Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS

doi:10.1016/S0140-6736(00)04007-1

The Lancet

Volume 357, Issue 9254, 10 February 2001, Pages 432-435

https://doi.org/10.1016/S0140-6736(00)04007-1 Get rights and content

Summary

Background

There has been an increase in high-risk sexual behaviour and sexually transmitted diseases (STD) during the time period when highly active antiretroviral therapy (HAART) became widely available. We examined whether taking HAART increased the risk of acquiring an STD—an epidemiological marker of unsafe sex—in people with AIDS.

Methods

We did a computerised match of people in the San Francisco STD and AIDS registries. People with AIDS who were diagnosed before 1999 and alive in November, 1995, or later, were classified as having had an STD after AIDS diagnosis or not having had an STD after AIDS diagnosis. We used a Cox proportional hazards model to see whether use of antiretroviral therapy was associated with acquiring an STD after AIDS, after adjustment for sex, age, race, HIV-1 risk category, and CD4 count at AIDS diagnosis.

Findings

People with AIDS who had had HAART showed an independent increase in the risk of developing an STD (hazard ratio 4·10; 95% CI 2·84–5·94). Americans of African origin, younger age, and higher CD4 count at AIDS diagnosis were also associated with acquiring an STD after AIDS. The number of people living with AIDS who acquired an STD increased over time from 60 (0·66%) in 1995 to 113 (1·32%) in 1998 (p<0·001).

Interpretation

We have shown that people on HAART are more likely to develop an STD, an epidemiological marker of unsafe sex. More intensive risk-reduction counselling and STD screening for people with AIDS is needed.

Introduction

The use of highly active antiretroviral therapy (HAART) has substantially lowered morbidity and mortality from HIV-1 infection1, 2 and has improved the quality of life of HIV-1 infected people.3, 4 These newer treatments have also been effective in decreasing serum⁵ and genital fluid concentrations of HIV-1,5, 6, 7, 8 thereby potentially reducing sexual transmission of HIV-1.9, 10, 11

Several reports have documented increases in high-risk sexual behaviour and sexually transmitted diseases (STD) with the increased availability of HAART.12, 13, 14 There is also evidence that uninfected individuals are less worried about acquiring HIV-1 infection,15, 16, 17, 18, 19, 20 and that there has been a decrease in the perceived risk of sexual activity with HIV-1 infected people on HAART.21, 22, 23 Additionally, the presence of STDs has been shown to increase genital HIV viral load²⁴ and could affect the resistance pattern of genital HIV-1.²⁵

Non-HIV-1 STDs are epidemiological markers for unprotected sexual activity that may also transmit HIV-1.²⁶ Moreover, presence of an ulcerative or inflammatory STD increases the likelihood of HIV-1 transmission and acquisition.²⁷ We have therefore assessed whether taking HAART increases the risk of acquiring an STD in people with AIDS.

Section snippets

Selection of participants

AIDS surveillance in San Francisco is done by active and passive reporting, and has been reported to be more than 95% complete.²⁸ We did a computerised match of people in the San Francisco STD and AIDS registries. Adults (13 years or older) who were diagnosed with AIDS before 1999 and were alive in November, 1995, or later (the time that HAART became available) were included.²⁹ The Centers for Disease Control and Prevention, USA, 1993 AIDS case definition was used. The vital status of AIDS

Results

There were 11 832 people living with AIDS in San Francisco between 1995 and 1999. We excluded 316 people who did not have any follow-up information in the AIDS registry. The race, age, and sex of those excluded did not differ significantly from those included. Of the remaining 11 516 people, 233 (2%) were diagnosed with an STD after the date of their AIDS diagnosis. Most STD diagnoses were in men who have sex with men. The most common STDs were gonorrhoea, diagnosed in 196 cases (84%) and

Discussion

Several studies have reported increases in unsafe sex with the advent of HAART.12, 13, 14 We have confirmed these findings and shown that people on HAART are actually more likely to develop an STD.

One possible reason that HAART is associated with developing an STD is that people on such treatment are likely to feel better and have an increased interest in sex,3, 4, 30 which lent support to our finding that a higher CD4 count at time of AIDS diagnosis (a marker of better health) was also

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ArticlesEffect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Selection of participants

Results

Discussion

Lancet

Soc Sci Med

Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection

N Engl J Med

Effectiveness of potent antiretroviral therapy on time to AIDS and death in men with known HIV infection duration

JAMA

Quality of life in asymptomatic and symptomatic HIV infected persons in a trial of ritonivur/saquinivir therapy: the Prometheus Study Group

AIDS

High viral load in semen of human immunodeficiency virus type-1 infected men at all stages of disease and its reduction by therapy with protease and nonnucleoside reverse transcriptase inhibitors

J Virol

Effect of antiviral treatment on the shedding of HIV-1 in semen

AIDS

Quantification of HIV in semen: correlation with antiviral treatment and immune status

AIDS

Potent antiretroviral treatment of HIV-1 infection results in suppression of the seminal shedding of HIV

AIDS

Potential for the transmission of HIV-1 despite highly active antiretroviral therapy

N Engl J Med

Sexual transmission of HIV: infectiousness and prevention

AIDS

Viral load and heterosexual transmission of human immunodeficiency virus type 1: Rakai Project Study group

N Eng J Med

Increases in unsafe sex and rectal gonorrhoea among men who have sex with men—San Francisco, California, 1994–95

MMWR Morb Mortal Weekly Rep

Gay men report high rates of unprotected anal sex with partners of unknown or discordant status

AIDS

Are advances in treatment changing views about high-risk sex?

N Engl J Med

Articles
Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS