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Treatment and Viral Load: What Do We Know About Their Effect on HIV Transmission?

Fall 2013

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Key Messages for People Living With HIV and Their Sexual Partners

While the above questions about HIV transmission risk are difficult to answer, there are key messages we can give to both people living with HIV, and their partners, to help maximize the prevention benefit of treatment and lower their risk of HIV transmission.

Key messages for monogamous serodiscordant couples

  • Don't assume that the viral load is undetectable once treatment is started. It normally takes a few months after starting treatment for the viral load to reach undetectable levels. Your viral load should be undetectable for at least 6 months to ensure the risk of HIV transmission is reduced as much as it can be.
  • Getting regular viral load tests is the only way to make sure the viral load is undetectable and stays that way. If medications are missed or drug resistance develops, the viral load may no longer be undetectable. Wait until your next viral load test to be sure.
  • Both partners should get tested regularly for STIs and, if diagnosed, seek treatment as soon as possible. The risk of HIV transmission may be higher when there is an STI in either partner.6
  • The risk of HIV transmission when the viral load is undetectable may be higher for receptive anal sex. Generally speaking, insertive anal sex (topping) is lower risk than receptive anal sex (bottoming) for the HIV-negative partner.11,25 Therefore, for same-sex male couples, the risk of HIV transmission may be reduced if the HIV-positive partner is the bottom (takes the receptive role) during anal sex.
  • Condoms are highly effective at reducing the risk of HIV transmission when used consistently and correctly. Using condoms (with condom-compatible lube) as often as possible -- particularly when the risk of HIV transmission may be elevated, such as when medications are missed or either partner is diagnosed with an STI -- will help reduce the overall risk of HIV transmission.
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Additional considerations for people with casual sexual partners

Although the above key messages apply to people who are not in a monogamous serodiscordant relationship, additional factors need to be considered for those who are having sex with casual partners.

For example, there is generally a higher risk of STI transmission in this context because it is more difficult to know for certain if either partner has an STI. This is because these infections don't always produce symptoms and a person may have become infected with an STI since their last test. Since STIs may increase the risk of HIV transmission when the viral load is undetectable, consistent use of condoms and regular screening for STIs may be important to lower the risk of STI and HIV transmission. In the context of casual sex, it is also important that HIV-negative individuals do not assume a casual partner (of known or potential HIV-positive status) has an undetectable viral load.

Those who have casual partners -- and are also in a stable serodiscordant relationship that is "open" -- may want to discuss and agree upon what is and isn't allowed outside of their relationship. One agreement may be the use of condoms with casual partners to avoid the transmission of STIs and, subsequently, an increased risk of HIV transmission.


Resources

Your sexual health from Managing your health, CATIE's guide for people living with HIV

