Adoption of Protective Behaviors Among Persons With Recent HIV Infection and Diagnosis --- Alabama, New Jersey, and Tennessee, 1997--1998

A comprehensive human immunodeficiency virus (HIV) prevention strategy includes knowledge of HIV status, counseling to reduce high-risk behavior, and referral for appropriate care (1). After diagnosis, a substantial percentage of HIV-infected persons reduce their high-risk sexual behaviors (2--4). This report presents data characterizing the sexual practices of persons with newly diagnosed HIV infection who have evidence of recently acquired infection. Characterizing these persons may assist in the development of risk-reduction efforts for HIV-infected populations to prevent further HIV transmission.

To examine risk behaviors (e.g., condom use and number of sex partners) after HIV diagnosis, CDC analyzed data on HIV testing history and sexual behavior of persons who may have recently acquired HIV infection as part of a CDC-sponsored study in Alabama, New Jersey, and Tennessee. For purposes of this study, criteria for recent HIV infection included persons with diagnosed and reported HIV infection with CD4 T-lymphocyte counts >700 cells/µL or percentage >36, documented HIV seroconversion within 18 months of confirmed HIV infection diagnosis, or persons aged 13--24 years when diagnosed (5). Respondents were told that questions about behaviors before they learned of their HIV status concerned sexual activities after 1977 but before the first time respondents were told they were HIV-positive. Questions about behaviors since they learned of their HIV status concerned the period after a doctor, health-care provider, or counselor informed respondents that they were HIV-positive.

During January 1997--September 1998, 615 persons with HIV infection diagnosed and reported met the criteria for the study; these persons represented 15% of all persons with HIV infection diagnosed and reported during this period from Alabama, New Jersey, and Tennessee. Of the 543 persons determined eligible after follow-up by state health departments, 180 (33%) completed interviews, 127 (23%) refused to be interviewed, and 235 (43%) could not be located. Among persons with known dates, 148 (86%) of 173 were interviewed within 12 months of the self-reported date they learned they were HIV-infected (median: 6 months).

Among the 180 persons interviewed, 99 (55%) were female; 96 (53%) were age <25 years; and 105 (58%) were non-Hispanic black, 49 (27%) were non-Hispanic white, 24 (13%) were Hispanic, and two (1%) were self-reported as "other." These demographic characteristics were similar for persons not interviewed. Twenty-three (28%) of 81 males and 69 (70%) of 99 females could not be classified as having recognized transmission risk or as having sexual contact with an HIV-infected partner or one with a documented transmission risk. All except one of these persons reported heterosexual activity but was unaware of the partner's HIV status or risk for HIV infection.

Among 68 males stating a primary reason for being tested, the leading reasons were because a doctor or friend told them to be tested (28%) and because they were worried they might be infected even though they were not sick (22%). Among 90 females stating a primary reason for testing, the leading reasons were because of pregnancy care (33%) and because a doctor or friend told them to be tested (18%). Of 180 persons interviewed, 162 (90%) responded that they had changed their sexual behavior since learning of their HIV infection. Among these persons, 97 (60%) stated they used condoms more often, 80 (49%) did not have sex as often, 58 (36%) had not had sex, 16 (10%) had sex with persons they knew were infected, and eight (5%) had only oral sex. No differences were reported in these behavior changes by sex, except having only oral sex (9% among males and 1% among females).

Among 97 females reporting vaginal sex with males and among 45 males reporting anal sex with males, 25%, 69%, and 6% reported using condoms before diagnosis never, sometimes, and always, respectively. After diagnosis, 30% reported not having sex, and 6%, 11%, and 47% reported never, sometimes, and always using condoms, respectively. Self-reported condom use after learning of HIV infection among a subset of these persons who reported some unprotected sex before HIV diagnosis indicated that a high proportion of males and females adopted protective behaviors (Figure 1).

Fifty-two (79%) of 66 females having vaginal sex with men after diagnosis reported having one partner since learning of their HIV infection; 15 (50%) of 30 men having anal sex with men since diagnosis reported having one partner. Among males and females interviewed within 6 months of diagnosis, 41 (44%) of 94 reported not having sex; among males and females interviewed more than 6 months after diagnosis, 14 (18%) of 79 reported not having sex.

