Lack of Effectiveness of Antiretroviral Therapy in Preventing HIV Infection in Serodiscordant Couples in Uganda: An Observational Study

Abstract

BackgroundWe examined the real-world effectiveness of ART as an HIV prevention tool among HIV serodiscordant couples in a programmatic setting in a low-income country.MethodsWe enrolled individuals from HIV serodiscordant couples aged ≥18 years of age in Jinja, Uganda from June 2009 – June 2011. In one group of couples the HIV positive partner was receiving ART as they met clinical eligibility criteria (a CD4 cell count ≤250 cells/ μL or WHO Stage III/IV disease). In the second group the infected partner was not yet ART-eligible. We measured HIV incidence by testing the uninfected partner every three months. We conducted genetic linkage studies to determine the source of new infections in seroconverting participants.ResultsA total of 586 couples were enrolled of which 249 (42%) of the HIV positive participants were receiving ART at enrollment, and an additional 99 (17%) initiated ART during the study. The median duration of follow-up was 1.5 years. We found 9 new infections among partners of participants who had been receiving ART for at least three months and 8 new infections in partners of participants who had not received ART or received it for less than three months, for incidence rates of 2.09 per 100 person-years (PYRs) and 2.30 per 100 PYRs, respectively. The incidence rate ratio for ART-use was 0.91 (95% confidence interval 0.31-2.70; p=0.999). The hazard ratio for HIV seroconversion associated with ART-use by the positive partner was 1.07 (95% CI 0.41-2.80). A total of 5/7 (71%) of the transmissions on ART and 6/7 (86%) of those not on ART were genetically linked.ConclusionOverall HIV incidence was low in comparison to previous studies of serodiscordant couples. However, ART-use was not associated with a reduced risk of HIV transmission in this study.

‘People say that we are already dead much as we can still walk’: a qualitative investigation of community and couples’ understanding of HIV serodiscordance in rural Uganda

“…The HAARP study compared HIV incidence between HIV negative members of serodiscordant partners who were or were not receiving ART during the study and was conducted from June 2009 to December 2011. The study did not find a benefit from ART in terms of preventing HIV seroconversion in the negative participant [27]. As a result of these findings, we enrolled a selection of previous study participants in a qualitative sub-study for a series of in-depth interviews beginning in June 2013 and continuing until August 2014.…”

‘He said, she said’: assessing dyadic agreement of reported sexual behaviour and decision-making among an HIV sero-discordant couples cohort in Uganda

“…Data for this study were obtained from the Highly Active Antiretroviral therapy as Prevention (HAARP) study, an observational cohort investigating the effectiveness of antiretroviral therapy (ART) in preventing HIV transmission among sero-discordant couples in Jinja, Eastern Uganda (June 2009–June 2011) 6. Polygynous couples (where the male participant has more than one female spouse) were excluded from this analysis to avoid misclassification bias.…”

HIV treatment as prevention in men who have sex with men: examining the evidence

“…Third, as suggested by the aforementioned studies in rural China 12 and rural Uganda, 13 treatment as prevention will function only if people have access to care. When such access is limited, HIV viral loads cannot be monitored, sexually transmitted infections cannot be treated, important psychosocial factors cannot be addressed, and the outcome may be a similar rate of HIV transmission, irrespective of antiretroviral therapy use.…”

“…13 Reported condom use was 51% and 67% among those receiving and not receiving antiretroviral therapy, respectively. 13 Birungi and colleagues 13 concluded that a number of factors influence HIV transmission and that, in the absence of routine monitoring and access to HIV care, these factors appear to reduce the prevention benefits of treatment as prevention.…”

“…When such access is limited, HIV viral loads cannot be monitored, sexually transmitted infections cannot be treated, important psychosocial factors cannot be addressed, and the outcome may be a similar rate of HIV transmission, irrespective of antiretroviral therapy use. 12,13 This situation highlights how access to care and the ability to address HIV transmission cofactors may potentially strengthen or weaken the extent to which treatment as prevention can prevent HIV transmission. Access to care is also important with regard to consistent and appropriate medication usage.…”