AIDS and Behavior

, Volume 16, Issue 6, pp 1708–1715 | Cite as

Behavioral Surveillance Study: Sexual Risk Taking Behaviour in UK HIV Outpatient Attendees

  • Richard Harding
  • Claudine Clucas
  • Fiona C. Lampe
  • Sally Norwood
  • Heather Leake Date
  • Martin Fisher
  • Margaret Johnson
  • Simon Edwards
  • Jane Anderson
  • Lorraine Sherr
Original Paper

Abstract

This study aimed to determine demographic, behavioural and self-report disease/treatment variables among HIV-infected individuals (n = 666) that predict unprotected intercourse with a partner of unknown/discordant status. Sexual risk behaviour was reported by 12.8%. In multivariable analysis, risk was more likely to be reported by gay men compared to women or heterosexual men, and for those with higher psychological symptom burden. Psychological symptoms should be assessed and managed in the HIV outpatient setting to ensure integrated care that enhances prevention.

Keywords

HIV Behavior Risk Prevention 

Introduction

Analysis of UK data has revealed a high and increasing proportion of recent infections among new HIV diagnoses in the UK, with 50% of new diagnoses being recent infections among men who have sex with men (MSM) [1]. Further evidence suggests that between one quarter and one third of HIV-infected African migrants resident in the UK, and one half of HIV-infected migrant African MSM, may have acquired their HIV infection in the UK [2]. Community-based studies assessing sexual risk behaviour have reported that, among MSM, rates of unprotected anal sex with casual partners increased from the mid 1990s [3], but may have leveled off in recent years [4]. Among persons diagnosed with HIV, MSM have been found to be significantly more likely than Black Africans heterosexual individuals to report recent unprotected intercourse with a person of unknown or negative HIV status, thereby posing a risk of HIV transmission to an uninfected person [5, 6, 7, 8, 9].

Extrapolation from the most recent public health surveillance data in the UK suggests a strong health economic argument for redoubled effort to reduce new HIV infections. Prevention of the 3,550 HIV infections that were probably acquired in the UK, and subsequently diagnosed in 2008, would have reduced future HIV-related costs by more than £1.1 billion [10].

Studies among HIV-diagnosed individuals have examined a number of potential factors associated with sexual risk behaviours, although these studies have not generally included measures of the patient self-report experience of disease. Evidence suggests that a high psychological and physical symptom burden persists among HIV-diagnosed individuals despite new treatments [11, 12, 13, 14], and that patient-reported symptoms and health-related quality of life may be important predictors of clinical and virological outcomes [15, 16] but few studies have assessed the association of symptoms and quality of life with sexual risk behaviour.

This study aimed to determine the demographic, behavioural and self-report disease/treatment variables that predict sexual risk behaviour, defined as unprotected intercourse with a partner of unknown or negative HIV status, among HIV-infected outpatients in the UK.

Methods

This cross-sectional questionnaire study was conducted in five HIV outpatient clinics in London and Brighton in 2005/2006. Consecutive attending patients were approached and invited to participate (n = 1,007). The inclusion criteria (HIV positive adults with sufficient English language and cognitive/physical ability to self-complete) were fulfilled by 904 patients who received a questionnaire, of which 778 were completed and returned (77% of all patients, 86% of those eligible to receive a questionnaire). 666 provided information about risk behaviour and are included in the analysis. Multi-centre UK ethical approval was granted by the Royal Free Hospital Clinical Ethics Committee (ref 05/Q1907/26).

Data Collection

The questionnaire comprised of three components: demographics, behavioural/attitudinal measures and self-report disease/treatment oriented measures. The items and the item levels for responses used in subsequent analysis were as follows.

Demographic variables were age (continuous), gender/sexuality (three levels of female, heterosexual male, gay/bisexual male), ethnicity (Caucasian/non-Caucasian), country of birth (UK born or not), education (University level/not), and employment (paid employment or not).

