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Abstract

Participants were recruited from a sexually transmitted disease (STD) clinic in Florida and were assessed regarding the knowledge and awareness of non-AIDS conditions associated with HIV infection. Questionnaires were administered before and after a brief information session on non-AIDS conditions associated with HIV infection. Participants included men (n = 46) and women (n = 51). Prior to the information session, at baseline, only 34% of the participants were worried about HIV infection. Most participants (82%) agreed that HIV could be treated with antiretroviral therapy (ART), while only 38% were aware that HIV-associated conditions cannot be easily treated with ART. After the information session, almost all participants reported they were concerned regarding the risk of HIV infection. High-risk patients may have limited knowledge about the consequences of HIV infection beyond the traditional AIDS-associated conditions. Increased awareness of these less known consequences of HIV infection may decrease the potential for complacency regarding acquiring HIV infection.

Keywords

HIV AIDS non-AIDS defining

Introduction

HIV infection remains as an ongoing problem in the United States. An estimated 1 178 350 persons 13 years and older were living with the HIV at the end of 2011.¹ Among these, 20% are still not diagnosed.² About 50 000 people are newly infected with HIV each year in the United States. In 2010, there were 15 500 deaths among men who have sex with men (MSM), the group most severely affected by HIV. In 2010, MSM accounted for 63% of new HIV diagnoses in the United States.³ The majority of these new infections were sexually transmitted, that is, 27% were in heterosexual men and women who did not inject drugs and 64% were in MSM, including 3% in MSM who inject drugs.⁴ Surveillance data suggest that the annual number of new HIV infections among MSM has been increasing since the mid-1990s.⁵ A potential contributor to the continuing sexually transmitted HIV infections is complacency with safe sexual practices.

Dramatic decline in deaths and in the incidence of opportunistic diseases attributed to HIV/AIDS have been observed since antiretroviral therapy (ART) first became available in late 1995.^6
–8 A possible unintended consequence of this effective therapy is that the public may become complacent about HIV infection.⁹ A 2009 Kaiser Family Foundation survey found that the sense of urgency about HIV has fallen considerably in recent years. The percentage of Americans who named HIV/AIDS as the most urgent health problem facing the nation dropped from 17% to 6% between 2006 and 2009.⁹ However, recent epidemiological data provide evidence that the causes of mortality in HIV-infected people may have shifted, and that, currently, the main causes of mortality are not traditional HIV-associated conditions (e.g., Pneumocystis carinii pneumonia or PCP, although the causative organism has been renamed as Pneumocystis jiroveci, Cryptococcus neoformans meningitis, disseminated Mycobacterium avium complex infection, tuberculosis, etc).^10

–13 Additionally, HIV-associated cardiovascular, bone and renal disease, neurocognitive decline, and premature aging are also contributors to continued morbidity and mortality, in particular in people without well-controlled HIV infection (undetectable viral load [VL] with CD4 counts above 500 cells/mm³).^14

–19 The impact of knowledge about or awareness of these potential conditions on HIV risk behavior that may result in infection is unclear.

The Health Belief Model (HBM) has been used to study diverse health issues such as tuberculosis, cancer, diabetes, multiple sclerosis, and most recently sexually transmitted diseases (STDs).²⁰ In short, the HBM is based on the assumption that individuals who perceive themselves to be at risk of contracting a serious or embarrassing infectious disease, and perceive the disease as preventable, will more likely adopt preventive behaviors.^21

–25 The objective of this study was to evaluate knowledge of non-AIDS complications and their potential impact on perceived concerns regarding the threat of HIV infection before and after a brief information session among high-risk patients. It was theorized that the perception of the threat of illness would influence concerns regarding potential HIV infection.

Research Design and Methods

Design

Institutional Review Board (University of Miami, Miller School of Medicine and Florida Department of Health) approvals and written informed consent were obtained before recruitment, assessment, and any study-related intervention.

Clinical Site

The study was conducted at the Miami-Dade County Health Department Sexually Transmitted Diseases (STD) clinic. The clinic serves more than 1000 patients/month who are either Miami-Dade County residents or visitors. An average of 80 patients is seen in the clinic daily, and approximately 60% of the patients are males and 40% are females. More than 90% of them are African American, Haitian, or Hispanic.

Participant Eligibility

Eligible participants were men and women aged 18 or older who presented for STD testing and who were either HIV-negative or of unknown HIV status. There were no exclusions based on literacy.

Study Procedures

All clinic staff was briefed about the objectives of the study. Potential participants were referred from clinicians to study staff for assessment of eligibility and recruitment into the study. Participants were administered questionnaires pre- and post-information session. The questionnaires collected data about demographics, sexual behavior, perception of risk of HIV infection, knowledge of HIV prevention strategies, and preferences for them. Participants also completed an assessment of their level of concern regarding the threat of HIV infection and awareness/knowledge of nontraditional AIDS-associated complications focused in cognitive decline, bone/cardiovascular/renal diseases, and premature aging (see Appendix A for the scale).

