increased sexual risk behaviour in Kenyan female sex workers.

Treatment with antiretroviral therapy is not associated with increased sexual risk behaviour in Kenyan female sex workers.

The objective of this study was to test the hypothesis that sexual risk behaviour would increase following initiation of antiretroviral therapy. A prospective cohort of Kenyan female sex workers were recruited in Mombasa, Kenya between 1993-2008. Eight hundred and ninety-eight women contributed HIV-1-seropositive follow-up visits, of whom 129 initiated antiretroviral therapy. Beginning in March 2004, antiretroviral therapy was provided to women qualifying for treatment according to Kenyan National Guidelines. Participants received sexual risk reduction education and free condoms at every visit. Main outcome measures included unprotected intercourse, abstinence, 100% condom use, number of sexual partners, and frequency of sex. Outcomes were evaluated at monthly follow-up visits using a 1-week recall interval. Compared with non-antiretroviral therapy-exposed follow-up, visits following antiretroviral therapy initiation were not associated with an increase in unprotected sex [adjusted odds ratio (AOR) 0.86, 95% confidence interval (CI) 0.62-1.19, P = 0.4]. There was a nonsignificant decrease in abstinence (AOR 0.81, 95% CI 0.65-1.01, P = 0.07), which was offset by a substantial increase in 100% condom use (AOR 1.54, 95% CI 1.07-2.20, P = 0.02). Numbers of sex partners and frequency of sex were similar before versus after starting antiretroviral therapy. A trend for decreased sexually transmitted infections following antiretroviral therapy initiation provides additional support for the validity of the self-reported behavioural outcomes (AOR 0.67, 95% CI 0.44-1.02, P = 0.06). In the setting of ongoing risk reduction education and provision of free condoms, initiation of antiretroviral therapy was not associated with increased sexual risk behaviour in this cohort of Kenyan female sex workers.

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Editors’ note: This finding of no risk enhancement/risk compensation behaviour in these Nairobi sex workers after they started on antiretroviral treatment stands on firm ground. In fact, a highly significant increase of more than 50% in consistent condom use was reported. This prospective study collected considerable amounts of data on sexual behaviour before antiretroviral therapy was initiated, followed women for a median of more than 2 years after treatment started, had similar intensity risk-reduction counselling before and after treatment began, and was large enough to control for multiple potential confounding factors. As well, biological indicators such as the presence of sperm in genital secretions indicating recent unprotected sexual intercourse and incident sexually transmitted infections suggesting inconsistent condom use helped validate self-reports of sexual behaviour. There has been concern that the benefits of treatment scale-up in decreasing viral loads and reducing HIV transmission might be shot out of the water by increased sexual risk taking as people feel better but this study of Nairobi sex workers confirms findings from the majority of African studies demonstrating no increase in risk behaviour when people start on antiretroviral therapy.