Condomless Sex With Virologically Suppressed HIV-Infected Individuals: How Safe Is It?
JAMA. 2016 Jul 12;316(2):149-51.
Daar ES1, Corado K1.
1Los Angeles Biomedical Research Institute, Division of HIV Medicine, Harbor-UCLA Medical Center, Torrance, California.
The use of antiretroviral therapy (ART) across the globe has had a profound influence on the natural history of HIV infection. Although the pandemic continues to spread, one of the greatest advances in prevention since the use of ART in pregnancy to avoid vertical transmission was the recognition that the same treatment prevents horizontal transmission. Many cohorts have suggested this benefit,1,2 findings that in part led to the Swiss Commission statement in 2008 that HIV-infected individuals who have had suppressed plasma HIV RNA load for longer than 6 months and who do not have sexually transmitted infections (STIs) were not sexually infectious.3 Although the statement was controversial at the time, the cohort data were compelling, and there have been very few case reports of an HIV transmission event from a virologically suppressed person and no events identified in a systemic review of patients with suppressed plasma HIV RNA load in cohort studies and randomized controlled trials…
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JAMA. 2016 Jul 12;316(2):171-81.
Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy.
Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, Corbelli GM, Estrada V, Geretti AM, Beloukas A, Asboe D, Viciana P, Gutiérrez F, Clotet B, Pradier C, Gerstoft J, Weber R, Westling K, Wandeler G, Prins JM, Rieger A, Stoeckle M, Kümmerle T, Bini T, Ammassari A, Gilson R, Krznaric I, Ristola M, Zangerle R, Handberg P, Antela A, Allan S, Phillips AN, Lundgren J; PARTNER Study Group.
Pompeyo V, Trastoy M, Palacio R, Gutiérrez F, Masiá M, Padilla S, Robledano C, Clotet B, Coll P, Peña J, Estrada V, Rodrigo M, Santiago E, Rivero A, Antela A, Losada E, Lires C, Aguilera A, Gatell J, Guerrero J, Dronda F, Soriano V, Asboe D, Nwokolo N, Sewell J, Gilson R, Esteban N, McNamara S, Rodger A, Sturgeon K, Gompels M, Jennings L, Allan S, Leen C, Morris S, Brady M, Campbell L, Fisher M, Dhar J, O’Connell R, White D, Fox J, Fidler S, Stanley P, Natarajan U, Ghanem M, Ainsworth J, Waters A, Wilkins E, Minton J, Calderwood J, Patel H, Lascar M, Lunzen J, Kümmerle T, Fätkenheuer G, Rund E, Lehmann C, Krznaric I, Ingiliz P, Motsch J, Baumgarten A, Bogner J, Brockmeyer N, Stellbrink H, Jessen H, Rockstroh J, Stoeckle M, Battegay M, Weber R, Grube C, Braun D, Günthard H, Wandeler G, Furrer H, Konrad T, Rauch A, Vernazza P, Rasi M, Bernasconi E, Tarr P, Gerstoft J, Quist T, Handberg P, Clausen B, Mathiesen L, Oestergaard S, Stenvang S, Ristola M, Kivelä P, Westling K, Frisén E, Blaxhult A, Cortney G, Clumeck N, Vandekerckhove L, Prins J, Brinkman K, Verhagen D, Eeden A, Pradier C, Durant J, Serini M, Bréaud S, Raffi F, Pialoux G, Ohayon M, Coquelin V, Rieger A, Touzeau-Roemer V, Zangerle R, Kitchen M, Gisinger M, Sarcletti M, Geit M, Bini T, Comi L, Pandolfo A, Suardi E, Ammassari A, Pierro P, Carli G, Orchi N, Celesia M, Mussini C, Biagio A, Janerio N.
A key factor in assessing the effectiveness and cost-effectiveness of antiretroviral therapy (ART) as a prevention strategy is the absolute risk of HIV transmission through condomless sex with suppressed HIV-1 RNA viral load for both anal and vaginal sex.
To evaluate the rate of within-couple HIV transmission (heterosexual and men who have sex with men [MSM]) during periods of sex without condoms and when the HIV-positive partner had HIV-1 RNA load less than 200 copies/mL.
DESIGN, SETTING, AND PARTICIPANTS:
The prospective, observational PARTNER (Partners of People on ART-A New Evaluation of the Risks) study was conducted at 75 clinical sites in 14 European countries and enrolled 1166 HIV serodifferent couples (HIV-positive partner taking suppressive ART) who reported condomless sex (September 2010 to May 2014). Eligibility criteria for inclusion of couple-years of follow-up were condomless sex and HIV-1 RNA load less than 200 copies/mL. Anonymized phylogenetic analysis compared couples’ HIV-1 polymerase and envelope sequences if an HIV-negative partner became infected to determine phylogenetically linked transmissions.
Condomless sexual activity with an HIV-positive partner taking virally suppressive ART.
MAIN OUTCOMES AND MEASURES:
Risk of within-couple HIV transmission to the HIV-negative partner.
Among 1166 enrolled couples, 888 (mean age, 42 years [IQR, 35-48]; 548 heterosexual [61.7%] and 340 MSM [38.3%]) provided 1238 eligible couple-years of follow-up (median follow-up, 1.3 years [IQR, 0.8-2.0]). At baseline, couples reported condomless sex for a median of 2 years (IQR, 0.5-6.3). Condomless sex with other partners was reported by 108 HIV-negative MSM (33%) and 21 heterosexuals (4%). During follow-up, couples reported condomless sex a median of 37 times per year (IQR, 15-71), with MSM couples reporting approximately 22,000 condomless sex acts and heterosexuals approximately 36,000. Although 11 HIV-negative partners became HIV-positive (10 MSM; 1 heterosexual; 8 reported condomless sex with other partners), no phylogenetically linked transmissions occurred over eligible couple-years of follow-up, giving a rate of within-couple HIV transmission of zero, with an upper 95% confidence limit of 0.30/100 couple-years of follow-up. The upper 95% confidence limit for condomless anal sex was 0.71 per 100 couple-years of follow-up.
CONCLUSIONS AND RELEVANCE:
Among serodifferent heterosexual and MSM couples in which the HIV-positive partner was using suppressive ART and who reported condomless sex, during median follow-up of 1.3 years per couple, there were no documented cases of within-couple HIV transmission (upper 95% confidence limit, 0.30/100 couple-years of follow-up). Additional longer-term follow-up is necessary to provide more precise estimates of risk.
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