HIV status of sexual partners is more important than
antiretroviral treatment related perceptions for risk taking by
HIV positive MSM in Montreal, Canada
J Cox, J Beauchemin, R Allard
See end of article for
Joseph Cox, 1301
Sherbrooke Street East,
Montreal, Quebec, H2L
1M3 Canada; jcox@
Accepted for publication
9 September 2004
Sex Transm Infect 2004;80:518–523. doi: 10.1136/sti.2004.011288
Objective: To examine the role of antiretroviral treatment related perceptions relative to other clinical and
psychosocial factors associated with sexual risk taking in HIV positive men who have sex with men (MSM).
Methods: Participants were recruited from ambulatory HIV clinics in Montreal. Information on
sociodemographic factors, health status, antiretroviral treatment related perceptions, and sexual
behaviours was collected using a self administered questionnaire. At-risk sexual behaviour was defined
as at least one occurrence of unprotected insertive or receptive anal intercourse in the past 6 months.
Multivariate logistic regression was performed to evaluate the associations between at-risk sexual
behaviour and covariates.
Results: 346 subjects participated in the study. Overall, 34% of subjects were considered at risk; 43% of
sexually active subjects (n=274). At-risk sexual behaviour was associated with two antiretroviral treatment
related perceptions: (1) taking antiretroviral treatment reduces the risk of transmitting HIV (adjusted odds
ratio (OR), 2.10; 95% confidence interval (CI), 1.16 to 3.80); and (2) there is less safer sex practised by
MSM because of HIV treatment advances (OR, 1.82; CI, 1.14 to 2.90). Other factors, however, were more
strongly associated with risk. These were: (1) safer sex fatigue (OR, 3.23; CI, 1.81 to 5.78); (2) use of
‘‘poppers’’ during sexual intercourse (OR, 6.28; CI, 2.43 to 16.21); and (3) reporting a greater
proportion of HIV positive anal sex partners, compared with reporting no HIV positive anal sex partners:
(a) ,50% HIV positive (OR, 16.79; CI, 4.70 to 59.98); (b) >50% HIV positive (OR, 67.67; CI, 15.43 to
Conclusion: Despite much emphasis on HIV treatment related beliefs as an explanation for sexual risk
taking in MSM, this concern may play a relatively minor part in the negotiation of risk by HIV positive
MSM. Serosorting, safer sex fatigue, and the use of poppers appear to be more important considerations
in understanding the sexual risk behaviours of HIV positive MSM.
HIV cases were in MSM and the percentage of incident HIV
cases annually increased by 17% over this time.1High rates of
new HIV infection in MSM continue to be observed in some
Canadian cities.2Since 2000, a cohort study of MSM in
Montreal observed an increase in annual HIV incidence from
0.43 to 0.83 per 100 person years overall. Although this
increase was not statistically significant, during the same
time period there was a 20% increase in unprotected receptive
anal sex.3This return to less safer sex in the HIV negative
MSM population has also been documented in other
jurisdictions.4 5In addition, increases in the incidences of
other sexually transmitted infections (STIs) such as rectal
gonorrhoea and infectious syphilis have been documented.4–7
Antiretroviral medications for the treatment of HIV have
been available for more than a decade. The positive impact of
highly active antiretroviral therapy (HAART) on morbidity
and mortality has been well described.8
Several researchers have proposed a link between HAART
and the at-risk sexual behaviours of MSM.5 7 9 10It has been
suggested that HAART might increase sexual practices that
lead to transmission of HIV and other STIs. That is, as a result
of HAART, HIV negative MSM are less concerned about
contracting HIV, HIV positive MSM are less concerned about
transmitting it, and both groups are more likely to engage in
unsafe sex, resulting in more HIV infection.11
en who have sex with men (MSM) continue to be one
of the populations most affected by HIV infection. In
the United States during 1999–2002, 42% of incident
The literature on this topic is equivocal for both HIV
negative,9 12and HIV positive MSM.4 12–16Regardless, the
hypothesis of ‘‘treatment optimism’’ as the reason for
observed at-risk behaviours of HIV positive MSM has
received a great deal of attention.9 12 14 16 17A recent review
of determinants of at-risk sexual behaviours for people living
with HIV, however, highlights the numerous psychological,
social, interpersonal, as well as treatment related factors
associated with risk taking.18
There are good epidemiological and clinical reasons to
study the role of antiretroviral treatment related perceptions
relative to the sexual risk behaviours of HIV positive MSM.
MSM are thought of as a sentinel population in a constantly
changing epidemic and as such may experience or exhibit
changes in risk behaviours first. Also, primary HIV resis-
tance19and HIV ‘‘superinfection’’ have been identified as
important and potentially disastrous consequences of at-risk
sexual behaviours.20Recent trends in the occurrence of rectal
gonorrhoea and syphilis among both HIV negative and HIV
positive MSM further justify efforts to better understand this
issue.7 21 22Clearly, a definition of at-risk sexual behaviours
which includes risk for transmission to others as well as
acquisition of treatment resistant virus and other STIs is
Abbreviations: HAART, highly active antiretroviral therapy; MSM, men
who have sex with men; STIs, sexually transmitted infections
JC and JB designed and implemented the study; RA provided input
regarding study design and sample size estimation; all authors
participated in the analysis of data and interpretation of study
results; JC was the lead author on the manuscript; JB and RA
assisted in editing and finalising the initial and revised manuscripts.
J Cox, J Beauchemin, R Allard, Montreal Public Health Department,
J Cox, J Beauchemin, R Allard, National Institute of Public Health of
Quebec, Montreal, Canada
J Cox, Immune Deficiency Treatment Centre, Montreal General Hospital,
McGill University Health Centre, Montreal, Canada
J Cox, R Allard, McGill University, Montreal, Canada
Conflict of interest: None.
Ethical approval: The study protocol and questionnaire were reviewed
and approved by the McGill University Faculty of Medicine Institutional
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