Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study

Bavinton, Benjamin R.; Pinto, Angie N; Phanuphak, Nittaya; Grinsztejn, Beatriz; Prestage, Garrett; Zablotska‐Manos, Iryna; Jin, Fengyi; Fairley, Christopher K.; Moore, Richard D.; Roth, Norman; Bloch, Mark; Pell, Catherine; McNulty, Anna; Baker, David; Hoy, Jennifer; Tee, Ban Kiem; Templeton, David J; Cooper, David A.; Emery, Sean; Kelleher, Anthony D.; Grulich, Andrew E.

doi:10.1016/s2352-3018(18)30132-2

Cited by 372 publications

(363 citation statements)

References 18 publications

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“…This again pointed to the importance of asymptomatic STIs screening and treatment among HIV‐positive MSM prior to and during the first year of ART initiation. Our finding supports the confirmed efficacy of treatment as prevention seen among discordant gay couples with high STIs burden in the PARTNER and the Opposites Attract studies . Data from a cohort of HIV‐positive MSM in London also showed that the presence of asymptomatic rectal chlamydia and gonorrhoea was not associated with increased rectal HIV RNA in those fully suppressed on ART .…”

Section: Discussionsupporting

confidence: 81%

Sexually transmitted infections and HIV RNA levels in blood and anogenital compartments among Thai men who have sex with men before and after antiretroviral therapy: implication for Treatment as Prevention programme

et al. 2018

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IntroductionSexually transmitted infections (STIs) are common among HIV‐positive men who have sex with men (MSM). There have been concerns that undiagnosed and untreated STIs could undermine efforts to use antiretroviral therapy (ART) for prevention due to genital secretion infectiousness. We evaluated the correlation between STIs and HIV RNA in anogenital compartments among HIV‐positive MSM before and after ART.MethodsMSM participants newly diagnosed with HIV were offered ART regardless of CD4 count during November 2012 to November 2015. Syphilis serology, oropharyngeal swab, rectal swab, urine collection for gonorrhoea and chlamydia nucleic acid amplification testing, and HIV RNA measurement in blood, semen and rectal samples were performed at baseline, 12 and 24 months thereafter.ResultsOf 143 HIV‐positive MSM, 16.1% had syphilis, 23.1% had gonorrhoea and 32.8% had chlamydia at baseline. Participants with STIs at baseline had higher median HIV RNA levels in blood plasma (p = 0.053), seminal plasma (p = 0.01) and rectal secretions (p = 0.002) than those without STIs. Multivariate models identified HIV RNA 100,000 to 500,000 (OR 6.74, 95% CI 2.24 to 20.28, p = 0.001) and >500,000 (OR 9.39, 95% CI 1.08 to 81.72, p = 0.04) copies/mL in blood, CD4 count <350 cells/mm3 (OR 4.20, 95% CI 1.05 to 16.70, p = 0.04) and having any STIs (OR 2.62, 95% CI 1.01 to 6.80 p = 0.047) to be associated with detectable (>40 copies/mL) seminal plasma HIV RNA. Having chlamydia at any sites (OR 3.17, 95% CI 1.07 to 9.44, p = 0.04) was associated with detectable rectal HIV RNA. Incidences of syphilis, gonorrhoea and chlamydia were 13.4, 16.4 and 18.1 per 100 person‐years respectively. Nine participants had detectable HIV RNA (five in blood, one in semen, two in rectal samples and one in both blood and rectal samples) at 12 and/or 24 months after ART.ConclusionsSTIs were extremely common among HIV‐positive MSM prior to and after ART. ART effectively reduced HIV RNA in all compartments. The correlation between STIs and anogenital HIV RNA, especially prior to ART and likely until complete HIV RNA suppression from ART is achieved, points to the importance of integrating asymptomatic STIs screening into Treatment as Prevention programme for MSM.

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Section: Discussionsupporting

confidence: 81%

Sexually transmitted infections and HIV RNA levels in blood and anogenital compartments among Thai men who have sex with men before and after antiretroviral therapy: implication for Treatment as Prevention programme

et al. 2018

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“…For persons in the model with viral suppression, the reduction in transmission rate was 100% † ( 2 – 5 ). Based on population risk group and the cumulative amount of time spent in each age group and care-continuum step, the model estimated the number of infections each subgroup generated.…”

Section: Methodsmentioning

confidence: 99%

“…The benefits of treatment are maximized with suppression of the virus (<200 copies of HIV/mL of blood on the most recent viral load test), which benefits health and decreases rates of transmission. Four recent studies found that viral suppression prevented sexual transmission of HIV ( 2 – 5 ). Together, these prospective studies found no HIV transmissions attributable to sex between HIV-discordant couples when the partner with HIV infection was on treatment and maintained viral suppression, despite documenting tens of thousands of acts of condomless sex in which the HIV-negative partner was not using preexposure prophylaxis.…”

Section: Introductionmentioning

confidence: 99%

Vital Signs:HIV Transmission Along the Continuum of Care — United States, 2016

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Sansom

et al. 2019

MMWR Morb. Mortal. Wkly. Rep.

