Introduction

Despite an overall decline in new HIV infections globally, identification of strategies to reduce HIV transmission among people living with HIV/AIDS (PLWHA) remains a major public health priority [1]. Antiretroviral treatment-as-prevention (TasP) interventions have offered promising results in serodiscordant heterosexual couples as evidenced by the dramatic results of the HPTN052 study [2]. However, not all patients in HIV treatment attain or sustain a suppressed viral load [3–5]. Comprehensive secondary HIV prevention interventions will need to address behavioral factors such as assuring treatment adherence, controlling sexually transmitted co-infections, and promoting condom use for prevention of primary HIV transmission or superinfection [6]. Secondary HIV prevention efforts will be the most powerful when administered as a combination of biomedical and behavioral approaches interventions [7–9].

While previous studies have shown a reduction in condomless sex immediately following HIV diagnosis [10–12], reports have also suggested that a substantial proportion of HIV-infected individuals do continue to engage in condomless anal and vaginal sex after their HIV diagnosis [13–16]. Brazil, Thailand, and Zambia, all have HIV epidemics that are primarily driven by sexual transmission, despite experiencing different HIV epidemics. General population prevalence estimates between the countries vary widely—0.6% in Brazil, 0.8% in Thailand, and 10.4% in Zambia [1]. There is an emerging body of research exploring the sexual behaviors of PLWHA in each of the three settings. Factors such as substance use, gender norms around sexual negotiation, instability in sexual relationships, being on antiretroviral therapy (ART), and the number and characteristics of sex partners have all found to be associated with rates of condomless sex among PLWHA in Brazil, Thailand, and/or Zambia [17–23]. However, most of our current knowledge comes from quantitative studies. One notable exception (among a handful of others) is a qualitative study conducted by Kerrigan et al. (2006) among PLWHA in Rio de Janeiro, Brazil [24]. Findings showed that sexual risk-taking was framed for many PLWHA as a pathway for social validation and was linked to intense feelings of shame about HIV, but also in a more general sense. Moreover, participants in the study expressed considerable fear and anxiety about disclosing their HIV status to sex partners. As this and other studies like it suggest, in-depth qualitative research that seeks to contextualize the sexual lives and relationship dynamics of PLWHA in these settings has the potential to enrich our understanding of these important issues.

The present study considers the perceived impact of HIV on the sexual practices and relationships of in-care HIV-infected men who have sex with men (MSM) and heterosexual men (MSW) and women (WSM) in Thailand, Brazil, and Zambia who engaged in high-risk sexual practices. To gain information about how to extend secondary prevention efforts to these settings, and add contextually relevant behavioral components to TasP efforts, this qualitative study was conducted as part of a mixed methods multi-site preparatory research initiative across demographically and geographically distinct populations of PLWHA engaged in HIV care. Analogous to the work of psychologist Eric Erikson, we frame our findings in relation to the stage of human development that is defined by the need to establish intimate relationships. The presence of HIV introduces distinct challenges to intimacy and thus has important implications for the psychosocial development of PLWHA.

Methods

Participants and Procedures

Semi-structured qualitative individual interviews were conducted between June 2010 and June 2012 with in-care PLWHA from Chiang Mai, Thailand, Rio de Janeiro, Brazil, and Lusaka, Zambia. A total of 80 participants were interviewed, including 30 MSW (10 per site), 30 WSM (10 per site), and 20 MSM (10 each at the Chiang Mai and Rio sites). Note that for study inclusion criteria, those in the MSM category were to be biologically born men who currently identify as having sex with men. Accordingly, five individuals who identified as transgender were included. This qualitative study was one component of HPTN063 which also had a longitudinal quantitative component (N = 751; analysis underway). Involvement in the qualitative study was voluntary. Recruitment for this qualitative study followed a selective sampling technique whereby, study staff approached participants in the parent study who they thought would be willing to share their experiences in a qualitative interview. Individuals were recruited for the study at hospitals and clinics where they received HIV care. They were approached by a member of the study team in the waiting room of the clinic or hospital. In Zambia, the setting was a local HIV clinic. In Brazil, the setting was a clinical research institute that also provides HIV care. In Chiang Mai, the site is part of a public university, and participants were recruited from several local HIV clinics. All sites had local community advisory boards (CABs) that helped shape the study procedures, questions, recruitment, and retention plans. Eligibility criteria for this study and the parent study were the same. Eligible individuals were over the age of 18, HIV infected, had attended at least two HIV-related medical appointments in a formal health care setting (clinic or hospital) in the prior nine months and reported sexual risk behavior (acquisition of a sexually transmitted infection, condomless vaginal or anal intercourse, difficulty negotiating condom use, or non-disclosure of HIV status to an HIV-uninfected sex partner or sex partner of unknown HIV serostatus) within 12 months of enrollment. Table 1 provides information on the socio-demographics and sexual practices reported by participants in the qualitative sub-study. The interviews lasted for approximately one hour and were conducted by trained research staff in a private space. They were audio recorded, reviewed for identifying information and transcribed verbatim. Transcripts were translated into English by a bilingual staff person and independently assessed for accuracy and consistency.

