Psychosocial correlates of inconsistent condom use among HIV-infected patients enrolled in a structured ART interruptions trial in Côte d’Ivoire: results from the TRIVACAN trial (ANRS 1269)
2010; Wiley; Volume: 15; Issue: 6 Linguagem: Inglês
10.1111/j.1365-3156.2010.02524.x
ISSN1365-3156
AutoresCamélia Protopopescu, Fabienne Marcellin, Marie Préau, Delphine Gabillard, Raoul Moh, Albert Minga, Amani Anzian, Patrizia Carrieri, Christine Danel, Bruno Spire,
Tópico(s)HIV, Drug Use, Sexual Risk
ResumoObjective To investigate the relationship between unsafe sexual behaviours and poor self-perceived health among people living with HIV and AIDS (PLWHA) in western Africa. Methods In March 2006, a survey was conducted among patients continuing their participation in the TRIVACAN trial (ANRS 1269) in Côte d’Ivoire, in which patients had been randomized to either continuous or interrupted antiretroviral therapy (ART) (2-months-off/4-months-on cycles [2/4-ART]) after 6–18 months of continuous ART (C-ART). Socio-demographic and psychosocial information, including data on sexual behaviours during the previous 6 months, was collected using face-to-face interviews. Sexually active patients with either a steady partner (serodiscordant or of unknown HIV status) or casual partners were considered to have unsafe sexual behaviours if they reported inconsistent condom use (ICU). Results Seventy-seven of the 192 patients reported ICU. In multivariate logistic regression, men were significantly less likely to report ICU than women (OR [95% CI] = 0.45 [0.20–0.98]). After adjustment for educational level and reduced sexual activity since ART initiation, concealment of HIV status (2.08 [1.02–4.25]) and poor self-perceived health (2.32 [0.97–5.52]) were independently associated with ICU. Conclusion HIV prevention strategies in resource-limited settings should take into account self-perceived health and difficulties to disclose HIV status. Counselling interventions need to be developed to help PLWHA to adopt or negotiate safe behaviours respecting their individual cultures. Corrélats psychosociaux de l’utilisation irrégulière du préservatif chez les patients séropositifs inclus dans un essai structuré sur les interruptions de l’ART en Côte d’Ivoire: Résultats de l’étude TRIVACAN (ANRS 1269) Objectif: Investiguer la relation entre les comportements sexuels à risque et une mauvaise perception sur la santé pour les personnes vivant avec le VIH et le SIDA en Afrique occidentale. Méthodes: En mars 2006, une surveillance a été menée auprès des patients poursuivant leur participation à l’essai TRIVACAN en Côte d’Ivoire, dans lequel ils ont été randomisés pour recevoir la thérapie antirétrovirale (ART) soit en continue, soit en discontinue (cycles de 2-mois-avec/4-mois-sans) après 6 à 18 mois continus sous ART. Des informations sociodémographiques et psychosociales comprenant des données sur les comportements sexuels au cours des six précédents mois ont été recueillies lors d’interviews face-à-face. Les patients sexuellement actifs avec un partenaire stable (sérodiscordants ou de statut sérologique inconnu) ou occasionnel ont été considérés comme ayant des comportements sexuels à risque s’ils rapportaient une utilisation irrégulière du préservatif (UIP). Résultats: 77 des 192 patients ont rapporté une UIP. Dans la régression logistique multivariée, les hommes étaient nettement moins susceptibles de rapporter une UIP que les femmes (OR [IC95%] = 0,45 [0,20-0,98]). Après ajustement pour le niveau d’instruction et l’activité sexuelle réduite depuis le début de leur traitement, la dissimulation du statut VIH (2,08 [1,02-4,25]) et une mauvaise perception sur la santé (2,32 [0,97-5,52]) étaient indépendamment associées à l’UIP. Conclusion: les stratégies de prévention du VIH dans les pays à ressources limitées devraient tenir compte de l’auto-perception sur la santé et des difficultés à révéler la séropositivité. Des interventions de conseil devraient être développées afin d’aider les personnes vivant avec le VIH et le SIDA à adopter ou à négocier des comportements sûrs en respectant leurs cultures individuelles. Correlación entre variables psicosociales y el uso inconsistente de preservativos por pacientes infectados con VIH participando en un ensayo estructurado de interrupción del TAR en Costa de Marfil: resultados del ensayo TRIVACAN (ANRS 1269) Objetivo: Investigar la relación entre los comportamientos sexuales no seguros y una autopercepción de mala salud entre personas que viven con VIH y SIDA (PVCVS) en África Occidental. Métodos: En Marzo 2006, se realizó un estudio entre pacientes que participaban en el ensayo TRIVACAN en Costa de Marfil, en la cual los pacientes habían sido aleatorizados bien para una terapia continua o interrumpida (en ciclos de 2-meses-sin/4-meses-con) con antirretrovirales (TAR) tras haber recibido entre 6 y 18 meses de TAR continuado. Se recolectó información socio-demográfica y psicosocial, incluyendo datos sobre el comportamiento sexual durante los seis meses anteriores, mediante entrevistas cara a cara. Los pacientes sexualmente activos con una pareja estable (con estatus serológico discordante o estatus de VIH desconocido) o compañeros esporádicos fueron