Does access to antiretroviral drugs lead to an increase in high-risk sexual behaviour?

Over the last few years the fight against the HIV epidemic appears to be yielding increasingly positive results: the number of people surviving and living with HIV has been on the rise and, overall, the numbers of new infections have been on a steady path of decline. This progress is largely attributed to the increased accessibility to antiretroviral therapy (ART). Not only does ART improve the length and quality of life, the drugs are an important tool in suppressing HIV viral loads, thus reducing a) opportunistic infections such as Tuberculosis; b) transmission of HIV from a mother to her child; and c) transmission of HIV via sexual contact. These reasons have led to the emergence of a 'treatment as prevention' approach to tackling the epidemic, which urges for a scale-up in ART distribution worldwide. Initiatives such as that of the U.S. PEPFAR (President's Emergency Plan for AIDS Relief), have advanced this strategy by making antiretroviral drugs exponentially accessible in low-income public health systems. However, at this point the impact of the large-scale distribution of antiretroviral drugs needs to be critically examined – the positives have been outlined above so let us take a look at another potential facet altogether. First let us agree that the large-scale influx of ART is changing the perception of HIV: from a disease inevitably incurring suffering and death to a less feared and pronounced chronic disease. With this in mind we should thus venture to ask ourselves: could this lowered anxiety associated with HIV and AIDS lead to an increase in population-wide high-risk sexual behaviour (either because HIV transmission appears to be less likely-since HIV carriers are no longer as visibly distinguishable as they once would have been-or because HIV is no longer perceived to be the death sentence it once was)? There has been very little research on the potential impact of large-scale ART distribution on the sexual behaviour of a general population (comprising of both HIV infected and uninfected people). During the 1990's, some high-income countries reported an increase in high-risk sexual behaviour amongst men who have sex with men when antiretroviral drugs were made extensively accessible in their public health systems 1,2,3. Although inconclusive, more recent studies exploring heterosexual behaviour amongst non-ART users (that consist of both HIV infected and uninfected people) in low-income settings suggest that access to ART may have led to an increase in risky behaviour 4,5,6. Nevertheless, perhaps …