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Table 1. Sociodemographic, behavioral, and health characteristics of participants (N = 80).

https://doi.org/10.1371/journal.pone.0120957.t001

Results

By comparing the data across the sites and risk groups, we identified commonalities and variations in participants’ sexual practices, attitudes towards sex, and sexual relationships. The results of these qualitative data are presented according to three themes: (1) protective behaviors; (2) barriers to engaging in sexual safety; and (3) HIV stigma and sexual partnerships.

Discussion

To our knowledge this multi-site study represents the first qualitative examination of sexual behavior and decision-making among demographically and culturally distinct communities of PLWHA in care. These data highlight a number of similarities in experiences and attitudes between MSM, MSW and WSM across the three settings. Table 2 provides a summary of the thematic similarities and differences between the risk groups and sites. Overall, participants revealed a significant degree of conscientiousness about HIV transmission risk and emphasized the importance of risk reduction efforts after being diagnosed with HIV. PLWHA practiced different strategies to reduce the risk of HIV transmission to a sex partner, including a decrease in the number of sex partners, as well as an increase in condom use, external ejaculation, and non-penetrative sexual activities. However, the emphasis placed on external ejaculation as an effective risk reduction method suggests that many were not fully aware of the transmission risk presented by, for example, pre-ejaculate. None of the participants discussed pre-exposure prophylaxis (PrEP), and this was not available to potential partners at the study sites. Similarities also emerged in that participants across all settings discussed sexual safety in terms of their own health. Several emphasized the importance of condoms with seroconcordant primary partners due to the potential for reinfection with different strains of HIV. Nevertheless, use of condoms or other safer sex strategies proved difficult for a variety of reasons.

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Table 2. Similarities and differences in themes according to risk groups and setting.

https://doi.org/10.1371/journal.pone.0120957.t002

Many of the sexual practices and relationship considerations described by participants were related to a struggle for culturally embedded sexual intimacy and fear of isolation. Across the three sites, MSM, MSW and WSM described condom use as an obstacle to sexual intimacy between primary sex partners. WSM at all sites spoke about the unwillingness of primary partners to use condoms and the challenges of sexual communication in intimate situations. Consistent use of risk reduction techniques may also be particularly difficult for those who view them as impediments to sexual intimacy and satisfaction. These issues are likely connected to problems with introducing regular condom use into existing primary sexual partnerships. Fears of HIV-related stigma and consequent isolation colored conversations about relationships with sex partners and were not distinct to risk groups or site. In some cases, anxiety about intimacy resulted in participants shunning primary sexual relationships to limit the potential for rejection/isolation and avoid disclosure of HIV status. Also within the context of isolation, a central theme to emerge was reduced sexual activity after becoming infected with HIV. This was largely prompted by a decline in sexual desire that was related to worry about HIV transmission to a sex partner and guilt about sexual enjoyment. Although an underlying level of risk awareness motivates engagement in safer sex, excessive anxiety around sex may be connected to difficulties with sexual intimacy and is thought to exacerbate psychological distress for PLWHA [28]. Adverse mental health outcomes are known to reduce the effects of TasP efforts via suboptimal ART adherence and inconsistent condom use [12, 29–31].

This is not the first study to consider the sexual behaviors of PLWHA in each of the three countries. Studies among PLWHA in Brazil, Thailand, and Zambia have documented factors associated with patterns of condom use [17–24]. The present study builds upon some of these findings but also moves beyond them to highlight the thematic salience of intimacy and isolation in the sexual narratives of in-care PLWHA from these settings, and the similarities across various sites. Prior research has shown that HIV-infected women in the U.S. experience guilt about sex and worry about transmitting to sex partners [32]. In the U.S. and U.K., studies of PLWHA in long term relationships have emphasized the tension between intimacy and HIV prevention but have primarily focused on reproductive decision-making [33–35]. To date, however, there is limited data exploring these topics in developing world contexts. In a recent review article of the psychosocial factors that affect PLWHA across different settings, social isolation was identified as a theme in three studies [36]. However, two of these articles examine isolation in the context of non-disclosure to family, peers, and community [37, 38], and the other article discusses social support in the context of ART adherence [39]. By contrast, our study focuses on sexual activity and explores the themes of isolation, intimacy, stigma, and disclosure within the context of sexual decision-making. These qualitative data seek to contextualize the impact of HIV on sexual activity by looking at participants’ experiences, attitudes, and feelings around safer sex strategies, sexual communication, and the dynamics of sexual relationships.