HIV viral load, HIV treatment and sexual HIV transmission -- CATIE Fact sheet


References

  1. Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal of Medicine. 2000 Mar 30;342(13):921-9.
  2. Baeten JM, Kahle E, Lingappa JR, Coombs RW, Delany-Moretlwe S, Nakku-Joloba E, et al. Genital HIV-1 RNA predicts risk of heterosexual HIV-1 transmission. Science Translational Medicine. 2011 Apr 6;3(77):77ra29.
  3. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011 Aug 11;365(6):493-505.
  4. Hasse B, Ledergerber B, Hirschel B, Vernazza P, Glass TR, Jeannin A, et al. Frequency and determinants of unprotected sex among HIV-infected persons: the Swiss HIV cohort study. Clinical Infectious Diseases. 2010 Dec 1;51(11):1314-22.
  5. Van Den Boom W, Stolte IG, Witlox R, Sandfort T, Prins M, Davidovich U. Undetectable Viral Load and the Decision to Engage in Unprotected Anal Intercourse Among HIV-Positive MSM. AIDS and Behavior. 2013 Jul;17(6):2136-42.
  6. Ward H, Rönn M. The contribution of STIs to the sexual transmission of HIV. Current Opinion in HIV and AIDS. 2010 Jul;5(4):305-10.
  7. Jia Z, Ruan Y, Li Q, Xie P, Li P, Wang X, et al. Antiretroviral therapy to prevent HIV transmission in serodiscordant couples in China (2003-11): a national observational cohort study. Lancet. 2012 Nov 30;
  8. World Health Organization. WHO and U.S. NIH Working Group Meeting on Treatment for HIV Prevention among MSM: What Additional Evidence is Required. Geneva; 2011 Nov.
  9. Rodger AJ, Bruun T, Vernazza P, Collins S, Estrada V, Van Lunzen J, et al. Further research needed to support a policy of antiretroviral therapy as an HIV prevention initiative. Antiviral Therapy. 2013;18(3):285-7.
  10. Loutfy MR, Wu W, Letchumanan M, Bondy L, Antoniou T, Margolese S, et al. Systematic Review of HIV Transmission between Heterosexual Serodiscordant Couples where the HIV-Positive Partner Is Fully Suppressed on Antiretroviral Therapy. PLoS ONE. 2013 Feb 13;8(2):e55747.
  11. Baggaley RF, White RG, Boily M-C. HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention. International Journal of Epidemiology. 2010 Aug;39(4):1048-63.
  12. Boily M-C, Baggaley RF, Wang L, Masse B, White RG, Hayes RJ, et al. Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies. Lancet Infectious Diseases. 2009 Feb;9(2):118-29.
  13. Wilson DP, Grulich AE, Boyd M. Overly Optimistic Forecasts for the Impact of Treatment of HIV Prevention for Men Who Have Sex With Men. Clinical Infectious Diseases. 2011 Sep 15;53(6):611-2.
  14. Stürmer M, Doerr HW, Berger A, Gute P. Is transmission of HIV-1 in non-viraemic serodiscordant couples possible? Antiviral Therapy. 2008;13(5):729-32.
  15. Cu-Uvin S, DeLong AK, Venkatesh KK, Hogan JW, Ingersoll J, Kurpewski J, et al. Genital tract HIV-1 RNA shedding among women with below detectable plasma viral load. AIDS. 2010 Oct 23;24(16):2489-97.
  16. Sheth PM, Kovacs C, Kemal KS, Jones RB, Raboud JM, Pilon R, et al. Persistent HIV RNA shedding in semen despite effective antiretroviral therapy. AIDS. 2009 Sep 24;23(15):2050-4.
  17. Politch JA, Mayer KH, Welles SL, O'Brien WX, Xu C, Bowman FP, et al. Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active HIV-infected men who have sex with men. AIDS. 2012 Jul 31;26(12):1535-43.
  18. Marcelin A-G, Tubiana R, Lambert-Niclot S, Lefebvre G, Dominguez S, Bonmarchand M, et al. Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma. AIDS. 2008 Aug 20;22(13):1677-9.
  19. Lampinen TM, Critchlow CW, Kuypers JM, Hurt CS, Nelson PJ, Hawes SE, et al. Association of antiretroviral therapy with detection of HIV-1 RNA and DNA in the anorectal mucosa of homosexual men. AIDS. 2000 Mar 31;14(5):F69-75.
  20. Kiviat NB, Critchlow CW, Hawes SE, Kuypers J, Surawicz C, Goldbaum G, et al. Determinants of human immunodeficiency virus DNA and RNA shedding in the anal-rectal canal of homosexual men. Journal of Infectious Diseases. 1998 Mar;177(3):571-8.
  21. Atashili J, Poole C, Ndumbe PM, Adimora AA, Smith JS. Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies. AIDS. 2008 Jul 31;22(12):1493-501.
  22. Mugo NR, Heffron R, Donnell D, Wald A, Were EO, Rees H, et al. Increased risk of HIV-1 transmission in pregnancy: a prospective study among African HIV-1 serodiscordant couples. AIDS. [Internet]. 2011 Jul 21 [cited 2011 Sep 12]; Available from: http://www.ncbi.nlm.nih.gov.myaccess.library.utoronto.ca/pubmed/21785321
  23. Curlin ME, Leelawiwat W, Dunne EF, Chonwattana W, Mock PA, Mueanpai F, et al. Cyclic changes in HIV shedding from the female genital tract during the menstrual cycle. Journal of Infectious Diseases. 2013 May 15;207(10):1616-20.
  24. Polis CB, Phillips SJ, Curtis KM. Hormonal contraceptive use and female-to-male HIV transmission: a systematic review of the epidemiologic evidence. AIDS. 2013 Feb 20;27(4):493-505.
  25. Vallabhaneni S, Li X, Vittinghoff E, Donnell D, Pilcher CD, Buchbinder SP. Seroadaptive Practices: Association with HIV Acquisition among HIV-Negative Men Who Have Sex with Men. PLoS ONE. 2012;7(10):e45718.

James Wilton is the coordinator of the Biomedical Science of HIV Prevention Project at CATIE. James is currently completing his master's degree of Public Health in Epidemiology at the University of Toronto and has completed an undergraduate degree in microbiology and immunology at the University of British Columbia.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
 
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