236 AIDS/HIV
Erringer, & Edlin, 2000), and patients recruited through HIV
clinics (De Rosa & Marks, 1998) indicate that at least 30% of
persons living with HIV engage in risky behaviors.
Sexual risk behavior among persons living with HIV are
of obvious public health concern in terms of the risks such
behavior poses to people who are not yet infected. An in-
creasing concern, however, is that HIV-infected patients, es-
pecially those who develop multiple drug resistances to HIV
combination therapies, may then transmit drug-resistant HIV
strains to others through unprotected sex or needle sharing.
Transmission of treatment resistant strains of HIV through
sexual or drug use behaviors is still the subject of ongoing
study, but initial reports suggests such transmission is possi-
ble (Hecht, 1998). Besides posing an alarming risk to unin-
fected partners, the possibility of drug resistant strains of
HIV being transmitted through sexual or drug use practices is
also of concern for HIV-positive individuals, in that HIV •re-
infectionŽ with a treatment resistant strain of HIV would
likely contribute to poor treatment outcomes.
Paradoxically, the availability of improved HIV treat-
ments may actually be eroding commitment to safer sex due
to the belief that AIDS is no longer the dire health threat it
had been (Kelly, Hoffmann, Rompa, & Gray, 1998). Such
concerns may be particularly relevant to persons living with
HIV because they have had more direct experience with the
newer therapies. In a study involving HIV-positive and HIV-
negative gay men in Chicago (Vanable et al., 2000), a full
27% of respondents endorsed agreement with one or more
items re”ecting reduced concern about HIV due to new treat-
ments. In addition, respondents perceived the risk of HIV
transmission as lower in hypothetical scenarios describing
unprotected sex with an HIV-positive partner with unde-
tectable viral loads, relative to scenarios in which a seroposi-
tive partner had not been taking combination treatments.
More important in terms of prevention implications, reduced
HIV concern was associated most strongly with sexual risk
taking (unprotected anal sex) among HIV-positive partici-
pants, suggesting that the availability of combination treat-
ments has had a greater impact on the sexual behavior of men
living with HIV.
Such overly optimistic beliefs regarding the effectiveness
of new treatments, coupled with the prospect of behaviorally
transmitted drug-resistant strains of HIV and more general
concern for reducing HIV transmission behaviors to unin-
fected men and women, point to the urgent need for HIV risk
reduction interventions for persons living with HIV. To date,
however, HIV risk-reduction interventions involving persons
living with HIV have been quite limited. Research on HIV
counseling and testing suggests that posttest counseling
promotes short-term reductions in HIV risk behavior among
newly infected men and women (Weinhardt et al., 1999), but
other research reveals continued high risk behavior among
persons with HIV (Kalichman, 2000). Taken together, these
“ndings suggest that posttest counseling is not enough.
Given the importance of sexual and drug use practices
among HIV-positive persons, it is surprising to note the rela-
tive paucity of intervention research involving persons living
with HIV. Our review of the literature identi“ed only one RCT
designed to test speci“cally the ef fectiveness of a risk reduc-
tion intervention for HIV-positive men and women. This RCT
involved 271 HIV-positive blood donors from New York City
and tested the effectiveness of providing risk reduction infor-
mation and emotional support (Cleary et al., 1995). Results in-
dicated a general decline in sexual risk taking among all par-
ticipants, but no clear advantage of the risk reduction
intervention over the gains observed among control patients
who were randomized to a community referral source.
Perhaps the most informative research on approaches to in-
terventions for persons living with HIV comes from work
originally developed to assist people with emotional adjust-
ment and coping with HIV infection. For example, researchers
in San Francisco conducted a stress management program for
HIV-positive men in San Francisco that included relaxation
training, systematic desensitization, physical exercise, and
self-management training (Coates et al., 1989). Although risk
reduction was not a primary goal of the intervention, partici-
pation in the program was associated with a reduction in par-
ticipants• number of partners. Kelly et al. (1993) found similar
effects in a support group study of depressed HIV-positive
men. Participants were randomized to either an eight-session
support group, an eight-session cognitive-behavioral inter-
vention group, or a wait-list control group. The results
indicated that participants who received the social support
intervention reduced their frequency of unprotected receptive
anal intercourse, relative to the other two groups. Taken to-
gether, these “ndings raise the possibility that HIV risk reduc-
tion counseling might be most bene“cial if it is included
within a broader array of mental health and psychosocial ser-
vices for persons living with HIV.
In summary, continued high-risk sexual and drug use be-
havior among HIV-positive persons poses enormous health
risks for uninfected men and women, as well as for those al-
ready infected with HIV. Because all new HIV infections
originate with a person who is HIV-positive, the development
of effective risk-reduction interventions for HIV-positive per-
sons is arguably an extremely ef“cient means of reducing the
occurrence of new infections. Risk-reduction interventions
would also provide considerable bene“ts to those living with
HIV by reducing the likelihood of contracting drug-resistant
strains of HIV (as well as reducing the likelihood of coinfec-