% Transgender 9 2% Race/Ethnicity White, non-Hispanic 113 29% Black, non-Hispanic 196 40% Hispanic 144 26% Other 17 5% Age Category 18-29 years 38 9% 30-39 years 108 23% 40-49 years 142 29% 50+ years 182 39% Education Less than high school 106 21% High school degree/equivalent 132 28% Greater than high school 232 51%
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Statement 1: If my partner tells me he or she is HIV positive, I am more likely to have unprotected sex n=462 7
100% Responses to Statement 1 90% 80% 78% 70% 60% 50% 40% 30% 17% 20% 10% 5% 0% Neutral Agreed Disagreed
Associations significant at p<0.0001
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Condomless Sex by Level of Agreement to Statement 1 n=450 8
100% 90% 80% 40% 46% 70% 60% 88% 50% 40% 30% 60% 54% 20% 10% 12% 0% Neutral Agreed Disagreed Associations n=24 (5%) n=76 (17%) n=350 (78%) significant at Any condomless sex past 12 months No condomless sex in past 12 months p<0.0001 Statement 1: If my partner tells me he or she is HIV positive, I am more likely to have unprotected sex
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Sexual Behavior and Partner Status by Level of Agreement with Statement 1 n=450 9
100% 5% 90% 7% 29% 80% 40%
70% 34%
60% 24% Condomless sex with at least one HIV- or unknown status partner 50% 20%
13% Condomless sex with HIV+ 40% partners only
30% 16% 54% Sex with condoms only 20% 34% 10% 24% Celibacy/Low risk sex 0% Neutral Agree Disagree n=24 (5%) n=76 (17%) n=350 (78%) Associations significant at p<0.0001 Statement 1: If my partner tells me he or she is HIV positive, I am more likely to have unprotected sex
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Statement 2: If my partner tells me or she is HIV positive, we don’t have to worry about using condoms n=461 10
100% Responses to Statement 2 90% 84% 80%
70%
60%
50%
40%
30%
20% 11% 10% 5% 0% Neutral Agreed Disagreed
Associations significant at p<0.0001
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Condomless Sex by Level of Agreement to Statement 2 n=449 11
100% 90% 80% 41% 70% 61% 60% 82% 50% 40% 30% 59% 20% 39% 10% 18% 0% Neutral Agreed Disagreed n=22 (5%) n=50 (9%) n=377 (86%) Associations Any condomless sex past 12 months No condomless sex in past 12 months significant at p<0.01 Statement 2: If my partner tells me he or she is HIV positive, we don’t have to worry about using condoms
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Sexual Behavior and Partner Status by Level of Agreement with Statement 2 n=449 12
100% 9% 90% 28% 9% 80% 35% 70% 11% 33% Condomless sex with at 60% least one HIV- or unknown status 24% partner 50% 21% Condomless sex with 40% 4% HIV+ partners only 30% 49% Sex with condoms only 20% 37% 40% 10% Celibacy/Low risk sex 0% Neutral Agree Disagree n=50 (9%) n=377 (86%) n=22 (5%) Associations significant at p<0.01
Statement 2: If my partner tells me he or she is HIV positive, we don’t have to worry about using condoms
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Statement 3: If I have an undetectable HIV viral load, I am more likely to have unprotected sex n=461 13
100% Responses to Statement 3 90% 84% 80%
70%
60%
50%
40%
30%
20% 12% 10% 4% 0% Neutral Agreed Disagreed
Associations significant at p<0.0001
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Condomless Sex by Level of Agreement to Statement 3 n=448 14
100% 90% 80% 40% 48% 70%
60% 84% 50% 40% 30% 60% 52% 20%
10% 16% 0% Neutral Agreed Disagreed n=15 (3%) n=56 (12%) n=377 (85%) Associations significant at Any condomless sex past 12 months No condomless sex in past 12 months p<0.0001 Statement 3: If I have an undetectable HIV viral load, I am more likely to have unprotected sex
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Agreement with Statement 3 and Viral Load Status by Sexual Behavior n=433 15
Agreement/Viral Load Any No condomless Status* condomless sex in past 12 sex in past months 12 months Agreed with Statement 3
Undetectable VL (n=45) 45% 55%
Detectable VL (n=11) 83% 17% (p<0.05)** Disagreed with Statement 3
Undetectable VL (n=292) 17% 83%
Detectable VL (n=85) 15% 85% *Most recent VL in medical chart (p=0.75) ** Associations significant at p<0.05
Statement 3: If I have an undetectable HIV viral load, I am more likely to have unprotected sex
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Statement 4: Having an undetectable viral load means I can worry less about having to use condoms n=461 16
100% Responses to Statement 4 90% 90% 80% 70% 60% 50% 40% 30% 20%
10% 4% 6% 0% Neutral Agreed Disagreed
Associations significant at p<0.0001
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Condomless Sex by Level of Agreement to Statement 4 n=448 17
100% 90% 80% 49% 50% 70% 60% 82% 50% 40% 30% 51% 50% 20% 10% 18% 0% Neutral Agreed Disagreed n=19 (5%) n=27 (6%) n=402 (89%) Associations significant at Any condomless sex past 12 months No condomless sex in past 12 months p<0.01
Statement 4: Having an undetectable viral load means I can worry less about having to use condoms
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Agreement with Statement 4 and Viral Load Status by Sexual Behavior n=429 18
Agreement/Viral Load Any No condomless Status* condomless sex in past 12 sex in past months 12 months Agreed with Statement 4
Undetectable VL (n=22) 47% 53%
Detectable VL (n=5) 60% 40% (p=0.65) Disagreed with Statement 4
Undetectable VL (n=311) 18% 82%
Detectable VL (n=91) 20% 80% *Most recent VL in medical chart (p=0.69) ** Associations not significant
Statement 4: Having an undetectable viral load means I can worry less about having to use condoms
Source: 2012 TX/HOU MMP weighted interview and MRA datasets Conclusions
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Texas MMP data suggest significant differences between the level of agreement with serosorting and viral load statements and condom use.
As sexual harm reduction strategies are increasingly incorporated into prevention messages, a focus towards behavioral change beyond just using condoms is needed as transmission and spread of HIV depends on volitional behavior of people.
It is important to use behavior change theories that consider knowledge, beliefs, and skills needed to make changes.
Educating PLWH on evaluating the risks associated with each strategy is needed to make informed decisions. Limitations
20 Limitations: •Potential for recall bias and social desirability bias in interview data
•This analysis makes inferences between serosorting beliefs/viral load status and condom use. Participants are not asked their reasons for not using condoms. Acknowledgements
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Texas MMP/Houston MMP Collaborating Healthcare Providers
Texas MMP/Houston MMP Staff and Management
Clinical Outcomes Team, Behavioral and Clinical Surveillance Branch, Behavioral and Clinical Surveillance Branch, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention (CDC)