The primary behavioural item used as the outcome measure for this analysis was sexual risk behaviour (defined as unprotected sexual intercourse with a partner of unknown or negative HIV status in the previous 3 months, or not). This was based on the following question “In the last 3 months have you had penetrative sex without a condom with anyone you weren’t sure also had HIV?” Additional behavioural items were: stable relationship in previous 3 months (yes/no, queried by asking participants. “In the last 3 months, have you been in a stable relationship?”); disclosure of HIV status to at least one other person (based on Kalichman [17] and analysed on two levels: disclosed status to no-one/disclosed status to at least one other person); STI diagnosed in the previous 3 months (yes/no) and number of sexual partners in the previous 3 months (none/one/more than one).

Attitudinal items were treatment optimism and infectiousness optimism. Infectiousness optimism was queried by asking participants the extent to which they believed that new drug therapies make people with HIV less infectious. Treatment optimism was queried by asking participants the extent to which they felt less worried about HIV infection now that new treatments have improved. The response scale for both items was from 1 (not at all) to 5 (a lot). Both items were analysed on two levels, optimistic or not: a score of 4 (quite a lot) or 5 (a lot) corresponded to optimistic and a score of 1 (not at all), 2 (a bit) or 3 (somewhat) corresponded to not optimistic) [18].

Disease/treatment items were current treatment status (on ART/off ART; the latter group included treatment naïve participants and those who had stopped their treatment), symptom scores based on the Memorial Symptom Assessment Scale Short Form, a standardised instrument that captures the presence of, and distress caused by 26 physical symptoms, and the presence and frequency of occurrence of six psychological symptoms, during the previous 7 days. Three subscale indices of Physical Symptom Distress (MSAS-Phys), Psychological Symptom Distress (MSAS-Psych) and Global Distress Index (MSAS-GDI) were derived [19]. Each of these three subscales is based on average symptom score for a range of symptoms and has a possible score range of 0–4. Full details of the scoring method have previously been described [19]. MSAS scores were divided into tertiles for the analysis. Health-related Quality of life was measured using the EUROQoL-5D and EUROQoL general health visual analogue scale, a brief, standardized, generic measure of health related quality of life that provides a profile of patient function and a global health state rating variable [20]. The EuroQoL scores were grouped into tertiles for analysis.

Analysis

Firstly, descriptive statistics were used to report the sample characteristics.

Logistic regression analysis was used to obtain odds ratios [with 95% confidence intervals (CI)] for univariable associations between the demographic, behavioural and disease/treatment self-report variables and reported unprotected sex with a partner of unknown or negative HIV status in the previous 3 months. Following univariable analysis, multivariable logistic regressions models were constructed, with unprotected sex with unknown/negative status partner as the dependent variable. Independent variables were entered simultaneously into the multivariable model if found significant in univariable analysis at the 15% level [21]. Cases with missing data were excluded from the multivariable models. Having been diagnosed with an STI was not included in the multivariable model as it is a potential proxy for risk behaviour. The model also excluded the number of sexual partners (0 vs. 1. vs. more than 1) because sexual risk behaviour is only relevant for participants with a sexual partner. A second multivariable model was however constructed among the subgroup of participants with a sexual partner to explore the role of number of sexual partners (1 vs. more than 1). A sensitivity multivariable analysis was undertaken adding a ‘missing’ category for those variables that had more than 30 missing values, and thereby including these missing cases in the analysis. SPSS version 15 was used to carry out the analyses.

Results

Sample Demographic Characteristics

The sample mean age was 40.3 years (SD = 8.5, range = 54). The majority identified as gay or bisexual males (n = 451, 67.7%), with n = 138 (20.7%) female and n = 62 (9.3%) heterosexual male (missing n = 15). The majority were Caucasian (n = 460, 69.1%), with n = 145 Black (21.8%), n = 18 Asian (2.7%), and n = 32 (4.8%) mixed/other (missing n = 11). The majority were UK born (351, 52.7%, missing n = 2). Overall, n = 294 (44.1%, missing n = 15) had a university degree, and 325 (48.8%) were in current paid employment (missing n = 55).