Intervention

Following the baseline questionnaire, participants met individually with a bilingual study staff person who provided them with information in their preferred language (English or Spanish) on the emergence of cognitive decline, bone/cardiovascular/renal diseases, and premature aging associated with HIV infection. Participants were also given the option to review the information by reading a pamphlet or by viewing a brief video containing the same information. Following the information session, participants were retested on their level of perceived threat of HIV infection.

Data Analysis

Data was coded and uploaded into the Statistical Package for Social Sciences (SPSS) software for statistical analysis.

Results

Demographics and HIV Risk

Study participants (n = 97) included 51 women and 46 men, most of them were younger than 30 years (68%). Most participants (61%) reported at least one prior episode of an STD. The majority (87%) had undergone an HIV test within the past year, but almost half (44%) were not aware of the HIV status of all of their sexual partners and about a third (28%) reported having sex with someone they did not know. Only 31% of participants felt they were at risk of HIV infection if they continued to engage in their current sexual behavior. Thirty-eight percent of participants reported having sex while intoxicated by drugs or alcohol. Twenty-eight percent reported never using condoms with regular partners and 20% reported using condoms less than 10% of the time with “other” partners (Table 1).

Table 1.

Self-Perceived HIV Risk and Risky Activities.

Practices	Percentage, %
HIV test within last year	87
Aware of partner’s HIV status	56
Sex with no known person	28
Sex while intoxicated with drugs/alcohol	38
Never condoms with regular partners	28
Condom less than 10% with “other” partners	10
Felt at risk of acquiring HIV with these practices	31

Knowledge and Attitudes toward Nontraditional HIV Complications

At baseline, only 34% of the participants were worried about HIV infection. Most of the participants (82%) either strongly agreed (38%) or somewhat agreed (44%) that HIV can be fully treated with ART. Only 38% were aware of the existence of HIV-associated conditions that cannot be easily prevented by partial immune reconstitution after the use of ART.

Post-Information Session

Following the information session, 73% were very concerned and 25% were somewhat concerned regarding HIV. This represents an over 2-fold increase in acknowledging vulnerability and the seriousness of HIV infection (2.14; 95% confidence interval [CI] 1.6-2.8; P < .00001). We analyzed the answers regarding concerns about acquiring HIV infection by age (30 years and younger versus older than 30 years) and gender and found no statistically difference, at baseline or after the information was provided. Additionally, all but one participant believed that HIV is either the most urgent health problem (47%) or one of the most urgent health problems (52%) facing society. Also, all but one participant, who said that HIV prevention studies are somewhat important, believed that HIV prevention studies are very important. Finally, most stated that HIV prevention is very important to them (96%) after the informative session.

Discussion

We found that STD clinic patients who participated in this study had very limited knowledge about nontraditional AIDS-associated conditions. We also found that a brief intervention that provided information about these conditions led to an increased knowledge and concerns regarding HIV infection.

It is already clear that mortality associated with traditional AIDS-associated conditions decreased in the United States in the 90s after the widespread use of ART.⁷ About a third of participants in this study were unconcerned regarding acquiring HIV infection, which supports previous research suggesting the belief that HIV is no longer a serious health threat due to treatment advances.²

In our study sample of participants who were HIV negative and mostly younger than 30 years, we found no evidence of increased complacency about acquiring HIV infection in the younger group. In contrast to data from research conducted in HIV-infected individuals who reported increased complacency about acquiring HIV infection in younger individuals who were not exposed to the high rates of mortality seen in the 80s and early 90s.²⁵ Decreased fear about acquiring HIV may be one of the contributing factors of the ongoing transmission in some risk groups. For example, it has been reported that the annual number of infections in young MSM (13-24 years) increased to 22% from 2008 to 2010.^1,2

Although most of the participants in this study believed that HIV prevention is important to them and that HIV prevention studies are important, many described unsafe sexual behaviors that placed them at higher risk of acquiring HIV infection. Results suggest that participants relied only on HIV testing as an individual preventive activity and were not aware of the risks inherent in other high-risk activities. This pilot study suggests that providing information to high-risk individuals about the risk of health problems associated with HIV infection may be a useful prevention strategy. Intervention studies will be needed to demonstrate if increased awareness of the non-AIDS HIV-associated conditions will increase the uptake of HIV-preventive strategies.

Limitations

The lack of a comparison group was a limitation of this study. In conclusion, STD clinic patients who participated in this study had very limited knowledge about the deleterious health consequences of HIV infection beyond the traditional AIDS-associated conditions. Increasing awareness of these less known consequences of HIV infection may decrease the perceived relative complacency with acquiring HIV infection in certain groups.

Footnotes

Appendix A

Acknowledgment

We acknowledge support from the Miami Center for AIDS Research at the University of Miami.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Miller School of Medicine funded by a grant (P30A1073961) from the National Institutes of Health (NIH).

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