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Dutch research supports intensified HIV prevention efforts

19 January 2012 - In high-income countries such as Canada, new cases of HIV infection are occurring, particularly among men who have sex with men (MSM). Over several decades researchers in the Netherlands have been studying changes in the sexual behaviour of MSM before and after their diagnosis of HIV infection. Their findings suggest that there has been a significant increase in unprotected anal sex in the present era, when potent combination therapy for HIV (commonly called ART or HAART) now allows people to survive for decades.

The Dutch researchers call for intensified efforts to help reduce the further spread of HIV infection. This would require more frequent and widespread HIV testing; counselling that includes guidance about what the researchers call "making optimal choices for a healthy sex life for [HIV-positive people] and their future partners"; and, possibly, very early initiation of therapy for HIV. If implemented, such a concerted plan of action should help to not only reduce future transmission of HIV but also other health threats arising from sexually transmitted infections (STIs) such as syphilis, LGV (lymphogranuloma venerum) and hepatitis C virus (HCV).

Study details

Researchers in Amsterdam have been conducting a study to better understand the sexual spread of HIV and how this virus affects the health of men. HIV-negative participants were enrolled starting in 1984. They were monitored with regular blood tests to assess HIV status every three to six months and completed surveys about their sexual behaviour. If participants became HIV positive, they continued in the study (but were no longer tested for HIV).

Researchers analysed the data they collected and divided the study into two periods, as follows:

  • pre-HAART era - 1984 to 1995
  • HAART era - 1996 to 2008


During the study, 206 MSM became HIV positive (seroconverted).

The study team found that the 206 new HIV infections were distributed in time as follows:

  • pre-HAART era - 61% of HIV infections occurred
  • HAART era - 39% of HIV infections occurred

On average, in the pre-HAART and HAART eras, CD4+ counts shortly after the men became HIV positive were around 650 cells.

In the year prior to their HIV diagnosis, most men in both eras had two or more sexual partners.

Anal sex-In the time before HAART

Unprotected anal intercourse (UAI) places participants at high risk of HIV infection, so the researchers enquired a great deal about this behaviour. They found that in the year prior to becoming HIV positive, 68% of MSM had engaged in UAI. A year after diagnosis this figure fell to 38%, and four years after diagnosis it fell further to 32%.

Anal sex-In the HAART era

In the year prior to becoming HIV positive, 72% of MSM disclosed that they had had UAI. A year after their diagnosis this figure fell to 53%. However, four years after their diagnosis, 61% of MSM disclosed that they were having UAI.

Comparisons-Before and after HAART, before and after HIV

Statistical analysis found that in the pre-HAART era there were no significant differences in high-risk behaviour in MSM before a diagnosis of HIV when compared to the present era. However, there was a significant increase in UAI in the HAART era compared to the pre-HAART era.

What happened?

According to the research team, it is likely that one reason for the increase in unprotected anal sex since 1996 is that more HIV-positive people are having sex with other HIV-positive people-a behaviour known as serosorting. Some HIV-positive men may mistakenly perceive that further engagement in unprotected anal sex has few consequences. However, while serosorting among HIV-positive people helps reduce HIV transmission, it does not protect them from other sexually transmitted health threats, including the following:

  • syphilis - this can affect the brain, heart and other organs
  • hepatitis C virus - this damages the liver and can lead to serious complications
  • LGV - this can damage the genitals and internal organs and, in some cases, can cause arthritis
  • HPV (human papilloma virus) - some strains of HPV can cause ano-genital warts while other strains can cause abnormal growths in the anus, some of which can transform into anal cancer

False assumptions can lead to unprotected sex

Many other possible factors may have played roles in deemphasizing the need for safety and perhaps inadvertently leading to the transmission of HIV. Other research teams have found that some MSM may hold one or more of the following assumptions that could influence their risk of acquiring or transmitting HIV:

  • Seroguessing - Both HIV-negative and HIV-positive people may make assumptions about their sex partners, assuming that partners have the same HIV status as themselves. In such cases, protected sex might not be optimized.
  • Top vs. bottom - Some HIV-negative and HIV-positive people may assume that in cases of unprotected intercourse being the insertive partner carries little or no risk of acquiring HIV infection compared to being the receptive partner. This is not the case, although some studies suggest that sometimes there may be a reduced (but not zero) risk of HIV transmission for the insertive partner. However, at the individual level, many factors affect a person's susceptibility to HIV when they are the insertive partner, including the presence of STIs, viral load in the rectum of their receptive partner(s), and so on. The bottom line: Being the insertive partner does not offer the same degree of protection as consistently and correctly using condoms.
  • Misperceptions of HIV and its treatment - Some people who perceive themselves to be HIV negative may engage in unprotected anal sex, assuming that HIV is not a major health threat. This can particularly be the case in high-income countries, where the presence of people dying from AIDS-related complications is no longer evident on a day-to-day basis and because of the widespread availability of ART. They may also assume that HIV infection with simple once-daily regimens is not a major issue and may give little thought to complications arising from HIV-related inflammation over the long term.
  • Misunderstanding the impact of STIs - These infections can cause sores, lesions or inflammation on or inside delicate ano-genital tissue; however, sometimes STIs can be apparently symptom free. In either case, STIs can heighten the risk of transmitting or acquiring HIV.


The Dutch team suggests that after an HIV diagnosis the following ought to be offered: "supportive interventions aimed at assisting [MSM] in making optimal choices for a healthy sex life for themselves and their future partners." Such interventions should include comprehensive counselling, offering early initiation of HAART, and testing and treatment for STIs. The team also supports "increased efforts to identify primary HIV infection" among MSM so that further transmissions can be reduced.

Although the Dutch study focused largely on HIV-positive men, unmentioned in the Dutch report was this: It is also possible that HIV-negative men who engage in high-risk behaviour could benefit from a comprehensive prevention package (counselling, testing and so on) that includes the provision of pre-exposure prophylaxis (PrEP) such as Truvada (a fixed-dose formulation of two anti-HIV drugs-tenofovir + FTC). For further information about PrEP in MSM, see the following CATIE materials:

CATIE Fact Sheet on PrEP

CATIE-News story on iPrEx trial

-Sean R. Hosein


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From Canadian AIDS Treatment Information Exchange (CATIE). For more information visit CATIE's Information Network at


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