Understanding Sexual Risk-Taking in the Age of HIV

Sexual Behaviors That Put Individuals at Avoidable or Unnecessary Risk

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Sexual risk-taking is a concept that people often find difficult to understand, particularly among those seen to be at high risk of HIV. From a societal standpoint, there remains a strong disapproval of certain sexual activities that some might consider "immoral" or "taboo" (such as homosexuality, group sex, and commercial sex work), and the stigmatization associated with these activities only drives the conversation further underground.

What we do know is that people who take sexual risks don't inherently do so out of self-destructiveness or ignorance (although these can certainly contribute to such behaviors). More often, they are driven by psychological and behavioral factors that inform their sexual decision-making. These can include such factors as sexual behavioral disinhibition and sexual risk compensation.

Understanding Sexual Disinhibition 

Sexual behavioral disinhibition (or, simply, sexual disinhibition) implies the loss of constraint in sexual behaviors considered socially unacceptable or undesirable, manifesting with impulsivity, sensation-seeking and poor risk assessment.

While the term is often assigned to behaviors that are suggestive of a mental illness or psychological impairment, it can be applied more broadly to any sexual behavior which puts an individual at avoidable or unnecessary risk—either in terms of physical or emotional harm; of harm to others; of damage to personal or professional relationships; of criminal or legal action; or of the acquisition of a sexually transmitted disease.

While hypersexuality (i.e., extremely frequent sexual urges or desires) can be a feature of sexual disinhibition, it is by no means synonymous with it. Neither is it necessarily associated with aggressive, hyperactive or anti-social behavior (features commonly included within the clinical context of behavioral disinhibition).

Causes for sexual disinhibition can range from serious clinical and psychiatric disorders to a broad range of emotional or socio-behavioral issues, including:

  • Alcohol or substance abuse
  • Misperceptions about person risk
  • Misinterpreting social cues or norms
  • Depression
  • Previous sexual trauma, (including childhood trauma)
  • Peer or gender group dynamics (including school, social or sexual networks)

The term is also popularly applied to social messaging and networks, wherein a person acts in a sexually provocative manner when instant messaging, text messaging ("sexting"), or posting online —essentially behaving in a different way online as they might offline.

Within the context of HIV, sexual disinhibition may be a direct response to feelings of fear, anger, depression or anxiety—and not only among those who are infected. HIV-negative people can often have feelings of despair and hopelessness ("I’m going to get it anyway") or experience condom fatigue (a.k.a. prevention fatigue) in such a way as to abandon behaviors that might otherwise protect them.

Even those who possess a strong understanding of HIV transmission and prevention can sometimes be influenced by information that adversely alters sexual behavior. A number of studies, for example, have reported steep drops in condom use following the introduction of a biomedical HIV breakthrough. In short, individuals will often take greater risks if they believe—or want to believe—that either the consequences or risk of HIV are somehow less.

Understanding Sexual Risk Compensation

Risk compensation, by contrast, implies that individuals will adjust their behaviour based on their perception of risk. It suggests that people who believe themselves to be at lesser risk will take greater chances even if that assessment is misdirected or ill informed.

Within the context of HIV, risk compensation can fuel perceptions that a person is somhow less vulnerable to infection or transmission than they might actually be. These perceptions often coincide with the introduction of a biomedical prevention tool such as HIV pre-exposure prophylaxis (PrEP), HIV treatment as prevention (TasP), or voluntary medical male circumcision (VMMC).

By way of example, while VMMC has shown significant benefit in reducing HIV rates in hyper-prevalent populations, follow-up research has shown that circumcised men will sometimes engage in high risk behaviors if they perceive their  risk of infection to be reduced. By doing so, a newly circumcised man can potentially erase the benefits of VMMC by engaging in high risk practices he had previously avoided.

Similarly, individuals who believe themselves "protected" by condoms or TasP can undermine the protective benefit if engaging in sex with multiple partners—particularly if condom use or treatment adherence is inconsistent.

Impact of Sexual Risk-Taking on HIV Transmission

While it is clear that sexual risk-taking will, in and of itself, increase likely the likelihood of HIV transmission, a 2014 study aimed to identify that impact of such behaviors on HIV prevalence rates in Ugands, one of the countries hardest hit by the disease. A mathematical analysis has concluded that if antiretroviral therapy (ART) is provided at the time of infection, the prevalence of HIV country would decrease by 2025 if levels of risky sexual behavior do not increase.

However, if levels were to increase, the benefit of universal of universal ART would be wiped out altogether, resulting in an increase in the number of people infected with HIV.

With this being said, there is some evidence to suggest that the initiation of ART may be associated with decreases in sexual risk-taking in some individuals. A study from the Johns Hopkins Bloomberg School of Public Health reported that people who seek HIV-specific treatment and care are more likely to understanding risk factors associated with HIV infection and thus less likely to engage in risky sexual behavior.  

The same results were echoed in studies which to measure changes in sexual behaviors in uninfected persons placed on the HIV prevention drug, Truvada (also known as HIV pre-exposure prophylaxis, or PrEP). A review of seven, high-quality randomized trials supported the conclusion that PrEP usage in at-risk individuals is neither associated with increased sexual risk-taking nor increases in the incidence of sexually transmitted infections.

Sources:

Muchimba, M.; Burton, M.; Yeatman, S.; et al. "Behavioral Disinhibition and Sexual Risk Behavior among Adolescents and Young Adults in Malawi." PLoS|One. September 9, 2013; DOI: 10.1371/journal.pone.0073574.

Harper, S. and Harris. F. College Men and Masculinities: Theory, Research, and Implications for Practice. John Wiley & Sons; published March 8, 2010.

Shafer, L.; Nsubuga, R.; Chapman, R.; et al. "Impact of Antiretroviral Therapy and Sexual Behavior Changes in HIV Epidemiologic Trends in Uganda." Sexually Transmitted Infections. 2014; 90(5):423-429.

Kennedy, C.; O’Reilly, K.; Medley, A.; et a. "The impact of HIV treatment on risk behaviour in developing countries: a systematic review." AIDS Care. 2007;19:707-720.

Liu, A.; Vittinghoff, E.; Chillag, K.; et al. "Sexual risk behavior among HIV-uninfected men who have sex with men (MSM) participating in a tenofovir pre-exposure prophylaxis (PrEP) randomized trial in the United States." Journal of Acquired Immune Deficiency Syndrome. Online edition; March 11, 2013; DOI:10.1097.

Blumenthal, J. and Haubrich, R. "Risk Compensation in PrEP: An Old Debate Emerges Again." Virtual Mentor. November 1, 2014; 6(11):909-915.

Crepaz, N.; Hart; T; and Marks, G. "Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review." Journal of the American Medical Association. July 14, 2004; 292(2): 224-e36.

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