Behavioural disinhibition in the general population during the antiretroviral therapy roll‐out in Sub‐Saharan Africa: systematic review and meta‐analysis

Abstract

Abstractobjectives Improved life expectancy and reduced transmission probabilities due to ART may result in behavioural disinhibition -that is an increase in sexual risk behaviour in response to a perceived lower risk of HIV. We examined trends in sexual risk behaviour in the general population of subSaharan African countries 1999-2015.methods We systematically reviewed scientific literature of sexual behaviour and reviewed trends in Demographic and Health Surveys. A meta-analysis on four indicators of sexual risk behaviour was performed: unprotected sex, multiple sexual partners, commercial sex and prevalence of sexually transmitted infections.results Only two peer-reviewed studies met our inclusion criteria, while our review of DHS data spanned 18 countries and 16 years (1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015). We found conflicting trends in sexual risk behaviour. Reported unprotected sex decreased consistently across the 18 countries, for both sexes. In contrast, reporting multiple partners was decreasing over the period 1999 to the mid-2000s, yet has been consistently increasing thereafter. Similar trends were found for reported sexually transmitted infections and commercial sex (men only).conclusions In conclusion, we found no clear evidence of behavioural disinhibition due to expanded access to ART in sub-Saharan Africa. Substantial increases in condom use coincided with increases in reported multiple partners, commercial sex and sexually transmitted infections, especially during the period of ART scale-up. Further research is needed into how these changes might affect HIV transmission.keywords literature review, sexual risk behaviour, behavioural disinhibition, antiretroviral therapy, sub-Saharan Africa

No effect of test and treat on sexual behaviours at population level in rural South Africa

“…And finally we observed a decrease over calendar time in the proportion of men reporting two or more sexual partners in the past six months and of concurrency. This time trend is however different from what was found in a recent meta-analysis, where reporting multiple partners over the past 12 months increased consistently across almost all study countries30 .…”

Factors associated with condom use among men and women living with HIV in Lilongwe, Malawi: a cross-sectional study

“…Although our data demonstrate that condom use continues to be inconsistent among this study population, overall data from the Demographic and Health Surveys (DHS) in sub-Saharan Africa suggests increased condom use over the last one to two decades 10. Most participants recognise that condoms reduce HIV transmission risk; however, safe sexual practices seem to be influenced more by other factors, such as relationship dynamics, fertility intention and self-efficacy than perception of infection or transmission risk.…”

Widespread changes in sexual behaviour in eastern and southern Africa: Challenges to achieving global HIV targets? Longitudinal analyses of nationally representative surveys

“…A limited number of studies in eastern and southern Africa found optimistic beliefs about HIV due to ART associated with risky sexual behaviour . A review and analysis of nationally representative data from sub‐Saharan Africa found increasing multiple and transactional sexual partnerships but also decreasing condomless sexual intercourse . It is therefore unclear whether and to what extent changes in sexual behaviour have led to increased numbers of people exposed to elevated HIV/STI risks.…”