Effects of HIVAntiretroviral Therapy on Sexual and Injecting Risk-Taking Behavior: A Systematic Review and Meta-analysis

Background. Increased global access and use of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) has been postulated to undermine HIV prevention efforts by changing individual risk-taking behavior. This review aims to determine whether ART use is associated with changes in sexual or injecting risk-taking behavior or diagnosis of sexually transmitted infections (STIs). Methods. A systematic review and meta-analysis was conducted of HIV-seropositive participants receiving ART compared with no ART use in experimental or observational studies. Primary outcomes included (1) any unprotect-ed sexual intercourse, (2) STI diagnoses, and (3) any unsafe injecting behavior. Results. Fifty-eight studies met the selection criteria. Fifty-six studies containing 32 857 participants reported unprotected sex; 11 studies containing 16 138 participants reported STI diagnoses; and 4 studies containing 1600 participants reported unsafe injecting behavior. All included studies were observational. Unprotected sex was lower in participants receiving ART than in those not receiving ART (odds ratio [OR], 0.73; 95 % confidence interval [CI],.64–.83; P <.001; heterogeneity I2 = 79%) in both high-income (n = 38) and low-/middle-income country (n = 18) settings, without any evidence of publication bias. STI diagnoses were also lower among individuals on ART (OR, 0.58; 95 % CI,.33–1.01; P =.053; I2 = 92%); however, there was no difference in injecting risk-takin