considerados como teniendo un comportamientos sexual no seguro si reportaban un uso inconsistente de preservativos (UIP). Resultados: 77 de los 192 pacientes reportaron UIP. En una regresión logística multivariada, era significativamente menos probable que los hombres reportasen UIP que las mujeres (OR[95% IC] = 0.45[0.20-0.98]). Después de ajustar para el nivel educativo y una reducción de la actividad sexual desde la iniciación del TAR, el esconder el estatus de VIH (2.08[1.02-4.25]) y una autopercepción de mala salud (2.32[0.97-5.52]) estaban asociados de manera independiente con UIP. Conclusión: Las estrategias de prevención del VIH en lugares con recursos limitados deberían tener en cuenta la autopercepción de la salud y las dificultades para revelar el estatus de VIH. Es necesario desarrollar intervenciones con aconsejamiento con el fin de ayudar a PVCVS a adoptar o negociar comportamientos seguros, respetando sus culturas individuales. Unsafe sexual behaviours remain the predominant mode of HIV transmission in sub-Saharan Africa (UNAIDS 2008). Few studies have analysed the determinants of such behaviours in poor-resource settings (Kiene et al. 2006; Bunnell et al. 2008), notably among patients initiating antiretroviral therapy (ART) (Moatti et al. 2003; Diabate et al. 2008). In addition, psychosocial correlates of unsafe sex have only been investigated in high-income countries (Vincent et al. 2004; Bouhnik et al. 2006). Data collected during the TRIVACAN trial (ANRS 1269) of structured ART interruptions enabled us to investigate the relationship between unsafe sexual behaviours and poor self-perceived health among people living with HIV and AIDS (PLWHA) in Côte d’Ivoire. TRIVACAN (ANRS 1269) is a randomized trial of structured ART interruptions conducted in Abidjan, Côte d’Ivoire between 2002 and 2007 among 840 ART-naive HIV-infected adults (Danel et al. 2006). After 6–18 months of continuous treatment with zidovudine plus lamivudine plus either efavirenz (600 mg once a day) or indinavir (800 mg twice a day) as well as ritonavir (100 mg twice a day) (for HIV-2-infected patients, women refusing contraception, and women with a history of nevirapine prophylaxis), patients with CD4 count >350 cells/mm3 and plasma HIV RNA level 16 obtained on the CES-D scale (Furher & Rouillon 1989)). A perceived health index was calculated as follows: patients who reported having less than 12 symptoms (the mean number of symptoms reported by study patients during the previous 6 months) and who perceived their health status as ‘very good’ were considered as having ‘good’ self-perceived health, while the others were considered as having ‘poor’ self-perceived health. Logistic regression models were used to identify factors associated with ICU. Factors with a P-value 0.25). In the same way, treatment strategy (CT vs. 2/4-ART), treatment status at the time of the survey and HIV viral load at last assessment were not significantly associated with ICU. In the multivariate analysis, female gender, poor self-perceived health and concealment of HIV status were independent predictors of ICU, after adjustment for educational level and reduced sexual activity since ART initiation. The present study in Côte d’Ivoire clearly shows that ICU is relatively frequent even among ART-treated patients, and that it concerns especially women, individuals concealing their HIV status, and individuals reporting poor self-perceived health. Interestingly, no significant relationship was found between patients’ report of ICU and the treatment strategy to which they were allocated or to their treatment status at the time of the survey. These results bring additional evidence about the absence of more frequent unsafe sexual behaviours while on ART (Crepaz et al. 2004). They may also be paralleled with the results of a recent Kenyan study underlining that psychosocial support plays a stronger role than treatment itself in creating favourable conditions for safe sexual behaviour (Sarna et al. 2008). Patients’ perception of their health status was the only health-related factor found to be significantly associated with ICU. This echoes evidence from studies conducted in France among specific subpopulations of PLWHA with other indicators of perceived health, such as poor mental health-related quality of life among gay men (Bouhnik et al. 2006) and self-reported side effects among injecting drug users (Vincent et al. 2004). Female gender was also found to be associated with ICU (Glass et al. 2004). It has long been observed that, in heterosexual relationships, women often prefer not to use condoms because of their emotional attachment to their partners (Fullilove et al. 1990; Maticka-Tyndale 1992). In addition, in many African countries, women’s social status is closely related to their ability to have children (Caldwell et al. 1992; WHO 1994), with those without children facing disgrace and rejection (Desgrées du Loû & Ferry 2005; Criton & Fener 2007). The desire to have children to overcome social stigma may thus take precedence over the risk of infecting someone else with HIV (Moore & Oppong 2007). It is also possible that some women do not even consider using condoms in the context of steady partnerships (Moore & Oppong 2007). Finally, social phenomena such as cross-generational relationships with financial motivation must be taken into account. In such relationships, material gain, sexual gratification, emotional factors and recognition from peers often override concerns about the risk of sexually transmitted infections (Longfield et al. 2004). The present study also shows that educational level has a significant impact on protective behaviours, as already observed in previous studies conducted in several sub-Saharan Africa countries (Lagarde et al. 2001; Zellner 2003; De Walque 2006). This could be explained by a higher efficacy of HIV prevention campaigns among educated populations (De Walque 2007). Individuals with a lower education level may also have more difficulties to negotiate condom use. However, it must be pointed out that the relationship between educational attainment level and HIV prevalence in developing countries is complex and changes from place to place and by stage of epidemic. Indeed, large studies in four areas in Africa showed an increased risk of HIV infection among the more educated (Hargreaves & Glynn 2002). In addition, a recent study in Tanzania (Hargreaves & Howe 2010) shows that HIV prevalence significantly decreased between 2003 and 2007 among people with primary or secondary education, while it remained stable among people with no education, which suggests that prevalent HIV infections in Tanzania are now concentrating among less educated groups. Concealment of seropositivity was also associated with ICU, as already shown in South Africa among PLWHA in clinical care (Kiene et al. 2006), and in France among serodiscordant homosexual couples (Bouhnik et al. 2007). These findings underline the dilemma that PLWHA face between disclosing their HIV status to potential sexual partners and protecting these partners as well as themselves against infection or super infection (Schiltz & Sandfort 2000). The present study is limited by its cross-sectional design, which prevents the possibility of exploring longitudinal changes in PLWHA’s sexual behaviours. However, to our knowledge, it is the first study to document sexual behaviour in the context of planned ART interruptions in sub-Saharan Africa. In conclusion, this study highlights the importance of social barriers to the use of condoms in sub-Saharan Africa, as well as the central role of individuals’ experience with HIV disease, in terms of both perceived health and disclosure of HIV status to non-medical persons. Counselling interventions need to be developed with the help of patients’ associations and healthcare or social workers to help PLWHA to adopt or negotiate safe behaviours respecting their individual cultures. Support should especially target women with actions helping them to find the balance between their needs for protection against HIV infection and their desire to have children, be it for personal or societal reasons. Investigators Clinical care in Abidjan, Côte d’Ivoire - Service des Maladies Infectieuses et Tropicales (SMIT): Emmanuel Bissagnene (Principal Investigator), Serge Eholie, Auguste Kadio, Gustave Nzunetu, Cyprien Rabe, Aristophane Tanon. Centre Intégré de Recherches Biocliniques d’Abidjan (CIRBA): Olivier Ba-Gomis, Henri Chenal, Charles Diby, Denise Hawerlander. Centre National de Transfusion Sanguine (CNTS): Lambert Dohoun, Charlotte Huet, Seidou Konate, Albert Minga, Abo Yao. Unité de Soins Ambulatoires et de Conseil (USAC): Constance Kanga, Jonas Séri, Calixte Guéhi. Centre de Prise en Charge et de Formation (CePReF): Amani Anzian, Mamadou Diarrassouba, Nicole Dakoury-Dogbo, Joachim Gnokoro, Eugène Messou, Catherine Seyler, Siaka Toure. Biology Centre de Diagnostic et de Recherches sur le SIDA (CeDReS), CHU de Treichville, Abidjan, Côte d’Ivoire: Dominique Bonard (mycobacteriologist), Arlette Emieme (trial monitor), André Inwole (immunologist), Hervé Menan (parasitologist), Timothée Ouassa (bacteriologist), François Rouet (virologist), Thomas-d’Aquin Toni (virologist), Ramatou Toure (trial monitor). Service de Virologie, CHU Necker, Paris, France: Marie-Laure Chaix (virologist), Christine Rouzioux (virologist). Service de Pharmacologie Clinique, CHU Bichat Claude-Bernard, Paris, France: Gilles Peytavin (pharmacologist). Trial coordination team Abidjan, Côte d’Ivoire – Programme PACCI: Christine Danel (Coordinator), Romuald Konan (trial pharmacist), Raoul Moh (trial monitor), Delphine Sauvageot (trial monitor), Souleymane Sorho (data manager). Bordeaux, France - INSERM U593: Xavier Anglaret (Coordinator), Delphine Gabillard (trial statistician), Yves-Antoine Flori (economist), Roger Salamon (Principal Investigator). Steering Committee Françoise Barré-Sinoussi, François Boué, Geneviève Chêne, François Dabis, Pierre Marie Girard, Catherine Leport, Yves Souteyrand. Independent Data Safety Monitoring Board Dominique Costagliola (independent statistician), Daniel Sereni, Nicolas Meda, Thérèse N’Dri-Yoman, Philippe van de Perre. Representatives of the French Agence Nationale de Recherches sur le SIDA (ANRS, Paris, France) Brigitte Bazin, SÕverine Blesson, Chantal Canon, Jean-François Delfraissy
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