Antiretroviral Therapy Use and HIV Transmission Among Discordant Couples in Nonresearch Settings in Kigali, Rwanda

Abstract

Background: Antiretroviral therapy (ART) efficacy for HIV prevention among discordant couples has been demonstrated in clinical trials. Effectiveness outside of research settings is less well understood.Methods: HIV-discordant couples were enrolled in couples' testing and follow-up at 20 government clinics in Kigali from 2010 to 2014. We performed viral linkage analysis on seroconverting couples to determine infection sources (intracouple vs. extracouple). Antiretroviral therapy use in index partners was collected at baseline and during follow-up by self-report with verification of government medical records.Results: A total of 3777 HIV-discordant couples were identified and followed up at government health clinics. Fifty-four incident HIV infections were identified, of which 36 were confirmed linked to the index partner, 4 were unlinked, and 14 were unknown. Among the 50 linked or unknown transmission pairs, 38% occurred among couples in which the index partner was on ART (HIV incidence rate of 0.63/100 person-years), whereas 62% occurred among couples in which the index partner was not on ART (HIV incidence rate of 5.51/100 person-years; adjusted rate ratio, 6.9). HIV acquisition was higher in women than in men with non-ART using index partners (P < 0.001). Conclusions:Couples in a government clinic couples' HIV testing and follow-up program in Rwanda had an 89% reduction in HIV incidence when index partners were using ART, slightly lower than efficacy estimates from randomized trials. Antiretroviral therapy for prevention should be prioritized for key populations including discordant couples identified via couples' voluntary counseling and testing, with increased efforts to improve uptake, adherence, and viral load monitoring.

Risk of Sexual Transmission of HIV with Antiretroviral Therapy and Variable or Suppressed Viral Load

“…18 The 14 primary studies were published between 2018 and 2022, all of which employed nonrandomized study designs. 13,14,[19][20][21][22][23][24][25][26][27][28][29][30] Seven of the nonrandomized studies used a prospective cohort design 13,14,19,[21][22][23]25 and 7 used a retrospective method. 20,24,[26][27][28][29][30]…”

“…Of these potentially relevant articles, 72 publications were excluded for various reasons, while 15 studies met the inclusion criteria and were included in this report. 13,14,[18][19][20][21][22][23][24][25][26][27][28][29][30] These comprised 1 overview of SRs and/or MAs, 18 and 14 nonrandomized studies. 13,14,[19][20][21][22][23][24][25][26][27][28][29][30] Appendix 1 presents the PRISMA 31 flow chart of the study selection.…”

“…13,14,[18][19][20][21][22][23][24][25][26][27][28][29][30] These comprised 1 overview of SRs and/or MAs, 18 and 14 nonrandomized studies. 13,14,[19][20][21][22][23][24][25][26][27][28][29][30] Appendix 1 presents the PRISMA 31 flow chart of the study selection.…”

“…32 Results of the 2 relevant SRs included in the overview are summarized in the current report. Of the 14 primary studies, 13,14,[19][20][21][22][23][24][25][26][27][28][29][30] only data describing characteristics and findings relevant to the current report were abstracted and summarized herein.…”

“…The lead author of the included overview of the reviews was from Iran. 18 Countries represented by the eligible primary studies included Brazil, 13,27 China, 19,24,26,[28][29][30] Ethiopia, 20 India, 22,23 Kenya, 25 Rwanda, 21 and 2 international studies, 1 of which was conducted in 14 European countries, 14 and the other which including participants from Australia, Brazil, and Thailand. 13…”