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. 2010 Jun 12;375(9731):2092-8.
doi: 10.1016/S0140-6736(10)60705-2. Epub 2010 May 26.

Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis

Deborah Donnell  1 , Jared M Baeten, James Kiarie, Katherine K Thomas, Wendy Stevens, Craig R Cohen, James McIntyre, Jairam R Lingappa, Connie Celum; Partners in Prevention HSV/HIV Transmission Study Team
Collaborators, Affiliations

Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis

Deborah Donnell et al. Lancet. .

Abstract

Background: High plasma HIV-1 RNA concentrations are associated with increased risk of HIV-1 transmission. Initiation of antiretroviral therapy (ART) reduces plasma HIV-1 concentrations. We aimed to assess the effect of ART use by patients infected with HIV-1 on risk of transmission to their uninfected partners.

Methods: Participants in our prospective cohort analysis were from a randomised placebo-controlled trial that enrolled heterosexual African adults who were seropositive for both HIV-1 and herpes simplex virus type 2, and their HIV-1 seronegative partners. At enrolment, HIV-1 infected participants had CD4 counts of 250 cells per microL or greater and did not meet national guidelines for ART initiation; during 24 months of follow-up, CD4 counts were measured every 6 months and ART was initiated in accordance with national guidelines. Uninfected partners were tested for HIV-1 every 3 months. The primary outcome was genetically-linked HIV-1 transmission within the study partnership. We assessed rates of HIV-1 transmission by ART status of infected participants.

Findings: 3381 couples were eligible for analysis. 349 (10%) participants with HIV-1 initiated ART during the study, at a median CD4 cell count of 198 (IQR 161-265) cells per microL. Only one of 103 genetically-linked HIV-1 transmissions was from an infected participant who had started ART, corresponding to transmission rates of 0.37 (95% CI 0.09-2.04) per 100 person-years in those who had initiated treatment and 2.24 (1.84-2.72) per 100 person-years in those who had not-a 92% reduction (adjusted incidence rate ratio 0.08, 95% CI 0.00-0.57, p=0.004). In participants not on ART, the highest HIV-1 transmission rate (8.79 per 100 person-years) was from those with CD4 cell counts lower than 200 cells per microL. In couples in whom the untreated HIV-1 infected partner had a CD4 cell count greater than 200 cells per microL, 66 (70%) of 94 transmissions occurred when plasma HIV-1 concentrations exceeded 50 000 copies per mL.

Interpretation: Low CD4 cell counts and high plasma HIV-1 concentrations might guide use of ART to achieve an HIV-1 prevention benefit. Provision of ART to HIV-1 infected patients could be an effective strategy to achieve population-level reductions in HIV-1 transmission.

Funding: Bill & Melinda Gates Foundation; US National Institutes of Health.

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Conflict of interest statement

Conflict of Interest:

JM and CC received research grant support from GlaxoSmithKline, which did not include salary support, and JM has received speaker fees from Abbott Laboratories.

Comment in

  • HIV drugs for treatment, and for prevention.
    Dabis F, Newell ML, Hirschel B. Dabis F, et al. Lancet. 2010 Jun 12;375(9731):2056-7. doi: 10.1016/S0140-6736(10)60838-0. Epub 2010 May 26. Lancet. 2010. PMID: 20537377 No abstract available.

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