Behavioural/Attitudinal Variables

Unprotected sexual intercourse in the previous 3 months with a person who respondents were not sure was also HIV-infected was reported by 12.8% (85/666) of the sample. Half of the sample (n = 338, 50.8%) had been in a stable relationship in the previous 3 months (missing n = 32). With respect to optimism, 21.3% (n = 142) of the sample was optimistic (as defined in the “Methods” section) with regard to treatment (missing n = 50), and 19.5% (n = 130) were optimistic with regard to reduced infectiousness associated with antiretroviral treatment (missing n = 41). An STI had been diagnosed in the previous 3 months among 8.3% of respondents (n = 55) (missing n = 92), and 6.2% respondents (n = 41) had not disclosed their HIV status to anyone (missing n = 65). With respect to number of sexual partners, 157 (23.6%) had none, 242 (36.3%) had 1 and 200 (30%) had more than 1 partner (missing n = 67).

Disease/Treatment Variables

The majority of patients were currently on ART (455, 68.3%), with 136 (20.4%) treatment naïve (the remaining 51 having stopped treatment, missing n = 24). The mean number of reported symptoms was 17.7 (SD = 12.1), the mean (standard deviation) symptom distress subscale indices were physical distress 0.80 (0.7), psychological distress 1.32 (1.0) and global distress 1.14 (0.8). With respect to quality of life, the mean score on the EUROQoL 5D was 0.7 (SD 0.3), and general health on the visual analogue scale had a mean score of 67.8 (SD 20.7) on a scale of 0–100.

Associations with Risk Exposure Behaviour

The univariable analyses are reported in Table 1. Demographic factors significantly associated with unprotected sex with a negative/unknown status partner were gender/sexuality (gay/bisexual men were much more likely to report unprotected sex compared to heterosexual men and women), UK birth, and university education (P < 0.05 for all). There was a trend for younger age to be associated with reporting unprotected sex (P = 0.090). There was no association with ethnicity or employment. The proportion reporting unprotected sex was somewhat lower among patients who had not had a stable relationship in last 3 months (P = 0.14), but did not differ according to treatment or infectiousness optimism. Having had a recent STI diagnosed was strongly associated with reporting unprotected sex (P < 0.001) and there was a trend for disclosure of HIV status (to at least one other person) to be associated with reporting unprotected sex (P = 0.079). The psychological symptom score was positively associated with unprotected sex (P = 0.040 for trend across tertiles), but there was no significant association with physical or global symptom scores, or quality of life measures. Patients on ART were less likely than those off ART to report unprotected sex (P = 0.055). Patients with more than one sexual partner were more likely than those with one sexual partner to report unprotected sex (P < 0.001).
Table 1

Univariate analyses for n = 666 who provided data on sexual risk behaviour

 

N

Yes for sexual risk behaviour (%)

N = 85

No for sexual risk behavior (%)

N = 581

Odds ratio (95% CI)

P value

Demographic variables

Age in years

    

 0.017*

 17–36

222

14.9

85.1

1

 

 37–42

204

15.2

84.8

1.03 (0.60, 1.75)

 

 43–72

228

7.5

92.5

46 (0.25, 0.85)

 

Gender/sexuality

    

0.006

 Female

138

5.8

94.2

1

 

 Heterosexual male

62

6.5

93.5

1.12 (0.32, 3.87)

 

 Gay/bisexual male

451

15.3

84.7

2.93 (1.38, 6.27)

 

Ethnicity

    

0.179

 Caucasian

460

14.1

85.9

1.44 (0.85, 2.45)

 

 Non-Caucasian

195

10.3

89.7

1

 

UK born

    

0.020

 Yes

351

15.7

84.3

1.75 (1.09, 2.82)

 

 No

313

9.6

90.4

1

 

University education

    

0.035

 Yes

294

15.6

84.4

1.65 (1.04, 2.64)

 

 No

357

10.1

89.9

1

 

Paid employment

    

