HIV This Week

Cohen CR, Montandon M, Carrico AW, Shiboski S, Bostrom A, Obure A, Kwena Z, Bailey RC, Nguti R, Bukusi EA. Association of attitudes and beliefs towards antiretroviral therapy with HIV-seroprevalence in the general population of Kisumu, Kenya. PLoS ONE. 2009;4(3):e4573.

Since antiretroviral therapy became available in the developed world, the prevalence of unprotected sex and the incidence of sexually transmitted infections (STIs) and HIV have increased. Cohen and colleagues hypothesized that a similar phenomenon may be occurring in sub-Saharan Africa concomitant with the scale-up of HIV treatment. They conducted a general population-based survey in Kisumu, Kenya. Participants completed an interview that included demographics as well as antiretroviral therapy-related attitudes and beliefs and then underwent HIV serological testing. Exploratory and confirmatory factor analyses of attitudes and beliefs about antiretroviral therapy indicated two factors: 1) antiretroviral therapy-related risk compensation (increased sexual risk taking now that antiretroviral therapy is available); and 2) a perception that HIV is more controllable now that antiretroviral therapy is available. Logistic regression was used to determine associations of these factors with HIV-seroprevalence after controlling for age. 1,655 (90%) of 1,844 people aged 15-49 contacted, including 749 men and 906 women, consented to participate in the study. Most participants (n = 1164; 71%) had heard of antiretroviral therapy. Of those who had heard of antiretroviral therapy, 23% believed antiretroviral therapy was a cure for HIV. Antiretroviral therapy-related risk compensation (Adjusted (A)OR = 1.45, 95% CI 1.16-1.81), and a belief that antiretroviral therapy cures HIV (AOR = 2.14, 95% CI 1.22-3.76) were associated with an increased HIV seroprevalence in men but not women after controlling for age. In particular, antiretroviral therapy-related risk compensation was associated with an increased HIV-seroprevalence in young (aged 15-24 years) men (OR = 1.56; 95% CI 1.12-2.19). Antiretroviral therapy-related risk compensation and a belief that antiretroviral therapy cures HIV were associated with an increased HIV seroprevalence among men but not women. HIV prevention programs in sub-Saharan Africa that target the general population should include educational messages about antiretroviral therapy and address the changing beliefs about HIV in the era of greater antiretroviral therapy availability.

Editors' note: This general population household survey is the first to examine attitudes and beliefs about antiretroviral treatment and their relationship with HIV seroprevalence. The numerous studies to date in the US and Europe that have identified an upward trend in risky sexual behaviours since the introduction of antiretroviral treatment in 1996 have all been conducted in key populations at higher risk of HIV exposure, particularly men who have sex with men. This study in Kisumu, where 28% of those in need of antiretroviral treatment were receiving it at the start of 2007, found that young men with treatment-related risk compensation beliefs were more likely to be HIV-positive than young men without such beliefs. The relationship may reflect personality traits related to risk-taking rather than being causal. Nonetheless, the implications are evident for integrated HIV prevention and treatment programming in Kisumu and widespread dissemination of accurate information about antiretroviral treatment and the need for changes in social norms to reduce sexual risk-taking as treatment rollout continues.