1. 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

2. 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

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

4. 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died, 5 transferred out of Mombasa, 4 refused, 3 went up country for extended period, 2 incapacitated, 1 imprisoned, 1 withdrawn by hospital committee

5. 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

6. 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.

7. 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

8. 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) cells/mm3 (SD 53)

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

10. 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

11. 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

12. 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

13. 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

14. 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) 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

15. 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

16. 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

17. 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

18. 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

19. Thank you