0.394

 Yes

325

12

88

81 (0.51, 1.30)

 

 No

286

14.3

85.7

1

 

Behavioural/attitudinal variables

Stable relationship in past 3 months

    

0.142

 Yes

296

10.9

89.1

70 (0.44, 1.12)

 

 No

338

14.9

85.1

1

 

Infectiousness optimism

    

0.714

 Yes

130

12.3

87.7

0.90 (0.50, 1.61)

 

 No

495

13.5

86.5

1

 

Treatment optimism

    

0.280

 Yes

142

16.2

83.8

1.33 (0.79, 2.25)

 

 No

474

12.7

87.3

1

 

Disclosed HIV status

    

0.079

 Yes

560

13.0

87.0

6.00 (0.81, 44.28)

 

 No

41

2.4

97.6

1

 

Diagnosed STI in last 3 months

    

0.001

 Yes

55

34.5

65.5

4.74 (2.5, 8.86)

 

 No

519

10.0

90.0

1

 

Sexual partner in last 3 months (for patients with at least one sexual partner only)

    

0.001

 1

242

4.1

95.9

1

 

 >1

200

31.0

69.0

10.42 (5.17, 21.00)

 

Disease/treatment variables

Taking ART

    

0.055

 Yes

455

10.5

89.5

0.62 (0.38, 1.01)

 

 No

187

16.0

84.0

1

 

MSAS global distress score

    

0.371*

 <0.64

202

11.4

88.6

1

 

 0.64–1.44

229

12.2

87.8

1.08 (0.60, 1.95)

 

 >1.44

232

14.2

85.8

1.29 (0.73, 2.28)

 

MSAS physical distress score

    

0.913*

 <0.33

211

10.4

89.6

1

 

 0.33–1

213

15.5

84.5

1.58 (0.89, 2.80)

 

 >1

205

10.7

89.3

1.03 (0.55, 1.93)

 

MSAS psychological distress score

    

0.040*

 <0.73

221

9.5

90.5

1

 

 0.73–1.73

217

12.4

87.6

1.35 (0.74, 2.48)

 

 >1.73

211

16.1

83.9

1.83 (1.02, 3.27)

 

Quality of life 5D score

    

0.669*

 <0.69

196

10.2

89.8

1

 

 0.69–0.83

136

15.4

84.6

1.61 (0.83, 3.10)

 

 >0.83

282

12.1

87.9

1.21 (0.67, 2.17)

 

Quality of life VAS—general health score

    

0.180*

 <60

201

13.9

86.1

1

 

 60–79

213

15

85

1.09 (0.63, 1.89)

 

 >79

252

9.9

90.1

0.68 (0.38, 1.21)

 

* Test for trend

The main multivariable logistic regression is reported in Table 2, including all factors with P < 0.15 in univariable analyses (with the exception of STI diagnosis), and based on 517 patients with complete data. Gender/sexuality and psychological symptom index were associated with unprotected sex. Compared to women, adjusted odds ratios (95% CI) of unprotected sex were 3.6 (0.0.5, 28.7) for heterosexual men and 7.1 (1.6, 30.6) for gay/bisexual men (P = 0.027). Compared to patients with a low psychological symptom score (1st tertile), adjusted odds ratios for the 2nd and 3rd tertiles were 1.9 (0.9, 4.1) and 2.6 (1.2, 5.5), respectively (P = 0.016 for trend). There was also evidence that education status was independently associated with unprotected sex [adjusted odds ratio (95% CI) 1.7 (1.0, 3.1) for university education compared to other, P = 0.061].
Table 2

Multivariable logistic regression with dependent variable of sexual risk behaviour, n = 517, Yes (n = 58), No (n = 459)

Variables

Groups

N

Odds ratio (95% CI)

P value

Age in years (entered as trend, per unit increase)

17–36

182

1

0.149 for trend

37–42

159

1.09 (0.56, 2.13)

43–72

176

57 (0.27, 1.21)

Gender/sexuality

Female

104

1

0.027

Heterosexual male

43

3.78 (0.49, 28.93)

Gay/bisexual male

370

7.06 (1.63, 30.58)

UK born

Yes

284

1.38 (0.74, 2.58)

0.313

No

233

1

Stable relationship in past 3 months

Yes

280

0.75 (0.42, 1.35)

0.338

No

237

1

Disclosure of HIV status

Yes

483

0.000

0.998

No

34

1

Taking ART

Yes

368

0.72 (0.39, 1.33)

0.294

No

149

1

Education

University or above

246

1.74 (0.98, 3.11)

0.061

Non-university

271

1

MSAS-Psych score (entered as trend, per unit increase)

<0.73

173

1

0.016 for trend

0.73–1.73

176

1.87 (0.85, 4.10)

>1.73

168

2.55 (1.18, 5.49)

The second multivariable logistic regression among participants with a sexual partner is reported in Table 3, including number of sexual partners in addition to all factors included in the first multivariable logistic regression, and based on 344 patients with complete data. Number of sexual partners and psychological symptom index were independent predictors of unprotected sex in this subgroup. Compared to patients with 1 sexual partner, adjusted odds ratios (95% CI) of unprotected sex were 7.96 (3.01; 21.03) for patients with more than one sexual partner (P < 0.001). Compared to patients with a low psychological symptom score (1st tertile), adjusted odds ratios for the 2nd and 3rd tertiles were 2.72 (1.03, 7.19) and 4.20 (1.59, 11.05), respectively (P = 0.004 for trend).
Table 3

Multivariable logistic regression with dependent variable of risk behaviour among participants with a sexual partner, n = 344, Yes (n = 50), No (n = 294)

Variables

Groups

N

Odds ratio (95% CI)

P value

Age (entered as trend, per unit increase)

17–36

126

1

0.629 for trend

37–42

109

1.20 (0.54, 2.67)

43–72

109

0.80 (0.34, 1.88)

Gender/sexuality

Female

53

1

0.595

Heterosexual male

24

3.75 (0.19, 74.69)

Gay/bisexual male

267

3.01 (0.33, 27.24)

UK born

Yes

197

1.80 (0.83, 3.89)

0.135

No

147

1

Stable relationship in past 3 months

Yes

197

0.89 (0.45, 1.79)

0.751

No

147

1

Disclosure of HIV status

Yes

336

0.000

0.999

No

8

1

Taking ART

Yes

237

0.71 (0.35, 1.43)

0.335

No

107

1

Number of sexual partners in past 3 months

1

187

1

<0.001

More than 1

157

7.93 (3.00; 20.93)

Education

University or above

170

1.73 (0.88, 3.42)

0.113

Non-university

174

1

MSAS-Psych score (entered as trend, per unit increase)

<0.73

112

1

0.004 for trend

0.73–1.73

121

2.66 (1.00, 7.07)

>1.73

111

4.22 (1.60, 11.14)

For the sensitivity analyses a ‘missing’ category was included for the following variables that had more than 30 missing values: employment, stable relationship, treatment and infectiousness optimism, disclosure, diagnosed STI, and quality of life. The multivariable associations of gender/sexuality, education, and psychological symptoms, with risk behaviour were similar in the multivariable model when subjects with missing values for one or more of the explanatory variables were included (n = 613 in first multivariable model; results not shown).

Discussion

In our study of HIV outpatients, 12.8% of participants reported sexual risk behaviour (unprotected sex in the previous 3 months with someone who was HIV-negative or of unknown HIV status), demonstrating an ongoing need for appropriate intervention to improve primary prevention. Gay/bisexual males, and those with higher MSAS-SF psychological distress scores, were significantly more likely to report risk behaviour. The identification of gay/bisexual males and those with a higher psychological burden offers clinical services an opportunity to target their resources toward those most likely to engage in risk. A trend was identified for those with a university degree or higher qualification to be more likely to report sexual risk behaviour than those with other or no educational qualifications; this trend did not appear to be explained by confounding with gay male identity. Among the subgroup of patients who had at least one sexual partner in the past 3 months, the psychological symptom score remained a strong independent predictor of sexual risk behaviour, together with the number of sexual partners.

