By the end of 2009, an estimated 5.2 million people in low- and middle-income countries received antiretroviral therapy (ART). In sub-Saharan Africa, nearly 37% [34%–40%] of people eligible for treatment had access to those life-saving medicines (UNAIDS 2010). This is an extraordinary achievement, considering that as recently as 2003, relatively few people living with HIV/AIDS had access to ART in Africa. The scaling-up of ART in Africa and other regions has saved the lives of countless people and we hope will continue to do so.
At the same time, access to HIV/AIDS treatment might have transformed the perception of AIDS from a death sentence to a manageable, chronic condition, not necessarily different from any other chronic disease. Such a change in perception could lead to change in sexual behaviors. If AIDS is not perceived as a killer disease anymore, it might induce complacency and increase risky behaviors and the mixing between higher- and lower-risk groups in the population. That’s what has been described as the “disinhibition” hypothesis.
One of the earliest studies of the possibility of disinhibition behaviors looked at change in condom use by sex workers in Nairobi, Kenya (Jha et al., 2001). The findings are summarized in the figure below. The figure offers suggestive evidence that condom use by sex workers decreased when two fake cures of AIDS, Kemron and Pearl Omega, were announced. Such a pattern is consistent with disinhibition behaviors, although the result may not be repeated in the general population, since it is based on a very specific segment of the population.
|Figure 1: Percent of condom use in a cohort of sex workers: Nairobi, 1985-1999|
|Source: Jha et al. (2001)|
In a recent working paper, we test the disinhibition hypothesis using data that we collected in Mozambique. We find suggestive evidence that easier access to antiretroviral therapy can lead to more risky sexual behaviors. We reach that conclusion by drawing on Mozambique household panel data, which cover both randomly-selected, HIV-positive individuals and the general population in 2007 and 2008.
Our results suggest that men and women respond differently to increased access to therapy: risky behaviors increase for men who believe, wrongly, that AIDS can be cured; while risky behaviors increase for women who believe, correctly, that antiretroviral therapy can treat AIDS but cannot cure it.
A proposal under active consideration for combating AIDS is the so-called “Test-and-Treat” policy, that all HIV-infected people in severely affected countries be started immediately on treatment, without waiting 8 to 10 years for symptoms to develop. One of the key assumptions supporting this policy is that better access to antiretroviral treatment will be accompanied by a 40 percent reduction in risky sexual behavior.(Granich et al., Lancet, 2009). The findings of our study support the doubts raised by Garnett and Baggaley (2009), Baggaley and Fraser (2010) and others regarding this assumption, suggesting instead that better access to antiretroviral therapy may actually increase risky behavior, because people perceive that the risk of AIDS has diminished. These findings have two main policy implications. First, our results suggest that, to the degree that men incorrectly believe that AIDS can be cured (in Mozambique 8% in 2007 and 6% in 2008), prevention programs correcting this misconception may diminish men’s tendency to revert to riskier behavior in reaction to treatment access. Second, correcting misinformation is not enough to prevent disinhibition among the majority of men who already know AIDS cannot be cured or among women. Most of the adult population must instead be persuaded that, even with access to treatment, AIDS is a dangerous disease, warranting caution in sexual contacts.