Of 180 persons interviewed, 151 (84%) reported receiving medical care for HIV infection since diagnosis. Among the 27 persons who responded that they had not received medical care for their HIV infection since diagnosis, 13 (48%) reported feeling well and not thinking it was important to seek medical care right away, and 12 (44%) reported not wanting to think about being HIV-positive as reasons for postponing seeking health care right away. Twenty-two (81%) of 27 respondents not receiving medical care reported changing their sexual behavior since learning of their HIV infection compared with 139 (93%) of 149 respondents receiving medical care.

Reported by: S Higginbotham, R Holmes, MPH, Alabama Dept of Public Health. H Stone, MSSW, Tennessee Dept of Health. J Beil, MPH, GB Datu, S Costa, MA, S Paul, MD, New Jersey Dept of Health and Senior Svcs. Div of HIV/AIDS Prevention--Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note:

The findings in this study suggest that a high proportion of infected persons adopted safer sexual behaviors following diagnosis of HIV infection and are consistent with other studies showing adoption of safer behaviors after diagnosis in some groups (2--4). The findings also are consistent with a report describing an increase in reported safe behaviors 6 months after beginning HIV-related primary care (6). Because persons who have not had sex since their diagnosis may become sexually active later, sustained interventions must be available for maintenance and adoption of safe behaviors.

In this and other studies (7), most persons report receiving HIV-related medical care within 1 year of learning of their positive HIV status. These encounters provide an opportunity for behavioral risk-reduction counseling and intervention. Health-care providers should emphasize the need to sustain safe behaviors, especially because persons benefitting from antiretroviral therapy may be living longer, healthier lives and, therefore, may engage in risky sexual activity over time.

The findings in this report are subject to at least five limitations. First, the findings may be biased toward persons receiving medical treatment because this group was easier to locate and interview than those not in treatment. Second, face-to-face interviews about sexual behavior may bias results toward socially desirable responses. Third, although this study included many young persons, some older persons may have been sexually active for many years and this analysis did not control for variation in length of time persons had been sexually active before diagnosis. Fourth, although knowledge of laws related to HIV is limited (8), local laws related to knowingly exposing persons may have influenced candid replies to condom-use questions. Finally, this study was conducted as a pilot project in only three states and these findings may not be generalizable.

Young persons and others with evidence of recent HIV infection can provide insights into prevention needs and failures. Areas conducting HIV and AIDS surveillance can characterize persons with recently acquired infection and therefore can describe recent patterns of transmission and risk behaviors. CDC recommends that all states adopt HIV case surveillance to assist in monitoring the epidemic (5).

Of the estimated 800,000--900,000 persons infected in the United States, approximately one third have yet to be diagnosed (5). Most women were unaware of their partner's HIV status and a high percentage were tested related to pregnancy. HIV testing and counseling programs should encourage persons at high risk for HIV infection to seek knowledge of their status and should facilitate referrals to ongoing care and prevention services for persons found to be infected (9). Increasing the availability and improving access to testing in public and private settings early in the course of disease will increase opportunities for sustained prevention and treatment for all HIV-infected persons.

References

1. CDC. HIV counseling, testing, and referral: standards and guidelines. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, May 1994.
2. Denning PH, Nakashima AK, Wortley P, et al. High-risk sexual behaviors among HIV-infected adolescents and young adults [Abstract]. Atlanta, Georgia: 1999 National HIV Prevention Conference, August 29--September 1, 1999; abstract no. 113.
3. Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985--1997. Am J Public Health 1999;89:1397--405.
4. Wolitski RJ, MacGowan RJ, Higgins DL, Jorgensen CM. The effects of HIV counseling and testing on risk-related practices and help-seeking behavior. AIDS Educ Prev 1997;suppl B: 52--67.
5. CDC. Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR 1999;48(no. RR-13).
6. Samet J, Hingson R, Savetsky JB, Sullivan LM, Stein MD. Sexual practices of HIV-infected persons at initial primary care presentation and six months later [Abstract]. Geneva, Switzerland: XII International Conference on AIDS, June 28--July 3, 1998; abstract no. 14178.
7. Osmond DH, Bindman AB, Vranizan K, et al. Name-based surveillance and public health interventions for persons with HIV infection. Ann Intern Med 1999;131:775--9.
8. Hecht FM, Chesney M, Lehman JS, et al. Does HIV reporting by name deter testing? AIDS (in press).
9. CDC. Anonymous and confidential HIV counseling and voluntary testing in federally funded testing sites---United States, 1995--1997. MMWR 1999;48:509--13.

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