The overall prevalence of 12.8% for unprotected sex in the past 3 months with an HIV-discordant partner is almost identical to that found in the East London study of HIV outpatients carried out in 2004/2005 (prevalence 13.2% using the same definition). These figures appear lower that those found in community venue-based studies of MSM [6, 8] but are likely to be more representative of the HIV diagnosed population overall.

Factors identified in previous studies to be associated with unprotected sex between HIV discordant status partners include younger age, alcohol, and recreational drug use [22]. There is also some evidence from previous studies of an association with psychological variables such as depression, lower self-efficacy and less optimistic attitude [22]. The association seen in this study between sexual risk behaviour and higher educational status differs from that found in some previous studies [23].

There was evidence in univariable analysis that those on ART were less likely to have unprotected sex than those not taking treatment, although this association was attenuated after adjustment for other factors. These results are broadly consistent with previous studies, which have found either no association between ART use and sexual risk behaviour among HIV-positive individuals [5, 24, 25] or a negative association between ART use and risk behaviour [26, 27, 28]. However one recent study of Swiss HIV patients found that individuals on ART and those with suppressed viral load reported higher levels of unprotected sex with stable partners [29]. With increasing awareness and publicity regarding the effect of viral suppression on HIV-transmission risk, continued monitoring of the relationship between ART use and sexual risk behaviour among UK HIV-patients will be important.

There are some limitations to our conclusions. Firstly, the sample is restricted to outpatients who agreed to participate in the study and had sufficient written English language to self complete the questionnaire. Secondly, the cross-sectional nature of the data can only establish associations and not causality. For example, it is possible that the practice of unsafe sex led to psychological symptom distress rather than the other way round. Thirdly, as with all studies of this topic, it is possible that there may be differential reporting bias in sexual risk behaviour according to factors such as social class, ethnicity or sexuality.

Our data present evidence that psychological wellbeing should be routinely assessed among outpatient attendees, and that adequate attention should be paid to the management of psychological problems. Previous evidence among gay men has suggested that poor mental health is a primary unmet need and that psychological wellbeing is not routinely assessed [30]. The present data suggest that physical, psychological, and behavioural interventions should not be delivered separately, and that integrated approaches to clinical management of HIV may improve both the self-report experience of disease and levels of behavioural risk.

Notes

Acknowledgments

We wish to acknowledge the contribution of Gilly Arthur and Sarah Zetler. Also research assistance from Amanda Jayakody, research nurses at participating clinics, and all survey respondents. We are grateful to Lucy Bradley for manuscript management. This research was assisted with an unrestricted educational grant from GlaxoSmithKline, with input from the Adherence Strategy Group.

Conflict of interest

The authors state they have no conflict of interest.

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Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Richard Harding
    • 1
  • Claudine Clucas
    • 2
  • Fiona C. Lampe
    • 2
  • Sally Norwood
    • 3
  • Heather Leake Date
    • 4
  • Martin Fisher
    • 4
  • Margaret Johnson
    • 5
  • Simon Edwards
    • 6
  • Jane Anderson
    • 7
  • Lorraine Sherr
    • 3
  1. 1.Department of Palliative Care, Policy and Rehabilitation, King’s College LondonCicely Saunders Institute, King’s Health PartnersLondonUK
  2. 2.Research Department of Infection and Population HealthRoyal Free University College Medical SchoolLondonUK
  3. 3.Department of Primary Care and Population SciencesRoyal Free University College Medical SchoolLondonUK
  4. 4.Brighton & Sussex University Hospitals NHS TrustBrightonUK
  5. 5.Royal Free Centre for HIV MedicineRoyal Free University College Medical SchoolLondonUK
  6. 6.Department of Genitourinary MedicineMortimer Market Centre, Camden PCTLondonUK
  7. 7.Homerton University Hospital NHS Foundation TrustLondonUK

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