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Background In 2016, an estimated 1.1 million persons had human immunodeficiency virus (HIV) infection in the United States; 38,700 were new infections. Knowledge of HIV infection status, behavior change, and antiretroviral therapy (ART) all prevent HIV transmission. Persons who achieve and maintain viral suppression (achieved by most persons within 6 months of starting ART) can live long, healthy lives and pose effectively no risk of HIV transmission to their sexual partners. Methods A model was used to estimate transmission rates in 2016 along the HIV continuum of care. Data for sexual and needle-sharing behaviors were obtained from National HIV Behavioral Surveillance. Estimated HIV prevalence, incidence, receipt of care, and viral suppression were obtained from National HIV Surveillance System data. Results Overall, the HIV transmission rate was 3.5 per 100 person-years in 2016. Along the HIV continuum of care, the transmission rates from persons who were 1) acutely infected and unaware of their infection, 2) non-acutely infected and unaware, 3) aware of HIV infection but not in care, 4) receiving HIV care but not virally suppressed, and 5) taking ART and virally suppressed were 16.1, 8.4, 6.6, 6.1, and 0 per 100 person-years, respectively. The percentages of all transmissions generated by each group were 4.0%, 33.6%, 42.6%, 19.8%, and 0%, respectively. Conclusion Approximately 80% of new HIV transmissions are from persons who do not know they have HIV infection or are not receiving regular care. Going forward, increasing the percentage of persons with HIV infection who have achieved viral suppression and do not transmit HIV will be critical for ending the HIV epidemic in the United States.

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“…Less than 5% of all anal sex acts were neither protected by condoms nor by a biomedical strategy. Although it must be acknowledged that condoms, PrEP and TasP all rely on adherence and correct use, we found high levels of adherence to both PrEP and ART in those taking them . Within the acts not protected by condoms or biomedical prevention, two‐thirds had reduced risk due to the HIV‐negative partner being insertive (strategic positioning).…”

Section: Discussionmentioning

confidence: 81%

Strategies used by gay male HIV serodiscordant couples to reduce the risk of HIV transmission from anal intercourse in three countries

et al. 2019

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Introduction There are few data about the range of strategies used to prevent sexual HIV transmission within gay male serodiscordant couples. We examined HIV prevention strategies used by such couples and compared differences between countries. Methods Opposites Attract was a cohort study of male serodiscordant couples in Australia, Brazil and Thailand, from May 2014 (Australia) or May 2016 (Brazil/Thailand) to December 2016. At visits, HIV‐positive partners had viral load (VL) tested; HIV‐negative partners reported sexual behaviour and perceptions of their HIV‐positive partner's VL results. Within‐couple acts of condomless anal intercourse (CLAI) were categorized by strategy: condom‐protected, biomedically protected (undetectable VL and/or pre‐exposure prophylaxis [PrEP]), or not protected by either (HIV‐negative partners engaging in insertive CLAI, receptive CLAI with withdrawal, or receptive CLAI with ejaculation). Results A total of 343 couples were included in this analysis (153 in Australia, 93 in Brazil and 97 in Thailand). Three‐quarters of HIV‐positive partners were consistently virally suppressed (<200 copies/mL) during follow‐up, and HIV‐negative partners had correct perceptions of their partner's VL result for 76.5% of tests. One‐third of HIV‐negative partners used daily PrEP during follow‐up. Over follow‐up, 73.8% of couples had CLAI. HIV‐negative partners reported 31,532 acts of anal intercourse with their HIV‐positive partner. Of these, 46.7% were protected by condoms, 48.6% by a biomedical strategy and 4.7% of acts were not protected by these strategies. Australian couples had fewer condom‐protected acts and a higher proportion of biomedically protected acts than Brazilian and Thai couples. Of the 1473 CLAI acts where the perceived VL was detectable/unknown and were not protected by PrEP (4.7% of all acts), two‐thirds (n = 983) were when the HIV‐negative partner was insertive (strategic positioning). Of the 490 acts when the HIV‐negative partner was receptive, 261 involved withdrawal and 280 involved ejaculation. Thus, <1% of acts were in the highest risk category of receptive CLAI with ejaculation. Conclusions Couples used condoms, PrEP or perceived undetectable VL for prevention in the majority of anal intercourse acts. Only a very small proportion of events were not protected by these strategies. Variation between countries may reflect differences in access to HIV treatment, education, knowledge and attitudes.

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Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study

Cited by 372 publications

References 18 publications

Sexually transmitted infections and HIV RNA levels in blood and anogenital compartments among Thai men who have sex with men before and after antiretroviral therapy: implication for Treatment as Prevention programme

Sexually transmitted infections and HIV RNA levels in blood and anogenital compartments among Thai men who have sex with men before and after antiretroviral therapy: implication for Treatment as Prevention programme

Vital Signs:HIV Transmission Along the Continuum of Care — United States, 2016

Strategies used by gay male HIV serodiscordant couples to reduce the risk of HIV transmission from anal intercourse in three countries

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