This study has limitations. Firstly, to facilitate comparisons across sites, the interviews were semi-structured using qualitative interview guides. This type of interview format may have inhibited interviewers from probing for emergent themes that were not otherwise addressed in the guide. Great thought was given to develop interview guides that could meaningfully examine similar experiences in a diverse set of contexts. The guides were sufficiently uniform to allow for a comparison across the risk groups (MSM, MSW and WSM) and sites (Brazil, Thailand and Zambia) but had enough flexibility to encourage a natural flow of conversation. Second, there may have been slight variations in the interview guides based on language. To enhance data collection uniformity, interview trainings were conducted by the same investigators across the three sits. Additionally, English-language versions of the transcripts were used in the analysis. Although translations were verified for accuracy and completeness, there may have been some loss of information in the transcription process. Notably though, the analysis was conducted with significant input from a qualitative committee comprised of investigators and the staff members who conducted the interviewers who clarified context and meaning of quotations as necessary. All participants engaged in high-risk sexual practices and were enrolled in HIV medical care. This sample may not necessarily be representative of all PLWHA in the settings. Additionally, study staff selected in-care PLWHA for enrollment who they thought would be willing to share their experiences with the interviewer. Individuals who were shy and/or had difficulties talking about their sexual lives may represent a more vulnerable population. Finally, the study was not intended to attend to all of the socio-structural domains that undoubtedly influence sexual risk taking for MSM, MSW, WSM PLWHA in these countries.

Despite these limitations, these data offer a unique opportunity to deepen our understanding of the shared experiences of sexually active PLWHA with respect to barriers and facilitators of safer sexual practices across three distinct regions of the world. Behavioral interventions to reduce sexual risk for PLWHA, even for those who have achieved viral suppression, are critically important to maximizing and sustaining the effects of the success of TasP [8, 9]. However, secondary prevention efforts in international settings are limited and effective behavioral programming in diverse settings requires careful preparedness work. Our findings have the potential to inform the development of future context-specific behavioral components to support existing TasP efforts. Provider-led behavioral programs should acknowledge and build off of existing HIV transmission risk awareness and sense of personal responsibility for risk reduction that patients already have. Strength-based approaches have been shown not only to support provider-patient relationships but improve outcomes along the HIV care continuum [42]. Further, the thematic overlap in participants’ experiences and attitudes suggests that similar content could be suitable for care-based secondary HIV prevention interventions among MSM, MSW and WSM across a diverse array of settings. While adapting programs to the local socio-structural context is critical, grounding future intervention efforts in similar foundational content across international settings may better allow us to meet the challenges of expanded secondary prevention responses.

One possible explanatory model of our findings is Erik Erikson’s theory on the stages of psychosocial development [40]. According to Erikson, “Intimacy vs. Isolation” is one of a series of personal crises that individuals negotiate throughout their lives. Adults in this stage (usually aged 19–40) begin to share themselves more intimately with others with the goal of establishing meaningful relationships and a sense of commitment and care. Conversely, avoiding intimacy leads to isolation and a fear of self-disclosure, which can have negative lasting effects on future personal development. As participants’ mean age was 25, the majority was experiencing this Ericsonian stage while also living with HIV. Our findings suggest that HIV posed significant barriers to intimacy for MSM, MSW and WSM in all of the settings, such as worry of infecting sex partners, guilt about sexual enjoyment, HIV-related stigma, and struggles with sexual communication with intimate primary sex partners. Such manifestations are known to threaten sexual risk reduction efforts and engagement in HIV care. PLWHA may therefore benefit from sex-positive programs that underscore sexual health and intimacy as a critical component of secondary HIV prevention. Interventions designed to help PLWHA reduce sexual anxiety and guilt, engage in healthy sexual relationships and enhance sexual self-image may improve risk reduction self-efficacy and mental health over the long-term. Such an approach could augment the efforts of provider-led interventions focused on condom use, sex in the context of suppressed viral load, and optimum utilization of services in the HIV care cascade [41]. For those in a stable partnership, a couples-based approach may be well suited to address sexual partner intimacy in the context of secondary prevention. Couples-based interventions emphasizes the mutual responsibility for health of both partners and the role of the couple’s relationship in behavior change through the promotion of sexual communication and negation skills [42]. There are a growing number of studies demonstrating the advantages of the couples-based modality, yet further research is needed to identify strategies for integrating such an approach into the HIV care setting. Furthermore, this type of programme would likely be augmented by structural interventions focused on the gender-based power imbalances that influence sexual decision-making [43]. While Erikson’s theory may be a particularly relevant lens through which to view our findings, it should be underscored that there are myriad other orientations through which to frame them. For example, a sociological model may understand the observed struggles for intimacy within the context of seeking to achieve social normative status as it relates to cultural meanings of what it is to be connected or intimate. While the field of HIV prevention is fluid, qualitative studies that explore the sexual lives and practices of individuals living with HIV will be necessary to stay abreast of how to best promote interventions across the continuum of HIV care.

Acknowledgments

The authors would like to thank Jonathan Lucas at FHI 360 and all of the staff at the HPTN 063 study sites for their assistance and expertise.