Winter 2011 Damien de Walque, Harounan Kazianga, and Mead Over

Access to HIV/AIDS treatment, by changing perceptions about the risk of AIDS, may lead to an increase in risky behaviors

In December 2009 an estimated 5.2 million people in developing countries were receiving antiretroviral therapy (ART) and in Sub-Saharan Africa nearly 37 percent of people eligible for treatment were able to access those lifesaving medicines, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). This is an extraordinary achievement when one considers that as recently as 2003 only a few privileged HIV/AIDS patients had access to ART in Africa.The scaling up of ART in Africa has saved many lives and 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 a change in sexual behaviors. If AIDS is no longer perceived as a killer disease, this might induce complacency and increase risky behavior and mixing between higher- and lower-risk groups in the population. This has been described as the “disinhibition” hypothesis.

Using data from Mozambique, a new paper by de Walque, Kazianga, and Over tests for disinhibition behaviors resulting from increased access to ART for HIV/AIDS patients. The main hypothesis tested is that people may alter their sexual behaviors in response to a perceived decrease in the opportunity costs of contracting AIDS that results from expected access to ART. Such compensating behaviors, if large enough, could potentially offset some of the positive effects of greater access to ART.

The analysis draws on household panel data that cover both randomly selected HIV-positive individuals and the general population in 2007 and 2008. After controlling for individual fixed effects, the authors find suggestive evidence of isinhibition behaviors, consistent with earlier literature on risk taking in the United States and Europe following the introduction of ART.

The findings suggest that men and women responded differently to perceived changes in risk that occur with greater access to ART. Men’s demand for risky sexual behaviors increases with the false belief that AIDS can be cured and decreases with the correct belief that AIDS can be treated but not cured. Women’s demand for risky sexual behaviors increases only with the correct belief that AIDS can be treated. While the authors do not have a straight explanation for the observed gender difference, one possible explanation may stem from the cultural context of Sub-Saharan Africa. Men generally have greater autonomy in sexual choices than women, so in general it would be easier for men than for women to adjust their sexual behaviors when new information becomes available.

Regardless of the reason, it appears that providing the correct information on ART is associated with reduced disinhibition for men and increased disinhibition for women. If these associations were to be confirmed as causal relationships, then overall women may be benefiting less from ART scale-up than men. But the authors also observe that the share of individuals who wrongly believe that AIDS can be cured remains small and is declining (from 8 percent in 2007 to 6 percent in 2008). The impact of programs correcting the wrong perceptions about AIDS treatment is therefore bound to be limited.

The results suggest that scaling up access to ART without prevention programs may not be optimal if the objective is to contain the disease, since people would adjust their sexual behavior in response to the perceived changes in risk. Prevention programs therefore need to include educational messages about ART and address the changing beliefs about HIV in the era of increasing availability of ART. In addition, prevention messages need to account for the gender difference in disinhibition behaviors.

The authors’ results also provide a framework for assessing the public effects of occasional media coverage of false cures for AIDS. Their findings suggest that men may respond to these types of announcements by increasing their demand for risky sexual behaviors, thus contributing to the spread of the disease.

Damien de Walque , Harounan Kazianga, and Mead Over. 2010. "Antiretroviral Therapy Awareness and Risky Sexual Behaviors: Evidence from Mozambique." Policy Research Working Paper 5486, World Bank, Washington, DC.